How Employee Wellness Can Build a Better Patient

April 2017. 

Presenters:

• Jesse Hercules – President, Extracon Science LLC
• Ted Dacko – President, Arbor Dakota
• Dr. Steven Schwartz, Chief Science Officer for IndividuALLytics

Transcript:

Ted:  Good morning and welcome to this webinar, sponsored by Extracon Science.  Today’s webinar is How Employee Wellness can Build a Better Patient.  I’m Ted Dacko, and I’ll be your host for today’s session.

Ted:  I’d like to introduce our two presenters.  Jesse Hercules is the CEO of Extracon Science.  He’s been writing and speaking in the employee wellness field for 10 years now, and leading Extracon in working with clients from the Fortune 500 on down.  His background is in engineering and software technology, but he’s also an attorney and has advised many wellness programs on legal compliance issues.

Our second presenter is Dr. Steve Schwartz. Steve is a Licensed Clinical Psychologist and has worked extensively in patient engagement and patient activation.  He’s worked as a scientist and product developer for HeathMedia and for Wellness & Prevention Inc, a division of Johnson & Johnson.  He is now the Chief Science Officer at IndividuALLytics and Digital Health Experience, consulting with employers and health plans nationwide.

Ted:  This webinar is sponsored by Extracon Science.  Jesse, can you tell us about Extracon?

Jesse:  Extracon creates employee wellness program that include the employee’s primary care physician, and build a better patient.   We’re committed to a different vision for employee wellness, that focuses on getting results by using the healthcare system that’s already in place and the doctor that your employee already has a relationship with. 

We offer turnkey and custom wellness programs that run on our own technology platform and apps.  We also consult with employers who have their own technology in place from other vendors.

Either way, we combine design, technology and incentives to create engagement and results.

Jesse: Our customers include insurance organizations like Highmark Blue Cross.   Large employers like MARS and UCSF, all the way down to smaller employers like Connectivity Wireless which has less than 200 employees.

We work with a number of hospitals and healthcare organizations, including Methodist healthcare. 

Ted:   So here’s the agenda for today.   Jesse will start out by explaining why Employee Wellness needs Better Patients.

Then Dr. Steve is going to draw on his background as a clinician, scientist and product designer to give us the Science and Strategies for building a better patient.

Then we will move from theory to application.  Jesse will share practical examples of how wellness programs can be structured to build a better patient.  These are examples from programs Extracon has created, but you can apply them in your own program as well.

Finally we’ll have a summary, Q&A and next steps. 

Jesse:  Let’s get started.

Jesse:  So we have about 400 organizations on the call today, covering hundreds of thousands of employees and health plan members.   Are they good patients?  Are they doing their part? 

Unfortunately, a lot of research coming out of the CDC says no.  Only 25% of middle aged adults are up to date on prevention.  Most adults have gaps.

75 million Americans have high blood pressure, that’s one in three.  A little over half of them have it under control with daily medication.  The other half do not their blood pressure under control.

73 million Americans have high LDL cholesterol, again that’s one in three.  Only 29% of them have it under control.  That’s much less than half.

86 million Americans have pre-diabetes, that’s more than one in three.   90% of those with prediabetes are doing anything to keep it from becoming diabetes – that’s because in fact 90% are not even aware they have it. 

This is where we’re starting from in employee wellness and population health.  It’s not a pretty picture. 

So what is employee wellness doing about these problems? 

We did a survey across 8,000 employers and wellness programs last year, and here’s what we found.  Almost everyone has health risk assessments and screenings.  Most HRA’s do not ask in detail about prevention status, so they are not usually helpful for finding prevention gaps.  Screenings are designed to find things like high blood pressure, high cholesterol and pre-diabetes.   Amazingly enough 58% of the programs in our survey stopped there.  So they are finding biometrics problems but not doing anything to fix the problems. 

The next biggest slice did a little bit more (CLICK).  They targeted outreach and coaching to those who had health risks.  Many of them paid incentives to those who completed a certain number of coaching calls. 

This is the current standard for employee wellness.   And you’ll notice there isn’t any healthcare in this process diagram.   The primary care doctor and the healthcare system are not part of employee wellness. 

So now I want to make this personal, and practical.  Let’s talk about two people with very common health risks. 

