For some time, employers have offered employees wellness programs that provide incentives for maintaining healthy lifestyles. While these programs can offer positive returns on investment, those returns are dependent upon plan participation and, in particular, whether at-risk employees participate and improve their health. Additionally, wellness programs typically have been disconnected from employers' insurance plans. Although employees were rewarded with incentives such as discounted health club memberships or merchandise, there was no direct impact on plan benefits.
However, that connection has begun to develop. "In the past few months there has been an uptake on the health-plan side to design benefit packages that tie employee participation in health and wellness programs with changes in premiums and co-payments rather than [insurers'] just charging premiums for when people get sick," observes Cynthia Burghard, research director in Gartner's healthcare insurance industry advisory services.
"It makes sense for health insurers to do this because they are in the health business, and it fundamentally makes more sense for employers to have just one company dealing with health [coverage] and wellness [benefits]," she adds. It also has the potential to spur greater employee participation in wellness programs if employees who do not participate in the program are charged greater premiums or are responsible for higher deductibles, co-payments, or other out-of-pocket healthcare costs.
One insurer that recently rolled out a combined insurance and wellness plan is Priority Health, headquartered in Grand Rapids, Mich. As the plan, called HealthbyChoice Incentives, is structured, all new members are placed in "choice" status on enrollment. Within 90 days, members must complete an online health risk assessment and their physician must complete an online attestation the member is a non-tobacco user, has a body-mass index (BMI) under 30, and has a blood pressure of less than 140/90.
If they do not meet those physical benchmarks, members must undergo additional blood tests and establish a wellness plan with their doctor. If they fail to do that, or fail to complete the initial assessment in 90 days, they drop to "standard" benefit status, which has higher co-payments and deductibles.
"We're not interested in the actual lab results, and we don't want to tell physicians how to treat patients. We want to help people identify areas where they can take better control of their health and to foster an active patient-physician relationship," says Scott Woods, director of product development at Priority Health.
Woods indicates it was important Priority Health develop the ability to move members back and forth automatically from choice to standard benefits in order to administer the plan efficiently and to ensure claims paid and online member information accurately reflect members' current status. The insurer leveraged an existing patient profile system and its connections to third-party data and service providers such as WebMD (which supplies the online health risk assessment) and the testing labs used by Priority Health. The insurer also created a data warehouse into which member health data is loaded and developed internally a new rules-based administration system–what Woods calls the "magic program"–on top of the warehouse to track whether or not members complete required assessments and tests on time.
Beyond tracking member compliance, the system connects with a document generation system to create reminder mailings. "We want to give members fair warning of pending deadlines," explains Rich Lange, director of Web experience at Priority Health.
The open architecture of the system gives Priority Health the flexibility to refine the plan as its experience develops. For instance, the insurer could consider ways in which to connect data regarding paid claims to confirm when members have certain physical exams rather than relying on the manual completion of an assessment either by the member or physician.
Having issued its first policy effective July 1, Priority Health already has seen "brisk" interest from employers, according to Woods. Aside from advancing Priority Health's marketing goals, he adds, the company hopes this interest encourages more healthy lifestyles.
"The plan doesn't just provide differentiated benefits," Woods concludes. "It provides members a comprehensive view of their healthcare and gives them both the information and incentive to make choices about what to do in the future."
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