5 Reasons the Employee’s Doctor Should Be Part of Your Employee Wellness Program

Making the Employee’s Doctor a part of your Wellness Program

Jesse Hercules, President Extracon Science LLC
Dr. Fikry Isaac, WellWorld Consulting

Ted Dacko, Arbor Dakota LLC

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. Fik Isaac.  Dr. Isaac is best known for his role as Vice President of Global Health Services for Johnson & Johnson, as well as Chief Medical Officer for Johnson & Johnson’s Health and Wellness Solutions.  Dr. Isaac has been the author of a number of published, peer-reviewed studies in employee wellness. He’s a medical doctor, and also holds a master’s degree in public health, and is a fellow in the American College of Occupational and Environmental Medicine. 

Dr. Isaac has been a pioneer in employee wellness for more than 25 years, and has become one of the best-known speakers and writers in our field.  Having recently retired from JNJ, he has started an independent consulting business to bring his expertise to a wider group of clients.   

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

Jesse: Extracon brings the doctor into employee wellness programs.

We offer turnkey and custom wellness programs that run on our own technology platform and apps.

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 discussing the problems in employee wellness programs because they don’t include the doctor.  

Then Dr. Isaac is going to draw on his experience and medical training to tell us why the doctor is a natural fit in employee wellness.  

Then Jesse will tell you about a proven, step by step approach for including the doctor.  It’s the process they use at Extracon, but it’s something that you can also use in your own program.

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

Jesse:  Let’s get started

In this first section, we’ll talk about what problems employers are having today, because they don’t have the doctor in the wellness program. 

The first problem. Prevention isn’t‘ getting done.  Only one in four middle-aged adults are up to date on everything they need for prevention.

The second problem: Onsite screenings are not coupled to diagnosis and treatment.   Too many people are not getting the treatment they need. 

The third problem. Employers that are using incentives to improve biometrics are doing it in some really unfriendly and counterproductive ways.

The fourth problem.  Employers are paying twice.  Because their wellness programs don’t coordinate with the doctor, they are paying twice for duplicate services. 

Let’s talk about each of these problems in detail.

Jesse:  Let’s talk about the first problem.  Prevention isn’t getting done.   The CDC research says that only 25% of US adults aged 50 to 64 are up to date on recommended preventive services. 

If you dive into the details (read slide). 

So this is a big problem.   And the strategy most employers are using, to close prevention gaps, is not working.

·         Mammography: http://kff.org/womens-health-policy/state-indicator/mammogram-rate-for-women-40-years/

·         Flu shots: http://www.cdc.gov/flu/fluvaxview/coverage-1415estimates.htm

·         Colorectal Screening: https://www.cdc.gov/media/releases/2013/p1105-colorectal-cancer-screening.html

·         Alcohol screening at primary care:  http://www.jfponline.com/home/article/primary-care-physicians-views-on-screening-and-management-of-alcohol-abuse-inconsistencies-with-national-guidelines/230cb50d7f6b6638a23a3dfbcd0adb8e.html

·         Rates for PAP test: http://www.cdc.gov/nchs/fastats/pap-tests.htm

·         Rates for Tetanus / TDAP: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6404a6.htm

·         Rates for OVERALL PREVENTION:  https://www.cdc.gov/aging/services/

Jesse:  Most employers  are using onsite biometric screenings as their way to close prevention gaps. It’s the #1 thing in the wellness budget.  It’s the biggest thing they do all year.  But unfortunately, you can’t meet the prevention guidelines using an onsite screening. 

What this slide shows is the things employers typically cover onsite in green, compared to the rest of the official prevention recommendations which are in red.   The official recommendations come from the USPSTF, which is the US Preventive Services Task Force.   The official recommendations are tailored based on age, gender and other factors. 

As you can see onsite screenings cover the heart health recommendations pretty well.  But they are missing many of the cancer prevention recommendations.  They are missing the mental health recommendations.  They are missing the items for pregnancy and women’s health.  And although many employers include flu shots, they are missing the rest of the important immunization recommendations. 

And onsite screenings tend to be one-size-fits-all.   They ignore differences in age, gender and risk level. 

So prevention isn’t getting done, and the typical approach in employee wellness is not enough to fix the problem.   And while we’re talking about screenings…. (transition)

Jesse:  There’s another problem with onsite screenings.  The second problem in our list is, that onsite Screenings are not coupled to diagnosis, treatment or medical follow-up.  And many people are not getting the treatment and follow-up they need. 