Let’s start with Nancy.  (CLICK) She’s one of the 75% of middle aged adults who is not up to date on prevention.  Even though 1 in 9 US Adults has depression, nobody has ever done a simple, quick depression screening for Nancy.  Because of her age as a Baby Boomer, she’s supposed to have a once-in-a-lifetime screening for Hepatitis C.  She has never had the Hep C screening.  Like a lot of adults, she’s behind on her tetanus shot, which is required every 10 years.  And she’s a year overdue for a mammogram. 

And Let’s talk about Bart.  (CLICK).  He has high blood pressure and he’s obese with a BMI of 30.  He knows he has high blood pressure, but he let his prescription expire a couple of years ago.  He doesn’t currently have a primary care doc.  We said earlier that half of hypertension patients don’t have their blood pressure under control today – that’s Bart. 

So what’s Nancy’s experience in a standard employee wellness program? 

The screening is going to look at blood pressure, cholesterol, BMI and glucose.  (CLICK) So she is going to pass the screening with a score of 100%, and so the program is not going to target any coaching or outreach to her.   The Health Assessment she takes, like most health assessments, does not ask about or identify these prevention gaps.   So the wellness program actually misleads Nancy a little bit.  She thinks she’s doing great on prevention, she’s actually less likely to see her doctor.  

Now, let’s look at what Nancy needs (CLICK). 

She needs to have a prevention visit with her primary care doctor where she and the doctor go through the prevention checklist and find these gaps.  She needs to close her prevention gaps – some of them at the primary care doctor’s office and some of them at a specialist’s office.  Then she’s up to date on prevention.  None of that happens within the employee wellness program.  It’s all on the other side of the wall, over in the healthcare system.

So Nancy is not going to have a good experience in the standard wellness program, and it’s not going to help her meet her needs.  This is a pretty common scenario for the 75% of middle aged adults who are not up to date on prevention.

So what is Bart’s experience with the wellness program. 

As you will remember, Bart knows he has high blood pressure, but he doesn’t have a primary care doctor and has let his prescription expire.  So if he goes to the onsite screening they are going to tell him something he already knows. (CLICK) And they are going to assign him a coach and he’s going to start getting these phone calls and voicemails asking him to talk to a coach.  And usually there’s an incentive he can earn if he talks to the coach 4 times during the year. 

So it’s pretty likely that Bart talks to the coach and earns his incentive.  But you have to ask…. Is that what he needs to fix his blood pressure?  Does talking to a coach for 30 minutes decrease blood pressure by 20 points? 

(CLICK).  Not exactly.  What Bart actually needs is to get a doctor, and visit the doctor for a new prescription.  To fill the prescription and take his medications daily.  And to go to a followup visit with the doctor and retest.   And then, after all of that, the doctor can confirm that the blood pressure is now under control.

Now, look at all that stuff that Bart needs.  None of that happens inside the employee wellness program.   It’s all on the other side of the wall, over in the healthcare system.  It’s not measured and it’s not part of the incentive.

So, I know what many of you are thinking.  You thinking, but maybe the coaches will motivate Bart to get a doctor, work with his doctor, take his medications, all those things.   Well, maybe?  And maybe not.   Do you measure it?  Or do you just hope? 

When we run surveys across real employee wellness programs, they do NOT measure those things.  Only 3% of wellness programs measure whether the doctor confirms the problem is resolved.   And even fewer than that tie the incentive to that criteria.  So there’s a big gap between what they hope is going to happen and what they measure and reward. 

And Bart may well fall through that gap. 

So what have we learned?  Traditional employee wellness is doing its thing, totally separate from the healthcare system.  And yet, for participants like Nancy and Bart and many others, the only way for them to be healthy is to become a better patient.  To get the healthcare they need, from the existing healthcare system.

They need to have a primary care doctor and work proactively with the doctor on prevention.  They need to close the prevention gaps they and their doctor find.  They need to follow up on biometrics until the doctor says it’s under control.  And they need to support all of this with healthy lifestyle habits like physical activity and healthy eating. 

The only way for Employee Wellness to achieve its objectives is if Bart and Nancy and others like them become better patients.  We can’t succeed otherwise.  That’s why better patients are needed.

