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A Road Map: Moving From Participation Based Wellness to Outcomes Based Wellness
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A Road Map: Moving From Participation Based Wellness to Outcomes Based Wellness

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    A Road Map: Moving From Participation Based Wellness to Outcomes Based Wellness A Road Map: Moving From Participation Based Wellness to Outcomes Based Wellness Presentation Transcript

    • Results BasedWellness
    • Healthcare – Current State
    • U.S. Healthcare Crisis – Quick Facts Employers represent 1/3 of all healthcare spending U.S. healthcare costs exceed $3 trillion annually – more than any other nation 2010 healthcare costs were more than 3 times more than in 1990, and over 8 times more than in 1980 More than 1/4 of healthcare costs are related to obesity, overweight and physical inactivity and the associated health problems, including heart disease, hypertension, diabetes and some forms of cancer Healthcare costs of obese workers are up to 21% higher than for non-obese workersIntercare Insurance Solutions • Private & Confidential • CA Insurance Lic #0D80830 • intercaresolutions.com pg. 3
    • Adult Obesity Rates  Adult obesity rates increased in 16 states in the past year and did not decline in any state.  In 2011, 12 states had obesity rates above 30%.  In 2007, only 1 state was above 30%Source: Trust for America’s Health, July 2011 Intercare Insurance Solutions • Private & Confidential • CA Insurance Lic #0D80830 • intercaresolutions.com pg. 4
    • Childhood Obesity Rates “Today, the state with the lowest obesity rate had the highest rate in 1995,” Jeff Levi, Trust For America’s Health, Executive DirectorSource: Trust for America’s Health, July 2011 Intercare Insurance Solutions • Private & Confidential • CA Insurance Lic #0D80830 • intercaresolutions.com pg. 5
    • So What Are We To Do?
    • Incentives Drive Outcomes Reward process or reward outcomes Greater incentives drive greater participation Intercare Insurance Solutions • Private & Confidential • CA Insurance Lic #0D80830 • intercaresolutions.com pg. 8
    • U.S. Healthcare CrisisHow Employers Are Addressing Engaging employees in wellness is proving to be a difficult challenge and a growing number of employers are re-thinking their current strategies. 70% of employers plan to establish results-based or participation-based contribution strategies in 2012. 2010 marked a two fold increase in outcomes based design with another 33% of employers planning to adopt an outcomes based program in 2012.Intercare Insurance Solutions • Private & Confidential • CA Insurance Lic #0D80830 • intercaresolutions.com pg. 9
    • So What Is Results BasedWellness?
    • Participation Based Versus Results Based ProgramsParticipation Based Results BasedIntroduced over 20 years ago Introduced in 2001; final legal rules in 2008Biometric Screenings/Health Biometric Screenings/Health RiskRisk Assessments AssessmentsHealth coaching/Disease Health coaching/DiseaseManagement ManagementIncentives/penalties for Incentives/penalties for healthparticipation resultsNo true accountability Appeals and AlternativesROI is measurable over the ROI is quantifiable and easier tolong term measure Intercare Insurance Solutions • Private & Confidential • CA Insurance Lic #0D80830 • intercaresolutions.com 11
    • Why Are Outcomes Important?Intercare Insurance Solutions • Private & Confidential • CA Insurance Lic #0D80830 • intercaresolutions.com 12
    • Rules of the Game GINA HIPAA ADA ERISASource: www.dol.gov
    • Genetic InformationNon-Discrimination Act (GINA)Effective On October 1, 2009 the IRS, DOL and CMS issued a joint final interim regulation under GINA. The regulations affect group health plans for the plan years beginning on or after December 6, 2009.What It Does Prohibits group health plans from collecting genetic information either for underwriting purposes or prior to or in connection with enrollments.What Is Genetic Information?The manifestation of a disease or disorder in family members,which includes, family history.Intercare Insurance Solutions • Private & Confidential • CA Insurance Lic #0D80830 • intercaresolutions.com
    • Genetic InformationNon-Discrimination Act (GINA)What does it mean to me as an Employer? If you require a completion of an HRA at the time of enrollment, make sure that the HRA does not include FAMILY HISTORY QUESTIONS. If you offer an incentive for completing an HRA, make sure that the HRA does not include FAMILY HISTORY QUESTIONS. Penalty: Employers could be forced to pay as much as $50,000 for each violation.Intercare Insurance Solutions • Private & Confidential • CA Insurance Lic #0D80830 • intercaresolutions.com
