New Paths to a Healthier Workforce, Part 2:
Seizing the Right Moment for Change

By Michael Kriner

This company analyzed its biggest health risks and then deployed modern technology at the point when employees are most open to change.

Data is powerful. Unless you understand your population, you'll end up with generic solutions that don't work very well. At NCR, for instance, we know that we've got 32,000 employees globally, about 11,000 of them in the U.S. at four locations. Our average employee is 44 years old and has 14 years of service, and we're heavily male-dominated. We spend about $72 million for active employees and another $40 million on retirees. About 7 percent of our population drives 75 percent of the health care costs. In terms of using Health Risk Assessments (HRAs), it's important that 95 percent of our people have online access.

But those are just raw numbers. Working with Hewitt, we looked deeper into the impact of specific diseases not only on the medical cost but also on short- and long-term disability and productivity. Asthma's financial impact on NCR, for instance, stems largely from medical expense, and less so from lost productivity. Conversely, medical costs account for only about a quarter of the impact of diabetes. The other three quarters are productivity loss. Information like this helped us design more precisely the kinds of programs that make sense for NCR and let us build a business case to present to senior management.

We expected a good reception, because NCR has always embraced a health and wellness strategy. We cover routine physicals and female health screenings. We do on-site risk assessments and health education programs. We've integrated our employee assistance program with behavioral health. We have fitness centers in key locations. We think all this improves the health and productivity of our employees. Have we validated that? No. Even if this doesn't save any money, it's a good thing to do. You help people. You improve their quality of life. Philosophically, that appealed to us.

The HRA tool was a necessary adjunct to the disease management components, and it had to fit in the context of our existing programs. We were concerned that our members would be getting communications from all the providers we do business with. Is CIGNA going to send them something on cardiovascular care one day and Medco Health something else the next?

We realized that we didn't have the resources to manage all these independent organizations, so we challenged them to develop a best-in-class disease management program for NCR — to take advantage of the touch-points among them. If an employee calls CIGNA or Intracorp about an illness, for instance, why not screen that caller for depression? It's a possible comorbidity. And why not find out whether someone who is depressed would be receptive to talking to Magellan, our behavioral health partner? And why shouldn't Medco, as part of managing our pharmacy benefits, help Magellan do a better job by supplying data on the use of antidepressants? It took about a year and a half, but the organizations came together. They understood what their core competencies were — and what they weren't — and actually focused on NCR.

We wanted to reach out to people early on, to use the moment of impact when someone has that new diagnosis, that first prescription. Compliance drops off dramatically after those first few weeks, because people are feeling okay. For sure, this is a major transition from passive to active in dealing with risks like being overweight or having high cholesterol, raising issues that we all face around privacy of data.

Confidence in confidentiality

Never underestimate people's sensitivity about offering their own health data on the Internet. Their fears may not necessarily be justified, but we have to deal with them. All employees got a letter from our senior vice president of human resources, signaling real support from upper management.

We explained that we're not directly managing any of these programs. We do not get any identifiable data. Everything is in aggregate. We talked about why disease management is important. Why do we want you to complete an HRA? What are we going to do with the data? What are we not going to do with it?

We talked openly to establish a context, so that when someone from Magellan called one of our employees or retirees there would be a baseline to support our partners. Employees can opt out if they're not comfortable, but 98 to 99 percent really don't have a problem with it. Still, you want to give them a chance to say, "Hey, I don't want to do this."

Another message was the importance of taking ownership of your own health. This is crucial to the process of changing behavior. We sent out a pre-enrollment communication about the importance of taking care of yourself. In our mind, it was critical that the HRA raise awareness. No matter where you are in the platform of consumer-driven health care, the reality is that we need people to be more engaged and be better consumers. Here was a tool that allowed us to do that.

The moment of truth

We introduced the online tool last September before open enrollment, so we'd get that moment of impact when people are making choices. The tool itself looks like a lot of others that you may be familiar with: You sign on. It's secure. You can look at your online results. You can put in your cholesterol numbers. You can update it throughout the year. There's information about medications and questions to ask your doctor.