What happens when you work at building a better patient?    In other words, when you ask participants to get a primary care doctor, work with their doctor on prevention, find and close prevention gaps, manage biometrics and chronic diseases, and coordinate their healthcare? 

That model has been extensively adopted and tested over the last 5 years.   In the health plan world, its called a PCMH, patient centered medical home.  But as we’ll see in the last section of this presentation, all of these same design elements can be part of an employee wellness program.  So what happens under this model?   A recent review of 30 studies shows the impact.  Almost every study shows costs go down – because fewer people go to the emergency room, fewer go to the hospital, fewer go to a specialist, and fewer go to urgent care.    Building a better patient who works with primary care saves a lot of money in all those other areas. 

Steve: I’d like to start this section with a quote from Hippocrates.  “It's far more important to know what person the disease has than what disease the person has.”

I love this quote because it reminds me that Building a Better Patient begins with the individual and we in healthcare have known the importance of the individual since antiquity. 

We want individuals to take charge of their health but both patients and practitioners continue to struggle?

How can we use what we know about human nature to design a better Health Experience and thereby a Better Patient?

Steve: To answer these questions, let’s use a concept from game theory called a Core Loop. 

So what’s a core loop?  A core loop is the beating heart (the behavioral engine) that makes games so engaging, sticky and habit-forming. 

A core  loop specifically is a well designed set of cues, actions and engagement steps.  Most importantly, it includes a reason to start & restart the loop driven by cues to engage and re-engage, feedback and value.  You know you have a good core loop when participants had a great experience and they’re primed to repeat the loop over and over again. 

The truth is core loops are not unique to the digital age, nor are they unique to games.  Core loops are embedded in everyday experiences. Those of us that get up and go to work everyday for compensation are in a core loop.

Lets examine the concept of the “Core Loops” in Health, Health risk and healthcare to see why the core loop for acute care works so well and the core loop for wellness and prevention is so deeply broken and requires a very different paradigm if we are to enable a better patient.

Steve:  I would like to compare and unpack the core loops for acute care vs wellness or preventive care.  

Healthcare has historically and continues to be treatment driven rather than prevention driven.  Care is transactional and most often triggered when someone gets ill or has an event like a heart attack, broken bone of ketoacidosis, and we spend significant time, effort and money treating a problem?

This is a compelling core loop. 

First, the patient has a really strong “Why” regarding engaging the system.  They’re in pain!  They are motivated to get relief from illness or symptoms.  

Second, they know what to do.  They make an appointment and see the doctor for diagnosis and treatment.  

Third, In most cases, the doctor can help.  The patient ultimately gets immediate relief (are very personally and saliently rewarded for their efforts). 

It’s a satisfying health experience in which they are primed to re-enter the loop if or when they get were sick. 

Steve: Unfortunately, the wellness loop does not work and Jesse gave you come clues as to why.  So lets unpack the consumer wellness experience loop.  

Let’s start from the top.  What’s the “Why”?  What value does a onsite screening or an annual wellness visit hold for the employee or consumer?  They’re not sick.  They have no unpleasant symptoms and therefor no sense of urgency or importance for prevention.  Is it any wonder S our calls to action in wellness fall on deaf ears?  Get a screening?  See a doctor?  Get a check up.  

So lets examine their perceived value proposition here. At best, they will go through all the tests and screenings and do all that work… and then they will find out that they’re fine.  No problems found.   Back to square one.  They took time out of their day, got poked and prodded and at the end of the day they are back where they started. 

Now if as intended the screening identifies a risk or issue (maybe blood pressure went up or cholesterol is elevated).  This too is an unrewarding experience!  Now they have been labeled with a health risk and with it a variety of time consuming and costly requirements like take a pill every day, change your diet, see the doctor more often, etc.  Its no wonder conditions without symptoms are the most difficult from an adherence perspective.

Steve:  The Journal of the American Medical Association estimates that only  20% of patients are actively working with their doctors on prevention.

What makes this 20% of people  different from the 80% that don’t? 

What could possibly be motivating those few, that could be used to motivate all?  It begins with a better why (value proposition for them).  This why can be broken down into 3 components.  

Purpose:  Connecting health and wellness to a persons sense of purpose in life or what brings meaning to their life set the stage for aspirational motives and goals?  

