1

Prevention and Wellness Programs of

Commercial Health Insurance Plans

Technical Report

June 21, 2017

By America’s Health Insurance Plans

Please direct correspondence to Aparna Higgins, MA, Senior Vice President,

Private Market Innovations and Center for Policy and Research, AHIP at

(202) 778-3246 or ahiggins@ahip.org.

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Technical Report prepared and reviewed by America’s Health Insurance Plans:

Aparna Higgins

Kevin Fahey

German Veselovskiy

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I. Introduction

Analysis conducted by the RAND Corporation using Medical Expenditure Panel Survey Data

showed that in 2014 60% of adults in the U.S. had at least one chronic condition and 42% had

more than one chronic condition.1 Health risk behaviors such as poor nutrition, lack of physical

activity, and tobacco use contribute to the onset of chronic disease and associated mortality and

morbidity.2 Thus, preventing the onset of chronic disease through promotion of prevention and

wellness is critical to reducing mortality, morbidity, and healthcare spending.

The National Prevention Strategy (NPS) and Healthy People 2020 (HP 2020) outline specific

priorities and measurable indicators to assess progress towards improved health and wellness.

These specific priorities include tobacco cessation, healthy eating and other behaviors that are

recognized as conducive to better health. Some of the challenges and successes in enhancing

wellness are evident from the November 2016 final report of CDC’s Winnable Battles3 , which

describes the progress in such areas as reducing tobacco use, increasing physical activity,

improving nutrition, and reducing obesity, but demonstrates that further sustained progress is

needed to achieve the ultimate objectives of Healthy People 2020.

Historically, health plans have implemented programs to promote prevention and wellness

among their members. Health plans typically promote prevention and wellness using two

specific approaches. The first approach is to provide coverage for clinical preventive services

such as preventive screenings and immunizations. The second approach is to offer wellness

programs, such as those promoting a healthy lifestyle, directly to their members for self-insured

and fully insured populations. Not all members may have access to their health plan’s wellness

programs, as it can, for example, depend on employer decisions about benefit packages.

Previous studies in prevention and wellness have evaluated individual prevention and wellness

programs, described the characteristics of effective programs, as well as surveyed the prevalence

of wellness and benefit plans across large and small firms. We are unaware of existing studies

1 Multiple Chronic Conditions in the United States, Christine Buttorff et al., RAND Corporation, TL-221-PFCD, 2017.

Accessed on June 13, 2017 at http://www.fightchronicdisease.org/sites/default/files/TL221_final.pdf 2 Centers for Disease Control and Prevention. (2016). Chronic Disease Overview. Accessed on June 13, 2017 at

http://www.cdc.gov/nutrition/ https://www.cdc.gov/chronicdisease/overview/index.htm 3 Centers for Disease Control and Prevention. Winnable Battles. November 28, 2016

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that focus on the prevalence of prevention and wellness programs across health plans, and

include an in-depth exploration of various aspects of these programs such as types and

combinations of services, use of incentives, program effectiveness, barriers, and lessons learned.

Examining the experience of health plans in designing and implementing such programs can help

inform policymakers, providers, and other healthcare stakeholders in advancing the goals and

priorities of the NPS and HP 2020.

The primary objective of this study is to conduct a systematic examination of prevention and

wellness programs implemented by health insurance plans in the commercial population,

including lessons learned and challenges encountered.

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II. Methodology

To effectively address the study objectives, we used a mixed methods approach that combined a

targeted literature review, a survey of health plans, and structured qualitative interviews. Such

an approach enabled us to systematically characterize the “state” of prevention and wellness

programs in the commercial population and gain a nuanced understanding of the successes,

challenges, and barriers. Figure 1 shows the key steps in our methodology.

Figure 1. Key Methodological Steps

Conduct Literature

Review

Design & Obtain

Feedback on

Survey Instrume

nt

Revise Instrument

& Pilot Test

Survey

Create final

Survey Instru

ment & Field

Survey

Analyze Survey Data

Draft Discussi

on Guide and

Conduct Health

Plan Intervie

ws

Analyze Data from

Survey and

Interviews

Write Report

Construct Survey Sample

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Literature Review

The first step in our methodology was to conduct a targeted literature review to guide the

development of the subsequent data collection.

The purpose of the review of peer-reviewed and grey (e.g. trade publications) literature was to

examine the methodology and results of studies on prevention and wellness activities of health

plans and employers. Such a review helped guide the framework and questions for the survey on

the wellness and prevention practices of health insurance plans.

The literature review was conducted by a two-person research team. The research team

conducted a systematic search of the publications using the PubMed online database and the

following keyword terms: wellness incentives AND employer/health plan, employer/health plan

wellness programs, tobacco cessation programs, worksite wellness programs, health

plan/employer wellness barriers. We conducted the search during September and October 2013.

The timeframe for our search was the years 2010-2013. Our search yielded 1859 English

language publications.

The literature review research team reviewed abstracts of the articles and identified those

relevant to the study (101 articles). We subsequently obtained the full text of the relevant articles

and entered the structured summary information into a Microsoft Access database, categorizing

the article content according to our research questions. Additionally, we included such

programmatic documents such as the NPS and HP2020 in the literature review. The full list of

the reviewed literature could be found in Appendix A).

Based on the literature review we compiled a bulleted summary of key findings, describing

objectives and key components of wellness programs, strategies used to identify members who

may benefit from wellness programs, member incentives in wellness programs, tools offered to

providers and members to advance wellness, strategies for collaboration with providers and

community organizations, quantifiable outcomes of wellness programs, barriers and lessons

learned, and similarities and differences in prevention and wellness programs by health plan

characteristics.

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In addition to the literature review, from January through March 2014 we also conducted

informal, unstructured interviews with health plan medical directors and/or prevention and

wellness program staff of five health insurance plans aimed at learning about recent

developments in health plan design and implementation of prevention and wellness programs

among the commercially-insured population. Health plans were selected for these preliminary

interviews based on size and geographic region.

Survey Development

The survey questionnaire was developed based on the literature review, input from the CDC and

internal experts, and preliminary health plan interviews described above. Table 1 shows the key

focus areas for the survey. Based on the literature review and preliminary interviews with health

plans we defined prevention and wellness for the purposes of this study in the following manner:

Prevention Program

Prevention activities refer to the delivery and promotion of clinical preventive services that help

protect against disease or reduce the likelihood of disease, disability, and premature death.

Wellness Program

A wellness program refers to structured approaches such as tools, rewards, and/or interventions

intended to improve and promote health and fitness. For example, rewards and interventions to

reduce risk for cardiovascular disease are typically included in a wellness program. Disease

management programs that aim to help individuals manage or control existing diseases or

conditions are outside the scope of this study.

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Table 1: Survey Focus Areas

Health Plan Approaches to Prevention and

Wellness

Focus Areas

Provision of clinical preventive services • Objectives

• Efforts (including use of incentives and

partnering with providers) to promote provision

of clinical preventive services among members

• Interventions that plans have found useful in

promoting clinical preventive services

Wellness Programs • Objectives

• Use of evidence-based studies in program

design

• Primary areas of focus for wellness programs –

e.g. healthy lifestyles.

• Key components and determinants of program

structure

• Efforts (including use of incentives, tools) to

promote wellness through: provider

partnerships, direct member outreach and

engagement, and community efforts.

• Program evaluation including observed

outcomes, evaluation methods etc.

• Challenges and lessons learned in implementing

wellness programs

The survey instrument consisted of 28 questions. Not all survey participants were asked all 28

questions because the survey included skip-patterns based on specific plan responses to certain

questions.

The Qualtrics survey tool was used to develop and deploy a web-based survey. We invited nine

health plans to pilot test the survey. The nine health plans were chosen based on membership

size, geographic area, and type of plan (integrated vs. non-integrated). Participation in the pilot

and provision of feedback was voluntary. We requested feedback on ease of answering the

survey, comprehensiveness of survey questions, appropriateness of survey length, and time

needed to complete the survey. In accordance with the Paperwork Reduction Act our data

collection effort was reviewed and approved by the Office of Management and Budget in August

2015.

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Survey Sample

Our sampling frame was the national directory of commercial health insurance plans derived

from the Atlantic Information Services (AIS) Directory of Health Plans: 2015. In our selection

process, we used the definition of a health plan as given in AIS’s Directory of Health Plans:

2015: health insurance company operating in the U.S. that offers some type of risk-based,

primary care health insurance product based on a regional provider network. The unit of

sampling was the corporate entity, i.e., subsidiaries of a corporation were not surveyed

independently. Table 2 lists the exclusion criteria used to construct the sample.

Table 2 – Exclusion Criteria for Survey Sample

Exclusion Criteria Rationale

Health insurance companies operating outside of 50

states and District of Columbia (Puerto Rico,

Guam, Virgin Islands etc.).

The health insurance organization working in the

unincorporated territories of the United States

(Puerto Rico, Guam, Virgin Islands, etc.) operate

in a very distinct regulatory and social

environment. The study of their prevention

practices would require designing a separate

survey instrument and interview guide. We

determined that the scope of this study should be

on health insurance companies operating in the 50

states and District of Columbia.

Leased preferred provider (PPO) networks

(organizations that do not provide health insurance

products directly to individuals or employers but

instead build the provider networks and lease them

to other health plans).

Leased preferred provider networks are not

involved in designing or implementing prevention

and wellness activities.

Health insurance companies that offer only

specialty care (e.g. behavioral care).

Specialty care companies offer health care

services for a limited number of health conditions

via contracts with health insurance plans or self-

insured employers. These companies do not

provide the full suite of medical benefits and

therefore not included as part of the study. Health

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Exclusion Criteria Rationale

plans were asked to respond on all of their

prevention and wellness programs, be they

administered in-house or through the vendors,

including any specialty care companies.

Subsidiaries of health plans Our experience has shown that prevention and

wellness strategies and programs are established at

the corporate level with the intent of achieving

uniformity in operations. Occasionally,

assimilation into such a uniform corporate

structure may not have occurred for newly

acquired subsidiaries and in the past health plans

have asked to respond separately for such

subsidiaries. Health plans in our study sample

were given the option of submitting a separate

response for their subsidiary based on their

knowledge of programs.

Health plans with the commercial enrollment of

less than 10,000 according to the data from AIS’s

Directory of Health Plans: 2015.

Our experience working with the plans of this size

has shown that often a low enrollment indicates an

unusually structured insurance product or a niche

market. Given the specialized nature of these plans

we excluded them from our sample. The total

enrollment in these 36thirty-six plans based on the

2015 AIS Directory is approximately 119,000 or

0.06% of the total commercially-insured

enrollment, which makes the effect of their

exclusion negligible.

These exclusion criteria resulted in a sampling frame of 140 health plans who were invited to

participate in the survey. We fielded the survey via email to the sample of health plans using a

key informant approach. Data collection occurred between November 2015 and June 2016. We

made multiple outreach attempts via telephone and email to encourage participation in the

survey.

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Survey Response Rate

Forty-six (46) health plans covering a total of 125.6 million commercial members (as of January

1, 2015) responded to the survey. Thus, the survey responses describe practices in wellness and

prevention among the plans covering 64% of commercial health plan members (based on the

statistics from AIS’s Directory of Health Plans: 2015, with the total commercial health plan

enrollment being 197 million). The response rate for the AHIP member plans was 51%, and the

response for both AHIP members and non-members combined was 33%. The health plans who

submitted the survey responses as a group reflected the diversity of the modern health plan

industry: they operated in all Census regions, included plans of all types (for profit, not-for

profit, integrated model, provider-owned etc.) and varied in size from 11,000 to more than

10,000,000 of commercial members.

Data Analysis

We analyzed the survey responses by calculating frequencies and percentages for each survey

question. As some health plans did not respond to all survey questions, the denominator for

calculating percentages among the questions varied. Complete results from the survey for each

question is included in Appendix B. Analysis of survey responses was conducted using the

statistical package SAS Enterprise Guide 6.1 and Microsoft Excel 2016.

Health Plans Interviews

Following the analysis of the survey data, we conducted structured follow-up interviews with a

subsample of the survey participants. The purpose of these interviews was to attain a deeper

understanding of the goals for health plans’ prevention and wellness programs, specific

interventions used, and program evaluation results. The interviews were conducted with the

representatives from nine health plans. We selected plans for the interviews based on the

following three criteria: size of the plan, the geographic area of operation (defined as a Census

region), and the level of care integration.

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The nine interviewed plans represented three commercial enrollment groups (less than 250,000

members, 250,000 – 4,999,999 members and 5,000,000 members or more), with three plans in

each enrollment stratum. Further, the selection process ensured that within the first two

enrollment groups, each of the three plans operated in a different Census region (the plans in the

5,000,000 and over stratum were considered to be “national plans”, i.e. operating in all four

Census regions). Finally, one plan in each enrollment group was an integrated care delivery

system defined as common ownership for the health plan and some or all of the medical care

providers in its network.

