A new survey, by Fidelity Investments and the National Business Group on Health, reported that the use of employee incentives to promote health and wellness continues to rise. The Fidelity survey covered 147 companies with between 1,000 and 100,000 employees. The average employee incentive rose 65% to $430 last year from $260 in 2009.
While incentives can be used in all sorts of way, one of the most common uses is for promoting completion of a health-risk assessment (HRA), the idea being that employers can then identify patients who are at highest risk for poor clinical outcomes and target these patients for enrollment in targeted wellness and disease management programs.
When I first joined the care management industry and began to study evaluate wellness programs, I had two fundamental questions: 1) what is the validity of the self-report HRAs that are so common in the industry and 2) how well do incentives improve participation and longer-term behavior change? Here is what we found:
- Using self-reported health-risk assessments to identify high-risk patients will miss 90% of your high-risk population.
We examined more than a dozen employers who had simultaneously incentivized completion of a self-report HRA and biometric screening.. Participation was between 70 and 80% across employers, providing an ideal scenario for assessing the validity of the self-reported HRA. Examining more than 5,000 patients, we found that the percent of members failing to report or under-reporting their risks at baseline ranged from about 20% to more than 60%, depending on the particular measure, as shown below. An example of under-reporting would be when a member reports that their total cholesterol is 180 md/dl (low risk), but the biometric test finds that the actual score is 250 (high risk).
Percent of Members Failing to Report or Under-Reporting Their Risk
For individual patients, the underreporting was not limited to just one risk factor. Nearly 50% of respondents failed to report or underreported 3 or more risk factors. The reasons for underreporting are multiple, likely reflecting a lack of prior testing, lack of memory, or confusion about different biometric scores. Of course, some of the gap also reflects an unwillingness to share health-related data with their employer due to confidentiality concerns, embarrassment, questions about the program’s value, etc. Regardless of the reason, the impact of the poor quality data on an employer’s ability to identify high-risk patients was profound– Across these employers, the biometric scores identified 18 percent of the responders as being high risk where the self-report HRA identified only 1 percent of responders as high-risk. In other words, the self-report missed more than 90% of the high-risk patients.
Improving the quality/validity of responses to self-reported HRAs is no small task given the complex nature of the problem. However, the alternative of incentivizing biometric scores, while increasingly popular, raises fundamental questions about the employer’s role in promoting wellness.
A second note of caution relates to the effectiveness of incentives.
2. Incentives can increase enrollment in a wellness program, but their ability to impact longer-term behavior change and ultimately, outcomes has yet to be seen.
Incentives can be quite effective in promoting completion of an HRA, enrollment in an online wellness program, or other programs that represent a low “cost” to the patient if they enroll. However, incentives for participation have yet to be shown to lead to longer-term behavior change in employer-based wellness programs. Perhaps more concerning, there is a notable lack of research which demonstrates that incentives paid for health improvement are effective. This is not particularly surprising as we know the non-adherence to healthy behaviors (e.g., medication compliance) is a multi-factorial problem in which financials play only a small, if any role, for the majority of employees.
As evidenced by this recent survey, employers are spending a growing amount of money on employee incentives, perhaps with an over-confidence in the effectiveness of these programs given the research to date. Furthermore, as many companies will inevitably pass on the cost of these incentives to workers in the form of higher premiums, the importance of prudent purchasing becomes even more critical.