The future of EHM is full of possibilities that go well beyond methods and concepts reflected in current trends and practices.  While there are probably many more, there are at least three that deserve some consideration, in my view at least.  They are not really innovations, per se, but different applications of methods and pursuits of different outcomes, than are reflected in present EHM practices.  These include pay-for-performance, employee-directed health management, and positive presenteeism.

Pay-for-Performance (P4P)

While P4P schemes are already common in paying for sickness care, they also have two major advantages for employers in terms of EHM and their other value-based efforts to optimize the value of their workforces.  In the first place, P4P systems have delivered productivity and performance improvements, even without any health efforts, while also dramatically reducing employee turnover.  Given this potential, it is a good idea to consider the potential for including it as part of EHM efforts.

And perhaps even more important, P4P brings with it more sophisticated performance measurement methods, which would significantly improve the EHM assessment of productivity/performance impairment and improvement levels in the workforce.  This would create a far more credible basis for evaluating economic benefits for employers, meaning that EHM providers would have far better evidence for their economic impact.  With better evidence of impact come better methods for matching EHM interventions to the reward potential of individuals and segments, and of entire populations.

Measured P4P-based bonuses, raises and promotions may prove at least as good an incentive basis as the current use of incentives for EHM participation, behavior and health status change.  They can be matched precisely to the added value of individual employees in terms of their performance improvement, for example, rather than based on guesses as to how much of an incentive is needed for all employees to achieve high EHM participation.  And performance-based incentives, as far as I know, are not subject to the same kinds of restrictions under HIPAA, ERISA, or ADA as are those based on health behavior or status measures.

The argument can be made that healthcare organizations have much to gain from P4P systems, since they have significant added revenue potential if they meet third-party payers’ P4P criteria.  Since meeting such criteria is mainly due to how workers perform, it would be logical to tie workers’ performance ratings and P4P to the specific criteria that determine HCO’s P4P bonuses and other revenue or advantages gained through improved performance.  This should make EHM and P4P behave synergistically.

Employee-Directed Health Management

As employers increasingly move toward “Consumer-Directed Health Plans” (CDHPs) with high deductibles and personal spending accounts, it is natural to consider coupling these with “EDHM”.  This approach to EHM would empower employees more than seeking to manage them, and offer them significantly more choices regarding what kinds of health issues EHM would address, and how they would be addressed.  Given the known effect of empowerment on employee enthusiasm and effort, it makes sense to at least consider it as an element of EHM.

For example, it would be possible, with the use of predictive modeling forecasts of the risk/reward potential of individuals, to use this as the basis for offering each a “budget” to be spent on efforts to achieve selected health goals and improvements.  Each could reserve an optimum amount as a “success incentive” based on measured productivity/performance improvement, depending on how confident each is in succeeding.  Or employees could choose to reward themselves for efforts such as behavior and health status changes, if they feel they can control such outcomes more effectively.

Already, there are a few examples of EHM programs where employees (spouses and dependents, retirees, where applicable) choose their own health goals, rather than being “recruited” to a particular EHM intervention based on what the employer or provider decides.  These are too early in their development and application to offer reliable insights into how well they work, and are not in situations where random control comparisons can be made to another population in any case.  But they may help in enlisting higher levels of participation with costs based on predicted value of EHM achievements.

“Positive Presenteeism”

There has been clear evidence that the “normal” level of productivity/performance impairment, in the sense of falling short of one’s full potential, is high even without health factors.  Health is by no means the sole, or even the most important factor determining workforce commitment and effort.  Low motivation and support, family life problems, etc. conflicts with or distrust of management often affect more employees, and can affect their performance more than do health problems.  This is one of the reasons for integrating EHM with all employer efforts to optimize employee contributions to the firm.

Even in the health domain, however, by focusing on promoting employees’ energy levels, via factors that are known to affect such levels, such as sleep, nutrition, physical fitness, emotional health, etc., gains may arise in productivity and performance.  These may go well beyond what is currently “normal” for officially unimpaired workers.  Studies have indicated anywhere from one-quarter to one-half of the time workers spend at work is not devoted to work, at all.  Overall improvements in morale, commitment, trust, identification with the organization’s goals and interests, etc. may enable moving well past overcoming impairment.

Because few have even considered the potential of positive presenteeism, there is little in the way of research on what the its potential might be.  On the other hand, research has indicated that even the proportion of their time, much less energy and enthusiasm, that employees spend actually doing work tends to be anywhere from one-half to two-thirds of their available and paid-for time at work.  While such “underperforming” is clearly due to factors other than health, the EHM provider HealthMedia, Inc. in Ann Arbor, Michigan, has found average health-related impairment levels from six to nine percent or more in populations it has analyzed.  In most cases, the overall impairment attributable to any one health behavior or condition causing impairment is less than the average level unrelated thereto.

While it may take some time to get past impairment factors in the workforce as a whole, there are likely to be individual members of the population who are already at no worse than average impairment.  For these, some effort to move them into or even further into realizing their full positive presenteeism potential may be worthwhile, particularly if they are high-talent, high-worth employees.  The model of empowerment reflected in EDHM efforts to address health-related impairment factors may also work well in addressing other factors that limit employees’ motivation, ability, or consciousness relative to improving their already normal levels of performance.   And P4P systems could certainly help in this direction, as well.

The Safelite example demonstrated how P4P alone, for example, increased the average productivity by 56% in just one year, and was able to increase the productivity of individual employees by as much as 100%. [B. Hall, E. Lazear, et al. “Performance Pay at Safelite Auto Glass” Harvard Business School Dec 6, 2001 (Case Studies 9-800-291 & 292)]  A similar approach by Best Buy in its corporate headquarters increased productivity by 36% and reduced turnover from 16.7% to zero. [M. Conlin “Smashing the Clock”, Business Week Dec 11, 2006]

These are but three of who knows how many possibilities might be tried by employers and EHM providers that are already making use of current trends in their strategies and interventions.  Arguably, EHM is at roughly the stage in its development as were airplanes in the early 20th century, with a wide range of methods, including some pretty zany ones, being employed, though there are signs that some discipline in the form of rigorous analyses to identify best practices, is at least beginning.  And future best practices, at least, are likely to go beyond what is common practice now.