Health Risk Assessments and Measurement: The Driver of EHM Success
A common characteristic of successful employee health management (EHM) programs is the effective measurement of population employee health risk. There are many published studies that show the positive financial impact of measuring and reducing health risks. The purpose of this discussion is to review how a system of risk measurement can fuel a company's EHM program.
Health Risk Assessments
The most common method of measuring employee population health risks is by way of a questionnaire often referred to as a health risk assessment (HRA). A HRA usually consists of 30 to 90 questions that an employee completes either online or in hardcopy form. There are many very good HRA tools available for use and are often bundled with other services form a health services vendor. When selecting a HRA tool to use, I would suggest that there are two criteria that must be met in order to maximize the benefit.
First, be sure that the questionnaire includes a section for entering key biometric data including total cholesterol, HDL, LDL, triglycerides, blood sugar, blood pressure, and height and weight (for a body mass index calculation). Some of the most significant opportunities for health care cost reduction will come from this biometric data.
Other key information will come from questions related to level of physical activity, tobacco use, stress level and on-the-job productivity. Second, ensure that the HRA results can be easily integrated with other key health services vendors.
With data on employee health risks being a fundamental necessity for a holistic approach to health, it is important that each vendor that would benefit from having individual employee risk data have access to it.
Constructing an Accurate Population Health Risk Profile
An accurate population health risk profile can only be constructed if a representative sample of the employee population participates. According to some health and productivity researchers, striving to have 80 percent or more of employees complete a HRA is necessary to achieve a representative sample. This has much to do with the fact that lower levels of participation are often skewed toward the less risky individuals, thus understating the population risk profile.
If you are already using a HRA and have lower levels of participation, compare your results to national and regional norms and then decide how aggressive you need to be to increase the participation level. To reach the 80 percent or greater threshold, it may be necessary to employ incentives. These can include financial or non-financial incentives and should be tailored to the organizational culture that exists in your company.
Key considerations are what level of participation you are striving for and the timeframe for achieving that level. If you are on an accelerated timetable, it is likely that significant financial incentives will need to be considered. A common illustration of this is to increase the annual health care contributions/premiums that employees who choose not to complete a HRA pay.
For example, if the annual increase in health care contributions for non-participation is $500, this amount would be factored into regular payroll deductions evenly throughout the year. This presents no financial risk to the employer while providing choice for employees. A thorough evaluation of incentives would need to occur prior to implementing to ensure consistency with current or desired future culture.
At one manufacturing company the HRA completion rate in 2005, with no incentives, was 30 percent. Realizing that an accurate employee health risk profile was foundational to a newly implemented integrated health model this company implemented a $600 contributions incentive as described in the previous paragraph and was able to achieve a 94 percent HRA completion rate in 2006.
The same incentive has remained in place and the annual HRA completion rate has averaged 91 percent through 2008. Note below the dramatic difference in the risk profile at a 30 percent versus a 94 percent completion rate.
Year 0-2 Risks 3 or 4 risks 5+ Risks
2005 (30% participation) 21% 47% 32%
2006 (94% participation) 13% 45% 42%
The financial implications of misunderstanding the population risk profile are significant if the actual risk profile is 30 percent to 35 percent worse than originally assumed. A high HRA participation rate can now be parlayed into an accurate assessment of which risk factors are most prevalent in the employee population. This will allow for investing in programming resources to reduce the risks that will add the most value to the company's bottom line.
Assuming a continued high rate of HRA completion, accurate longitudinal risk shift progress can be tracked to determine if the EHM program in aggregate is effective in driving risks down. This will also provide a solid basis for any return on investment (ROI) studies conducted on the EHM program.
Supercharging Analytical Capability
Risk shift alone can lead to lower health care costs but integration of risk data with medical and pharmacy claims data opens opportunities for deeper and more focused analyses. This is comparable to the difference between black and white and color TV or the difference between a simple melody and a fully scored symphony. The following examples from a national employer illustrate this deeper level of analysis capability:
The Value of Increasing the Level of Employee Physical Activity
HRA data indicates how employees report their frequency of daily exercise. When this data was matched with the associated medical and pharmacy claims for employees, it showed that there was a 35 percent difference in per employee per year (PEPY) costs between those reporting that they exercise Seldom or Never and those that exercise twice per week. While increasing exercise levels to three or more days per week is desirable, the data clearly showed that the greatest value would come from intervention programs that could get employees to move from exercising infrequently to twice weekly.