Wellbeing:  Make people more aware and mindful of the more immediate and present benefits of wellbeing.  They have more energy, sleep better, feel resilient to stress, keep up better with the grandkids.   

Incentives:  Incentives is a complex topic but we assume and advocate for a thoughtful approach to incentives including both carrots and sticks.

Steve: Now, let’s connect these elements to the actions needed to become a better patient. 

Purpose:  Many health preventing and promoting acts are generally boring or unpleasant in the short term with some vague pay off in the long term.   But what if we help participants better connect staying healthy as a goal to those more aspirational aspect of what gives life purpose.  Now we have connected motivational dots in the mind of the participant and moved them toward the why of being a better patient. 

Wellbeing:   We also need to make participants more cognizant of the short term benefits they are experiencing today.  They are doing it because it gives them more energy today sleep better tonight.  Perhaps they are now relaxed and less stressed.   

Incentives:  Regardless of your preference for carrots or sticks in your program, the most important part of their application is to tie them to moving or incenting the participant to move to the next stage of your core loop.  

Steve:  The why addresses reasons to start the loop.  But a loop implies a return, so how do we sustained motivation within the loop?   

It turns out theory and supporting research by Deci and Ryan on motivation indicates motivation increases when we get 3 needs met. 

SDT Competence:  SDT tells us people are more motivated to do things if they feel they are developing competent gaining mastery.  Clear recognition of improved skill or competency then feeds confidence.   So if we want to motivate people to take care of their health, we should spend a lot of time and effort in making them a skilled, confident consumer of healthcare.  We should train them for the job of being a better patient. 

SDT Relatedness:  Humans are social beings. Wellness programs that want people to close prevention gaps need to facilitate relationships between the participant and key social resources, their Primary Care Doctor is critical among these relationships.  We know this relationship is a key driver of motivation to modify risk and improve your health. 

Now lets take a deeper look at Autonomy…

Steve:  SDT Autonomy:   SDT tells that motivation is highest when people do not feel controlled or manipulated by their circumstances.  Many come to wellness from this controlled side of our chart.  They know they should.   Everyone tells them to.   

So our goal is to move our participants to the autonomous side of motivation and here you can see it may begin with a goal, both practical (SMART) goal and then made most powerful when tied to that aspirational we spoke of earlier. 

Steve: So as we wrap up this section wellness needs to move from a transactional or encounter model that works well in acute care to an experiential model.

First we need to change our thinking from a transactional model where the value is delivered in brief highly structured series of transactions to one that is experiential.

My friend, colleague David Vinson is a passionate advocate for this concept of  health and wellness as an “experience”.  The question is how?

What Constitutes an Experiential Model?

Longitudinal – There needs to be a strategic line of communication and interaction that is ongoing.  This appeals to both our sense of relatedness and responsibility. If we expect to interact again we expect to be accountable.

Conversational – Meets people where they are at, respects their values, concerns, questions. 

Relational – Develop a relationship where there is a sense of concern and trust.

Steve: So to summary the value of the core loop in our roadmap to building a better patient. 

First we must present them with a better WHY.  Getting participants to tie mundane health goals directly and explicitly to life goals or purpose in life increases motivation for health and prevention. 

Moving the value of health forward in time with attention to how a healthy lifestyle leads to feeling. 

Build better patient skills, recognizing and rewarding increased mastery of those skills over time leads not only to increased motivation but confidence as well.  

And lastly a really compelling core loop must meet the individual’s needs, feel rewarding and provide clear value with minimum friction to engage and re-engage the loop. 

Ted:  Thanks Steve.  Now that we’ve looked at the science and strategies for building a better patient,

Jesse is going to give us some practical examples of how employee wellness programs can redesign themselves to build a better patient. 

You will remember that in the first section we showed that standard employee wellness programs, that exclude the healthcare system, do not work for participants like Bart and Nancy.   If you want to close prevention gaps and improve biometrics you have to include the healthcare system, with data flowing from the healthcare side to employee wellness.  (CLICK – ARROWS APPEAR)

And we saw that the PCMH studies give us a roadmap for what works to produce better patients, improve healthcare quality and reduce costs.   So we have a proven model to work from, that involves including the primary care doctor, finding and closing prevention gaps, and getting biometrics under control.  So everything you see here is what those 30 studies have shown to be effective. 