The interview guide included 11 questions focusing on the goals of health plan prevention and

wellness programs, specific approaches and interventions used, and program evaluation results.

We created the interview guide based on survey responses and feedback from the CDC staff. The

number of questions were limited to salient topic areas to enable us to complete the interview in

an hour.

The interviews were conducted between January and April 2017. Prior to the interview the health

plans received an email invitation describing the purpose of the interview and its planned

duration along with the interview guide allowing the health plans to assemble a team with the

requisite knowledge of all aspects of plan operations to be discussed in the interview. Each of

the health plans selected for the interviews received assurances, including voluntary

participation, confidentiality of individual responses and with the assurance that no identifying

plan information will be released without plan consent.

The interviews were conducted by the AHIP research team (one moderator and two note-takers),

while the number and composition of the health plan interview participants (most commonly,

medical director, wellness director/other wellness staff, or quality improvement director/other

staff on quality team) was determined by each plan and ranged from 1 to 8. Each of the

interviewed health plans was asked all questions from the interview guide in the same listed

order. If needed, additional questions were asked to solicit health plans responses to the specific

areas not covered during their original response to the interview question or to further clarify

plan responses. All interviewed plans subsequently received the interview notes and had the

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opportunity to review the completeness and accuracy of notes and provide corrections/additions

as needed. Appendix C includes the interview guide.

The analysis of the interview data was conducted to supplement the findings of the survey.

Analysis was conducted by a two-person team for each question and was focused on identifying

common themes as well as unique aspects of health plan prevention and wellness programs.

Study Limitations

While most of AHIP member health plans responded to the survey, the response rate was

markedly lower for non-members, which makes the description of prevention and wellness

practices of non-members not generalizable. Also, since very small commercial health plans had

a low response rate to the survey (which, based on our previous experience is typical for health

plan surveys), the study findings may not adequately describe the unique experiences of wellness

and prevention program implementation in such plans, many of which serve unique member

populations. Finally, this study represents the views of health plans and does not include the

perspectives of providers or health plan members.

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V. Findings

Summary Findings from the Targeted Literature Review

In this section, we discuss the findings from the literature review (the full list of the reviewed

literature could be found in Appendix A). The literature review revealed a relative lack of peer-

reviewed studies that specifically examined health plan wellness programs. The review did yield

useful insights into program components and other key proposed survey topic areas from

descriptions of employer prevention and wellness programs.

1. Objectives of wellness programs:

The main objectives of wellness and prevention programs we found in the literature

included the following:

o Reducing healthcare costs and increasing employee productivity.

o Implementing programs that align with disease prevalence trends (i.e. common

and costly chronic conditions such as cardiovascular disease, diabetes, chronic

pulmonary conditions).

o Identifying employee population at risk for developing chronic diseases and

conditions such as elevated blood pressure, high cholesterol, overweight and

obesity, physical inactivity, poor nutrition, stress, and tobacco use.

o Implementing programs that reduce risk of chronic disease and encourage healthy

behaviors.

o Creating culture of wellness, including making organizational and environmental

changes.

o Less common, but still mentioned was improving the health of employee

dependents/family.

2. Key components of wellness programs: The following table (Table 3) summarizes the key

components of wellness programs.

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Table 3: Key Components of Wellness Programs

Program

Components Common Features Common targeted health risks

Health risk

assessment • Basic demographic information

• Basic biometric information (blood

pressure, blood glucose etc.)

• Activity level

• Eating behaviors

• Body Mass Index (height and weight)

• Smoking status

• Diagnoses of chronic diseases/

conditions

• Alcohol intake/substance use

• Stress levels

• Depression assessment

• Sleep habits

• Tobacco use

• Overweight and obesity

• High blood pressure

• Elevated blood glucose

levels

(prediabetes/diabetes)

• High

cholesterol/triglyceride

levels

• Sedentary lifestyle

• Stress management

• Depression

• Alcohol and substance

abuse Interventions • Tailored feedback to HRAs

• Educational materials

• Interactive online tools and programs

• Health coaching

• Policies that aim to improve the worksite

environment

• Promotional campaigns

• Employee challenges/competitions

• Onsite health fairs

Multi-channel

outreach • Continuous outreach

• Use of multiple channels (emails,

newsletters, mailings, posters/promotions

at the worksite, events at the worksite

etc.)

• Web-based, telephonic, and on-site

programs and outreach

Incentives • Incentives are commonly used for initial

participant engagement, as well for

retention and completion of programs

• Cash, premium reduction, gift cards,

novelty items are commonly used

• Tying incentives to program

participation more common than tying an

incentive to meeting a health standard.

• The median annual maximum incentive

for participating in an HRA is $300 per

full-time employee (according to the

RAND Employer Survey)

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• The literature review revealed a relative paucity of peer-reviewed studies that examined

specifically the components of health plans' wellness programs. Nevertheless, some

insights could be gained from the copious number of articles describing the composition

of worksite and employer wellness programs.

• The use of health risk assessments (HRAs)/screening activities is a standard practice in

wellness programs due to the ease of administration, low cost and the ability to identify

those who would benefit the most from the participation in such programs. HRAs

typically include self-administered questionnaires on health-related behaviors such as

exercise levels and eating habits, risk factors including body weight and smoking status,

and may include the collection of biometric data.

o Main goals of HRAs include using results for planning and evaluation purposes,

and for directing people to interventions aimed at reducing their risks.

o Common biometric screenings include blood pressure, glucose, lipids, body mass

index

• Interventions to facilitate risk reduction included the following:

o Tailored feedback based on HRAs (for example, directing an individual who has

been identified as a smoker and who has indicated an interest in quitting into a

smoking cessation program);

o Educational materials;

o Interactive online tools and programs;

o Health coaching;

o Policies that aim to improve the worksite environment (healthy vending, exercise

breaks and dedicated space for fitness, cafeteria labeling etc.).

o Promotional campaigns and activities that promote healthy lifestyle; and

o Onsite health fairs.

• Wellness programs are increasingly web-based, which enables them to be offered to a

large group of participants at a lower cost. These programs run the gamut from offering

general education to interactive health coaching and online support groups/forums.

• Many channels are used to reach people for initial engagement and for program retention:

emails, newsletters, mailings, posters/promotions at the worksite, events at the worksite

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(health fairs, walks, etc.). Evidence shows that multi-channel communication efforts are

the most effective in consumer engagement.

• Financial incentives are common to increase participation and encourage continued

engagement. According to the recent RAND Employer Survey, 69% of employers with at

least 50 employees that offer the workplace wellness program use financial incentives to

improve the program participation. The survey data show that participation rates for

intervention programs are higher when incentives are used.

• Financial incentives are also frequently used to reward health behavior changes, such as

quitting smoking. However, it is unknown whether such incentives encourage long-term

changes in behavior. The literature shows that wellness programs have been evolving to

reward participants for making progress towards changing behaviors as opposed to

meeting stringent health standards.

3. Strategies used to identify members who may benefit from wellness programs

• Most commonly used method for the identification of members (or workers in case of an

employer wellness program) who may benefit from a wellness program is the use of the

online health risk assessment (HRA). Employees learned of the HRA through emails,

phone calls, mailed postcards, or other promotions at work.

• Additionally, the open enrollment meeting was used as an opportunity for asking

members to complete a paper-based HRA, with the health plan representative being ready

to immediately discuss the HRA results and, if qualified, recruit employees for the

prevention and wellness program participation.

• Employee orientations were also a popular venue to recruit.

• Incentives are commonly used to encourage initial participation in HRAs.

• HRAs are perceived as a critical first step to identify risks, provide tailored feedback and

direct people to appropriate interventions

4. Types of incentives offered to individuals to advance wellness:

• Incentives are more common as “carrots” vs. "sticks". Incentives are most commonly

used for completing an HRA or completing a lifestyle management program (with

tobacco cessation, weight management, and fitness being most common).

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• Incentives are commonly set up as a point system – participants earn points for various

actions such as signing up for a program, attending a health fair, completing an HRA, etc.

and earned points translate to a financial incentive.

• Cash is the most commonly cited incentive (cash or health insurance premium

reductions).

• Gift cards were less common than cash rewards, but more common than other incentives

such as discounts or novelty items such as mugs, T-shirts etc.

• Tying an incentive to meeting a health standard was not as prevalent as tying incentives

to participating in programs. The goal of incentives was more frequently to make

progress toward a healthier lifestyle rather than meet a stringent health standard.

According to the recent RAND Employer Survey, 69% of employers with at least 50

employees that offer the workplace wellness program use financial incentives to improve

the program participation, while only 10% of them offered the results-based incentives.

• Tobacco cessation is an exception – it is common that employers pay a higher incentive

to individuals who successfully quit smoking (vs. simply participating in the program).

• It was difficult to get a sense of incentive ranges based on the literature we reviewed;

however, according to the RAND Employer Survey the median annual maximum

incentive for participating in an HRA is $300 per full-time employee.

5. Tools offered to providers and individuals to advance wellness:

• Typically, primary care providers are not directly connected to the wellness programs

offered by employers: most common is general advice to the participant to contact his or

her primary care provider if there are identified health risks.

• However, in one program members also had the option of selecting a review of all the

identified health risks and the blood test results by a licensed physician who provided the

member with written recommendations about his or her health status.

6. Strategies used to collaborate with providers in promoting prevention and wellness:

• In our literature review, primary care providers were not shown to be directly connected

to wellness programs offered by employers.

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7. Partnerships with community organizations to promote wellness:

• The literature search revealed few linkages between the worksite wellness programs and

the community. A small percentage of the programs connected employers to local gyms

and other community resources (such as the YMCA), and a small percent encouraged

employee participation in community walk events and other community fitness events.

8. Quantifiable outcomes observed as a result of implementation of wellness programs

• Most of the studies in the literature demonstrate that wellness programs result in the

measurable increase in healthy behavior (frequency of exercise, healthy eating, reduced

smoking) and the reduction of the participants' health risk (at least for the duration of the

program).

• Data from the RAND Employer Survey demonstrate that there is a wide agreement

among the employers that wellness programs produce tangible benefits, but relatively few

of them were able to quantify the savings from the specific programs that they offer to

their employees: more than 60% of employers stated that their program reduced health

care costs and around 80% - that it decreased absenteeism and increased productivity

but only 44% of employers reported regularly evaluating their wellness programs and

only 2% provided actual savings estimates.

• An evaluation of wellness programs outcomes conducted by RAND in their 2013 study

on worksite wellness found the following:

o Continuous participation in an exercise program over five years is associated with

about 1.5 additional days of at least 20 minutes of exercise per week.

o Participation in a program aimed to control body weight, improve nutrition, or

increase exercise is associated with a slight, but statistically significant decrease

in BMI (on the average, 1 pound over the three-year period).

o One year of smoking cessation program participation was shown to decrease the

smoking rate of participating smokers by nearly 30 percent compared to

nonparticipating smokers.

• Most of the studies we reviewed did not include estimates of cost savings resulting from

wellness programs.

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• However, a few studies mentioned such outcomes as reduced total health care costs and

lowered cost trend for the program participants. For example, the analysis of the data

from a sample of large employers in the Care Continuum Alliance (CCA) database

performed by RAND researchers found that wellness program participation is associated

with a reduction of $2.38 PMPM in the first year, with the subsequent increases up to

$11.12 PMPM savings in the fourth year of the program operation.

• Some studies demonstrated improved clinical outcomes following participation in

wellness programs, such as lower blood pressure and improved cholesterol levels.

9. Barriers/lessons learned from the implementation of wellness programs

• The successful implementation of the prevention and wellness program requires a

significant financial and organizational commitment on the part of the employer:

significant resources to incentivize program participation, structuring the program in a

way that respects participant privacy and prospectively seeks employee buy-in, and

continual communication about the program using multiple channels

• For individual participants, studies frequently cited such barriers to participation as lack

of knowledge about the program, costs associated with the program or goals of the

program (i.e., joining a fitness center), convenience, and time. More specifically:

o To be successful, weight management programs must be convenient and

affordable for participants.

o Exercise/fitness activities need to be incorporated into the work day as people

have many barriers outside of work

• Certain groups of members/workers (women, married people, older people, people with

higher levels of education) are significantly more likely to participate in wellness

programs, so the program design should include a special focus on the harder-to-engage

demographic groups.

• While financial incentives are very helpful at engaging people they cannot guarantee the

success of a wellness program on their own: participant's readiness to change/self-

efficacy must also be present.

• The positive financial outcomes of wellness programs may not be immediately evident:

for example, return-on-investment for smoking cessation interventions may not be

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realized for 3-5 years. Because of that, successful prevention and wellness programs need

to maintain a long-term focus.

• Finally, the long-term success of a wellness program depends on the continual, long-term

engagement of program participants: many behavior changes are transient and often

regress after intervention is complete.

