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Are You Managing or Leading? - Transcript

Hello, I'd like to welcome everyone to this webinar sponsored by Extracon. Here at Extracon, we know how to run wellness programs. Our online, social and moble platform has been proven at employers large and small across the USA for more than 5 years. Our client list includes Fortune 500 companies, major hospitals, and health insurance plans. If you'd like to learn more about our COMPLETE WELLNESS PLATFORM, please visit

The question for today is a simple one - are you leading or managing your wellness program? Most of us today are managing our programs. Today I'm going to present the argument that we should use a leadership approach and not just a management approach in our wellness programs. Why are we all managing rather than leading? It goes back to the core model used in our field - the Population Health Management model. As the name implies, this is a management approach. After 30 years of Population Health Management, we can assess successes and the limitations of this PHM model. We'll be referencing the PHM research as we discuss the successes and limitations of PHM, particularly the studies done by Dee Edington at the University of Michigan. Finally, we're going to show you how to start using a leadership approach in your health and wellness program, which is different from a management approach. I believe this is the big transition we will all be making in the next decade in order to address the limitations of the PHM model. You'll finish today's webinar with some concrete action steps to start using a leadership approach in your wellness program.

So let's spend a few minutes on the important differences between management and leadership. Because many people think that leadership is just a different word for management. So here are some definitions: Management is focused on a problem and how to reduce it. Management is a problem-solving approach. For the most part, the problem we deal with is the cost of health care for employee populations. We spend our time and energy and budget trying to reduce this problem. This is the management approach. But it's not the only approach. Leadership is focused on a destination and how to move towards it. So we start with a vision of where we want to go, and we spend our time and effort and budget every day on moving toward the destination. In the health and wellness field, this involves asking what a healthy, productive population looks like, acts like, and does every day. And then we focus on getting there. Our message for today is: How to Lead and Why it Matters.

Population Health management comes out of the long management tradition. The term management was coined by Frederick W. Taylor around 1900, and made famous by his book as shown here. Taylor was a foreman at a Steel Mill in Pennsylvania. Taylor created management as a set of tools to solve problems in factory production. And many other management approaches have been created. These are all PROBLEM SOLVING approaches, and they all share the three steps shown here. They define the problem, look for the root causes, and attack the root causes to solve the problem. As we will see in a moment, Population Health Management uses these same three steps.

This diagram of Population Health Management is put out by the Care Continuum Alliance, a major trade group within our industry. If you haven't seen this before, it probably looks very complicated. You may see some steps you recognize such as the Health Assessment. But it is a management approach that follows the same steps as Frederick Taylor. So let's make it a little simpler:

Here's the simplified version. We know what the problem is - Health Care costs that are large and getting bigger every year. Thanks to the research in our field, we also know that the root causes are health risk factors like high blood pressure and high cholesterol. So now we know the problem and what root causes we're looking for. Then at the beginning of every year we use Health Risk Assessments and Biometric screenings to collect data on what health risks each employee has. Then, we count up the number of health risks each employee has. Some employees may have zero or one health risk. Others might have five or more risk factors. We classify employees as low risk, medium risk, or high risk based on the number of risk factors they have. We call this risk stratification. So if you have lots of health risks - you are high risk. If you have only one or two you're low risk. Finally, we attack the root causes to solve the problem. That's the Intervene step. We target the high-risk and high-cost individuals with programs to move them to a lower risk category. That usually means health coaching for high-risk people and disease management for people with a chronic condition.

I think we can make this even simpler and clearer. So each dot here represents one person in our employee population. We've determined how many health risks each person has using a health risk assessment. Then we colored their dot green, yellow or red according to how many health risks they have. This chart shows what we have after we complete the health risk assessment and risk stratification. And then we get to work. We put most of our time and effort and budget on the high-risk, high-cost segment of the population. Because that's where the problem is. So this is a classic management approach of focusing in on the problem and putting our effort into working on the problem. But you have to ask yourself some questions here. First, are we helping enough people? Second, what is happening to all the other people who aren't being helped? We'll get to those questions in a moment. But first, I want to share with you some of the successes of this PHM model.

The good news is that PHM has been shown to be effective in some ways. First, employers are able to demonstrate a return on investment for PHM programs. We are doing well enough to recoup the cost of the PHM program and also deliver savings to the bottom line. In a famous 20-year study, Johnson & Johnson showed a 2.7 to 1 return on investment from their PHM program. A compendium of studies across many employers showed a 3.6 to one return on investment. So these programs are well worth the money spent. Second, employers are able to bend the trend and demonstrate a lower upward trend in health care costs. For example, instead of rising at 10% a year, an employer with a solid PHM program might see their costs rise at 8% a year. And that's a good thing. But PHM has not been completely successful. Even if you look at employers who have been using PHM for 20 and 30 years, like Johnson & Johnson or Xerox or Dow Chemical….. They are paying more today for health care than they were when they started using PHM. They are paying more than they did in 1990, or in 2000, or even 2005. Their costs go up every year, just as your costs go up every year. So now let's talk about the limitations of PHM.

