Employee Wellness Program Effectiveness 2016

Jesse Hercules, President Extracon Science LLC

This webinar is sponsored by Extracon Science.  Extracon is a technology company that offers solutions from turnkey wellness programs for employers to customized portals and apps for wellness companies. 

Jesse:  Our customers come in all shapes and sizes.  They’ve included insurance organizations like Highmark Blue Cross.  They include large employers like MARS and UCSF,  all the way down to smaller employers with 250 employees. They include wellness vendors who private-label our services.  And they include quite a few Hospitals and healthcare organizations. 

Ted:  So what’s on the agenda?

Jesse:  We’re going to talk about our Effectiveness Survey for 2016.  First we’ll talk about who took the survey, and what kinds of wellness programs they run. 

Then we’ll talk about the major finding from the survey.  It’s called the effectiveness gap.  Employers know what would make their wellness program more effective.  But they aren’t doing those things.  There’s a big gap between what employer say is effective, and what they’re doing today.  

Then we’ll talk about the barriers to a more effective program. 

And finally, we’ll conclude with a summary that explains how employers can close the gap and have kinds of effective programs they really want. 

Let’s get started.

In March 2016, we invited more than 8,000 leading employers and wellness consultants to participate in a survey on wellness program effectiveness.  We got 76 responses, from a representative sample of employers and wellness practitioners.

37% were fulltime Wellness Coordinators at an employer

20% were HR & Benefits leaders who also oversee a wellness program.  So they are running the wellness program off the side of their desk. 

24% were Wellness Consultants and vendors who oversee multiple programs.

Responses came from employers with several program types:

41% of programs were run internally by the employer.

15% used a vendor program, or a program from their Health Plan.

44% had a program that included a combination of the above.  Some parts of the program were run by the employer, others were from a vendor or the health plan.

Ted:  So what did you ask in this survey?

Jesse:  The first thing we asked was what effectiveness means to employers and wellness programs.  We have to agree on that first.  

The top two answers were not surprising.  79% said an effective program achieves high participation, and 85% said an effective program reduces health risks.  

But the other top responses were more surprising.

77% said that an effective program means participants work with their primary care physician.  Specifically, that they work with their PCP for overall prevention – not just when they are sick.  You have to get the doctor involved if you want to be effective.

64% said an effective program means biometrics are followed up until the problem is resolved, As verified by the participant’s doctor.  So it’s not enough to screen people, you have to actually fix the problems that are found at the screening.   And once again that means working with primary care physicians. 

61% said an effective program includes validated data on physical activity over 12 months, showing that sedentary people are becoming physically active.  Real data on long term physical activity.  

Ted:  Are employers really doing those things they say would be effective?

Jesse:  Most of them are not.  That’s the effectiveness gap.   Most are not including the physician, most are not following through on biometrics, and most are not using validated data for lifestyle. 

88% in our survey said their wellness programs could be more effective.

They agree on what a more effective program would look like.  It would have a better design in 4 key areas:  Physical Activity & BMI, Screenings & Prevention, Screening Followup, and Health Coaching.

And yet they are still running the same programs they know are less effective.   They know they have a problem.  They know how to fix it.  But very few are doing it! 

Jesse:  This is kind of like the definition of insanity.  Insanity is doing the same thing over and over again… and expecting different results. 

Ted:  Let’s move on to effectiveness for Physical Activity and BMI. 

Ted:  What kinds of lifestyle programs are effective?

Jesse:  That’s what we asked employers. Which is more effective, a program that allows self-report data and uses small incentives or points?  Or a program with significant incentives based on accurately measured app or device data only. 

63% agree that using only accurately measured data (app/device) and significant incentives would be more effective. 

Effectiveness for lifestyle means accurate data only + significant incentives.

Jesse:  But that’s not the kind of programs they are actually running.  90% of the programs in our survey still allow self report data. 

You can see how that breaks down in the pie chart.  34% only use self-report data in their lifestyle programs.  Another 49% use apps and devices in their programs, but also allow self-report data.   