10. Similarities and differences in wellness programs by health plan characteristics

• While we did not find any articles focused on health plan programs, the data from the

RAND Employer Survey demonstrate that the largest employers more often offered

wellness programs and their programs consistently offered more types of lifestyle

management programs, clinical screenings, and other wellness benefits.

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III. Findings from Survey and Interviews with Health Plans

In this section, we describe the findings from the survey of health plans coupled with insights we

gathered from the hour-long interviews with nine plans. Health plans that participated in our

interviews provided insights into how they approach prevention and wellness. Consistent with

the structure of our survey and definitions of prevention and wellness for the purposes of this

study, we report findings related to delivery of prevention services and wellness programs

separately.

A. Characteristics of Health Plans Responding to the Survey

Table 4 shows the size distribution of health plans responding to the survey.

Table 4. Survey Respondents by Number of Commercial Enrollment (N=45).

Group by size of commercial enrollment Number of plans

5,000,000+ enrollees 5

1,000,000 - 4,999,999 enrollees 13

250,000 - 999,999 enrollees 13

Less than 250,000 enrollees 14

The majority of survey respondents served employers and members in different types of markets:

fully-insured large group, small group and individual market, as well as providing services to

self-insured organizations (see Table 5).

Table 5. Survey Respondents by Commercial Markets Served (N=45).

Market type Number of plans Share of plans, %

Fully insured individual market 41 91

Fully insured large group market (100+ employees) 43 96

Fully insured small group market (< 100 employees) 44 98

Self-insured (ERISA) 38 84

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Almost all health plans (96%) that participated in the survey have established programs

promoting prevention and wellness among their members. The only exceptions were two

small local plans that did not have an established wellness program.

Under the Affordable Care Act (ACA), all non-grandfathered health plans must provide coverage

for a range of preventive services and may not impose cost-sharing on patients receiving these

services in four broad categories:

• Evidence-based screenings and counseling – United States Preventive Services Task

Force (USPSTF) rating of “A” or “B” in the current recommendations

• Routine Immunizations – Advisory Committee on Immunization Practices (ACIP)

• Childhood preventive services – Health Resources and Services Administration’s

(HRSA) Bright Futures Project

• Preventive services for women – Health Resources and Services Administration (HRSA).

Group health plans created before March 23, 2010 and individual health insurance policies

purchased before March 23, 2010 were, however, exempted from these ACA provisions. In the

survey, we asked plans about the number of members who were enrolled in grandfathered plans

to obtain a better understanding of the potential number of individuals who may be subject to

these preventive services exemptions. The health plans reported that only a small number of their

members were still enrolled in grandfathered plans at the time of the survey (on average, 9% of

the plan’s commercial enrollment), and only 5 plans (13%) reported having 20% or more of their

enrollment in grandfathered plans. Thus, or survey results indicate that a great majority of

commercial members at the time of the survey (91%) were in the plans offering prevention and

wellness benefits and providing first-dollar coverage for ACA-mandated preventive services.

B. Scope, Objectives and Approaches of Health Plan Prevention and Wellness Programs

Responding health plans reported having several objectives for their prevention and wellness

programs. Almost all plans considered promoting health in their covered population as their

24

primary objective (96%). Other common primary objectives were preventing onset of chronic

disease (73%), improving overall quality of care (60%), and reducing or mitigating health care

costs (56%). Among secondary objectives of health plan prevention and wellness programs the

most common was improving workforce productivity (62%).

Many of the health plans we interviewed reported using a holistic approach to prevention and

wellness and specifically described their health and wellness philosophy (either formally or

informally) as including the following elements:

• A view of prevention and wellness as fundamental to their mission

• Use of a population health framework with a commitment to “whole person care” along

the care continuum

• Partnerships within the health plan to promote consumer engagement

96

73

6056

33

0

25

50

75

100

Promote health in

covered population

Prevent onset of

chronic disease

Improve overall

quality of care

Reduce or mitigate

health care costs

Improve workforce

productivity

Per

cen

t o

f p

lan

s re

spo

nd

ing

Figure 2: Primary Objectives of Commercial Health Plans'

Prevention and Wellness Programs, %

25

• Focus on the community benefit and viewing community benefit as an integral part of

their approach to prevention and wellness

• Testing of programs within their own organizations as a source of learning before

marketing the programs more broadly to their members

• Evaluation of the capacity of the system to deliver a response at scale (including

communicating with members and addressing their needs) and having an ability to impact

outcomes.

Most interviewed plans also noted that their wellness and clinical prevention programs were

administered by separate departments or teams. However, many of these plans ensure that there

is communication between these departments/teams to help coordinate their member outreach.

Role of Culture of Health:

One theme that emerged from the interviews with the nine health plans was the emphasis on the

culture of health that they have in their prevention and wellness activities. Plans routinely

evaluate the culture of the employer groups and design and implement programs that work best

at the group level while also incorporating member readiness to change.

Of nine health plans interviewed, eight plans reported being both aware of and addressing

“culture of health” to a varying degree in their approaches to designing programs for their

members. One of these plans reported that several years prior they had a program for addressing

culture of health, but had scaled back due to lack of interest by employers. Finally, one health

plan out of nine interviewed reported being unaware of the concept “culture of health”. Some of

the key observations that emerged from the interviews regarding the culture of health include:

• The more successful prevention and wellness programs are those where leadership buys

in to the culture of health because employer engagement at the highest levels is needed to

change the trajectory of health for the employees. Prevention and wellness programs are

more successful when employers understand and promote culture of health. The plans

then give direction, guidance, and support to help the employers. “It’s a partnership and

26

we can do a lot to support the culture of health, but implementation requires all parties to

be committed.”

• The concept of culture of health is also used for benchmarking readiness to change before

introducing a wellness program. Plans measure current and future state of culture of health

by asking the employers questions to determine the baseline culture of health within an

organization which helps ensure that the “right” programs are introduced. Several plans

reported using a variety of recommendations, guidelines, and checklists from best practice

organizations like WELCOA HERO scorecard, American Heart Association (AHA), and

the National Business Group on Health to measure culture of health. One plan had launched

a proprietary index that combined elements from multiple platforms such as those

mentioned above to help with benchmarking the culture of health within employers.

• One interviewed plan noted that in their member education and prevention literature they

touch upon the culture of health components but are not really building a program around

that concept. Conversely, another plan’s approach to the culture of health was tactical and

included on-site visits to employers to address the culture of health, which included

identifying healthy food options in vending machines, access to stairways, opportunities

for exercise, tobacco-free environment, and other aspects of the workplace and company

culture that can affect wellness, in addition to clinical preventive services. “We look at

the members’ environment for healthful and unhealthful conditions.”

Our interviews revealed that plans’ ability to influence the culture of health for their employer

accounts depends on the willingness of the employer. For example, a plan may examine claims

data to identify wellness-related issues that may need to be addressed as a priority for an

employer group. While some employer groups are open to this type of assessment, others are not

open and, for example, do not want to have their cafeteria options evaluated for healthy eating

and nutrition.

C. Prevention Services Delivered to Health Plan Members

Clinical preventive services (such as immunizations and cancer screenings) are typically

delivered to health plan members directly by physicians and other clinicians. However, our

27

survey showed that health plans play an important role in promoting the uptake of clinical

preventive services.

C1. Provider Interventions

Our survey results showed that health plans rely on provider payment incentives and

alternative payment models to promote clinical preventive services. Ninety-one percent of

responding plans used payment incentives to promote clinical preventive services. Specifically,

78% of commercial health plans used alternative payment models (e.g., shared savings/shared

risk models, bundled payments, and global payment) focused on primary care, while another

78% of survey respondents used more traditional pay for performance (P4P) incentives.

Eight-eight percent (88%) of plans tied provider incentives to achievement of performance

targets in specific areas. These targets typically focus on delivery of cancer screenings (71%)

and immunizations (56%), as well as rewarding primary care providers for achieving wellness

visits among their patients (54%). While some plans rewarded providers for reaching targets on

BMI assessment, tobacco cessation, and weight reduction, such incentives were less common

(see Table 6). The analysis of survey responses and interview data demonstrates that the

calculation of performance targets is primarily based on HEDIS measures.

Table 6. Tying Provider Incentives to Achievement of Performance Targets (N=41) *.

Response options Number of plans Share of plans,

%

Cancer screenings 29 71

Immunizations 23 56

Well visits 22 54

BMI assessment 16 39

Tobacco cessation 8 20

Weight reduction 2 5

Other (e.g. chlamydia screening, postpartum care) 18 44

No, incentives are not currently tied to performance targets 5 12

28

* Note: since plans could choose multiple answers the percentages in the table do not add up to 100%.

Among the plans that currently use provider incentives to promote clinical preventive services,

almost all plans implemented pay-for-performance incentives (98%) and upside shared savings

(90%) – offering providers a percentage of net savings for a defined patient population without

including financial risk for providers that experience higher costs. Other types of incentives

which health plans use for clinical prevention were care management fees (78%), downside

shared risk models (63%) – sharing with providers a percentage of savings or losses for a defined

patient population, recognition programs or awards (61%), risk-adjusted PMPM payments

(56%), and partial capitation (54%).

However, plans felt that not all types of provider incentives are equally useful in

promoting clinical preventive services. Figure 5 shows the types of provider incentives

that plans reported as “very useful” in promoting clinical preventive services.

58%56% 55%

50%

31%

25%

20%

0%

25%

50%

75%

Shared savings(upside)

Risk-adjustedPMPM

Shared risk(downside)

P4P incentives Caremanagement

fee

Partialcapitation

Recognitionprograms

Per

cen

t o

f p

lan

s re

spo

nd

ing

Figure 5: "Very Useful" Types of Provider Incentives In Clinical Prevention, %

29

Besides incentivizing providers to achieve improvements in prevention targets, most of the plans

were also offering providers access to specific tools and resources to assist in the promotion of

clinical preventive services, such as:

• performance reports on preventive care quality measures (91%)

• lists of individual patients requiring specific clinical preventive services based on

claims data (89%)

• patient education materials on clinical preventive services (84%)

• real-time patient data (73%)

• clinical decision-support tools (73%).

C2. Role of new payment and delivery models in prevention

During the interviews, plans consistently emphasized the role of alternative payment and care

delivery models in prevention. All but one interviewed plans observed improvement in the

uptake of clinical preventive services among their members who have been receiving care from

providers participating in patient centered medical homes (PCMHs) and accountable care

organizations (ACOs).

Interviewed plans reported that providers in new payment models typically seek to improve their

performance on prevention measures. However, to achieve such improvements providers need

assistance and support from plans. Consequently, plans typically offer provider support that

typically includes incentives and bonuses, relevant data (HRA, gaps in care data etc.), and

training on how to monitor their patient population.

The only plan that reported not observing any effect of new payment models on the prevention

and wellness measures does not yet offer assistance to their providers. They anticipate that they

will be better able to share information on gaps in care with providers as paper-based records and

communications are replaced with electronic records, which would lead to improvements in

provider performance.

30

While plans routinely incentivize providers to achieve a high level of performance on common

HEDIS measures of immunization rates, cancer screenings, etc. one plan mentioned that

providers are overwhelmed with many quality measures and would like health plans to focus on

the most common measures as part of provider incentive and recognition programs and to align

these measures across different product lines (Medicare, Medicaid, commercial).

C3. Member Interventions

In addition to provider incentives and tools, health plans also target interventions at their

members to increase uptake of clinical preventive services. These interventions consist of

educational materials, preventive services reminders and member incentives aimed at increasing

members’ wellness visits and uptake of recommended preventive services.

Almost all health plans had experience in using member interventions such as reminders to

members for clinical preventive services (98%) and provision of educational materials (98%).

The majority of plans also had experience offering positive incentives to members for receiving

specific clinical preventive services (79%) and 59% of responding plans used value-based

insurance design for preventive services. Member disincentives (financial and non-financial

penalties) were used less frequently: only about a third (34%) of responding plans used financial

or non-financial member penalties for not receiving specific preventive services. Health plans,

however, could apply financial and non-financial penalties to their members who, despite the

absence of cost-sharing, do not receive these recommended services. In our subsequent

interviews with health plans we learned that plans typically do not find penalties useful in

promoting uptake of preventive services but do need to be responsive to employer requests that

such penalties be utilized.

In terms of usefulness among the member-focused approaches, member incentives for receiving

specific clinical preventive services and value-based insurance design (VBID) were reported to

be the most useful approaches for increasing member uptake of clinical preventive services: 49%

of responding plans found incentives to be “very useful” while 39% rated VBID similarly.

31

During the interviews, health plans noted that they do vary their communications with the

members and specific types of incentives that may be provided to improve performance rates.

Most plans use nuanced messaging that targets specific population segments, markets, and

employer groups regarding preventive services.

D. Wellness Programs

In this section, we describe the findings on wellness programs implemented by health plans

among their commercial members. The findings are drawn from our analysis of survey

responses and plan interviews.