The PHM research has pointed to two major limitations of the PHM model. First, it turns out we're not helping enough people. Second, the people we are ignoring are actively getting worse. Some of you may recognize the carnival game pictured at the bottom of the slide. It's called ‘Whack-A-Mole”. If you've ever played the game you know how it works. Keep that in mind as we dive into the research on PHM limitations.

So the first limitation of PHM is that we're not helping enough people. This chart is based on a study that was published in the Journal of Occupational and Environmental Medicine in 2006. The study was done by D. Edington at the University of Michigan, one of the leading researchers in our field. For those of you who don't know Dee, he was one of the inventors of PHM and developed one of the first and most successful HRA's. Here's how to read this chart. Going from left to right, it shows all the things we do each year in our PHM program. We start with 100% of the population. Then at the beginning of the year we ask them to take a Health Risk Assessment. Some take the HRA and some don't. Then we do risk stratification and IDENTIFY the ones that are higher-risk. That's the next bar. So that's 23.5 percent. Then we attempt to contact them, that's the next bar. Then we make contact with them, and that's the next bar, at 12%. We ask them to participate in a program. And in the next bar we see 5.8% actually start the program. And about half of those are successful in the program. So when we look at the big picture, only about 5% of the population is participating in our programs and only about 2% are successful participants in our programs. We just aren't helping enough people to solve the problem of health care costs.

The second limitation of PHM is that the other 95%, the people who aren't in our programs, are actively getting worse all by themselves. This is the reason that health costs are going up, even for employers that have had PHM in place for many years. The next set of charts are based on another study that D. Edington did at the University of Michigan, which was published in the American Journal of Health Promotion. The original version of this chart has confused a lot of people over the years, so I am presenting a simplified version. You can look up the whole graph at the citation below. So imagine this is your population and your wellness program. You have little over 4,000 people who are High Risk, about 10,000 that are Medium Risk, and about 28,000 that are Low Risk. And your job as the wellness person is to make those numbers improve over time. So when we get down to the bottom part of the slide we should see more fewer High Risk people. We should see fewer Medium Risk people. We should see more Low Risk people.

So you run your wellness program and work really hard to help those high risk people. In fact, over 1500 of the high risk people move down to medium risk. And you work hard on those medium risk people, and you find that over 4,000 of them move down to low risk. So you did a good job, right? You've been very successful, right?

Well, not really. When you look at the results later, you find out there are more High Risk people than before. There are more Medium Risk people than there were before. And there are fewer Low Risk people than there were before. This is the opposite of what you wanted. And yet you remember working really hard on your wellness program…. So what happened?

Here's what happened. The people who were not program participants - people who never set foot in your wellness center - have gotten worse. All by themselves. You can see the thin green arrows showing the people who reduced health risks - with or without the help of your program. But you can also see the much larger arrows of people who moved from Low Risk up to Medium Risk. And who moved from Medium Risk up to High Risk. And the numbers on the red arrows are larger than the numbers on the green arrows. So here we are in wellness, working our tails off to move a few people from High to Low, and all the while a much bigger group is moving from Low to High, all by themselves! So this is exactly how the carnival game of Whack-A-Mole works. You're busy fixing the problems that pop up, but new ones pop up faster than you can fix the old ones. So to recap, the two main limitations of the PHM model are these: First, we aren't helping enough people. If we have 5% participate in a wellness program and 2.5% complete the program successfully, then we just aren't helping enough people. Second, the other people we aren't helping are actively getting worse. And in many cases that cancels out all the progress we're making in our health programs.

So now we're into the second half of the webinar. It's time to talk about a completely different approach. What if we stopped focusing on problem solving. What if we focused on where we're trying to go? The Leadership approach is to begin with a vision of where we want to go, and then spend our time, our effort, and our budget every day on getting there. Can you see the difference? It's not about cutting down the problems. It's about building up the things we want. It's not about leaving problems behind, it's about getting where we want to go.

So now I'm going to work through an example with you. Imagine you're called in to consult with an employer on their wellness program. They have PHM programs and they are going to keep those programs. But they are looking for a new direction. So you start by asking them about the destination they are trying to reach. You ask them, what is the total value of health to their company? What kind of employee health is going to help the whole company reach its business goals? And if you work through that process with a client, Here's the kind of answer you'll wind up with. We want a workforce with the energy and vitality to engage in creative, high-quality work that builds shareholder value. In other words, we want people who can jump into their work each day and build high-quality products, deliver great customer service, invent new products and services, and still have enough energy left at the end of the day to go home and have a satisfying home life. If most of our people have that kind of health, we can do amazing things as a company. On the other side of the coin, it's clear that people who are sick and tired are not going to do their best work. If most of your people are sick and tired most of the time, it's going to be hard for the company to hit its business objectives. How do we get there? Our mission is to build up the health, energy and vitality of our employees so they can do their best work. Not just subtracting risks. So let me give you a diagram.

