It is pretty self-evident that employee cooperation is essential in employee health management (EHM) since employees are the people who must participate in health risk assessments, both baseline and repeated, in order to supply much of the data used to plan EHM strategies, target individuals for specific interventions, and evaluate results thereof.  Moreover, employee behavior changes, resulting in either positive health status changes or the avoidance of negative changes, are the source of cost savings, in medical care use/expense, absenteeism/presenteeism, workers compensation and disability expenses, representing the economic benefits measured for most EHM investments in order to determine ROI therefrom.

But employer cooperation is equally essential in almost all EHM applications where employers “outsource” some or all elements of such investments.  These elements usually include:

1. Initial health/expenditure/productivity-performance assessments, which may involve analysis of claims, risk screenings results, health risk assessment (HRA) surveys, including self-reported productivity impairment
2. Efforts to enroll employees (perhaps dependents or retirees as well) in particular EHM interventions aimed at specific health problems or risk/impairment factors
3. Conducting specific EHM interventions while retaining as many participants therein as possible for the duration of the intervention, and engaging them as much as possible in making positive health behavior changes
4. Evaluating results of separate interventions, as well as the overall EHM strategy, in whatever dimensions are of interest to employers and suppliers

Employers determine or at least influence the extent of success in each of these four elements, even if they outsource all four, along with the supplier(s) to which they outsource them.  For example, if they outsource the health/expenditure/productivity-performance assessments element, employers must either supply their own or give their insurer(s) permission and instruction to supply the health claims data and expenditure figures needed for the EHM supplier to analyze.  If they outsource the HRA and impairment assessment, employers’ cooperation in enabling suppliers to contact employees, perhaps offering incentives for employee participation in such assessments, is critical in gaining high levels of participation.

The numbers of employees who participate in assessments will both determine how many can be targeted correctly for enrollment in specific EHM interventions.  And the number who participate in repeated assessments for evaluation purposes, will often determine the amount and degree of improvement in health behavior, health status, and productivity-performance (PP) the EHM intervention is given credit for achieving.

Employers, after all, decide whether to extrapolate data from employees who participate in HRA and PP surveys to the entire participant population, or to give credence only to results actually reported in such surveys.  If only a modest proportion of intervention participants supply results data, the overall results and ROI may be greatly understated, and the supplier may end up being greatly underpaid.  It may be that non-participants in the repeat assessments are not as successful as participants therein, but they should be more successful than those who never participated in an EHM intervention at all.

Getting targeted employees (perhaps all employees where a comprehensive, workforce-wide risk prevention, reduction, and disease management strategy is adopted) to enroll and cooperate enthusiastically in EHM health behavior change initiatives is another arena where employer cooperation is essential.  While supplying employee names and addresses for enrollment efforts is clearly necessary, enabling EHM suppliers to contact them enough times to ensure adequate enrollment for optimal results is equally important.  This may mean no more than giving permission to contact them repeatedly, or include offering incentives for their participation.

Employers also determine the length of the time period used in evaluating EHM results.  They may be interested only in short-term results, for example, and only pay for a limited participation of their employee, particularly when the EHM supplier charges per participant.  Or they may recognize that EHM results tend to persist and often increase over time, and empower/assist suppliers in tracking longer-term results.  In the only published research on long-term results for a specific employee population that I know of, total savings achieved by the employer were only $233 in the first year.  But these increased to $375 in the second, then to $944 in the third, and $950 in the fourth year.  [G. Stave, et al. “Quantifiable Impact of the Contract for Health and Wellness” JOEM 45:2 2003 109-117]

Had the employer not tracked results at least as far as the third year, it might have made the wrong investment decision by terminating it after the first or second year.  Moreover, had it been paying its EHM supplier based on results, it would have severely underpaid if it based its payment only on the first-year results.  Even Medicare is relying on three to five year periods in its disease management demonstration projects, recognizing that results often increase with time, and its first-year results have often been disappointing. [R. Brown, et al. “The Evaluation of the Medicare Coordinated Care Demonstration: Findings for the First Two Years” Mathematica Policy Research, Inc. 2007]

Employers can also have a great deal of influence over what results they get, not merely what results they measure.  Employers that offer incentives for employee participation, or even better, rewards for employee success, can greatly increase the participation rates and results they achieve.  Paying for explicit health behavior changes, and perhaps for validation through biometric screening that such changes have made can both protect them against employees’ “gaming the system”, and provide evidence for the connection between EHM incentives and behavior changes they produce.

Paying employees for specific health status changes can be problematic, where either HIPAA regulations preclude asking employees about them, or federal labor rules preclude “discriminating” among employees based on health status.  However, it has always been an accepted practice to discriminate among employees based on their productivity and performance, unless union agreements preclude that, so paying incentives for these kind of results may actually be safer than paying for health status or even behavior change.

For example, federal regulations effective in 2008 seem to require paying employees for not smoking in the first place as much as is paid as an incentive for smokers to quit.  By contrast, since quitters should immediately and automatically improve their productivity and performance, if only because they don’t have to take so many “smoke breaks” away from their work station, paying them for the measured productivity/performance improvements noted among them should only involve paying quitters for quitting, not non-smokers for persisting in their absence.

In all four elements of EHM strategy and particular interventions, the extent to which the employer is an enthusiastic partner in the overall effort will have dramatic influence on how successful it is.  Unfortunately, the employer’s direct and short-term interests may seem to favor limited “enthusiasm and generosity”, in enabling, promoting and measuring the full results and value achieved, whenever the employer pays more to EHM suppliers for results measured.

For example, if it pays on a per participant basis, in any of the EHM elements, the employer may feel that targeting only the highest risk/reward employees will pay off in the short run, and miss out on far greater savings from longer-range targeting of employees merely at risk.  The employer may look only at “hard” or “direct” healthcare, disability and workers compensation expense reduction, and miss out on the employees and EHM interventions that pay off far more in productivity-performance improvements.   Or by not offering and paying any or sufficiently large incentives, for participation in the assessment process, or particular EHM interventions, employers may miss out on a greater proportion of potential economic gains than they achieve.

Perhaps most sensitive is the question of promoting and rewarding employees for participation in follow-up assessments.  If employers have to pay incentives or added costs merely to measure EHM results, they may decide to save themselves some money by not pushing or even paying for measurement.  A recent survey found that only 55% of employers surveyed even measured healthcare expenditures over time, and only 38% measured the ROI they achieved, though this was an increase over 23% that did so in 2006. [“Wellness: Saving Lives and Money” 2007 Willis Survey (Willis Americas Employee Benefits – North America)]

An even smaller percentage of employers routinely and reliably/validly measure employee absences, much less presenteeism or impairment while at work. This means that they may not even know the full extent of their EHM investments’ ROI. [W. Lynch & H. Gardner “Our People Are Our Greatest Asset… But No, We Don’t Track Their Performance or Attendance” Health as Human Capital, Dec 17, 2006] Of course, if they pay their EHM supplier based on value delivered, they may deliberately prefer ignorance of such effects.  Of course, EHM providers who guarantee results, or charge at least partly based on results achieved, will understandably insist that all results and value should be measured.

It can only be hoped that employers will recognize their long-term interest in achieving and measuring the total economic impact of EHM, rather than short-term gains possible through limited cooperation in any of the EHM elements.  It is rare that ignorance pays off better, in the long run, certainly, than does full and accurate/precise knowledge of the results achieved.  And only full employer cooperation will enable achieving the best results and knowing what they are.