D1. Design and Main Components of Wellness Programs

Our analysis of survey data show that health plan wellness programs for the commercially-

insured population include many components which are primarily administered by health plan

staff and vendors. The most common components of wellness programs were:

• targeted interventions to promote wellness identification (88%)

• providing feedback to employers/consumers (86%)

• monitoring and evaluation of programs (81%)

• stratification of risk for illness (77%)

• partnering with providers to promote wellness (53%).

In addition to the common program components listed above, the interviews helped us identify

key aspects that are important in the plans’ overall approach to wellness:

• Understanding the characteristics and needs of the members including age, health risks,

and willingness or readiness to change irrespective of whether these members were in the

large group or individual market

32

• A holistic approach to ensure that all member needs are addressed through personalized

programs that use all available data on members. Health conditions of members may be

so interrelated that it is hard to separate them and still achieve success

• Focus on national targets or guidelines such as those published by the government (HHS,

CDC, etc.)

• Employer input and direction

• High-touch approaches focused on the individual member, as well as considerations of

age-appropriate, individualized needs based interventions that can achieve desired results.

• Data-driven approaches targeting identifiable needs in a plan’s employer groups or

populations

• Costs associated with the wellness intervention and total cost of healthcare

• Customization where appropriate. For example, one smaller plan noted differentiating

itself by customization which occurs through a “hands on” and “boots on the ground”

approach to onsite wellness and which has generated positive feedback from the

employer groups.

In addition to a common set of wellness program components a great majority of health plans

(79%) used a mixed approach by designing and administering some elements of their wellness

programs in-house while relying on the specialized expertise of vendors for other elements.

Only 7% of plans designed and administered their wellness programs exclusively in-house and

another 12% completely outsourced them to vendors.

Health plans drew on a variety of sources in designing their wellness programs, with federal studies

or guidelines, behavioral and/or psychosocial theories, and NCQA wellness and health promotion

accreditation standards used by more than 80% of survey respondents (see Table 7).

33

Table 7. Guidelines, Standards and Studies Used to Design Health Plan Wellness

programs (N=43) *.

Response options Number of plans Share of plans, %

Federal studies or guidelines (e.g. CDC, NIOSH,

NHLBI, WHO, U.S. Department of Agriculture)

36 84

Behavioral and/or psychosocial theories (e.g. Stages

of Change, trans-theoretical model, etc.)

36 84

NCQA wellness and health promotion accreditation

standards

35 81

Condition-specific guidelines (e.g. American

College of Sports Medicine; American Dietetic

Association, American Heart Association, National

Cancer Institute; WELCOA; WebMD)

34 79

Best practices from successful wellness programs of

other health plans or employers

31 72

Peer-reviewed evidence-based studies 29 67

The Health Enhancement Research Organization

(HERO)

26 60

Findings or recommendations from regional

coalitions

15 35

The Guide to Community Preventive Services (The

Community Guide)

10 23

* Note: since plans could choose multiple answers the percentages in the table do not add up to 100%.

D2. Health Plan-Employer Collaboration in Wellness Programs

Our interviews provided additional insights into the health plan-employer interaction in the design

and implementation of wellness programs. All the plans interviewed described a process where

they develop programs in partnership or collaboration with their employer groups. Variations in

the wellness programs are largely dependent on the employer and based on such factors as size,

34

whether the employer is fully-insured or self-funded, the nature of the industry and whether the

employer’s operations lend themselves to such features as on-site wellness programs.

Key aspects of plan-employer interaction role include the following:

• A collaborative process where the areas of focus can be driven by plan suggestions to the

employer or by employer priorities, which often correlate with employer size. Large

employers typically have clear focus areas and more experience with wellness, and

sometimes clinical expertise within the organization. Larger employers will have the scale

for more customized programs while smaller groups will more often have something closer

to the plan’s standard or core program. For large employers, there may be use of integrated

benefits suites that focus on factors that impact absence, disability, and workers’

compensation/disability costs. Smaller, more regional clients, tend to lean more on the

plan’s expertise.

• One plan described their process where employers take an active role in shaping wellness

programs, including through mechanisms like a client advisory committee that provides

advice on priorities. The plan works with employers who experience low compliance on

wellness goals and targets interventions either specific to a population segment or that are

more broadly applicable based on gaps in preventive care. There are also programs

targeted towards HEDIS measures and focusing on risk reduction.

• Another plan noted that there are some employer groups that focus on specific strategies

that are viewed as important. Some of these strategies are linked to characteristics of the

business or the employee population (for example, a transportation company may focus on

specific risks for their drivers, or an athletic goods company may focus on fitness).

• It is unusual for a larger employer to offer a single insurance option to their employees and

will have more than one health insurance plan providing insurance. One multi-state plan

noted that they are very used to building partnerships in prevention and wellness with

employers, their vendors or other health plans. “It is usually a blended environment with

respect to the employer offering other insurance options that we are working in.”

35

• One plan discusses the types of wellness programs they can implement during the proposal

process. Based on employer group interest, program implementation begins immediately.

Although group interest drives program adoption, if a group does not express interest, the

plan uses the group’s data to show potential benefits from prevention and wellness

activities and then educate the employer group about their programs.

D3. Variations in Wellness Programs

During the interviews, some plans indicated little or no variation in the design and

implementation of wellness programs while other plans cited variations driven by members,

employers, population characteristics, and to a limited extent state and local variation due to

regulations that primarily impact multi-state plans.

Member Driven Variations:

Variation for wellness programs occurs in several different ways. Programs are flexible and can

focus on various aspects of wellness while allowing members to select focus areas for

improvements in their wellness from among several choices.

Variations Driven by Employers:

Plans work in partnership with employers; particularly with self-insured clients. Some areas of

focus are driven by plan suggestions to the employer and some are driven by employer priorities.

Plans approach an employer with a standardized program and, based on the drivers of that

employer’s medical cost (based on past claims, e.g., they may see more diabetes based on claims

for an employer and make diabetes prevention a focus) customize the program. One interviewed

plan however, stated that they follow the same strategy with fully-insured groups and self-

insured groups, but self-insured groups can opt out of the plan’s programs because they

sometimes contract with other vendors for wellness services. Differences in what is prioritized

36

or focused on can be driven by the amount of relevant information the plan can glean from the

various metrics they collect from a client.

Key factors in customizing programs are dependent on the employers’ objectives (e.g. reduce

costs, reduce specific risks such as back-injury, diabetes or high blood pressure). As result of

differences in employers’ priorities and specific needs, there is a wider degree of variation in

wellness programs design and implementation among various self-funded accounts than between

self-funded and fully-insured groups. Although program design is based on the needs of the

employer, it usually includes some core components that offered to all groups, such as weight

loss or tobacco cessation.

An employer may have specific needs due to occupational issues or demographics of its work

force or corporate image that they may seek to address. For example, a transportation company

may have health issues specific to truck drivers that need a focus while an athletic goods

company may have an interest in promoting physical activity. To address these unique

employer needs a plan can provide quick reference tools and kits to a trucking company working

on blood pressure control, as well as obesity and fitness. The kits include information on healthy

eating and specific exercises that can be helpful for employees in that specific industry.

Customization can also be driven by the specific objectives an employer seeks to achieve.

Although program success depends on employer support of the model and employee

participation, employers also need to understand which approaches can help achieve their

objectives. For example, if an employer wants to reduce costs then a wellness challenge may not

be able to achieve this objective. Plans mentioned that they advise employers of the best choices

of programs for example – employers may ask to add a “biggest loser” program for weight loss.

The plan will discourage that because there is no evidence base for benefits associated with rapid

weight loss and will steer the conversation to evidence based programs.

There are also differences for worksite versus non-worksite programs: worksite programs can be

very high-touch with in-person face-to-face interaction, while non-worksite programs tend to use

online, telephonic, and community-based outreach. Worksite wellness programs also include on-

site flu shot clinics, lunch and learn sessions, and group wellness coaching as options. The

added services depend on what an employer’s priorities and needs are. Additionally, plans may

37

consider social determinants of health when designing wellness programs. Aside from

customizations that are derived from culture of health and data analysis, variations also arise as

plans match the interventions with health risks.

State by state variation:

State regulations can require adaptation of wellness programs and incentives and are factored

into the wellness program offered to the employer. There is not a lot of state-specific impact on

design of wellness programs though multi-state plans acknowledge that they would prefer more

consistency across state lines due to employers operating in multiple states.

Plans did not report significant program variation by region, but did note that they sometimes

vary programs by region to adjust interventions to the prevalent health risks in the given

population. Plans report mining data to identify hot spots of health risks (e.g. obesity). For

example, in an area where obesity is a big factor they will adjust the programs to target this risk.

D4. Identification and Targeting in Wellness Programs

Health plans used a variety of methods to identify members who may benefit from participation

in their wellness programs (see Table 8), with the most common being patient self-report (such

as participation in health risk assessments), at 95%, biometric screening (81%), and provider

referrals (51%). These statistics suggest that there is a significant potential to improve the

wellness program member identification process by improving provider engagement in wellness.

38

Table 8. How health plans identify members for wellness programs. N=43.

Response options Number of

plans

Share of plans,

%

Patient self-report (e.g. HRA) 41 95

Biometric screening (i.e. weight, lipid profile etc.) 35 81

Provider referrals 22 51

Prospective analysis/predictive modeling 20 47

Retrospective data analysis 17 40

Medical chart reviews 9 21

Other 8 19

* Note: since plans could choose multiple answers the percentages in the table do not add up to 100%.

A sizable minority of health plans also used data analytics to better target members for the

wellness program outreach, such as predictive modeling (47%), retrospective data analysis

(40%), and medical chart review (21%).

Data and analytics are a fundamental component of health plan wellness programs and are used

to understand and support the plan’s population. In our interviews, most of the plans described

using data and analytics as important tools to ensure that the offerings are targeted appropriately

(e.g. greater need for weight control or physical needs, risk for depression), and take into

account the needs of employers/individuals. Plans profile members and, based on risk, share

relevant information on preventive care or wellness related activity – lifestyle related behavior,

stress and weight management, and physical activity. Data were also used to provide the

employer group with information on specific risks identified for their population.

Additional data sources and analytics mentioned by health plans in the interviews included:

o Use of EHRs to record and track vital signs including treating exercise as a vital sign

o Examining risk trajectories to identify the big contributors to overall health risks (e.g.

smoking, etc.) and the links of these risks to chronic conditions.

o Claims stratification for the plan to identify individuals with certain conditions/risks

(e.g. diabetes) and by connecting them with health coaching or disease management

programs

39

In our interviews, several plans also mentioned that decisions about which risks to target are also

driven by requirements from states or by health plan accreditation and HEDIS measures as well

as by guidelines, best practices, and priorities from government, associations, and other health

organizations (NIH, CDC, National Taskforce on Improvement; AHA, American Cancer Society

(ACS), etc.). Plans review all of the major reports, white papers, and guidelines on the topic to

gain insight on best practices. Strategy is influenced by a review of the literature, appropriate

evidence, and best national and international practices. As needed, plans receive external advice,

and always test hypothesis that are published in literature and attempt to adapt them to their

organization, population, and culture.

During the interviews, several plans also noted that they conduct a community health needs

assessment and focus on social determinants of health. Plans use CDC data to benchmark

relative to national data, health risks in a county such as tobacco use, obesity, and risks of

diabetes and heart disease. The CDC data combined with internal claims and HRA data are

used to develop programs to address the specific health risks through building (internal

capacity/capability), buying (acquiring outside help such as web services), or partnering (with

another organization/institution).

D5. Addressing employer-specific health risks

Most of the health plans offer their members a variety of programs targeting multiple health risks

(see Table 9). More than 80% of surveyed plans offered, to their fully-insured members,

programs that targeted tobacco use, stress, cardiovascular risk, low physical activity, prenatal

care, and mental health/substance abuse. Noteworthy, for all of those risks, self-insured members

of plans had a consistently lower level of access thank fully-insured plans (although it still was

well above 50%). As mentioned often in the interviews, this may stem from the fact that

employers vary in how much of a priority they assign to wellness programs and that some of

them choose to have more narrowly focused programs. The exception to this pattern was pre-

diabetes programs: both fully and self-insured members had a similar level of access to them, at

64% and 66%, respectively.

40

Table 9. Members Access to Programs Targeting Specific Risk Factors (N=44) *.

Programs that target:

Yes, our fully-

insured members

have access, %

Yes, our self-

insured

members have

access, %

No, we do not

offer this

program, %

Tobacco use 98 84 0

Stress 86 75 14

Cardiovascular risk (e.g. elevated lipid

levels, hypertension) 84 73 16

Low physical activity 84 73 16

Prenatal care for the eligible

subpopulation 82 70 16

Mental health/ substance abuse 82 66 18

Pre-diabetes 64 66 27

* Note: since plans could choose multiple answers, the percentages in the table do not add up to 100%.