This is what it looks like if we spend our time, energy and budget on building up the health of MOST of our employees. Not just targeting a few for risk reduction.

I really want to emphasize this difference between building up heath versus taking away health risks. So have a look at the patient in the picture at the left. He's doing a treadmill stress test. This is a test where you walk on a treadmill and it measures how much you can do. This is a test of FUNCTIONAL health, which is more closely related to productivity, energy and vitality than many of the tests you're doing today. This is a pretty good measurement of the kind of health that an employer wants. So here we have a patient or employee on the treadmill. There are different measurements for tests like these, but let's assume right now that the goal is for the patient to move their body 1 mile in 12 minutes or less. So first let's look a this from a health risk reduction point of view. From a management point of view, we would say the patient has a blood pressure risk, a cholesterol risk, and a maybe a BMI risk. We can treat two of those easily with medication, so we get out the prescription pad. Voila, we've taken this patient down from three risks to one. We moved them from medium risk down to low risk. So we congratulate ourselves. But is there any prescription we can write that will enable this patient to pass the treadmill test? Can we subtract enough health risks to get this patient to a 12-minute mile? Or do we also have to build health through daily habits and daily actions? I'm arguing today that the kind of health we really want is the kind of health we have to build. We can't get there just by subtraction. And we don't really have to choose between one approach and the other.

It turns out you can do both. If the patient has high blood pressure or high cholesterol, we can easily screen for that and we should do so. We can easily manage blood pressure and cholesterol with medications and we should do so. But we should NOT stop there. So this is where I think our best employers are going to. Their PHM programs are producing an ROI and helping bend the trend. So there is every reason to continue. But there's also every reason to ADD a leadership approach onto the management approaches you're already doing. The best employers are going to use both problem solving AND leadership approaches.

So if we're trying to Build Health, not just Reduce Risks, how can we do that? Let's look at what actually builds health. It's the daily actions we do or don't take every day. It's the difference between taking the stairs and taking the elevator. It's the difference between a healthy lunch and the latest bacon cheddar burger. It's a lot of daily actions that are HIGHLY INFLUENCED by the CULTURE at the worksite. Our organizations need to have a strong health positive culture that lets our employees resist the health-negative culture just outside your doors. (Click) so what does it look like when we are succeeding? When you see people making the right choice in a public and visible way, you'll know you are changing the culture toward health. People eat at most of our worksites. They eat at breakfast meetings, they eat in the cafeteria, they eat at end of year celebrations. One of the ways we'll know when building health is that when you see people eating, you will see them eating fruits and vegetables. You'll see a glass of water or black coffee on desks instead of a soda. When people have a choice of what food to offer to each other at meetings, they will choose the healthy food. You'll also see healthy choices front and center at the cafeteria and in the vending machines. When you look around the workplace and see healthy foods, you're on the right track. People also have opportunities to be more or less physically active at the worksite. They have the choice of parking nearest to the door, or parking at the back of the lot so as to walk a few more steps. They have the choice of using the stairwells or taking the elevator. In many cases, they have the option to arrange their desk or workstation to work standing up rather than sitting down. At many worksites, there are walking paths available. At many worksites, there is an on-campus fitness center. Are the machines full or empty? Are people using the machines only before and after work, or do you see people taking a half-hour mid-morning or mid-afternoon to exercise? When you look around the workplace and see people adding extra physical activity into their day then you're on the right track.

This is going to be a short discussion today, since this topic could be a whole webinar by itself. So I'm going to be brief. When you're trying to build up the health and productivity of your workforce, we think you should consider both wellness programs, and also changes you can make to the workplace environment that support your mission. In terms of wellness programs, you should be looking for programs that apply to everyone in the population. Everyone needs to eat healthy foods. Everyone needs to get enough physical activity. Everyone needs to get enough sleep. Everyone needs to maintain a healthy weight. When you run programs intended for EVERYONE, then you can reach enough people to move the needle on population health. Forget about the participation number for high-risk only programs that we saw earlier - it was 5.8% participation. You should be thinking about how to get 58% participation in each of several programs per year to engage the whole population? You should look for programs that incorporate healthy peer influence. Not just individual programs. You're looking for programs where people work together in groups or teams and become a health-positive influence on each other. That's how you build the healthy culture inside the company that can resist the unhealthy culture in America today. You should look for programs that drive daily behaviors. Simple daily behaviors like eating fruits & veggies, walking 30 minutes each day, and getting enough sleep are the daily behaviors that build up our health and enable us to be productive and creative at work. Your wellness program should build up those positive behaviors that build participant health. We also think you should look for ways to change your workplace environment to support health. The worksite or campus should have features to support physical activity, healthy eating, and smoking cessation. For example, having a smoke-free campus, a walking trail, and healthy food available in the cafeteria.

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