So let’s make that really clear with an example.  If an employee attends an onsite screening, and there’s a problem, what do they walk out with?  What’s literally in their hand when they walk out?  It’s a report or a note that says, basically, “Please see your doctor about this test result”.    They don’t walk out with a solution.  They walk out with one more item on their to-do list. 

Now, contrast that with what happens if that same screening happened at the doctor’s office.  What do they walk out with?   The first thing is a prescription for a medication that will resolve the problem.  The second thing is an appointment card that says when their follow-up appointment is scheduled.   A problem found at the doctor’s office leads directly to a solution.  A problem found at a screening?  Who knows if it leads to a solution? 

Jesse:  And in fact, It turns out that most employee wellness programs do NOT know if the problems found at these onsite screenings were treated and resolved. 

We sent a survey out to over 8,000 employers and wellness programs earlier this year.  When the surveys came back, the results said that 58% of employers don’t track anything that happens after the biometric screening.  Only 3% track whether the problem was treated and resolved according to the participant’s doctor.

But you can see it’s very popular to track whether participants talked to a health coach.  Is that the right answer?

Jesse:  We don’t think so.  Talking to a coach does not actually fix biometric problems like high blood pressure, high cholesterol, or high blood sugar.    People still have to go to the doctor. 

And to make that clear, you should ask, what do they walk out of that Coaching meeting with?   What’s the take-away.  Aha.  The coach tells them to “Please see your doctor”.  It’s the same thing they walked out of the screening with!  It’s literally the same thing.   

Coaching does not fill the gap when the doctor is left out of the program. 

Jesse:  The third problem is unfriendly incentive designs for biometrics.  I’m not against incentives for biometrics.  I just think the way they’re being done is really unfriendly and unproductive. 

First, they have that onsite screening.  It’s basically a test that you’re requiring participants to take.  But then many participants will fail the biometric test and have penalties applied.  Then they get a letter in the mail saying that if they want to stop paying the penalty, they have to fight an appeal against the employer.  And they will get this complicated appeals form.  And the doctor is only involved after the person fails the test and is trying to get out of paying the penalty.

This approach has generated a lot of backlash and more than a few lawsuits.  There has to be a better way to improve biometrics than this. 

http://www.businessinsurance.com/article/20150118/NEWS03/301189978

Jesse:  So here’s the last problem.  Employers are paying twice.   In many cases they are paying for an annual physical, a well-woman visit or a prescription renewal – and then paying again to have the same tests done at an onsite screening.  If you’re paying for an annual physical and also an onsite screening – that’s paying twice.  

There’s a more subtle example of paying twice.   Many of your employees today are going to the doctor once a year for a prescription renewal.  This could be allergy medicine, birth control medications, blood pressure medication, or anything else.  If you’re paying for a doctor visit and the only thing that gets accomplished is a prescription renewal, that’s a missed opportunity.  That prescription renewal visit could have been turned into a screening and wellness visit along with prescription renewal.

So when you think about it, paying for a prescription renewal visit and then paying for an onsite screening is also paying twice. 

In our 2016 survey, we asked employers to estimate on how many of their employees already see a doctor every year for a prescription renewal or annual physicial.   For most employers it was almost half.  At some employers, it maybe as high as 80%.   That’s a lot of times that employers are paying twice. 

Ted:  So that’s section one, on the problems that employee wellness programs are having because they don’t include the doctor.   But there is a solution, and that solution is to start including the employee’s doctor in the wellness program. 

Now in section 2,  Dr. Isaac will tell you why the Doctor is a Natural Fit in Employee Wellness programs. 

Dr. Isaac:As a doctor, I can tell you that doctors are not only interested in sickness.  Doctors have the training, tools, and desire to move your people toward wellness. 

Dr. Isaac:  One of the reasons doctors are so effective at moving the population toward wellness is that they are trusted by the patients.   This study shows the doctor is trusted more than anyone outside the family.

Dr. Isaac:  Trust is critical to success for wellness programs.  But not all wellness programs are trusted.  (discuss study).

Collaborating with the doctor is a good way for wellness programs to build trust with participants.