Some employers choose to target specific conditions and ask plans to have special, stepped-up

activities for these health risks: side-effects of being sedentary for an office-type environment,

reducing risks of back injuries and lower back pain for physically active jobs, and smoking

cessation for healthcare, secure, or clean facilities where smoking will adversely impact business

operations.

Finally, member readiness to change plays a role in the activities of plans open to customization:

“There are 36 different risk factors and condition states that will result in members receiving

some type of outreach, which is cross-tabbed with the member’s readiness to change”. Two plans

that participated in the interviews (both operating in a single state) reported that they have a

uniform list of specific conditions to focus on in their prevention and wellness activities: two

conditions for one and 36 conditions for another plan.

41

D6. Member Interventions

Health plans use different interventions to target member health risks and promote wellness. All

or almost all plans used patient self-management of health (100%), patient self-management

tools (98%), and nurse call lines (91%) to promote wellness. In-person coaching and mobile

health vans were used by less than a half of the plans but the plans that did use them regarded

these interventions as very valuable: 78% of plans that had experience in using in-person health

coaching and 63% of plans that had used mobile health vans considered these interventions to be

“very useful” in wellness promotion.

Our interviews revealed that plans do not use a single approach in matching interventions with

specific health risks: some plans offer similarly structured programs for all employers and

conditions, others offer highly customizable programs to employers. It is part of the overall

pattern of interaction of a health plan with employers. Additionally, during our interviews some

plans reported that it is not a specific type of health risk but the member risk level (assigned

based on HRA, biometrics and claims) that determines the level and choice of wellness outreach

and interventions. Members with higher acuity receive intense outreach (e.g., phone outreach and

counseling vs. directing them to a web-site for wellness education). Results from the HRA and

member readiness to change also drive the choice of interventions. Also, wellness staff may start

with the lower-intensity interventions, but the plan can provide higher-intensity services such as

coaching if requested by the member.

Health plans work in conjunction with members based on areas of focus chosen by the member.

They provide support to members and the care team to help with behavior change and ensure that

programs will reach each member wherever he/she is with the recognition that one size does not

fit all. Plans emphasize convenience along ensuring a certain comfort level for members and that

the program meets an individual’s needs. Care management techniques and interventions are

aimed at providing better coordinated care along with facilitating opportunities for members to

improve their overall health and lifestyle.

42

D7. Member Engagement

In addition to active engagement of members in uptake of clinical preventive services, health

plans also adopt strategies to engage members in their wellness. Our survey revealed that more

than 70% of plans use web-based tools, social media and smartphone apps to promote wellness

among their member (see Table 10).

Table 10. Using Technology to Promote Wellness Among Health Plan Members

(N=44) *

Response options Number of plans Share of plans, %

Web-based tools (e.g., portal) 43 98

Social media (Facebook, Twitter) 34 77

Smart phone apps 31 70

Employer-based web portal 29 66

Text messaging 17 39

Other (please specify) 10 23

Currently we do not use technology for this purpose 0 0

* Note: since plans could choose multiple answers, the percentages in the table do not add up to 100%.

Interviewed plans outlined using a wide variety of outreach methods: from traditional (mailings,

phone outreach, provider referrals, one-on-one in-person coaching) to technology-based (email,

web-site, online coaching etc.).

The choice of outreach is determined by the employer’s preferences and member risk level. The

level of risk determines the placement of the member in a specific program.

o “…if the potential participants were identified through an HRA, they may be

immediately enrolled in programs they could benefit from: depending on the

risk level, that could be health management, disease management, or health

coaching.”

o “Those at highest risk may be called, while those at lower risk will get

information sent to them.”

43

Several plans allow their members to choose the preferred method of communication. One plan

cited their efforts to do member messaging through newsletters and their website. They noted

that preferences vary as to how members like to receive information, so they conduct outreach

through multiple channels and focus on member experience with the plan. This plan also uses a

Member Experience Advisory Council to help provide input into program design.

Several plans provided information on how they determine the frequency of the initial outreach

attempts: it depends on the member interest (which is used as a proxy for the readiness to

change), the risk level and the identification method (e.g., provider referrals are treated as the

highest risk level and result in the most outreach activity).

D8. Member Incentives in Wellness Programs

Health plans use a variety of member incentives to promote wellness, with the most common

being merchandise or gift cards (75%), discounted gym or health club membership (68%), cash

payments (41%), lower insurance premium (or higher if penalties) (41%), and recognition

programs for achieving certain goals (41%).

The plans that used member incentives to promote wellness have been tying the incentives to a

wide variety of process and outcome metrics (see Figure 7).

44

In our interviews plans reported that incentives are primarily selected by employers. Large

employers are more interested in using incentives. Health plans assist employers in the incentive

selection process by sharing information on which incentives work, by offering tools that track

program participation, and by offering assistance in tracking participants’ biometrics.

Participation and outcome-based incentives

Three plans reported that most of their incentives are based on program participation, while one

reported that most of the incentives chosen by employers are outcomes-based (others stated that

it varies greatly by employer). One plan shared that employers typically start with participation

incentives and several years later may move to the outcome-based incentives.

Participation-based incentives are commonly offered to members who are identified as being

high-risk for developing specific conditions based on HRA results and biometrics. These

97%

94%

91%

89%

81%

70%

80%

90%

100%

Completion ofpersonal health risk

assessments

Participation inbiometricscreenings

Completion ofspecific programs

Enrollment inspecific programs

Achievement ofspecific health goals

Per

cen

t o

f p

lan

s re

spo

nd

ing

Figure 7. Tying Member Incentives to Specific Goals,%

45

members receive incentives to participate in wellness programs designed to mitigate specific

health risks, such as being overweight or not physically active.

With small groups, incentives tend to be participatory and employees receive incentives and

rewards for completing biometric screenings and HRAs. Outcome-based incentives are

commonly centered on achieving improvements in health outcomes and behavior changes.

Positive and negative incentives

Positive member incentives (“carrots”) are more common than negative (“sticks”), but the

employer makes the choice. One of the plans shared that combining both positive and negative

incentives improves wellness programs effectiveness.

Plans reported that the most effective incentives are those that are benefits-integrated (reduction

in deductibles and premiums), while free merchandise and discounts have limited success.

Role of leadership engagement and regulations on incentives

Plans reported that employer leadership engagement is critical to the success of the program, as

well as providing an environment conducive to wellness (ability to exercise, healthy food

choices, etc.).

One of the plans communicated that regulations affect the effectiveness of some incentive types:

for example, raffle or drawing-based incentives need to be open to all (i.e., those who

participated in the targeted activity and who did not) due to non-discrimination rules. Another

plan noted that regulations affect the offering of outcome-based incentives because plans must

offer reasonable alternatives to comply with federal law.

Finally, one plan reported that they did not see much evidence that incentives lead to positive

clinical outcomes and are still trying to understand what types of incentives are the best to offer.

46

D9. Engaging Providers in Wellness

In addition to working with providers on promoting clinical preventive services, our survey and

interviews showed that health plans are seeking to engage providers in promoting wellness. The

most common methods used by plans are sharing educational materials with providers (60%) and

sharing information on evidence-based wellness approaches (49%) – see Table 11. Other ways to

engage providers were aligned with the shift to value-based care and included wellness-related

financial incentives for providers (35%) and changing the care delivery through provider

participation in patient-centered medical homes (44%).

Table 11. Health Plans’ Strategies to Engage Providers in Wellness Programs (N=43) *

Response options Number of plans Share of plans, %

Sharing educational materials with providers 26 60

Sharing information on evidence-based wellness

approaches 21 49

Participation of physicians in patient-centered

medical homes 19 44

Decision support tools made available to providers 17 40

Via financial incentives 15 35

Other (e.g. sharing results of wellness screenings,

health coaches reaching out to physicians for

members with high medical care utilization etc.)

8 19

Currently, we do not engage providers in wellness 9 21

* Note: since plans could choose multiple answers, the percentages in the table do not add up to 100%.

Our interviews revealed that the role of providers in wellness depends on the nature of the plan-

provider relationship: integrated health plans and providers that are part of the same health

system are much more involved in health plans’ prevention and wellness activities, while other

providers in the plan network typically maintain a low level of involvement in plan wellness

programs.

47

Realizing potential of alternative payment and delivery models in wellness

All the interviewed plans, except one, observed improvement in wellness among members who

have been receiving their care from providers participating in patient centered medical homes

(PCMHs) and accountable care organizations (ACOs).

Plans reported that providers in new payment models typically want to do well and to improve

on wellness and prevention measures, however to achieve such improvements providers need

assistance and support from plans. Wellness-oriented provider support by plans typically

includes offering providers relevant data (HRA, gaps in care data etc.), an easy way to refer to

plan’s wellness programs, and provider training on how to monitor their patient population.

The interviewed plans reported that using new payment arrangements to improve member

wellness was more difficult compared to delivery of clinical preventive services

because wellness activities are typically not conducted directly by providers. Plans reported

focusing wellness efforts on improving provider referrals to plan-administered wellness

programs and the best results have been achieved by plans that were integrated with provider

groups.

One of the plans described the establishment of a program where providers are able to write a

“prescription” for specific wellness activities that is then communicated back to the plan’s care

management team. If the member does not contact the plan within 48 hours, the plan’s care

management team follows up with the member to “fill” the prescription and subsequently help

the member to join and begin the appropriate wellness program. Initial outcomes for this plan

show a significant increase in member engagement in wellness activities due to the advent of

these “wellness prescriptions.”

D10. Wellness Programs Monitoring and Evaluation

The overwhelming majority of commercial health plans (95%) monitor the implementation of

their wellness programs, with member participation (95%) being by far the most commonly

monitored area. Other monitored areas included health risk improvements (71%), member

48

satisfaction (43%), and return on investment (38%). Relatively few plans monitor the return on

investment of their wellness programs due to the complex nature of such programs and relatively

long period required to measure program effectiveness combined with the challenges posed by

lack of a stable cohort of members enrolled in the program (member disenrollment from plan).

Most health plans (77%) also conduct metric-based evaluations of their wellness programs. As a

result, those plans that used specific metrics were typically able to observe positive financial and

clinical outcomes, although often not in all of their programs (see Table 12).

Table 12. Observed Changes in Outcomes in Wellness Programs Evaluations

Response options In all of our

wellness

programs, %

In some of our

wellness

programs, %

In none of our

wellness

programs, %

Reduction in onset of chronic disease across

members (N=22)

23 77 0

Improved workforce productivity (N=22) 23 77 0

Reduction of risk factors for chronic

conditions across members (N=28)

25 71 4

Decrease in healthcare costs (N=26) 19 73 8

In the follow-up interviews with the nine survey participants, plans most commonly defined the

success of their wellness programs by using program participation measures (5 plans) and

clinical outcomes metrics (5 plans), with other success criteria mentioned being reduced

utilization of health services (3 plans), program graduation rates (2 plans), member satisfaction

(2 plans), and ROI (1 plan).

Health plans also evaluate the usefulness of specific interventions implemented in wellness

programs (see Figure 8). While some types of interventions are used by a much larger number of

health plans, all of them are considered to be somewhat or very useful, which suggests that plans

closely monitor the value of their interventions and quickly discontinue those that do not produce

49

results. The only exception to that rule was telehealth, where only 68% of the plans using it

considered this method to be useful in wellness programs.

Types of successful wellness programs

In our interviews, health plans described a variety of wellness programs that they considered

successful with frequently more than one program for the same plan being highlighted. Most

commonly mentioned were programs targeting specific health risks such as obesity (3 plans),

tobacco cessation (3 plans), diabetes (2 plans), and blood pressure control (1 plan).

Other successes focused on improvements in program delivery, such as engaging physicians in

wellness, improving health coaching, organizing on-site screening and on-site coaching, better

analytics around risk identification, and launching a wellness platform that facilitates the data

exchange between the health plan and providers in its network.

91% 93%88% 97%

97%

68%96%

100%0

10

20

30

40

50

Nu

mb

er o

f p

lan

s re

spo

nd

ing

Figure 8: Member-Facing Interventions: How Often Used (number of plans) and How Useful (%)

Found somewhat or very useful

Found not useful

50

Process and clinical measures of program success

Most common measures of wellness program success included clinical outcomes such as the rate

of weight loss or percent of participants who quit smoking. Several plans used high program

engagement rates or a large percentage of program participants achieving clinical improvements

in several areas as program success criterion.

Two health plans reported using satisfaction with programs as measures of program success. One

plan defined program success via improvements in general satisfaction of program participants

(such as improvements in self-reported member’s perception of their health and well-being).

Financial measures of program success

As stated previously, calculation of the return-on-investment (ROI) for the program has been

rarely used by plans to define the success of their wellness programs: it is difficult to calculate

due to account and employee turnover. As a result, many plans use the reduced utilization of

medical services by program participants as a proxy for the ROI analysis.

