Making It Stick

More companies are using health-risk assessments as a starting point for a comprehensive strategy to help their employees get healthier.

Wednesday, May 2, 2007
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In employers' war against rising health-care costs, one major battle is getting employees to get healthy and stay that way. For all its difficulty, it's a battle worth fighting, experts say, because better health can nip costs in the bud and raise productivity. The first weapon in employers' arsenal is the health-risk assessment.

For employees, health risk assessments -- 30- to 45-item questionnaires that evaluate a person's lifestyle habits and general health -- raise their awareness of personal health risks and, ideally, spur them to change bad behaviors such as smoking and lack of exercise.

For employers, they're a tool to determine their workforce's biggest health risks so the highest-impact programs can be offered.

What's challenging is that people need lots of support to make changes and stick with them. The health-risk assessment can only be a starting point for wellness and other health-promotion programs that can yield hoped-for savings.

Even so, many employers still haven't gotten the message: According to a major survey on health-risk assessments conducted by Hewitt Associates last September, only 32 percent of employees who completed an HRA said they were required to participate in any follow-up actions or activities, while less than a quarter said their spouses or partners were invited to complete one, making it difficult to assess family health needs.

"Bottom line, companies need to be the ones who support and influence consumers' health-care behaviors," says Jennifer Murphy, health-care communications leader at Lincolnshire, Ill.-based Hewitt Associates.

Awareness, Then Change

Health-risk assessments, also called health-risk appraisals, can influence healthy behaviors by helping employees understand and address their health-care needs, according to Hewitt's study, which surveyed more than 18,000 U.S. employees. Three-quarters of those who completed an assessment found the results valuable, the study shows. More than 40 percent said they learned something new about their health, and more than half took action to reduce or manage potential health risks.

But, as anyone who's tried to quit smoking knows, change often takes time and repeated attempts. Employers can ease the process by offering health-management programs that can range from prevention efforts such as smoking-cessation and weight-loss classes to disease-management programs, which help people with chronic conditions take better care of themselves.

Any wellness strategy starts with information gleaned from HRAs and a claims analysis. While individual results of health-risk appraisals are protected by privacy laws and not available to employers, companies get reports of aggregate results that show a population's major health risks and problems.

Details include the percentage of employees at low, moderate and high risk for various lifestyle habits and chronic conditions. A breakdown can show, for example, which work site has the highest percentage of smokers.

Some reports also show how employees stack up on a "readiness-to-change spectrum" and estimate the potential savings of reducing risks. Readiness-to-change refers to a widely accepted, five-step model of behavior change that begins with "precontemplation" -- basically, a lack of awareness -- and ends with maintenance of changes made.

The value of HRAs is not in the information they provide but in how it's applied, wellness experts say. It's not enough to offer them as employee self-awareness tools and do nothing more.

"The value's not in the report. It's in what you do with the report and the resources you put into it," says Jerry Ripperger, director of consumer health at Indianapolis-based Principal Wellness Co.

"If education were enough, everyone would be fit, but it doesn't work that way," adds Steven P. Noelder, a senior consultant at Mercer Health and Benefits. To get the full benefit of HRAs, employers should use them to target health programs according to employee risk and readiness to change, he says.

Healthier Argentinians

Dow Chemical Co.'s doctors, nurses and other medical specialists strive to keep 43,000 global employees in top shape, but the company also expects workers to step up to the plate.

"Your health status isn't owned by the company. It's yours. Dow offers help, but people have to take ownership. It's a mutually shared responsibility," says Mike Gondek, corporate medical coordinator at Dow, based in Midland, Mich.

Dow's health-risk assessment, the latest iteration of health testing it's conducted for 40 years, is one way employees get involved. About 80 percent of them have voluntarily taken the 49-item questionnaire, which asks about their smoking, eating and exercise habits, and personal and family medical histories.

Dow's health-services staff checks each participant's height, weight and blood pressure, and draws blood to measure cholesterol and blood-sugar levels. The numbers are then entered on the assessment.

Two years ago, the results showed that Dow employees' biggest health problems were obesity, smoking and inadequate physical activity, says Sergio Salomon, global leader of Dow's health-assessment program. But the analysis didn't stop there.

Assessment results were broken down by region so that managers could set priorities and develop the right programs for their sites. "All of the regions are developing a variety of programs based on their needs assessments and are measuring their success," Gondek says.

For example, Dow's site in Bahia Blanca, Argentina, implemented healthy cafeteria menus, referrals to dieticians and follow-ups by its own staff after finding high rates of cholesterol and blood pressure among employees. As a result, from 2003 to 2006 the percentage of workers with high cholesterol dropped from 34 percent to 14.4 percent, while the hypertension rate fell from 31 percent to 6.8 percent.

Marketed by health plans and wellness companies, health-risk assessments generally consist of questions about one's medical history and lifestyle habits, from fat intake to seatbelt use. Around for 20 years, their use by employers has steadily increased. Last year, 53 percent of large employers (500 or more employees) offered assessments, up from 46 percent in 2005 and 35 percent in 2004, according to Mercer's annual surveys of employer health plans.

"Employers are getting savvier about addressing the long-term risks of a population," says Krishnan Sastry, executive vice president of strategic development at SHPS, a health management company based in Louisville, Ky.