What I’m going to show you in this section is a pragmatic design that you can use in your employee wellness program, to build a better patient.  It’s not dependent on any particular vendor or technology.  But it is based on what the PCMH studies have shown to be effective.  It does include the healthcare system in our loop.  And it follows the principles for engagement and motivation that Dr. Steve talked about.    The point of this section is to show that building a better patient is something you can do, in your wellness program, with your vendor of choice. 

Here are the steps (click click read).  Now we’ll go through these steps with some examples, and talk about how it works for participants like Bart and Nancy. 

*) Step 1:  Patient Activation.  This is all the things you do to build intrinsic motivation and get participants trained and ready to work with their doctor.

*) Step 2:  Annual Wellness Visit.  This is a proven part of the PCMH model, where participants meet with their doctor to work on prevention. 

*) Step 3:  The Annual Wellness Visit produces a list of the prevention gaps and what followup is needed for biometrics. 

*) Step 4:  The participant works with their doctor to close the prevention gaps and get biometrics under control. 

*) Step 5:  The employee wellness program helps participants improve lifestyle

*) Step 6:  This is where we close the loop.  If participants have done everything they need to do, and completed the whole loop, they can earn incentives. 

Let’s talk about step 1, patient activation.

Better patients don’t happen by accident. (CLICK) If you want to build a better patient, your employee wellness program needs to start with building participants’ knowledge and skills in working with the doctor.   (CLICK)

But how do you do that?  Employers of all kinds train their people for the jobs they will be doing. So creating better patients is similar to other kinds of training that employers are familiar with.

Topics should include: how to find a doctor if you don’t have one, how to make the appointment, what to expect at the annual wellness visit, what follow-up may be required, how the visit(s) are billed and paid for, and how lifestyle change can improve the numbers the doctor measures.  

One important aspect is have participants link being healthy with their Purpose and core values.  For example, we’ve used Dr. Vic Strecher’s JOOL app as a way to link health to purpose in programs we’ve run for clients.  We have to give them a bigger WHY that motivates at an intrinsic level.   Make sure your training includes the WHY and not just the HOW.

One practical approach is to use online training modules supplied through your wellness vendor, along with health coaches who can answer questions and address specific concerns on a private, one-on-one basis.  

Failing to do this step is the biggest pitfall that we see for employee wellness programs that want to include the primary care doctor.  When we talk to programs that had trouble with physician forms, or with sending people to the doctor – those programs did not do a good job in this step. 

Now that we’ve gotten the ball rolling, let’s see how the process works for Nancy.   So it starts with patient activation as we discussed. 

The next step is for Nancy to go to the Annual Wellness Visit with her primary care doctor.  The whole point of the Annual Wellness Visit with the doctor is to go through the prevention checklist.  So Nancy and her doctor are going to find these four prevention gaps.  Nancy can close three of those gaps at the primary care doctor’s office at the same time as the Annual Wellness Visit.  (CLICK) So that means all she has left is the mammogram. 

If you look at the next step, it’s for the doctor to document the prevention gaps (CLICK) and then the wellness program gets the data. (CLICK).  The wellness program then sets up the customized goals for Nancy based on what the doctor found. 

When Nancy gets the Mammogram, (CLICK) the wellness program will get the data saying it’s complete.   So she has met her personalized goal, and she’s closed all her prevention gaps. 

CLICK.  And she earns her incentive. 

In other words.  Having the right things in the LOOP and having incentives for getting the right things done is making Nancy a better patient. 

She’s improved her knowledge and skills, she’s identified and closed the prevention gaps, and she’s gotten rewarded for doing so. 

OK, let’s talk about Bart.  As you probably remember, he had high blood pressure and he knew about it, but he hadn’t been working to keep it under control.   The first step, Patient Activation, is really important for someone like Bart.  He needs to build a bigger “why” in order to have a reason to start this process.  He also benefits from training about how to find a good primary care doc, and how to work with the doctor. 

(CLICK) so now Bart chooses a doctor and goes to his Annual Wellness Visit. 