Only 10% require accurate data in their programs.   There are a lot of wellness programs out there adding apps and devices to their programs, but they are not changing their programs and incentives based on apps and devices. 

So they aren’t really getting the benefit of this accurate data- it’s still mixed in with a lot of self report data.  

We don’t think it makes sense to mix accurate data from apps and devices with self-report data.    If you mix the two, you still have all the downsides of the original, self-report program.

First of all, the program length is still limited by self report.  People get tired of logging with self-report, so you have to keep programs short and you can’t cover the whole year.   Second, If you mix self report data with app/device data, the final data is still questionable.  It’s not good data.

And finally, program incentives are limited by self report.  You have to use small incentives because you don’t trust the data.

Mixing accurate data with self report data doesn’t work because you still have all the problems and limitations of a self report program. 

If you ever want to reach the sedentary people, and get them off the couch, you need a long-term program with significant incentives.

You can’t get there if you’re still mixing in self report data. 

Ted:  So what’s the conclusion for physical activity and BMI?

If you remember from a few slides ago, what makes a lifestyle program effective is accurate data only + significant incentives.

But in our survey, only 2% of the programs have significant incentives based on accurate data from apps or devices. 

Only 2% are doing that.  It’s a big gap. 

Jesse:  So we’re going to talk about what kinds of screenings and preventive services are effective.  There’s some background information you need before we get into the survey results.

The US Preventive Services Task Force makes the official, evidence based recommendations to Congress on what screenings and preventive services are effective.  The tests cover heart health, cancer prevention, mental & social health, Immunization’s, Women’s health and other topics.  The recommendations are tailored based on age, gender and other factors. 

So the good news is that there’s a blue-ribbon panel looking at the best evidence and giving official recommendations on what works.  Also, all the services rated A or B by the USPSTF must be paid for by health plans under the ACA.  And because of that, all the EMR’s now have templates that take the doctor through the USPSTF criteria.  So it’s now a lot easier for doctors to do the checklist and tailor a visit to exactly what that participant needs. 

That’s a contrast with the standard onsite biometric screening that employers have done for the past 30 years or so.  The standard onsite screening covers the heart health factors pretty well, but leaves out most of the rest of it.  And it’s one size fits all, where everyone gets the same tests regardless of age, gender and risk level.

So that’s the background on the USPSTF recommendations versus the typical onsite screening. 

Ted:  So what kinds of screenings do employers think are effective? 

Jesse:  In our survey, we asked, which program would have a bigger impact on your population health?  A program where employees complete an onsite biometric screening?  Or a program where employees complete all of the USPSTF recommended screenings and preventive services?  As verified by their physician. 

75% agreed that completing all of the screenings and preventive services recommended by the USPSTF would be more effective.  

Jesse:  But the vast majority of employers are still doing the onsite screening.  The biggest part of their wellness program budget is going to a screening that doesn’t meet the recommendations.

So we also asked employers, what do you do about all those things that don’t happen at the screening.  How do you make sure people get their colonoscopy, their mammogram, their tetanus vaccine, and all the rest? 

40% don’t track anything for those other prevention recommendations.  So 40% of employers are doing, literally, nothing about most of the USPSTF recommendations.

Another 42% have some questions on their HRA that are designed to ask about those other prevention recommendations.    So they are using self-report data.

Only 18% are asking the participant’s physician if they are up to date on the prevention recommendations.

So here’s the summary.  Everyone agrees that sending participants to their own doctor for a comprehensive wellness visit is effective.  But employers are still doing onsite screenings instead.

Ted:  So onsite screenings don’t cover most of the recommended prevention.  Are there any other downsides? 

Jesse:  Yes.  Many employers have low participation rates in their onsite screenings, and we asked why that might be. The biggest reason they gave was that many participants have already had the same tests done at their physician’s office.  The second most common reason was that the employee was uncomfortable with the employer or the employer’s vendor doing the screening.  Most of the downsides of onsite screenings can be solved by sending people to their own doctor for the screening.