D11. Challenges in Implementation of Wellness Programs

In our survey, health plans reported that they faced many challenges in implementation of their

wellness programs, with lack of member engagement (86%) and lack of employer commitment

(79%) being the two by far most commonly mentioned obstacles. Lack of member engagement

leads to the low uptake of available wellness services by plan members, while lack of employer

commitment results in plans not being able to offer and maintain wellness programs to employer

accounts.

Also, less than half of plans reported as challenges a lack of provider engagement (49%) and

employee turnover (39%). Our survey respondents reported “other” challenges including vendor

51

changes (mergers and vendor innovation), lack of staffing and financial resources, employee

distrust and the inefficient incentive design.

We categorized the challenges discussed buy health plans during the interviews as follows:

• Employer issues including size and how invested they are in their commitment to

employee wellness;

• Incentives;

• Longer term relationships including stability of the employee population and length of

relationship between the plan and employer;

• Patient/member issues; and

• Provider issues.

Employer Challenges

The lack of employer leadership buy-in and commitment can be a challenge for wellness

programs. If the employer is not fully committed, success can be difficult to achieve. Employees

8679

49

39 37

0

20

40

60

80

100

Lack of memberengagement

Employercommitment

Lack of providerengagement

Employee turnover Other challenges

Per

cen

t o

f p

lan

s re

spo

nd

ing

Figure 9: Challenges in wellness programs implementation, % (N=43).

52

may not be motivated if the leadership is not committed/invested/engaged. Employer leadership

needs to be engaged and not rely solely on the activities of the health plan. Also, if the CEO or

CFO does not personally practice healthy lifestyles, it can undermine the employer’s efforts in

promoting employee wellness.

Employer size can also present a challenge in the design and implementation of wellness

programs. Larger employers are more likely to have very specialized wellness staff with

experience in wellness while mid-sized employers might use someone in human resources, who

may not have a deep expertise in wellness, which can be a challenge to successful

implementation.

Some of the plans we interviewed also mentioned the importance of employers having the

“right” expectations regarding wellness and not an unreasonable focus on ROI. Also, if an

employer designs a program for an employee that is not a good fit or is too complicated, that

design will also be a barrier to success.

Employee turnover or retention factors into the success of wellness programs. The biggest and

most committed programs tend to be accounts that remain long-term with a plan; some accounts

for a decade or more. Larger employers tend to use future incentives and will typically have a

cohort of members who participate over a longer period, which is important to realizing benefits.

More stable groups have the greatest participation in wellness programs and many employers

invest in the health and wellness programs and to promote employee retention.

Challenges with Implementation of Incentives

Plans stated that the availability of funding for wellness incentives can be a challenge. Some

employer groups report that they cannot offer a significant incentive due to lack of sufficient

funding for incentives and therefore will choose to not implement a wellness program.

Sometimes while employers are aware of the need to implement wellness programs, they may

choose not to because of other competing priorities.

53

Member Engagement Challenges

Trust is one of the biggest challenges to improving member engagement, there may be employee

distrust of the reasons for wellness program implementation. Employees may have concerns

about the collection of biometrics and health risk data and whether these data will be used to

raise rates or lead to other types of employer bias. Plans emphasized the need to be proactive

and address this distrust and provide assurances to employees about the benefits of wellness

programs to employees.

Plans also reported challenges with identifying priority candidates for wellness programs

because of the lack of reliable data. For example, while codes for identifying smokers or obese

members exist, lack of consistent use of these codes makes identification of these members a

challenge.

Provider Challenges

Based on their experience, health plans report that the most effective approach to engage

members is through physician outreach. However, lack of provider engagement in wellness is a

challenge. Additionally, physicians and practices can be challenged due to competing priorities

and requirements. Provider engagement is also challenged by the fact that not everyone is on the

same documentation system. Plans reported that incentivizing providers can be challenging in

some instances. For example, if individual providers within a practice or group get paid on a

relative value unit (RVU) basis they will be less likely to be impacted by quality bonuses and

therefore less likely to engage in prevention and wellness.

Other Challenges

Wellness is a part of everything and it is hard to separate it to generate a causal effect/value. It is

not always easily quantifiable and confounding factors make it difficult to accurately identify

causes and measure the impact of specific interventions.

54

Plans noted that the ability to scale programs in a consistent manner is a major challenge. For

example, one self-funded employer asked a plan to implement the Diabetes Prevention Program

(NDPP) working with the YMCA. Although the plan and employer have been encouraging

members to join the program, fewer than 20% of members participate in the program after

multiple attempts at outreach.

E. Health Plans’ Relationship with Other Health Care Stakeholders and Public Health

Entities: Community Partnerships in Prevention and Wellness

Most health plans not only closely with providers in their implementation of prevention and

wellness programs but also collaborated with various community organizations, essentially

addressing prevention and wellness via the population-based approach (only 5% of the plans

reported not providing any financial or in-kind assistance to community organizations for their

prevention and wellness activities).

The most common areas where health plans promoted prevention and wellness in communities

by providing financial resources or in-kind assistance to community organizations and

partnerships were promotion of community health fairs/screenings (84%), reduction of risk for

chronic conditions (82%), promotion of fitness/physical activities (79%), and prevention of

overweight/obesity (75%).

Less common, but still done by most of commercial plans, were provision of financing or in-kind

assistance to community organizations focused on promotion of prenatal care (64%), support for

mental health and depression services (61%), and for child and adolescent health and safety

(52%). The only area where the level of community involvement for plans was low was

environmental health (32%). Our survey did not asked questions about the specific amount of

financial or in-kind assistance to community organizations in prevention and wellness.

The wide range of prevention and wellness programs where commercial health plans

collaborated with community organizations was matched by an equally wide variety of their

community organization partners (see Table 13). While the great majority of the plans reported

55

working with non-profit community support groups (86%) and disease-based organizations

(74%), the health plans’ partners included schools, business coalitions, foundations, faith-based

organizations, local health agencies and community health centers.

Table 13. Types of Community Organizations to Whom Commercial Health Plans

Provide Financial or In-Kind Assistance in Area of Prevention and Wellness

(N=43)*.

Response options Number of plans Share of plans, %

Non-profit community support groups (e.g. YMCA,

local racial/ethnic support communities and

associations) 36 84

Disease-based organizations (e.g. American Cancer

Society Cancer Action Network) 31 72

Schools or school systems (e.g. high schools,

universities, etc.) 27 63

Foundations 25 58

Business coalitions (e.g. National Business Group

on Health) 21 49

Health departments (e.g. state, local, etc.) 21 49

Churches and religious groups 18 42

Federally qualified health centers (FQHC) 18 42

Free medical clinics 16 37

Other (please specify) 9 21

* Note: since plans could choose multiple answers, the percentages in the table do not add up to 100%.

56

F. Lessons Learned and Best Practices in Implementing Health Plans’ Prevention and

Wellness Programs

We categorized health plan insights into lessons learned and best practices in the following areas:

F1. Incentives

Regarding provider incentives, health plans can choose two alternatives approaches: rewarding

improvement or attainment/achievement. Both approaches have support in the literature and best

practices, and the choice of a specific approach can be influenced by employer requests, the

nature of the plan-provider relationship, details of the program design etc. Currently, more plans

seem to focus on improvement and fewer on attainment.

Incentives can be used to ensure upfront participation and engagement. It is important to

combine incentives with a well-designed program that uses established successful methods.

Ensuring the appropriate program design is essential along with the right set of incentives

because the incentives drive participation regardless of the program merits. Interviewed plans

mentioned that in their experience higher incentives result in higher rates of participation.

However, negative incentives, in some plans’ experience, resulted in the highest participation

rate overall.

The interviewed plans believed that wellness programs needed to combine a “carrot and stick”

approach when implementing wellness incentives. Based on their experience they felt

participation would be improved not only if participants were offered positive incentives, but

non-participants were subject to disincentives. They also believed that outcomes-based

programs can result in more rapid achievement of program objectives such as a decrease in blood

pressure, or significant and sustained weight loss.

One of the plans we interviewed noted that member incentives coupled with the ability to track

member progress in reaching health goals is the cornerstone of their program, but it is not

centered on incentivizing the enrollee alone. Many of their incentive programs also involve

57

spousal participation, as plans view this approach to be a means for engaging entire families

instead of only the employee/primary member.

F2. Engaging Members and Building Interpersonal Connections

At a member level, plans felt that the focus should be on total health that includes physical, and

emotional elements. The concept of whole health needs to be tied to multiple types of

interventions that are non-traditional and go beyond health coaching.

Plans reported that a method with significant potential to improve wellness programs involves

the science of behavior change and engagement along with better ways of supporting and

maintaining behavior change.

Finally, plans viewed a human touch as fundamental to the success of wellness programs and

that it was important to not abandon this approach especially with the advent of scalable

technology. One of the plans stressed that in their experience, a key component in achieving

high levels of participation is face-to-face health promotion coaching sessions. This is the

cornerstone of their wellness programs. The added level of accountability stemming from the

face-to-face interaction helps program participants to continue to work toward their health and

wellness goals.

Plans also agreed that in wellness, one size does not fit all. Health plans need to know the

customer to design and implement a successful wellness program. It is important to meet the

individual where they are and provide a tailored solution for their unique situation. This type of a

tailored approach includes engaging members in ways they want to be engaged.

F3. Engaging Providers

Physician engagement was felt to be critical to member engagement. Plans reported that

members tend to trust and follow their physician’s advice and therefore physician engagement in

wellness was important to the success of the program.

58

F4. Using Technology in Wellness

In the interviews, plan representatives broadly agreed that technology (such as mobile medical

applications and telemedicine) will be another major driver of change and important to the

success of wellness programs. Increasingly, expansion of data and the integration of data from

devices and applications including self-reported information (such as physical activity, weight,

and food consumption data into integrated personal health platforms) are creating a connected

care experience for the member. Another promising development, in the eyes of health plans, is

the potential of using a wellness portal to reach as many members as possible, offer incentives,

promote community involvement, and meet members where they are.

Finally, integration of consumer engagement tools in the HRA allows wellness managers to

better understand where the patient fits in the system and guide outreach strategy.

F5. Other Factors That Contribute to Success of Wellness Programs

The plans we interviewed reported that, in their experience, the following factors also contribute

to the success of wellness programs:

• Length of time horizon – Plans stressed the importance of implementing wellness

programs over a longer time horizon, because it is important to make the case for these

programs from a business perspective and the calculation of a return on investment (ROI)

takes time.

• Integration of wellness with disease management programs - One plan reported that its

disease management and wellness programs were intentionally built under the same

umbrella so there is a clear collaboration and not duplication of efforts.

• Program administration - two plans mentioned that the success of their wellness programs

stemmed from bringing the program in-house or changing a program vendor, which

highlights the importance of plan-vendor relationships in wellness activities.

• Leadership buy-in - Another important component to success mentioned by several plans

is the leadership buy-in from employers and provider organizations.

59

VI. Conclusion

Wellness programs are an important component of health plans’ efforts to improve the

well-being of their members, reduce overall costs of healthcare, and may serve as means

of differentiating them in competitive markets while improving customer satisfaction.

Almost all health plans surveyed (96%) have established programs promoting prevention

and wellness among their members. A majority of the plans surveyed conduct metrics-

based evaluations of their programs, with reduction of risk factors for chronic conditions

and decrease in healthcare costs being the most common outcomes. Multiple challenges

to the efficiency and effectiveness of prevention and wellness programs remain and health

plans address them by engaging providers in wellness via new payment and delivery

models and increasing member engagement in wellness through incentives and

community partnerships. The programs may not always be available to all members

depending upon the type of coverage they have and what level of program has been

purchased.

Employers play an essential role in implementation and determining the ultimate success

of wellness programs. The financial support, choice of programs, as well as the culture

and organizational structure of the employer are all critical factors in determining whether

to implement a program as well as how likely it will be to succeed.

Member engagement and their readiness to change are important factors in the successful

outcomes of wellness programs. Identifying key motivating factors including the right

combination of incentives and making the program accessible and satisfying to the

individual are all important to this process.

Healthcare providers can play a significant role in getting their patients to participate as

evidenced by programs that rely on provider referrals and “prescriptions” to participate.

However, engaging providers in the process is a challenge for most plans that are not in

an integrated health system.

60

Data from the health plans, individuals, and employers, along with public health data and

research are essential to identifying how to focus programs for maximum benefit.

Increased availability and enhanced analysis of data will continue to help improve the

effectiveness of programs and demonstrate the value or return on investment (ROI). This

will help with addressing the persistent questions of more specifically identifying those

individuals at greatest risk for certain conditions or behaviors and who will respond best

to which specific interventions or programs.

In turn, this will help expand the potential reach and benefit of wellness interventions to

delay or prevent the onset of a broader spectrum of medical conditions and improve

public health overall.

61

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Whitmer RW. Evaluation of a best-practice worksite wellness program in a small-

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2011 Mar-Apr;25(4):272-80.

79. Thorndike AN. Workplace Interventions to Reduce Obesity and Cardiometabolic Risk.

Curr Cardiovasc Risk Rep. 2011 Feb;5(1):79-85.