    • HIPAA and Wellness •HIPAA requires uniform coverage and non-discrimination1996 •Interim “bona-fide wellness rules” introduce exceptions for wellness plans – very restrictive2001 •Final Wellness Rules issued •Distinction between incentives for participation and incentives “contingent upon the satisfaction of a health standard”2007 •Rules clarified in February, 2008 Checklist for Wellness Program •National Health Reform solidifies regulation as law and provides for expanded incentives/penalties tied to health lifestyle results2010Intercare Insurance Solutions • Private & Confidential • CA Insurance Lic #0D80830 • intercaresolutions.com 16 © 2011 Bravo Wellness
    • HIPAA Exception – Outcomes Based If an incentive is “contingent upon the satisfaction of a health standard”: It must be re-assessed at least once per year It must be designed to promote health and wellness It may not exceed 20% of the total cost of coverage offered (Raised to 30% effective January 1, 2014) It must be available to all “similarly situated individuals”, appeals and “reasonable alternatives” must be offered The availability of the appeal must be disclosed in all plan materials Healthcare Reform solidifies regulation as law and provides for expanded incentives/penalties tied to health lifestyle results.Intercare Insurance Solutions • Private & Confidential • CA Insurance Lic #0D80830 • intercaresolutions.com 17 © 2011 Bravo Wellness
    • SO I HAVE COMPLIED WITH GINA AND HIPAAIntercare Insurance Solutions • Private & Confidential • CA Insurance Lic #0D80830 • intercaresolutions.com
    • Americans With Disability Act (ADA) Purpose: Prohibit discrimination based on disabilities As it applies to employers: Employer shall not require a medical examination and shall not make medical inquiries of an employee unless it is job related and consistent with business  Medical Examination includes blood tests  Medical Inquiries include well being questionsIntercare Insurance Solutions • Private & Confidential • CA Insurance Lic #0D80830 • intercaresolutions.com
    • American with Disabilities Act (ADA) Impact on Wellness Programs“Voluntary Wellness ADA allows medical exams as part of wellnessPrograms” programs as long as participation is “voluntary”  What is voluntary? No clear guidanceBona Fide Plan ADA allows employers to require participation in aException wellness program that is part of a “bona fide benefit plan”, if participation helps underwrite, classify and administer risks in benefit plans that are based on, or not inconsistent with, state lawKey Actions to Communicate that the wellness plan is part of yourDemonstrate the Bona group health planFide Plan Exception  Include specific wellness language in SPD Wrap and all benefits materials  Clearly describe any rewards/penalties, and maintain thorough program documentation Intercare Insurance Solutions • Private & Confidential • CA Insurance Lic #0D80830 • intercaresolutions.com 20
    • So How Does It Really Work andand What Are The Results So Far?
    • SimplyWell’s Integrated ModelIntercare Insurance Solutions • Private & Confidential • CA Insurance Lic #0D80830 • intercaresolutions.com
    • Successful Incentive StructuresEngineering/Manufacturing – 80% participation rate Premium insurance discount $80 per month/ family and $40 per month/single – must earn quarterly point requirements to get the discount each quarter Health Score – first year Health Score is baseline only – second and subsequent Health Scores must achieve score of 85 or above, or show improvement: Improvement Incentive (Includes spouse) 10 points $150 20 points $300 30 points $450 For individuals who can earn an 80 $500 max per year or above (includes spouse for a potential of $1000) Offers Tobacco Cessation Program If family coverage, BOTH employee and spouse must participate to get insurance premium discount Intercare Insurance Solutions • Private & Confidential • CA Insurance Lic #0D80830 • intercaresolutions.com
    • Successful Incentive StructuresInsurance Company – 95% participation rate Must complete the HRA and attend a Health Screening for insurance benefits (CAUTION) Spouses on insurance must complete the HRA Must earn 5,000 points to receive reduced medical premiums (HRA and Health Screening are only worth 200 points each) Premium discounts are as follows: Discount Group (in annual savings) Employees $936.00 Employees + Child(ren) $1,680.00 Employee + Spouse $2,088.00 Employee + Family $2,976.00Intercare Insurance Solutions • Private & Confidential • CA Insurance Lic #0D80830 • intercaresolutions.com