At the doctor’s office, they are going to check Bart’s blood pressure.  The doctor will write a prescription and schedule a follow-up appointment.  (CLICK)

So based on the information from the doctor’s office, the wellness program is going to assign Bart some personalized goals.  (CLICK) He needs to have his high blood pressure under control as verified by the doctor.  And, because of his BMI he’s going to have some lifestyle change goals as well for physical activity and/or losing weight.  For an overweight patient with high blood pressure, improving lifestyle is very important.

So now Bart’s job is to fill his prescription, take his medications, and go to his followup appointment with the doctor.  The medication worked, and now his high blood pressure is under control as verified by his doctor. (CLICK)  And that data goes directly to the wellness program vendor.  Bart met his goal for blood pressure. 

Like 85% of your participants, Bart carries a smartphone with him.  He downloads an Apps that lets him prove how many steps he’s taking every day.  So this is real data, measured by an app.  (CLICK).   And now he’s meeting his personalized lifestyle goals in a provable way. 

And now we can close the loop (CLICK).  Bart gets his incentives for the year, because he met both of his personalized goals. 

So we can see that if Bart goes through this process and earns the incentive, he is becoming a better patient.  He’s working effectively with his doctor, and his blood pressure is under control. 

Now, we’ve been talking a lot of about how data, and especially data from the healthcare side, drives the process.  I want to be clear – this is a pragmatic process that you and your chosen vendor can do.  There’s no magic. 

The most common way that wellness vendors collect data from doctor’s offices is that they have a paper form, which the doctor’s office fills out and faxes back to the wellness vendor.  Your better wellness vendors can turn those faxes into data without a lot of manual intervention and retyping.  So that part is automated. But paper and FAX are still the pragmatic way to collect data. 

And doctors do fill these out and sign them.  You’re going to train your participants in how to make the appointment and ask the doctor to fill out the form.  And if you do that right, our experience across thousands of participant visits is that 98% of the time the doctors fill out the form and fax it to us.  

It’s possible to have a wellness program that builds a better patient, using the same budget that’s in place at most employers today.

For the same cost as an onsite screening, a wellness vendor can manage the process of building a better patient:

•       Getting participants ready for their visit

•       Collecting data from the Wellness Visit and Follow-Up Visits

•       Having health coaches available to assist participants

•       Administering incentives and keeping you compliant

•       Providing aggregate reports based on the physician data

So the pragmatic approach is to redirect the budget that’s been used for onsite screenings, and use those dollars toward building a better patient. 

You might worry about adding more doctor visits onto the health plan.  However, studies show that participants who work with their primary care doctor on prevention have lower overall healthcare costs.  That makes it a win/win for the wellness program and health plan.

So I can’t emphasize enough that building a better patient is a practical thing that employee wellness programs can do.  You can work with a vendor, or you can start doing this yourself.  I don’t want anyone to leave this webinar and say, building a better patient is nice in theory but impossible in practice.

To that end, we promised to share a demo site with webinar participants that has a complete, working example of this design for building a better patient.  There’s nothing more practical than that – a working example.   This is something you can buy from us or build your own version, today. 

You can see the web address and login information onscreen, we will also send this out via email to webinar participants. 

Jesse:  So here’s the summary. 

Better patients are needed.   If employee wellness is going to succeed in reducing health risks and improving population health, we need everyone to be up to date on prevention.  We need everyone to get their biometric risk factors under control.   And yet, all of those preventive services, all those medications for biometrics, all those follow-up appointment – take place OUTSIDE of employee wellness.  So the only way for employee wellness to succeed is to create better patients who with their doctors to get everything done. 

We have the theory and strategy:  The existing healthcare system, which is designed around acute care, is not designed to motivate prevention and wellness.  It doesn’t create a core loop.  At the same time, employee wellness uses a core loop around screenings, coaching and incentives – that isn’t really effective because it doesn’t connect with healthcare.  To be successful, employee wellness needs to create a new Annual Experience around health and wellness, that creates a motivating and complete loop.  It needs to tie into purpose, autonomy and self-determination. 

Closing the Loop:  There are practical designs available for employee wellness, that include the healthcare system in our process.  They collect data from annual wellness visits and follow-up visits, so that the healthcare system is in our Core Loop.  They activate patients with education and skill-building, motivate participants with effective incentives, and measure tangible outcomes that CFO’s want to see.