In the early years of employee health management (EHM), beginning in the 1970s, employers understandably used a management approach to their efforts to improve the health of their workforces.  Initially, employer-sponsored efforts almost always involved health promotion or wellness initiatives, aimed at improving overall health and fitness, with specific initiatives aimed at weight loss, smoking cessation, diet/nutrition, and physical activity.  When insurance plans became involved, somewhat later, they focused mainly on disease management for a few common and expensive diseases.

Both employers and insurers offered these EHM programs at no cost to employees, but mainly offered no incentives for participation in them.  Their primary, if not sole purpose, was to improve the health of the workforce as a good thing in itself, while reducing the trend in annual health insurance premium increases.  Insurers focused on the minority of their members who had one of the common chronic diseases, such as asthma, diabetes, heart and lung ailments, based on their prevalence and impact on health insurance costs.  Employers involved the minority of their employees who were motivated to improve or maintain their overall health.

Disease management has had an often checkered history in terms of delivering desired results.  The costs of interventions intended to improve control of the targeted conditions, and reduce the crises, complications, and worsening thereof, were often fairly high, relative to the cost savings achieved.  Medicare-sponsored examples seem to generally yield equivocal or disappointing results, except with the most expensive and remediable conditions, such as congestive heart failure, and often increase health care costs by promoting greater adherence to and expenses related to prescription drugs needed to control diseases such as diabetes or asthma.

Wellness programs offered by employers often attracted those already committed to personal health and fitness, while those most needing to improve these dimensions ignored the opportunity.  They made it easier to engage in healthy activities, by offering healthier food and exercise opportunities at the worksite, for example, but typically involved only a small minority of workers, as was true for disease management initiatives.

Once insurers and employers realized that the greatest returns on their investments (ROI) depended on getting more of their members and employees to participate in EHM programs, they began using more of a marketing approach.  The sponsor considered, and occasionally even asked prospective participants what they wanted or hoped for in an EHM program, and what it would take to get them to participate, conducting, in effect, market research to help guide their efforts.

The use of incentives became common, once it was learned that EHM programs without incentives often attracted only 10-30% of workers as participants, while with incentives, participation rates of as high as 95% were possible.  Executives and managers began serving as examples, while fellow employees supplied testimonials and case histories that could be used in promoting participation and supplement the effect of incentives, by describing the intrinsic benefits to participants, including dependents, along with extrinsic incentives.

EHM programs in this mode are typically one-size-fits-all “products”, though some are graduated to be high, medium, or low-cost alternatives for sponsors to selectively offer to high, medium, and low risk prospects.  Instead of focusing solely on healthcare and disability claims costs, the programs in this mode look also at absenteeism and presenteeism reduction as desired outcomes.  As a result, they look at employees who have “productivity impairment” behaviors and conditions, including emotional/behavioral problems, inadequate sleep, stress, and similar debilitating factors, as well as diseases and health risks.

Results from this mode have generally been far more positive than earlier EHM investments that focused just on healthcare cost reduction.  Productivity “recovery” often increases total economic benefit to employers by two to five times, compared to healthcare cost reduction alone.  Dramatically improved financial benefits have enabled employees to cover the added costs of “marketing” EHM through incentives and internal “advertising”, where healthcare cost reductions, alone, often could not.  Of course, insurers could not gain anything but lower healthcare costs, themselves, but pleasing their employer clients has led an increasing number of health plans to offer EHM strategies and programs to attract and retain such clients.

Only in the past few years has an additional option been explored, that of empowering employees to select or design their own EHM goals and initiatives.  Since it is the employees’ own personal efforts that make EHM successful or not, and empowerment approach might engage more of them at a higher level of commitment and personal investment if they have more choices in the matter.  Moreover, since individual employees rarely have only one health risk, productivity impairment, or other health behavior “problem, empowering them to focus holistically on their overall health, rather than marketing a single-focus “product” might lead them to do more about more things, and yield better results.

In order to make sure they still gain a positive ROI from an empowerment strategy, employers can adopt at least two approaches in this mode.  First, they can let the inherent attractiveness of enabling employees to choose their own goals and initiatives to substitute for reduced incentives, as compared to the marketing mode.  Second, they can graduate the type and costs of the support they offer to employees in their self-directed efforts to the predicted risk/reward potential of the goals each selects to pursue.

Those whose current health, risk, and impairment levels are on the low side, whose goals are less relevant to and likely to yield less ROI for employers, and whose personality profile, motivation and self-efficacy are lower, can be allocated fewer resources for their personal EHM quests.  Those at higher levels of many or all of these factors, can be allocated significantly more resources, e.g. personal phone coaching vs. automated e-mail efforts, in order to match resources and costs to the economic benefit predicted for each.

By more consciously matching resources and sponsor investments to the predicted economic benefit of individual participants or particular segments of the employee population, the empowerment mode can do a better job of achieving desired results.  By automatically doing a better job of matching the focus of EHM efforts to each individual’s personal goals and values, and enabling them to choose what to invest their own time and effort on, it can also lead to greater commitment and persistence in such efforts, and thereby greater success for participants, as well as for the employer or insurer sponsor.
Individual employers or insurers can follow this development history, in the same way that individual organisms repeat the history of their species in their own development. (“Ontogeny replicates phylogeny” in Darwinian evolution.)  Starting small, while maintaining total control over their EHM investment, may be an appealing option to sponsors getting their first experiences.  Or they may choose to leapfrog over the slow, gradual successes of their peers by learning from their example and experiences, and selecting the best mix of the three modes to improve their chances of initial, as well as eventual success.