Dec 01

Separating Illness from Wellness Benefits

Some experts believe that by separating preventive care or wellness benefits from the health plans, employers can create stronger messaging about wellness resources available to participants.

By Lydell C. Bridgeford
November 1, 2010

As employers search out many avenues to expose workers to wellness and preventive-care benefits, one way is through offering those benefits solely through the health plan.

However, if employees perceive the health plan as a benefit primarily addressing illness, can the messaging and benefits of wellness and preventive care through the plan get muddied?

“Employees don’t necessarily think of their health plan as a place to go for wellness. They think of the health plan as for care and treatment,” says Stephanie Pronk, principal and clinical, health improvement and measurement lead at Hewitt Associates.

Clearly, a paradigm shift needs to occur, according to some health experts. By separating preventive care or wellness benefits from the health plans, employers can create stronger messaging about wellness resources available to participants.

Separating the ‘illness’ benefit from the wellness benefit

The concept is to break out the health plan into two pieces, one focusing on wellness and the other on illness. The group of experts that advocates for the break out contends such a carve-out allows for more year-round communication and packaging of health benefits designed to create a healthy workforce.

Although more health insurance carriers are providing comprehensive wellness and preventive benefits to self-funded plans, some are wondering if health carriers can provide high-touch health coaching around wellness and preventive-care services.

Self-funded plans can tap into wellness and preventive-care benefits either through an independent third-party administrator or under an administrative services only contract with a health insurance carrier.

Some, of course, team up with multiple wellness vendors and the health plan to map out some health promotion strategies.

This may entail whether to position the preventive benefits with the wellness initiatives. Some employers bundle preventive care with their wellness programs, which includes health risk assessments, health coaches, disease management and nurse-line services.

It’s sometimes difficult for employees to sort out the wellness and preventive-care services within the plan. It all sort of blurs together, and some workers are not sure how to handle all of the services, says Jim Hansen, vice president and executive director of the Dossia consortium, and former president and CEO of CareEntrust.

“In the future, via electronic health records, there will be more connection points between the wellness data and primary care. But in terms of messaging to employees, my sense is that people want to keep the programs separately,” Hansen adds.

Insurers, of course, beg to differ

Health plans already have insight into the key health issues that affect employee populations and are well-equipped to help employers develop and implement meaningful programs to improve their employees’ health, explains Melissa Miner, senior program manager in prevention and wellness at Blue Cross Blue Shield of Massachusetts.

“To ensure that employees receive well-coordinated, quality health care, employers should work directly with their health plan to implement wellness programs. Because health plans have insight into the key health issues that affect employee populations, such as high blood pressure, diabetes and other unhealthy lifestyle choices,” Miner says, asserting that health plans are well-equipped to help employers develop and implement meaningful and tailored programs with the goals of improving their employees’ health and bringing down the cost of care for employers and employees.

Reform throws a wrench into strategies

Historically, preventive care and wellness benefits haven’t been integrated into health benefits. In the 1980s and 1990s, such benefits typically were a stand-alone component of the health plan. Back then, preventive-care services, such as mammograms and colonoscopies, were either not offered under the plan or included as a separate offering.

But in the early and mid-2000s, more employers started to push health plans to provide comprehensive wellness and preventive care services among plan offerings.

Now, some employers are wondering if they can get the same value by going out to a boutique vendor who specializes in engagement techniques and behavior changes around lifestyle behaviors, says Hewitt’s Pronk.

On some level, she adds, health care reform also is driving this discussion. Employers have to face the challenges posed in building out a health promotion strategy in a post-reform environment.

With reform, some employers will stop offering health care benefits and provide their workers with funds to enter the health exchanges.

“Those employers recognize there will still be a need for wellness programming because of the tie between performance and productivity. Employers want healthy workers whether the company has to pay directly or indirectly for health care benefits,” Pronk explains.

The wellness plan

Self-funded employers have been outsourcing their wellness programs for many years, similar to the way they have outsourced their pharmacy, dental and vision, or other benefit components, says Dr. Gordon Norman, chief innovation officer at Alere’s health improvement division, a Georgia-based health management services company.