80. Hochart C, Lang M. Impact of a comprehensive worksite wellness program on health

risk, utilization, and health care costs. Popul Health Manag. 2011 Jun;14(3):111-6.

81. Graham AL, Cha S, Papandonatos GD, Cobb NK, Mushro A, Fang Y, Niaura RS,

Abrams DB. Improving adherence to web-based cessation programs: a randomized

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physicians' smoking cessation counseling techniques to motivational interviewing. J

Addict Med. 2013 Mar-Apr;7(2):139-42.

83. Fishman PA. Impact of Broadened Coverage of Smoking Cessation Treatments on

Cardiovascular Disease. Curr Cardiovasc Risk Rep. 2012 Dec 1;6(6):542-548

84. Bock BC, Heron KE, Jennings EG, Magee JC, Morrow KM. User preferences for a text

message-based smoking cessation intervention. Health Educ Behav. 2013 Apr;40(2):152-

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85. McMenamin SB, Halpin HA, Ganiats TG. Medicaid coverage of tobacco-dependence

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Oct;43(4):e27-9.

86. Veeranki SP, Mamudu HM, He Y. Tobacco use and impact of tobacco-free policy on

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87. Quintiliani L, Stoddard A, Lederman R, Harden E, Wallace L, Sorensen G.

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treatments: the Arkansas experience. Am J Prev Med. 2012 Jun;42(6):588-95.

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LA, Estabrooks PA. Who participates in internet-based worksite weight loss programs?

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McLellan RK, Mueller KL, Roberts MA, Yarborough CM, Konicki DL, Larson PW.

67

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workforce. J Occup Environ Med. 2011 Jun;53(6):695-702

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MD, Lawrence S. Brown, MD, Alan Bostrom, PhD, Douglas Ziedonis, MD, and Mable

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Year Am J Public Health. 2012 May;102(5):e17-25.

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Zammarelli L, Levy M, Kolodziej M, Brigham G. Addressing Tobacco Through

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Reduction in Pregnancy Treatment (SCRIPT) methods in Medicaid-supported prenatal

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Haddock K. A content analysis of tobacco control policy in the US Department of

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seniors. Popul Health Manag. 2011 Feb;14 Suppl 1:S45-50.

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Richards J, Bush T, Swan GE. Utilization of Services in a Randomized Trial Testing

Phone- and Web-Based Interventions for Smoking Cessation Nicotine Tob Res. 2011

May;13(5):319-2.

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Keithly L. A longitudinal study of medicaid coverage for tobacco dependence treatments

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68

Appendix B.

Health Plan Prevention and Wellness Program Survey: Data Tables

Form Approved

OMB No. 0920-1079

Exp. Date 8/31/2016

Public reporting burden of this collection of information is estimated to an average of 30 minutes per

response, including the time for reviewing instructions, searching existing data sources, gathering and

maintaining the data needed, and completing and reviewing the collection of information. An agency

may not conduct or sponsor, and a person is not required to respond to a collection of information unless

it displays a currently valid OMB control number. Send comments regarding this burden estimate or any

other aspect of this collection of information, including suggestions for reducing this burden to

CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia

30333, ATTN: PRA, OMB No. 0920-1079

Overview

Thank you for your participation in the Health Plan Prevention and Wellness Program Survey.

America’s Health Insurance Plans (AHIP), in collaboration with the Centers for Disease Control

and Prevention (CDC), is conducting this survey to examine approaches to promote clinical

preventive services and wellness in the commercially insured population. This survey is

organized into the following five sections:

Section I. Health Plan Characteristics

Section II. Overall Approaches to Prevention and Wellness

Section III. Clinical Preventive Services

Section IV. Wellness Programs

Section V. Community Partnerships in Prevention and Wellness

Scope

Please answer all the survey questions based on the prevention and wellness programs you offer

in the COMMERCIAL MARKET for both fully insured and self-insured products. Prevention

and wellness programs aimed at Medicaid and Medicare Advantage beneficiaries are outside the

scope of this survey. Where feasible, please respond based on the most commonly implemented

prevention and wellness approaches.

Definitions

Prevention Program

69

For the purpose of this survey, prevention activities refer to the delivery and promotion of

clinical preventive services that help protect against disease or reduce the likelihood of disease,

disability, and premature death.

Wellness Program

A wellness program refers to structured approaches such as tools, rewards, and/or interventions

intended to improve and promote health and fitness. For example, rewards and interventions to

reduce risk for cardiovascular disease are typically included in a wellness program. Disease

management programs that aim to help individuals manage or control existing diseases or

conditions are outside the scope of this survey and should not be included in your responses.

Instructions / Tips

Please note that questions may require information from other staff members or other

departments within your organization. We recommend that you review the survey questionnaire

in the Word format first and, if needed, collect this information prior to submitting your answers

via the online web link.

We estimate it will take approximately 30 minutes to submit your responses.

Please answer the survey questions on behalf of your organization including all of your

subsidiary plans. If you would like to submit separate responses for your subsidiaries, please

forward the survey link to appropriate staff and they will be able to submit a separate survey

response.

Section I. Health Plan Characteristics

1. What is the name of your health plan?

N/A

2. What is your health plan’s total Commercial (individual and group market) enrollment as

of January 1, 2015? N=45.

Group by size Number of plans Total enrollment, million

5,000,000+ enrollees 5 87,437,484

1,000,000 - 4,999,999 enrollees 13 30,632,921

250,000 - 999,999 enrollees 13 6,289,380

Less than 250,000 enrollees 14 1,228,110

Total 45 125,587,895

70

3. Please estimate what percent of your commercial members are enrolled in grandfathered

plans4. (Note: Please do not include transitional plans in your estimate.) N=39.

Total

Minimum, % 0

Maximum, % 58

Mean, % 8.9

Total enrollment in grandfathered plans

(rounded to the nearest thousand) 6,394,000

4. What commercial markets does your health plan service? (Please select all that apply).

N=45.

Response options Number of plans Share of plans, %

Fully insured individual market 41 91.1

Fully insured large group market (100+ employees) 43 95.6

Fully insured small group market (< 100 employees) 44 97.8

Self-insured (ERISA) 38 84.4

4 Grandfathered plans are group health plans or group/individual health insurance coverage that existed on March 23,

2010, which do not meet all the requirements of the Affordable Care Act.

71

Section II. Prevention and Wellness

5. Please rank the objectives of your prevention and wellness programs. N=45

Objectives of your Prevention

and Wellness programs:

Primary

Objective,

%

Secondary

Objective,

%

This is not an

objective specific

to our prevention

and wellness

programs, %

Not

applicable

(N/A), %

Promote health in covered

population 95.6 2.2 0 2.2

Prevent onset of chronic disease 73.3 17.8 4.4 4.4

Reduce or mitigate health care

costs 55.6 37.8 4.4 2.2

Improve workforce productivity 33.3 62.2 2.2 2.2

Improve overall quality of care 60.0 28.9 8.9 2.2

Other objective(s) (please specify) 11.1 11.1 0 77.8

72

Section III – Clinical Preventive Services

6. In your experience, how useful are the following provider tools/resources at promoting

clinical preventive services? N=45.

Note: the percentage values for the responses that describe usefulness of approaches have been

calculated only on data from respondents who had experience with the listed approaches.

Tools & Resources Your Health Plan

Makes Available to Providers

We haven’t

implemented

these

approaches,

%

We have implemented these

approaches

Very

useful,

%

Somewhat

useful, %

Not

useful,

%

Don’t

know,

%

Share with providers real-time patient data 26.7 69.7 24.2 3.0 3.0

Make available to providers clinical

decision-support tools 26.7 24.2 60.6 9.1 6.1

Provide physicians with lists of individual

patients requiring specific clinical

preventive services based on claims data

11.1 65.0 35.0 0 0

Share performance reports with providers

on preventive care quality measures 8.9 75.6 24.4 0 0

Provide physicians with patient education

materials on clinical preventive services 15.6 13.2 63.2 15.8 7.9

Other (Please specify. If not applicable,

please select the “We have not

implemented these approaches” option for

this row.)

86.7 83.3 16.7 0 0

7. What types of provider incentives does your health plan currently use to promote

clinical preventive services? (Please check all that apply), N=45.

Response options Number of

plans

Share of plans,

%

New payment models (excluding pay-for-performance) with a focus

on primary care (e.g., shared savings/shared risk models, bundled

payments, global payment) 35 77.8

Pay-for-performance (P4P) incentives for meeting specific targets on

preventive measures (e.g. HEDIS measures) 35 77.8

Other (please specify) 11 24.4

Our health plan does not use provider incentives. 4 8.9

73

8. Are provider incentives currently tied to achievement of performance targets in specific

areas? (Please check all that apply), N=41.

Note: the percentage values in the table below have been calculated only on data from

respondents who currently use provider incentives to promote clinical preventive services.

Response options Number of plans Share of plans, %

Cancer screenings 29 70.7

Immunizations 23 56.1

Tobacco cessation 8 19.5

Well visits 22 53.7

BMI assessment 16 39.0

Weight reduction 2 4.9

Other (please specify) 18 43.9

No, incentives are not currently tied to performance targets 5 12.2

74

9. In your experience, what types of provider incentives are useful for promoting clinical

preventive services? N=41.

Note: the percentage values for the responses that describe usefulness of approaches have been

calculated only on data from respondents who had experience with the listed approaches.

Types of provider incentives

We haven’t

implemented

these

approaches,

%

We have implemented these approaches

Very

useful,

%

Somewhat

useful, %

Not

useful,

%

Don’t

know,

%

Risk-adjusted PMPM 43.9 43.5 30.4 4.3 21.7

Care Management Fee 22.0 25.0 46.9 9.4 18.8

Pay-for-performance incentives 2.4 42.5 40.0 2.5 15.0

Shared savings (upside) 9.8 48.6 32.4 2.7 16.2

Shared risk (downside) 36.6 42.3 26.9 7.7 23.1

Partial capitation 46.3 18.2 45.5 9.1 27.3

Recognition programs or awards 39.0 16.0 44.0 20.0 20.0

Other (Please specify. If not applicable,

please select the “We haven’t

implemented these approaches” option

for this row.)

85.4 66.7 0 16.7 16.7

75

10. In your experience, which approaches are useful for increasing uptake in clinical

preventive services? N=44.

Note: the percentage values for the responses that describe usefulness of approaches have been

calculated only on data from respondents who had experience with the listed approaches.

Approaches

We haven’t

implemented

these

approaches,

%

We have implemented these approaches

Very

useful,

%

Somewhat

useful, %

Not

useful, %

Don’t

know, %

Reminders provided to

members for clinical preventive

services

2.3 30.2 69.8 0 0

Member incentives (positive)

for receiving specific clinical

preventive services (i.e.

financial or non-financial

rewards)

20.5 48.6 48.6 0 2.9

Member disincentives for

receiving specific clinical

preventive services (i.e.

financial or non-financial

penalties)

65.9 26.7 20.0 26.7 26.7

Value-based insurance design

for preventive services5 40.9 38.5 42.3 11.5 7.7

Provision of educational

material 2.3 4.7 69.8 16.3 9.3

Other (Please specify. If not

applicable, please select the

“We haven’t implemented these

approaches” option for this

row.)

84.1 42.9 42.9 0 14.3

5 Value-Based Insurance Design (V-BID) is built on the principle of lowering or removing financial barriers to

essential, high-value clinical services for members. V-BID aligns patients’ out-of-pocket costs, such as coinsurance,

with the value of services.

76

Section IV. Wellness Programs

11. What are key components of wellness programs offered directly to your members?

(Please check all that apply). N=43.

Response options Number of

plans

Share of

plans, %

Identification and stratification of risk for illness 33 76.7

Targeted interventions to promote wellness 38 88.4

Monitoring and evaluation of programs 35 81.4

Providing feedback to employers/consumers 37 86.0

Partnering with providers to promote wellness 23 53.5

Other (please specify) 13 27.9

12. What guidelines, standards or studies does your health plan use in designing your

wellness programs? (Please select all that apply). N=43.

Response options Number of plans Share of plans,

%

The Guide to Community Preventive Services (The Community

Guide) 10 23.3

The Health Enhancement Research Organization (HERO) 26 60.5

NCQA wellness and health promotion accreditation standards 35 81.4

Best practices from successful wellness programs of other health

plans or employers 31 72.1

Findings or recommendations from regional coalitions 15 34.9

Peer-reviewed evidence-based studies 29 67.4

Behavioral and/or psychosocial theories (e.g. Stages of Change,

trans-theoretical model, etc.) 36 83.7

Condition-specific guidelines (e.g. American College of Sports

Medicine; American Dietetic Association, American Heart

Association, National Cancer Institute; WELCOA; WebMD)

34 79.1

Federal studies or guidelines (e.g. CDC, NIOSH, NHLBI, WHO,

U.S. Department of Agriculture) 36 83.7

Other (please specify) 9 20.9

77

13. How does your health plan administer your wellness programs? N=43

Response options Number of

plans

Share of plans,

%

Design and administer programs in-house 3 7.0

Contract with a vendor to design and administer programs 5 11.6

Both in-house and outside vendor 34 79.1

Don’t know (explain) 1 2.3

14. How does your health plan identify members who may benefit from wellness programs?

(Please check all that apply). N=43.