Trust issues in traditional wellness

http://www.brodeur.com/communications-disconnect-hinders-workplace-wellness-programs-brodeur-survey-suggests/

Dr. Isaac:  As we know, many adults don’t have a primary care physician (discuss statistics).  Does it matter to have a primary care physician?   The answer is yes. 

Dr. Isaac:  Here are the benefits of having a primary care doctor.    Having a doctor is significantly better than not having a doctor. 

Dr. Isaac:  New research is showing it’s not just about having a doctor.  The type of primary care relationship is also important. 

It’s not enough to move people from the red box to the yellow box.  We don’t want them to only see the doctor when they’re sick or need a prescription renewed.

The new research is showing you will have better health outcomes and lower health costs if participants move into the green box, where they work with the doctor on prevention and care coordination.

Dr. Isaac:  Here’s a summary of the recent research showing what happens when participants have the right kind of primary care relationship, focused on prevention and care coordination.

Dr. Isaac:  Here are some of the numerical results from the studies we just talked about. 

These are big results, much bigger than most of the results seen in the wellness studies.

Geisinger Health Study

7.9% total healthcare cost savings

$53 PMPM savings over 90 months

Vermont Blueprint for Health Study

$482 per member per year healthcare cost reduction

Costs reduced $5.80 for every $1 spent.

Community Care of North Carolina Study

9% savings per beneficiary

$312 per member per year savings

BCBS Louisiana Study

$25 PMPM total healthcare cost reduction

Dr. Isaac:  As I have said for25 years in these presentations, Wellness works and prevention pays.   If wellness programs can move people into the right kind of primary care relationship, everyone benefits.  The employees will benefit from better health, the health plan will benefit from lower cost, and the doctors benefit from doing the kind of work they enjoy most – moving patients toward wellness.

Ted:  So at this point we’ve explored what the problems are from not including the doctor, and why the doctor is a natural fit for employee wellness.

Now Jesse will talk to you about how employee wellness programs can work with the doctor in a pragmatic and proven way. 

Jesse:  Thanks Ted.

Jesse:  We’re going to build up a diagram of how to work with the doctor.   Obviously, it starts when the wellness program launches and you communicate the program to participants.    You will ask participants to visit their doctor for their Annual Wellness Visit.  Participants who don’t have a primary care doctor will need to get one, so they can do this annual wellness visit.  

Now, notice what’s not here.  There is no onsite screening.   It’s not needed, because you’re working with the doctor. 

Jesse:  The purpose of the annual wellness visit is for the doctor to go through the prevention checklist and get the person up to date on prevention.   If they need a flu shot, or a cholesterol test, or a depression screening – all of those things can happen right at the doctor’s office.  

If they need a colonoscopy or a mammogram, for example, that can’t be done at the primary care doctor.  So in those cases the primary care doctor makes a referral to a specialist.  

The Annual Wellness Visit is relatively new.  When the ACA was passed in 2010, it included a rule that the annual wellness visit and any services rated A or B by the USPSTF are covered under basically all health plans at 100% with no co-pay to the patient.   It’s a standardized product, and it’s charted and billed in a standardized way.   That’s really good for employee wellness programs, since everyone is on the same page about how this visit works. 

Jesse:  So here’s what we hope most of our patients walk out of the Annual Visit with.  The Annual Wellness Visit is complete.  That means people have a primary care doctor, and they are working with their doctor on prevention.  It’s all the things Dr. Isaac talked about.    Then, the second checkmark means doctor says your biometrics are OK.  So your blood pressure, cholesterol, and glucose are within the healthy range, or at least they are as good as they can be given your unique circumstances. 

And last, the doctor says we closed any gaps in prevention, so you’re up to date on prevention. 

I think we can all agree that if participants reach this destination, it’s a huge win for the wellness program. 

Jesse:  But of course sometimes there is a problem.   If there’s a problem with blood pressure, cholesterol, glucose or other biometrics, they will walk out with a prescription and a followup appointment.  ()

And sometimes there are gaps in prevention that can’t be closed at the primary care doctor’s office.  For example if a mammogram is needed.  So the patient may leave with a list of any prevention gaps, and a referral to a specialist to get those gaps closed. 

Jesse:  So, here’s an update to our slide.  There’s the Annual Wellness Visit, and then

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some participants will need to take their medication and complete a followup visit and re-test for Biometrics.  The primary care doctor will re-test the biometrics.   And in most cases, the primary care doctor will say, now after treatment your biometrics are OK. 