    • Health System Results Repeat Health Scores 2006 - 2010Health Score Changes 40% Health 2006 % 2010 % Score 35% Ranges 30% 45-59 0.6% 0.8% 25% 60-69 9.5% 7.7% 20% 2006 15% 2010 70-79 30.6% 24.0% 10% 80-89 30.4% 35.5% 5% 90 & Above 28.9% 32.1% 0% 45-59 60-69 70-79 80-89 90 + 114 (7.5%) of repeat participants with a score < 85 raised their Health Score 5 points or more from 2009-2010 Average Health Score in 2009 = 84.1 Average Health Score in 2010 = 85.9Source: Intercare Insurance Solutions • Private & Confidential yearInsurance Lic #0D80830 • intercaresolutions.com SimplyWell Repeat Report – 2 • CA repeat health score report
    • Health System Results Health Risk Trends970 Repeat Participants Health Screening Data –Measurable and ModifiableHealth Categories 2006 % 2010 %High RiskBody Composition 33.3% Female 32.5% FemaleScore 28.7% Male 25.0% Male(BMI 30+)Blood Pressure > 13.1% 12.5%140/90Total Cholesterol > 47.5% 26.8%200LDL >130 34.7% 18.3%Triglycerides >150 30.6% 24.4%Glucose >100 26.8% 17.4%Health Score > 85 43.3% 51.2%Source: SimplyWell Aggregate Report – Repeat Risk Summary 10/13/2010 Intercare Insurance Solutions • Private & Confidential • CA Insurance Lic #0D80830 • intercaresolutions.com
    • Population Health Management Compared To The General Population450040003500 2008 20093000 201025002000 SimplyWell Repeats Non-Participant Repeats Intercare Insurance Solutions • Private & Confidential • CA Insurance Lic #0D80830 • intercaresolutions.com 27
    • Cost vs. Risk$5,000$4,500$4,000$3,500$3,000 Minimal Risk$2,500 Moderate Risk$2,000 High Risk$1,500$1,000 $500 $0 2008 2009 2010 Intercare Insurance Solutions • Private & Confidential • CA Insurance Lic #0D80830 • intercaresolutions.com 28
    • Packing House Data$12,000.00$10,000.00 $8,000.00 Packing House $6,000.00 National Average $4,000.00 $2,000.00 $0.00 Intercare Insurance Solutions • Private & Confidential • CA Insurance Lic #0D80830 • intercaresolutions.com
    • ESMH Results For Packing House  Enrollment in insurance increased 5.6%  Total health care costs PMPM decreased 12.4% 2010 2011 % ChangeAverage 1501 1586 +5.6%MembersMedical Claims $179.87 $151.29 -15.9%Paid - PMPMPharmacyClaims Paid - $26.84 $29.54 +11.1%PMPM Insurance Packing House % Variance Plan-wideTotal PMPM $181.99 $311.89 -41.6%Claims Intercare Insurance Solutions • Private & Confidential • CA Insurance Lic #0D80830 • intercaresolutions.com
    • ESMH Medical Utilization For Packing House (2011 Plan Year) Insurance % Packing House Plan-Wide VarianceHigh Cost Packing House Insurance Plan- -58.9%Claimant % as compared to WideAverage Length Packing House Insurance Plan- -42.9%of Stay as compared to Wide Packing House Insurance Plan-Days/100 -77.0% as compared to Wide Packing House Insurance Plan-ER/1000 -5.9% as compared to Wide Packing House Insurance Plan-Office Visits/1000 -24.2% as compared to Wide Intercare Insurance Solutions • Private & Confidential • CA Insurance Lic #0D80830 • intercaresolutions.com
    • In Conclusion
    • Key Take Aways Results Based Wellness – tying employee medical plan contribution to health outcome – is growing in prevalence Many ways to design the incentive and overall program Legally compliant requirements are foundational – GINA, HIPAA and ADA Reasonable Alternative Standard is a must Impact on health care – on individual health and health care claims – is promising Intercare Insurance Solutions • Private & Confidential • CA Insurance Lic #0D80830 • intercaresolutions.com 33
    • Keys To Success Partnering with the “right” results based, third party administrator  Results based program requires objective third party administrator with the tools, resources and support that best match the culture  Legally compliant appeals and alternatives administration  NOTE – results based programs incorporate venipuncture blood draws rather than finger stick; increased accuracy Setting biometric targets and contribution strategy to create early success and positive behavior change over time  If possible, review historical biometric results and project how many employees will meet the targets  Obtain clinical perspective on the biometric targets  Start “gentle” and tighten targets over time Include spouses – voluntary initially, require year 2 or 3 Educate, educate, educate – combined with resources, support and the opportunity for personal/family success Intercare Insurance Solutions • Private & Confidential • CA Insurance Lic #0D80830 • intercaresolutions.com 34