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The Challenge of Authentication in EHM

by Scott MacStravic

Because employee health management (EHM) promises and delivers economic benefits that are many times that of the healthcare cost reductions that insurers are after, employers can afford and increasingly offer their employees (even dependents and retirees in some cases) incentives to participate in EHM efforts. This often begins with participation in the health risk assessment (HRA) which may include both biometric screenings and self-report surveys of employee health, motivations, attitudes, perceptions, readiness to change, and productivity impairment.

Incentives are often paid for such participation, not merely the initial HRA, but subsequent ones, since these are often a major element in the evaluation process. While there are cases where participation in the HRA alone have reduced medical care costs, other cases indicate it may or may not help with productivity improvement – that usually requires, or at least results are better if HRA participation is followed by enrollment, and continued participation in a targeted and focused EHM intervention. While by no means all participants succeed to the extent of contributing significant economic benefit to their employer, or personal benefit to themselves, many do, and “success” rates are usually greater among those who participate longest and most enthusiastically.

When incentives are paid for participation, in either the HRA repetitions or the EHM intervention, the employer can usually be sure that employees have contributed some effort. If they have shown reduced healthcare, disability, or workers compensation claims costs (“direct” cost reductions) or absence/impairment at work/turnover reductions (“indirect” cost reductions), or improved performance in terms of quality, customer satisfaction, new business, (“indirect” revenue increases), paying incentives for these is complicated by HIPAA and labor regulations.

Most incentives are paid for participation, and have been shown to improve participation significantly, from as low as 20% with no incentive to as high as 90% with a $250 incentive. [S. Sexner, et al The Art of Health Promotion Mar/Apr 2004] But an increasing number of employers are offering incentives for specific behavior changes (quit smoking, abusing alcohol/drugs), or condition changes (lose weight, reduce blood pressure/sugar/cholesterol). This practice brings with it the need to authenticate any change reported by participants in order to be sure only those eligible receive payment.

Incentives may also require continuous authentication, when they are paid for sustaining a change in behavior or condition. This means using some kind of objective “biometric” that can be readily measured, via blood or urine tests, or devices such as a blood pressure cuff, weight scale, etc. In turn, this requires that employees who report a behavior or condition change qualifying them for a reward must be measured in some objective way to prevent them from “gaming the system”.

One excellent example is offered by incentaHEALTH, in Denver, Colorado, which has been offering a weight/fitness management program for five years to employers and insurers, as well as to consumers, through physicians’ offices. It utilizes a “kiosk” machine called a “HEALTHspotSM” that simultaneously checks in the participant, weighs each, and takes a full-body photograph of each (fully clothed). This enables the authentication that the participant is standing on the scale correctly, and is the one who checked in rather than a confederate enlisted to “cheat”. Moreover, it enables the participant to use quarterly-repeated photos to monitor how much their appearance has improved as they continue to lose weight.

When participants earn a reward for making or achieving a change, there are likely to be positive effects on the participant as well, in other cases besides weight loss. It would be wise for the “authentication” process to look for benefits to participants that can be tried to improve employee participation by enabling them to track their personal intrinsic benefits, in addition to the extrinsic benefits paid by the employer or EHM supplier. Intrinsic benefits are likely to have longer and more consistent impacts than extrinsic, and can at least reinforce the extrinsic benefits without any added costs to the employer or supplier, other than whatever costs are incurred in asking and reminding participants about their personal benefit.

incentaHEALTH, for example, asks in its HRA why individuals enroll in the program, along with what barriers they perceive to succeeding. This information is used to customize the coaching communications that participants get via e-mail to their worksite computer, normally, about the extent to which their personal goals and motivations have been achieved or at least furthered.

This seems to have helped incentaHEALTH achieve pretty good levels of participation and weight loss in its program. On average, it reports 50% of those targeted for participation enroll in the program, but more important, that 66% of those remain as participants after three months, 57% after six, 48% after nine and 44% after twelve. Moreover, with one client where participation was tracked over two years, participation rose to 71% after the new year began, in the spirit of New Year’s Resolutions. It declined again, of course, to 55, 49, 46, and 32% during the second year, but slightly rebounded to 36% after the third year began.

The combination of promised extrinsic financial rewards and expected personal intrinsic benefits is likely to be more powerful than either one alone, where employers or suppliers offer a way for participants to be given incentive payments and provide grounds for confidence in personal benefits. The personal benefits expected in the future, thanks to the experience of the past, and any efforts made to reinforce that confidence, say by sharing success stories or statistics about peers or at least other participants, tend to be far more significant in promoting continuous participation and improvement than participants’ satisfaction with the past. [K. Lemon et al. “Dynamic Customer Relationship Management: Incorporating Future Considerations into the Service Retention Decision” Journal of Marketing 66:1 Jan 2002]

The incentaHEALTH method for authenticating weight loss doubles as a reminder of the personal benefits gained by participants who actually lose weight. It has helped achieve a pattern of continuous improvement among participants, with average weight loss among successful participants of from 7 up to 12 pounds during the first year, then from 12 to 27 pounds by the first quarter in the third year. Even drop-out participants lost some weight, as shown when the average pounds lost in the last quarter of the first year went down from 13 to only 12 while the participation rate went up from 36% to 71%, i.e. bringing in almost as many return participants as there had been continuous. Had the returnees not lost weight, the average weight loss would likely have been cut in half.

Authentication is what makes it possible to offer incentives and pay rewards with confidence. But it makes sense to not only give employers confidence that they are getting their money’s worth by authenticating the changes made, but authenticate the value of such changes by tracking the reductions in healthcare, disability, WC, absence and presenteeism “losses”, so there can be a dollar for dollar comparison.

At the same time, it makes sense to ensure that participants in the EHM program can be sure that they have also got their “investment” worth of personal benefit. It is there time and effort, and sometimes even added expenditures, e.g. for exercise equipment or gym membership, for healthier food, for example, that makes such gains by the employer possible. Enabling participants to “authenticate” their own gains is likely to be as valuable as doing so for the employer.

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