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Do EHM Solutions Match Problems and Potential?

by Scott MacStravic

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