Response options Number of

plans

Share of plans,

%

Medical chart reviews 9 20.9

Patient self-report (e.g. HRA) 41 95.3

Prospective analysis/predictive modeling 20 46.5

Provider referrals 22 51.2

Retrospective data analysis 17 39.5

Biometric screening (i.e. weight, lipid profile etc.) 35 81.4

Other (please specify) 8 18.6

78

15. Do your members have access to programs that are designed to assist them in minimizing

specific risk factors (Please check all that apply)? N=44.

Programs that target:

Yes, our fully-

insured members

have access, %

Yes, our self-

insured

members have

access, %

No, we do not

offer this

program, %

Cardiovascular risk (e.g. elevated lipid

levels, hypertension) 84.1 72.7 15.9

Mental health/ substance abuse 81.8 65.9 18.2

Pre-diabetes 63.6 65.9 27.3

Prenatal care for the eligible

subpopulation 81.8 70.5 15.9

Stress 86.4 75.0 13.6

Tobacco use 97.7 84.1 0

Low physical activity 84.1 72.7 15.9

79

16. What intervention methods does your health plan use to target risk factors and promote

member wellness? N=44.

Intervention Methods

We offer to all

our members

regardless of

their risk level

for disease, %

We offer only to

members who

are at high risk

for disease, %

We do not offer

this intervention

method, %

Digital coaching6 70.5 2.3 27.3

Educational material for patient self-

management of health 93.2 6.8 0

In-person health coaching 36.4 9.1 54.5

Mobile health vans 11.4 2.3 86.4

Nurse call lines 90.9 0 9.1

Patient self-management tools (e.g., calorie

counters) 95.5 2.3 2.3

Remote outbound telephonic coaching 47.7 27.3 25.0

Telehealth7 52.3 0 47.7

Other intervention method(s) (Please

specify. If not applicable, please select the

“We do not offer this intervention method”

for this row.)

20.5 0 79.5

6 By digital coaching we refer to software-based (e.g. website, mobile apps etc.) personalized wellness training that

seeks to facilitate member behavior change and typically includes health assessment, establishment of wellness goals

and tracking of participant's progress.

7 HRSA defines telehealth as the use of electronic information and telecommunications technologies to support long-

distance clinical health care, patient and professional health-related education, public health and health administration.

Technologies include videoconferencing, the internet, store-and-forward imaging, streaming media, and terrestrial and

wireless communications.

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17. In your experience which member-facing wellness interventions have been useful at

promoting wellness? N=44.

Note: the percentage values for the responses that describe usefulness of approaches have been

calculated only on data from respondents who had experience with the listed approaches.

Member-facing wellness

interventions

We haven’t

implemented

these

approaches, %

We have implemented these approaches

Very

useful, %

Somewhat

useful, %

Not

useful, %

Don’t

know,

%

Digital coaching 27.3 18.8 78.1 0 3.1

Educational material for patient

self-management of health 0 11.4 79.5 4.5 4.5

In-person health coaching 47.7 78.3 17.4 0 4.3

Mobile health vans 81.8 62.5 37.5 0 0

Nurse call lines 9.1 35.0 52.5 7.5 5.0

Patient self-management tools

(e.g., calorie counters) 2.3 20.9 72.1 2.3 4.7

Remote outbound telephonic

coaching 15.9 45.9 51.4 2.7 0

Telehealth5 43.2 24.0 44.0 0 32.0

Other (Please specify. If not

applicable, please select the “We

haven’t implemented these

approaches” option for this row.)

79.5 66.7 33.3 0 0

18. What types of technology does your health plan use to promote wellness among your

members? (Please check all that apply). N=44.

Response options Number of plans Share of plans, %

Smart phone apps 31 70.5

Social media (Facebook, Twitter) 34 77.3

Text messaging 17 38.6

Web-based tools (e.g., portal) 43 97.7

Employer-based web portal 29 65.9

Other (please specify) 10 22.7

Currently we do not use technology for this purpose 0 0

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19. What kinds of member incentives are offered to promote member wellness? (Please

check all that apply). N=44.

Response options Number of plans Share of plans, %

Merchandise or gift cards 33 75.0

Discounted gym or health club membership 30 68.2

Discounts for buying healthful foods 12 27.3

Cash payments 18 40.9

Lower insurance premium (or higher if penalties) 18 40.9

Recognition program for achieving certain goals 18 40.9

Other (please specify) 17 38.6

Currently, we do not offer member incentives 2 4.5

20. If member incentives are part of your program, to what activities are they tied? N=42.

Incentives Incentives

can be tied

to, %

Incentives

can NOT be

tied to, %

Not

Applicable

(N/A), %

Completion of personal health risk assessments 85.4 2.4 12.2

Participation in biometric screenings 76.2 4.8 19.0

Enrollment in specific programs 71.4 7.1 21.4

Completion of specific programs 76.2 9.3 14.3

Achievement of specific health goals 61.9 14.3 23.8

Other activities/outcome(s) (please specify) 21.4 0 78.6

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21. How does your health plan engage providers in wellness programs? (Please select all that

apply). N=43.

Response options Number of

plans

Share of plans,

%

Participation of physicians in patient-centered medical homes 19 44.2

Via financial incentives 15 34.9

Sharing educational materials with providers 26 60.5

Sharing information on evidence-based wellness approaches 21 48.8

Decision support tools made available to providers 17 39.5

Other (please specify) 8 18.6

Currently, we do not engage providers in wellness 9 20.9

22. What areas of your health plan wellness programs do you monitor? N=42.

Response options Number of plans Share of plans, %

Health risk improvements 30 71.4

Return on investment (ROI) 16 38.1

Member participation 40 95.2

Member satisfaction 18 42.9

Other (please specify) 9 21.4

Currently, we do not monitor wellness programs 2 4.8

23. Does your wellness program conduct evaluations using specific metrics? N=43.

Response options Number of plans Share of plans, %

Yes 33 76.7

No 10 23.3

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24. In evaluations of your wellness programs, what changes to outcomes have you observed?

N=33.

Outcomes

In all of

our

wellness

programs,

%

In some of

our

wellness

programs,

%

In none of

our

wellness

programs,

%

We do not

measure,

%

Decrease in healthcare costs 15.2 57.6 6.1 21.2

Reduction in onset of chronic disease

across members 15.2 51.5 0 33.3

Reduction of risk factors for chronic

conditions across members 21.2 60.6 3.0 15.2

Improved workforce productivity 15.2 51.5 0 33.3

Other (Please specify. If not applicable,

please select the “We do not measure”

option for this row 9.1 6.1 0 84.8

25. What challenges has your health plan encountered in implementing wellness programs

(Please select all that apply)? N=43.

Response options Number of plans Share of plans, %

Employee turnover 17 39.5

Employer commitment 34 79.1

Lack of provider engagement 21 48.8

Lack of member engagement 37 86.0

Other challenges (Please describe) 17 37.2

26. Please describe innovative prevention and wellness programs you have implemented in

the past 1-2 years. Please include any results, if available. (Data not shown)

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Section V. Community Partnerships in Prevention and Wellness

Please respond to question(s) in Section V based on your health plan activities. When responding

to this section, please do NOT include activities undertaken by your Foundation (if applicable).

27. Do you invest resources in community programs or participate in community

partnerships? (Please select all that apply). N=44.

Area

We invest

financial

resources in

community

programs, %

We provide in-

kind assistance to

community

partnerships, %

No, we do not

provide financial

or in-kind

assistance, %

Prevention of overweight/obesity

(child and adult) 47.7 50.0 25.0

Promotion of community health

fairs/screenings (e.g.

immunizations)

54.5 54.5 15.9

Promotion of fitness/physical

activities (e.g. fitness trails) 56.8 43.2 20.5

Promotion of prenatal care 40.9 38.6 36.4

Reduction of risk for chronic

conditions (e.g. cardiovascular

disease, diabetes, metabolic

syndrome)

56.8 50.0 18.2

Support for mental

health/depression services

(promote awareness, suicide

prevention, support, etc.)

40.9 36.4 38.6

Child and adolescent health and

safety (e.g. bullying, teen

pregnancy)

27.3 36.4 47.7

Environmental health 20.5 22.7 68.2

Other (Please specify. If not

applicable, please select the “No,

we do not provide financial or in-

kind assistance” option)

18.2 13.6 79.6

85

28. Please indicate the types of community organizations to whom your health plan provides

financial or in-kind assistance. (Please select all that apply). N=43.

Response options Number of plans Share of plans,

%

Churches and religious groups 18 41.9

Schools or school systems (e.g. high schools, universities, etc.) 27 62.8

Health departments (e.g. state, local, etc.) 21 48.8

Foundations 25 58.1

Business coalitions (e.g. National Business Group on Health) 21 48.8

Non-profit community support groups (e.g. YMCA, local

racial/ethnic support communities and associations) 36 83.7

Federally qualified health centers (FQHC) 18 41.9

Free medical clinics 16 37.2

Disease-based organizations (e.g. American Cancer Society

Cancer Action Network) 31 72.1

Other (please specify) 9 20.9

86

Appendix C.

Interview Guide

Interview Questions

We are conducting this interview as a follow up to the survey responses you previously provided. AHIP is

reaching out to select plans that responded to the survey to conduct interviews to learn more details about

your wellness and prevention programs. Consistent with what we communicated at the time we sent you

the survey, AHIP will be submitting a report and two issue briefs to CDC based on the results of the survey

and interviews and will provide national benchmarking data to survey respondents, based on the survey

results. AHIP also plans to submit a manuscript to a peer-reviewed journal.

Your participation in this discussion is completely voluntary. Your individual responses to the interview

questions will be treated by us as confidential. In the reports, issue briefs, benchmarking data, and

manuscript that will result from the survey and/or interviews, we will not specifically identify any

information, whether obtained by survey or interview, as coming from your plan unless agreed to by your

plan.

Scope

Please answer all the interview questions based on the prevention and wellness programs you offer

in the COMMERCIAL MARKET for both fully insured and self-insured products. Prevention

and wellness programs aimed at Medicaid and Medicare Advantage beneficiaries are outside the

scope of this interview. Where feasible, please respond based on the most commonly implemented

prevention and wellness approaches.

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Definitions

Prevention Program

For the purpose of this interview, prevention activities refer to the delivery and promotion of

clinical preventive services that help protect against disease or reduce the likelihood of disease,

disability, and premature death.

Wellness Program

A wellness program refers to structured approaches such as tools, rewards, and/or interventions

intended to improve and promote health and fitness. For example, rewards and interventions to

reduce risk for cardiovascular disease are typically included in a wellness program. Disease

management programs that aim to help individuals manage or control existing diseases or

conditions are outside the scope of this interview and should not be included in your responses.

Questions

1. What is your overarching approach in addressing prevention and wellness among your members?

2. Recently, some organizations launched campaigns to promote culture of health (for example, the Robert

Wood Johnson Foundation at http://www.rwjf.org/en/library/annual-reports/presidents-message-

2014.html). Do you address “culture of health” while designing and implementing your prevention and

wellness programs?

3. What, if any variations are incorporated in your prevention and wellness program, e.g., based on the

product, purchaser or population-specific factors? Note: Please provide your answers generally instead

of focusing on a specific contract or any information that might be competitively sensitive.

4. Tell us about your organization’s role in designing and implementing wellness programs for employer

accounts (fully and self-insured). Please provide your answers generally instead of focusing on a

specific contract or any information that might be competitively sensitive.

88

5. How do you structure outreach to different members in your wellness programs?

6. How does the choice of interventions (e.g. self-education brochures, health coaching etc.) to promote

wellness relate to specific health risks targeted?

7. In the survey, you indicated that your plan is using the following incentives (insert the survey responses)

to engage your members in prevention and wellness programs. How do you structure and time these

incentives for your members or member groups?

8. What effects have new payment and delivery models had on the design and implementation of your

prevention and wellness programs? Note: Please provide your answers generally instead of focusing

on a specific contract or any information that might be competitively sensitive.

a. If yes, how have they been affected?

9. Please describe the most successful wellness programs you have implemented in the past two years (or

use the information from the survey).

10. In the survey, you indicated that in implementing wellness programs you encountered such challenges

as (insert from the survey responses). Can you describe these challenges further?

11. In your opinion, what methods hold the most potential to increase the effectiveness of wellness

programs in the next 2 years?

a. Increasing provider involvement through new payment models?

b. Wider use of such technologies as social media or smart phone apps?

c. Obtaining evidence on effectiveness of specific wellness programs?

d. Lessons learned?