What is changing within the industry is that many health plans are now claiming to have the expertise to provide their own wellness programs, he adds.

“The issue does come down to what an employer prefers on costs, outcomes and preferences. For example, a key benefit to having a single specialized carve-out wellness program is that a wellness vendor is much better able to coordinate among all national and regional health plans,” Norman explains.

An employer with a single wellness company is more likely to have a seamless approach that ensures integration and coordination. Cost is a key concern for employers when considering how to structure wellness benefits, Norman notes. However, employers need to be sure they look at the net cost after determining the impact of programs on productivity.

Core competencies

Separating the wellness benefits from the health plan is a solid idea, says Robert Gearhart Jr., co-founder of Corporate Health IQ, an Ohio-based firm specializing in integrated results-based wellness incentives and health insurance solutions for mid- and large-sized employers.

“The challenge, when you add programs or bring other providers and carriers into the mix, is setting clearly defined goals, objectives and expectations that work together,” Gearhart explains.

“As health care evolves and as more employers begin to implement incentive- and results- based benefit designs, the need for a common platform on which to collect and analyze data, and use that data in ways that go beyond either historical analysis or predicated modeling to ‘descriptive modeling,’ has become necessary,” he adds.

To him, descriptive modeling means not simply predicting an outcome based on data, but identifying all cost drivers and then pointing a clear direction for the employer and plan participants to improved wellness.

The health plans serve as a great function for self-insured employers in terms of adjudicating claims. However, they weren’t designed to do customer configuration around wellness and preventive-care benefits, says Dr. Gregg O. Lehman, CEO of HealthFitness, a health promotion and fitness management company.

“The wellness market is starting to move toward configuration situations in which vendors address the unique health-risk needs of an employer population. This is not one of the health plan’s core competencies. This is not a negative or a positive, but it’s just a fact,” Lehman says. A one-size-fits-all approach toward offering wellness and preventive-care benefits doesn’t work.

Additional cost burden?

Health plan administrators and others might question the cost efficacy of establishing a wellness and preventive-care plan outside of the health plan. Besides, more leaders in the health insurance industry are realizing wellness means a combination of preventive care and other benefits aimed at creating a healthy workforce.

Many preventive services, such as screenings for cardiovascular, diabetes, osteoporosis, glaucoma, breast, prostate and colon cancers, are now mandated by health care and state laws to be covered under health insurance plans with no deductible.

“A good chunk of wellness and preventive care benefits are already offered within the plan, so carving out those benefits to create a new plan seems as if it’s an additional cost burden to the employer, instead of a benefit per se,” says Larry Steinberg, a financial adviser and insurance agent at Steinberg Financial Advisers, which is based in Arizona.

A hybrid approach

Some employers are offering wellness benefits and programs through a vendor and their health plan. For example, Eastman Chemical Co.’s wellness vendor delivers face-to-face health coaching programs while its health plan administrator delivers telephonic coaching to employees.

“Both CIGNA and HealthFitness [the wellness vendor] personnel are trained and expected to work together to make referrals to one another based on the needs and desires of our members,” explains David Sensibaugh, director of integrated health at Eastman, a Tennessee-based chemical manufacturing outfit.

According to the company’s latest numbers, it has been able to reduce employees’ health risks and lower medical claims to achieve a 3-to-2 return on investment for its core wellness program components.

“All of our partners and vendors understand our expectations about working within an integrated health care model. Recognizing that our members may prefer different methods and approaches to health coaching, our preference is a hybrid model of both face-to-face and telephonic programming,” says Sensibaugh, whose company employs 10,000 workers around the world.

For employers who are working with wellness vendors and health plans on health promotion programs, Sensibaugh says it is important to take the necessary steps to ensure the desired integration occurs.

“We have annual summit meetings where our partners come to our corporate headquarters to understand our vision and strategy, and discuss specific ways about how they can more effectively interface to improve the health of our members,” he adds.

“In fact, this was a requirement in our request-for-proposal process; candidates, if selected, agree to participate in such summit meetings. We also have a monthly coordination phone call with all of our partners to keep the lines of communication open and to address any issues.”

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