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Some patients will have a list of one or more prevention gaps to close.  Such as a mammogram.  So they go to the specialist to get that mammogram.   And when each gap on the list is closed, then they’re up to date on prevention. 

So I think this is still pretty simple. 

And at this point we arrive at the same destination.   The same three checkmarks.  The Annual Wellness Visit is Complete.  Your Biometrics are OK.  And You’re up to date on Prevention.  Different paths for different people, but the same destination.   And it’s still a huge win for the wellness program.   This is where we want people to be. 

Jesse: 

But we do have to ask a question here.  Will the participants do their part?   In the absence of a wellness program, the research suggests they may not. 

Even though they have insurance, many don’t have a primary care doctor today.  Even though they can have a free Annual Wellness Visit, most are not doing so today. 

And after the wellness visit, if the doctor writes them a prescription, will they fill the prescription?  Not always, ….(read slide). 

 In the absence of a wellness program, they may not do their part.  But the good news is, you’re running a wellness program. 

Jesse: 

So the solution here is to add incentives to motivate participants.  

If we want them to get a primary care doctor and complete an annual wellness visit, let’s put an incentive on it. 

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If we want them to work with their primary care doctor until the doctor says their biometrics are OK, let’s put an incentive on it. 

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And if we want them to get up to date on everything they need for prevention, let’s put an incentive on it.

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I know it looks really simple onscreen.  But this is the most powerful approach to wellness incentives that we know of today.  It’s light years ahead of what most companies do.  It’s putting  the incentives on results.  And yet it’s a friendly, respectful approach that goes over well with participants.   We think this is a real game changer. 

But now you’re asking, how can a wellness program possibly get the right data at the right time to do these kinds of incentives?  How do you solve the data problem? 

Jesse: So how do you collect the data from the doctor visit? 

It’s a combination of easy and low-tech for the doctor and patient, with a high tech and automated approach on our end as the wellness vendor.  Participants take a paper form to the doctor’s office for their Annual Visit or for their Follow-up Visit.  The doctor’s office fills out the form and faxes it to us.  On our end, we have a cloud-based process to turn those Faxes into data in an accurate and efficient way.  The technology we use is guaranteed 99.9% accurate and is scalable for use in large organizations. 

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Wellness programs often ask if doctors will really do their part and fill out these forms and send them to the wellness vendor.  We’ve been taking in physician forms for years now, and across thousands of participants this year, 98% of doctors return the completed form on the first try.  The remaining ones are usually sent after one phone call from the participant.   So this is a process that physicians are happy to do.

Jesse:  Let’s go into a little more detail on the Annual Visit Form.  You want to make it a one page form. 

Obviously, it asks for biometric measurements.  Blood Pressure, Cholesterol, Glucose, BMI.  And then it asks the doctor whether those biometrics are OK for that patient, or whether treatment and follow-up are required. 

Then it asks about prevention status.  At the end of the wellness visit, is the participant up to date on everything they need?  If not, what is the list of things they need to complete. 

And finally some information about lifestyle.  Are they tobacco-free?  Are they able to do normal amounts of physical activity?  If they are overweight, is it safe for them to try to lose weight? 

All of this can fit on one page, front and back.

Jesse:   Some participants’ doctors will say they need treatment and retesting for common biometrics like blood pressure, cholesterol and glucose.

They will bring a form to the followup appointment.  The Biometric Follow-Up Form is very simple.

After treatment, what are the participant’s updated biometrics?    What are the new numbers?

And second, does the doctor consider the problem resolved?   Are we done? Or do we need to go another round? 

This approach allows the wellness vendor to identify whether each biometric problem across your organization was treated and resolved by a doctor.  That’s really powerful data that only 3% of wellness programs get today.

The Prevention Follow-Up form is even simpler.  It’s signed by the doctor who is doing the preventive services, such as a colonoscopy or mammogram.  They say what they did, and sign at the bottom.

It’s really simple.  () But it allows the wellness vendor to compare the list of needs identified at the Annual Wellness Visit with the list of Completed preventive services to see if the person is Up to Date on prevention. 

And again, that’s powerful information that very few wellness programs have today. 

If you use the incentive approach we’re talked about, you will need some way to show participants where they are in the process and what they still need to do.  There are many ways to do this, but I want to share a simple example that you can use in your own program. 

