When proactive health management (PHM) efforts began in the 1970s, primarily with worksite wellness programs for employers, they mainly dealt with the arenas of wellness, health promotion and risk reduction. When insurers joined in the 1990s, they focused mainly on disease management (DM). Currently, employee health management (EHM) increasingly combines all these domains into comprehensive efforts, either operated by the employer, or often with multiple EHM suppliers, for risk assessments, specific screenings, lifestyle interventions, etc.

When EHM began, it focused primarily, often exclusively on reducing healthcare/insurance costs, with disability or workers compensation costs included in many cases. In recent years, a growing number of employers, at least those who evaluate their EHM investments, have included absenteeism, presenteeism, and worker productivity/performance (usually estimated, rather than objectively measured), as well, greatly increasing the economic impact of the challenges they identify and the financial gains they achieve.

The challenge in EHM assessments, planning, management, and evaluation is to match the problems and potential gains they identify with the particular EHM strategy and tactics they choose to invest in. Both the types of challenges and their numbers will vary in both the type and level of problems and potential, so the choices are complex. And logically speaking, employers may choose to invest only in those particular tactics and challenges that promise positive ROI, rather than being happy as long as the overall strategy yields positive results.

Among the problems and challenges to be considered are chronic diseases, risk behaviors, risk conditions, and productivity/performance impairment factors, which often overlap with the other categories, but not always. If chronic diseases are selected, particularly if only those patients with uncontrolled cases of these diseases or multiple diseases are selected, the overall number of employees (plus dependents and retirees, if desired) chosen is likely to be smallest. If risk behaviors and conditions are included, and certainly if impairment factors are included as well, the entire workforce may be targeted for participation in at least the assessment process.

Employer choices may vary depending on whether they expect and endure high levels of employee turnover or not. If so, they may choose to focus only on diseases, risk and impairment factors that promise to pay off within a year or two at most. Of course, they may also choose to focus on challenges that promise to reduce employee turnover, as well. When employers enjoy low turnover, they may focus on their entire workforce, or weed out those who intend to leave in the next year or two by simply asking them to indicate such intentions to a third party EHM supplier.

When EHM suppliers began offering solutions, most began with a “one-size-fits-all option, based on what they had decided delivered the best results with whatever challenges they took on. But as more have added close to a full range of challenges, they are increasingly offering a full range of different solutions, differing in intensity and cost to clients, as well as the particular challenges of individual diseases, risk or impairment factors, themselves.

A few employers offer employees choices as to which identified diseases, risk and impairment factors each may select, counting on advice by coaches in making such selection helping to ensure that they choose interventions that will yield good ROI for the employer as well. Since employees who choose their own intervention have been shown to do better in terms of active participation, lifestyle changes, and EHM success, letting them make the choices often works out well. Otherwise, as some already do, employers may vary the intensity and cost of the programs which different employees are eligible to join, in order to match the costs to the estimated/predicted potential gains for each individual.

The costs of EHM interventions vary over an enormous range, if we count examples already known in Medicare DM demonstration projects. Fifteen such projects involved DM fees that ranged from $80 to $444 per month, or $960 to $5328 per year! It is the programs that offer face visits, at the worksite for example, or depend on physician office visits elsewhere, that tend to be the most expensive, with phone coaching somewhat less so. Physicians and coaches that use group face or phone contacts can be somewhat less expensive than those who rely on one-to-one “visits”.

At the bottom end of the cost range are suppliers who rely on online communications, at least for participants who can be reached online, with mailed content substituting for those who are not online. Perhaps the least expensive options involve participant-initiated website visits, though these may also be prompted via e-mail reminders at little added costs. Online supplier-initiated contacts are more common and more effective, usually, particularly when they are customized for each participant, which can be done via automated computer analysis of health risk assessment (HRA) results.

When chronic diseases are involved, particularly those patients with uncontrolled or multiple costly conditions, high-intensity options may make sense, since the potential financial gains are likely to be great enough. With risk behaviors and conditions, and some though not all impairment factors, lower-intensity alternatives often make more sense, because potential gains are lower. Almost every employee, however, is likely to have at least one item on the list of chronic diseases, risk or impairment conditions or behaviors, so having a mix of interventions that vary by intensity/costs makes the most sense.

This reality has been recognized by EHM suppliers. Many have merged with or acquired rival suppliers, in order to expand the scope of their interventions, and often to expand the intensity/cost range they represent as well. Those that started at the high end of both have added options at the lower end, while those that started at the low end have added options at the high end, to deal with recalcitrant individuals or complex and difficult challenges, including mixes of diseases, risk and impairment factors.

Suppliers almost always offer multiple separate interventions, and limit their simultaneous use to as few as one at a time, and no higher than two or three to my knowledge, at least. Clearly, since participation takes time, few employers wish to lose productive time for employees because they are spending hours every week participating in multiple interventions. Of course, some interventions are multi-faceted in the first place, as with diabetes DM, which almost always includes attention to reducing blood pressure and cholesterol, not merely blood sugar levels among participants.

Whenever productivity/performance impairment is an explicit element of EHM, it is likely that challenges addressed will represent different priorities than they do when only healthcare, workers compensation or disability expenditures are considered. For example, challenges such as lack of sleep, poor diet and fitness levels, and particularly chronic pain can be major causes of impairment and lost labor costs or gains, where they may cause modest, even low levels of healthcare expense.

Moreover, at least one EHM supplier has reported productivity recovery of as much as 8.72% for each participant in a back pain program, which would equal to at least $4360 in financial gains with employees who make at least $50,000 a year. While such savings may arise in DM with uncontrolled or multiple diseases, they may not always arise for every participant, witness disappointing results for Medicare’s demonstrations. By contrast, $4360 would more than cover the costs of most EHM providers’ interventions, across the full range of intensity and fees. And since 15% of employees were found by this supplier to be affected by back pain, this gain represents a potential gain of $4360 x 15% = $654 for every person in the workforce, if all who are affected enroll in the intervention.

By estimating the potential financial gains against the predictable costs of EHM interventions, employers should be able to make the most informed investment decisions possible. Some challenges are very difficult to succeed in, for example, such as permanent weight loss and smoking cessation. Smoking cessation interventions often have success rates as low as 20% or so, which when combined with smoking rates of 21% (the U.S. adult average), means any gains per participant will translate into only 20% x 21% = 4.2% as much gain across the workforce.

Whether charges are based on the size of the workforce or total population, or on a per participant basis will also make a difference, of course. Charging per population may prove least expensive as long as high levels of participation are achieved, though this may require paying incentives – per participant, or per successful participant – which will add to the costs per participant. Charging per population when low participation levels are achieved will result in significant multiplication of the population charge, i.e. by as much as ten or twenty times for 10% and 5% participation, though such fees may be so low to begin with, they are still a good investment, nevertheless.

By consciously and carefully attempting to match the predicted problem/potential of each EHM challenge with the total predicted costs of options being considered, employers can be as sure as it is possible to be, given the difficulty of predicting the future, that they are making the best investment. And as more employers become more careful investors, the suppliers of EHM services will be forced to offer, guarantee, and deliver better results in order to survive.