The Excess Cost of Being Overweight and Obese
Body Mass Index (BMI) data from the HRA was matched with the associated claims cost for employees. Employees with a BMI between 25.0 and 29.9 (overweight) had PEPY costs 17 percent greater than those with normal BMI values. Obese employees (BMI >= 30.0) showed a more dramatic difference of 52 percent compared to employees with a normal BMI (<25.0). With a significant percentage of employees falling into the obese category, there was now a clear case for interventions that could reduce the level of obesity in the employee population.
Assessing the Level of Untreated Hyperlipidemia
From HRA data, a cohort of 417 employees that had both total cholesterol > 240 and LDL > 160 was identified. An analysis of this group's claims data showed that 84 percent of them were not taking a cholesterol lowering agent (statin), 47 percent of them had not seen a physician of any type in the last six months, and 45 percent of them had not seen a physician in the last six months and were not taking a statin. This analysis uncovered a serious gap in care (lack of treatment) for a group of high risk individuals. An additional look at this data showed that for the 16 percent that were being treated (those taking a statin), their treatment was not yielding effective results. This suggests a more aggressive approach to outreaching to these individuals for lifestyle coaching and/or proper medical treatment.
The financial impact described in the above examples considers only the direct cost associated with medical and pharmacy claims. When considering the significant additional cost of absenteeism and presenteeism the financial impact could be two or three times the value of the direct cost alone.
Other Benefits of Health Risk Measurement
As HRA completion rates increase and more people learn of their health risks, an increase in the demand for existing wellness programs will often follow. There are several dynamics driving the increased demand and these include the following:
- People often do not know their numbers and for the first time are confronted with their health risks. Many of these individuals do not have a primary care physician or rarely see the one they have. Also, health risks may not have manifested themselves in effects noticeable to the individual (i.e., hypertension).
- When coupled with effective and timely follow-up, HRA results can create a teachable moment and produce a newly motivated individual who is ready to engage in efforts to reduce their health risks.
When the organization takes an aggressive stance on health risk measurement, it can begin or accelerate the process of moving to a culture of health. Accurate measurement of the organization's health risk profile is a necessary first step to improving that risk profile over time.
When used to its full extent, population health risk measurement can help drive culture, program participation, health care cost reduction, and improved productivity. If you do not currently have a formal EHM program, health risk measurement is a good place to start. It will establish a fact-based foundation for building and sustaining the business case for EHM, create awareness for individuals of their health risks, enable outreach to employees for engagement in risk reduction programs, and measure the shift in the population health risk profile over time. A true reduction in employee risks will be validated through lower health care cost trend and improved productivity of employees.
1. Estimating the Return-On-Investment from Changes in Employee Health Risks on the Dow Chemical Company's Health Care Costs. Goetzel RZ, Ozminkowski RJ, Baase CM, Bilotti GM. J Occup Environ Med. August 2005; 47: 759-768.
2. The Relationship Between Modifiable Health Risks and Health Care Expenditures. Goetzel RZ, Anderson DR, Whitmer RM, Ozminkowski RJ, Dunn RL, Wasserman J, Health Enhancement Research Organization Research Committee. J Occup Environ Med. October 1998; 40: 843-854.
2. Health and Productivity as a Business Strategy: A Multiemployer Study, Loeppke R, Taitel M, Haufle V, Parry T, Kessler RC, Jinnett K. J Occup Environ Med. 2007;49:712-721
About the Author
Lloyd Herlong has more than 20 years of Fortune 500 experience in converting corporate intent into action, with the last 6 years serving as a senior-level health and productivity manager at Eastman Chemical Company charged with assessing and improving population health risks for 9,000 employees located in 4 U.S. locations. He is responsible for Eastman's comprehensive wellness program and for analysis and reporting from the company's health information database.
Lloyd has led major projects to implement and refine Eastman's Integrated Health model which is recognized as one of the most highly integrated and successful employee health management systems in the U.S. Lloyd has presented at national health and productivity forums on Eastman's successes with vendor integration, health risk management, value-based benefit design, and the effective use of incentives to drive employee engagement.