What you’re seeing here is a set of 5 badges corresponding to the incentives we’ve talked about here.  Annual Visit badge, the Prevention Badge, the Biometric Badge, the Tobacco-Free Badge, and one more.   You’re also seeing a Lifestyle badge, which we recommend.  It’s based on app or device measured steps, or BMI reduction. 

A badge-based approach is fun and gamified, and makes it easy for participants to see what their status is.  It’s like Pokemon, your mission is to collect them all. 

A badge based approach also makes it simple to set up incentive levels, like you see here.  So you can set the participant’s health plan premium reduction based on how many badges they earn. 

In a world of complicated point structures, we think an approach like this makes a lot of sense, and puts the motivation on getting all the badges.  After all, there are a lot of dollars on the line for getting that last badge. 

Proper promotion of this concept to employees is essential.   Employees have to understand why you’re bringing the doctor into the wellness process, and what they need to do to get the most out of their Annual Prevention Visit.

You’ll start by explaining that people who work with their primary care doctor on prevention have better health outcomes.   Then, you need to educate participants on how to ask for the appointment and what to say to the front desk on check-in.  They will want to have a list of questions for the doctor:

Questions may include:

•       Am I caught up on all screenings and immunizations?

•       Do you have any recommendations on how I can improve my health?

•       How are my levels for cholesterol, blood pressure and glucose?  What can I do to keep those numbers under control for the future?

You’ll also want to educate on how to avoid turning the Annual Preventive Visit into a sick-care visit.  If they are sick, they should reschedule the Annual Preventive Visit for a time when they are well.   Trying to combine an E/M visit with a wellness visit simply doesn’t work with doctor’s billing and coding systems.  They employees need to understand that to make it a zero-copay visit, they have to follow the rules of a wellness visit.

If you do a good job of this, and your physician forms are well designed, you’ll have a smooth ride.  

One of the biggest questions we get about including the doctor in the wellness program is, can the employer afford it?  If we upgrade the quality of the program by including the doctor, will it require a huge increase in our wellness budget?  Will it require a huge increase in the health plan budget?

There is some good news on this part.  First, a physician based approach actually requires LESS from the wellness budget.  The biggest item in most wellness program budgets is the onsite screenings.  Those are not needed.  (discuss rest of slide).

Jesse:

So I’d like to start our summary in kind of a fun way.  I call it 5 Reasons the employee’s doctor should be part of your wellness program.

So let’s start with #1. 

1. Doctor-Patient Relationship:  Your wellness program is building up the doctor patient relationship.  You’re actively encouraging people to get a primary care doctor and work with their doctor on prevention.  A lot more of your employees will have the right kind of doctor patient relationship.

2. Better Prevention:  Your employees will be sitting down with their doctors every year to see what prevention is needed and close those prevention gaps.  Right now maybe 25% of your employees are up to date on everything they need.  That number can be a lot higher if you bring the doctor into your wellness program and have an incentive for people who complete all their prevention. 

3. Better Follow-up:  The doctor combines screening, diagnosis and treatment in one step.  So you don’t lose people after the screening.  They walk out of that visit with a prescription and a follow-up appointment card in their hand. 

4.       Better Data:  Working with the doctor gives you access to better data. Data on preventive services comes from the electronic medical record – not what the patient remembers when they take the HRA. Biometric levels are more meaningful when the doctor says if those numbers are OK for that person. 

You’ll actually get the data on the biometric re-testing after a person is treated.   If they go to a specialist for preventive services, you’ll get notification the services are complete.  In so many ways, you are getting better data. 

5. Better Incentives:

So most employers today have an incentive for taking the health assessment and going to the biometric screening, and maybe for high-risk participants to talk to a coach.   By including the doctor, you can do better. 

You can have an incentive for people who go to an Annual Preventive Visit and work with their doctors ever year on prevention.  

You can have an incentive for people who are up to date on all the Prevention recommendations, as verified by their doctor.

You can have an incentive for people who have worked with their doctor to get their biometric issues resolved.

By including the doctor, you can actually put the incentive on things that matter.

Summary

•       Wellness Programs have several problems caused by not including the doctor. 

•       The Doctor is a Natural Fit:  Fully aligned with the wellness program and ready to help with prevention.

•       Three Steps to Work with the Doctor:  Annual Preventive Visits, Follow-up Visits, and Incentives.