Prompted by a relentless search for ways to reduce medical costs and a booming health-management industry, employers are increasingly aware of health risks -- and their impact on absenteeism, disability and productivity -- and have shifted their attention to prevention of illness as well as treatment of it, he notes.

For every $1 spent on preventive services and health promotion, employers can realize a $3 return on investment in the form of lower medical costs, less sick and disability leave and higher productivity, according to a March/April 2005 article in Compensation & Benefits Review by Ron Finch of the National Business Group on Health.

Weight-loss and exercise programs have broad appeal because almost anyone can benefit from them. Others, such as disease management, are aimed at individuals with certain conditions, such as asthma or heart disease. Reports to employers may also reveal that employees at different work sites have different health issues. That knowledge helps employers tailor site-specific programs that best meet employees' needs.

"Everything improves when you begin to exercise. That's usually a top priority," says Don Hall, president of Wellsource Inc. of Portland, Ore., which markets health-risk assessments and other wellness programs.

No employer can offer the works. "You pick and choose the ones that are the most promising, that will affect the most people or that will save the most money," says Helen Darling, president of the National Business Group on Health in Washington.

SCANA Corp., a utility company based in Columbia, S.C., has 231 of its employees and retirees enrolled in seven different health-improvement programs, says Chris McSwain, director of compensation and benefits. The company rolled out weight-loss, exercise and other programs in conjunction with assessments, all part of its "Live Well, Life Counts" health and productivity program.

SCANA had solid information on which to build its wellness strategy. In addition to medical claims, it had data from health-risk assessments taken by 94 percent of its 5,600 employees, McSwain says. Unlike Dow, SCANA does not use on-site clinical screenings, though it gives out wallet cards so employees can record their blood pressure and other "biometric" results when they visit the doctor.

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McSwain says SCANA's wellness strategy has played a large part in its health-care cost trends: a 3 percent decrease in costs in 2005.

HRAs can reveal information that medical-claims data often doesn't, says McSwain. "The claims system only captures half of your workforce's information, because the other half typically don't go to the doctor enough for it to show up in the system," he says. "Having a high participation rate in our health-risk assessments has given us an unprecedented look at the health of our whole population."

Truck manufacturer International Truck and Engine Corp. offers health-risk assessments every year, which helps workers select the best health-promotion activities, says Dr. William B. Bunn, vice president of health, safety, security and productivity.

The company's 18,000 predominantly blue-collar, male employees can tap smoking cessation, weight-loss and disease-management programs, all common offerings. Its U.S. workers also have access to physical therapy and work hardening -- important services for manufacturing employees with musculoskeletal problems -- at fitness centers at its major U.S. plants as well as company headquarters in Warrenville, Ill.

The group data from the assessments guides the company's selection of wellness programs each year. But wellness doesn't always involve new programs. Sometimes it's a matter of getting employees to use existing health-plan benefits, such as physical exams and cancer screenings. "It may not be changing the benefit design, it may be educating people to use the benefits," Ripperger says.

What's Your "Health Age"?

Health-risk assessments can also help employers evaluate the impact of health-management programs. Did a smoking-cessation class really help people quit smoking? Is a diabetes disease-management program working? Besides participation rates, employers can compare the before and after results of health-risk assessments, looking for prevalence of relevant risk factors.

"The ideal is to periodically assess what's going on with the same people," says Darling. She recommends setting a baseline one year, then comparing results a few years later to see if and how employee health has changed.

Although many employers administer health-risk assessments annually, improvements in health likely won't appear for two or three years, she adds. It simply takes time for employees to gain awareness and change their behavior. Ripperger says, "I encourage people to take a three- to five-year time horizon."

International Truck uses assessment results to track shifts in risk and cost among three risk groups as well as improvements in workers with diabetes, the number of smokers and whether the asthmatic children of employees use appropriate inhalers, Bunn says. SCANA hasn't done this kind of analysis because it hasn't had enough time to track results for participants in its health programs, which were introduced in January 2006, McSwain says.

Health-risk assessments benefit employees by raising their awareness of their own health risks and, at best, prompting them to quit smoking, lose weight or take other appropriate action. Those with suspected high blood pressure or other conditions are encouraged to see a doctor for diagnosis and treatment.

Employees usually take the 10- to 15-minute tests voluntarily, often encouraged by incentives such as health-premium discounts (see sidebar). Feedback in the form of an individual report is available instantly if the test is taken online or in a few days via mail if it's taken on paper.

Most health-risk appraisals yield a "health age" or "risk age," the age of the average man or woman with the same risk as the participant. For example, a 45-year-old woman who exercises regularly and eats well may have a health age of 43; one who's sedentary and overweight may be 50 health years old.

"The average person has five or six years they can add to their life expectancy if they lived a really healthy lifestyle," Hall says.

The best reports link individuals to helpful information and, if appropriate, refer them to physicians or company-sponsored wellness programs. An overweight employee is told about Weight Watchers and other programs to aid weight loss, for instance.

There are different ways to deliver the results. Many employees get an electronic or written report; others meet with a nurse or other health professional. "You sit down with someone with their results. It's a teachable moment," Ripperger says.

Members of Dow's health-services department meet face to face with everyone who takes an HRA to review the results and discuss future action. "That's the single largest commitment of our staff's time," Salomon says. "It takes a lot of time, but it has a lot of value. When a person gets good feedback, they'll come back."


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