Ted:  If you send employees to their doctor every year, will that cost a lot of money?

Jesse:  We asked about that.  Employers estimate that about half of their employees already see a doctor every year for a prescription renewal, preventive visit or well-woman visit.   At some employers, it maybe as high as 80%. 

By the way, the kind of visit is very important.  Because of the way medical billing works, a physician visit is either a visit for illness or for wellness.  It’s coded using either E/M codes for illness or CPT codes for wellness and prevention.  So we’re talking about turning a prescription renewal visit into an annual wellness visit.  Obviously, if they are already doing a preventive visit, the only difference is sending the data to the wellness program.  If someone is going to the doctor because they are sick, you can’t turn that into a wellness visit.

So in most cases there’s already a physician visit where the wellness program can ask the doctor to go through the USPSTF checklist.  Wellness programs can leverage these existing visits for most employees, instead of needing a whole extra physician visit.   It’s about using the physician visits you’re already paying for, rather than setting up a separate screening or separate physician visit.

Ted:  Let’s move on to Screening Followup

Ted:  So after the screening, what kind of followup would be effective? 

Jesse:  This is really important.  64% said that effective followup after the screening means following up until the participant’s doctor says the issue is resolved.  That’s the gold standard.  That’s what you really want to measure. And it makes sense.  If you’re spending all this money on screenings, to find the problems…. Logically you want to know if those problems get resolved. 

But once again there’s a big gap.  58% of programs surveyed don’t track follow-up after the screening.  Isn’t that amazing? Most employers are doing nothing about followup.

The next biggest slice is the 22% of employers who track whether participants talk to a health coach.  There’s nothing wrong with health coaching, but talking to a health coach is not the same thing as fixing the problem with your blood pressure.  A small number track whether the participant promises that they will talk to their doctor – that’s 8%.

Another 8% tracks whether participants improve their biometrics that year. 

Only 3% track whether the issue is resolved according to the participant’s physician. 

So there’s the gap.  Employers agree about what to do, but only 3% are doing it. 

Getting physician verification that the problem is resolved is actually very important.  That’s the only way you know that they close all the gaps.

For example, if they were at onsite screening, do they even make that first appointment to see their doctor about the problem?  19% don’t have a primary care doctor.

If they see the doctor and get a prescription, do they fill it?  31% of prescriptions are never filled, especially ones for long term medications like blood pressure and cholesterol.

If they fill the prescription, do they get into the habit of taking their medication every day?  In a recent study, 49% of hypertension patients were non-adherent with daily medications.

And if they do all of that, do they attend the follow-up appointment where their doctor can re-test and make sure the medication is working?  37% of followup appointments are cancelled or no-show.

So there are a lot of gaps.  And the only way to really make sure the gaps are closed is to track whether the participant’s doctor says the problem is resolved, based on that followup visit.  That’s what you really want to track.  

Ted: Let’s move ahead to Health Coaching

Ted:  So what kind of coaching is most effective? 

Jesse:  We asked employers which coaching format would be most effective.  Would it be a text-based coaching via email or a website?  Or telephonic coaching?  Or face to face coaching? 

74% they agree that face to face coaching is more effective.   And this makes sense.  50 years of research in communication theory says that seeing facial expression, body language, and gestures results in richer and more effective communication.  It enables faster relationship building. 

Ted:  Does it make sense to pay people to talk to a Coach?

Jesse:  That was the focus of our next question.  We asked which type of program and incentive would lead to more effective coaching.  The first bar is where coaching is required for high-risk participants to earn an incentive, based on their HRA or biometrics.  Incentives are paid for participating in coaching, not for any results or changes that happen.    So it’s paying people to talk to a coach.

The other choice was a program that puts incentives on objective targets – like 5,000 steps a day.  Coaching is available for participants who want help in reaching those targets.   In other words, people talk to a coach if they want to.  Not because of an incentive.