We made this available to everybody, whether they had health care with NCR or not. Intracorp and CIGNA manage over half our people in a PPO, but we still needed the 40 to 45 percent of our people outside the plan to get a big enough base to break out different demographic groupings. We wanted to see the differences between actives and retirees. We wanted to be able to customize our response by location, because San Diego's health needs could be very different from those of Dayton, Ohio.

In the first round, 1700 people completed the survey. We did a gift certificate drawing to get people engaged, and we're going to look at other types of incentives. Some employers put money in FSA accounts; some will pay for a physical. We didn't go out of the gate doing that, because we wanted to be sure the tool is giving us credible information. If we're going to spend $100 per employee to seed the FSA account for completing an HRA, we wanted to have a business case that this is a good investment.

We have not had anyone come back to us and say, "This is intrusive. You shouldn't be calling me." They've been very receptive to having someone help them understand and work through their problem.

Our vision is that people will actually print out their results and take them to their doctors on their next visit, and maybe that would help the doctor get to know more about that patient.

Encouraging results

Our respondents indicate there will be lower prevalence in most major disease categories such as heart disease and depression. We also found that most NCR people are generally better than average in managing their own care.

We identified 23 people through the HRA that we actually engaged with the Well Aware program with CIGNA. This means that in the absence of claim data, which is always too late for prevention, 23 people fit what we were targeting. That's not a lot of people. But whether it's 20 or 10 or 100, this is a significant starting point. These are people that we hadn't identified as being at risk and may not have had the ability to engage in conversation.

After all that, how much money did we save? About $23,000, but don't get caught up too much in the numbers. They're just a place to start. People reading this for ways to save millions might be disappointed, but that more than paid for implementation of an HRA. Everybody whom we identify after this will really start to show results. Remember, too, that the HRA is one tool among many, and the results are based on only a few months. It will be several years before this really becomes part of our culture.

We also identify point-of-need content as the person is completing the HRA. What does this mean? If you're overweight and need some exercise, you get an immediate prompt about our fitness center, including how to make contact and enroll. Thirty-one people referred themselves to the fitness center as a result of this program. You know how hard it is to get the right people to use the fitness program, as opposed to people that have already signed up at Bally's? That's a huge win — that we were able to have people actually take notice and do something.

Next steps

Where do we go from here? Obviously, we want to positively impact trend, so we'll continue integrating our medical and pharmacy data. You have to do that to become better at predicting and identifying the candidates.

We'll also continue to engage employees and retirees to be better-informed consumers who are knowledgeable about the importance of wellness. Communication — letting employees know what you're doing or why you're doing it — is perhaps the most important element for a successful HRA program. One of our next steps will be to go out and tell our employees about the early results and remind them that the HRA is available.

Finally, we'll continue to refine the business case. We think that as we roll out these programs, we will enhance attraction and retention and become an employer of choice. That's important in Dayton, Ohio. Not many people move to Dayton to work. We want to have a culture and philosophy that makes them want to be with us.

Michael Kriner of NCR is responsible for strategy, design and the administration for the Americas benefit programs. He is the president of the Tri-Rivers Employers Health Care Coalition and co-chair of NCQA's Employers Purchasing Advisory Council. This article was based on a presentation at the Washington Business Group on Health conference in March 2003.

More Business & Health Articles About This Topic:

New Paths to a Healthier Workforce, Part 1: HRAs are All Grown Up Now (June 15, 2003)

Lessons from a Health Promotion Victory (September 2000)

Union Pacific . . . On the Right Track  (November/December 2000)

America's Healthiest Companies: Scaling the Heights of Good Health (March 1, 2000)

Arm Yourself for a Shootout on Executive Row (March 18, 2003)

Resource Links:

American Healthways http://americanhealthways.com

The Wellness Councils of Americahttp://www.welcoa.org

The Washington Business Group on Health Center for Prevention and Health Serviceshttp://www.wbgh.org/programs/cphs/

National Committee for Quality Assurancehttp://www.ncqa.org/

Michael Kriner. New Paths to a Healthier Workforce, Part 2: Seizing the Right Moment for Change.

Business and Health

Jun. 15, 2003;21.