71% said it’s more effective to put incentives on objective targets, NOT to pay people to talk to a coach.  

And if you look across all possibilities for participation incentives, versus incentives for objective targets, employers consistently favor participation incentives.

The chart shown here is from the RAND study on workplace health promotion.  You’re looking at single digit numbers for any kind of results-based incentives.

So there is a gap between what employers know is effective, and what they are doing today.  Employers talk about incentives for objective targets and results, but they are paying for participation and talking to a coach.

Employers say that face to face coaching is more effective, but they still using telephonic coaching. 

Ted:  Next on the agenda, let’s talk about the barriers to a more effective program.

Ted:  So what barriers came up in the survey?

Jesse:  Good question.  We asked about all the barriers that we could think of.   But none of the barriers got a big response from the survey participants. 

We asked if the incentive amounts needed for an effective program would be a barrier.  Only 33% of employers said yes.  Self-insured employers can adjust premiums to make incentives cost-neutral.

We asked if a more effective program would require asking employees to make too much of an effort.  Only 22% of employers had this concern.

We asked it a more effective program would require spending too much on technology – such as fitness devices.  Only 38% of employers said yes. 

We asked if it was too difficult to coordinate wellness with healthcare and primary care physicians.  Only 41% said that could be a problem.

Ted:  Isn’t cost the biggest barrier? 

Jesse:  Based on the answers we got, cost is not a major barrier.  Technology is rapidly driving down the cost of a more effective program. 

Accurate data for steps and weight is now available at no extra cost. Almost 85% of working US adults now own a smartphone and carry it daily.  There are a variety of apps available to track steps.  You can even use the right App to do a validated weigh-in, by using the dual cameras on the phone to take a picture of the participant’s weight and their face.  Accurate data is here, at no extra cost. 

Face to face coaching is possible at the same cost as telephonic. Smartphones include forward-facing video cameras, and secure, HIPAA-compliant video-calling is now available for health coaches and participants.

And Many if not most already see their doctor every year for a prescription renewal.  60% of US adults are on one or more prescription medications. Because of the Affordable Care Act’s mandates, primary care physicians are now familiar with the USPSTF requirements and have EMR templates to ensure each patient gets the right preventive services and screenings.  So employers can get more out of the doctors visits they are already paying for. 

If employers can leverage the technology that’s already in employees’ pockets, and the doctor visits they are already paying for, they can have a better program for the same cost as today. 

Ted:  Let’s more on to the final section, Closing the Effectiveness Gap.

Ted:  So what’s the conclusion?  Why don’t employers have an effective programs, and how can they get there?

Jesse:  After poring over the survey results, and talking to a number of employers, here’s the conclusion that we’ve come to.    We think the problem is the “add-on” approach that employers have taken to their wellness programs.  It’s always easy to add one more element or incentive to a wellness program.  But that’s not enough.  An effective program has to be designed from the ground up, and employers will have to stop doing some of the things they are doing today. 

For example. Wellness programs need to consider replacing:

onsite screenings with a physician visit for comprehensive prevention. 

They should consider not using coaches for biometric followup and instead make sure participants work with their physicians until the doctor is satisfied with the outcome.

They should look at offering face to face coaching for participants who want a coach’s help to meet objective lifestyle targets.

And They should consider replacing lifestyle programs and incentives designed around self-report with new programs designed around Apps.  In other words, programs designed around accurate data and significant incentives.  

Ted:  So Extracon is the sponsor of this webinar.  Does Extracon help its clients make the kinds of changes you’re talking about?

Jesse:  Yes we do. 

Ted:  Many of the wellness leaders on this call are designing their 2017 programs, and thinking about how to be more effective.  What’s your advice for them?

Jesse:  Most of the people on this call probably have a vendor that they’re already working with.  My advice is to ask your vendor about making the changes we’ve talked about in this presentation.  Find out what they can do to help.  And if they can’t help, look for another vendor that can.