What’s Next in Wellbeing:  Physician and Smartphone Integration

Jesse Hercules, President Extracon Science LLC

Thanks everyone for being here today.   My name is Jesse Hercules, and I’m the president of Extracon Science.  This title of this webinar is…

Extracon creates digital employee wellness programs that include the doctor and the smartphone. 

Our programs use design, technology and incentives to create engagement and results.

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. 

This talk is about employee’s primary care doctor, and the smartphone in the employee’s pocket, into the wellness program.

So here’s our agenda for today.   

First, I want to introduce some of the problems employee wellness programs are having, because they are not using the doctor and the smartphone. 

Then we’ll talk about why and how to use Apps and devices in employee wellness. 

Then we’ll talk about how to bring the employee’s primary care doctor into the wellness program. 

Finally, we’ll wrap up with a summary and some Q&A.

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.  Lack of primary care relationship.  Many employees don’t have a primary care doctor and the wellness program doesn’t do anything to put doctors and patients together.

The second problem.   Employee wellness screenings are not coupled to diagnosis, treatment and medical followup.  It’s just a screening, and lots of people don’t get treatment and medical followup.  

The third problem. The CDC has found that only 25% of middle-aged adults are up to date on everything they need for prevention.

The fourth problem.  Lifestyle isn’t taken seriously.  Programs for physical activity and BMI are short term programs based on inaccurate data. 

Lack of Primary Care Relationship:

•       Less likely to receive recommended preventive services

•       Lower Quality of Care

•       Lower Satisfaction with their healthcare

•       Higher Healthcare Utilization

•       Higher Cost of Healthcare

•       Higher rates of ER / Emergency Department Use

•       Source:  Health Affairs

•       Primary Care:  A Critical Review of the Evidence on Quality and Costs of Health Care (2010)

So we talked about what’s in the red box, all the people who don’t have a primary care physician.   But I also want to talk about the even larger group of people in the yellow box.  Who have a primary care doctor but only see the doctor when they are sick.   The research suggests that’s not the best approach.   In fact, patients who are in the green box… who work with their primary care physician on prevention every year, and work with their primary care doctor to schedule their other healthcare have better health outcomes and lower costs than those in the yellow box.   

But if you want the best health outcomes and lowest costs, the research says it’s not enough just to have a primary care doctor.  The Type of Primary Care Relationship also matters. 

As we just showed, it’s a big deal to move from not having a PCP to having a PCP.

But the research also shows that many people only see their PCP when they’re sick or when they need a prescription renewed.  That’s not enough.

The best health outcomes and lowest costs come when people work with their primary care doctors annually on prevention, and to coordinate care. 

It’s not enough to have a PCP, you have to work with your PCP in the right way.

A major goal of wellness programs should be to move participants along this path to a better primary care relationship. 

Let’s talk about the next 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, flu shot rates remain stubbornly under 50%

37.1% have not had their tetanus vaccination

35% who need a colonoscopy have not had one. 

20.0% of women have not completed the

recommended mammogram screenings

30.6% have not had the recommended PAP test

And a whopping 78.8% who are recommended for pneumonia vaccine have not had it.  

Many of these people have a primary care doctor.  But nobody is asking the doctor and patient to sit down together and go through the prevention checklist. 

So as a result, most people have gaps in prevention that are not getting addressed. 

Most employers today are doing an onsite screening.  And you can’t get to full USPSTF compliance with an onsite screening.  It doesn’t cover most of the items.  And it’s one size fits all, regardless of age, gender or risk level.

And that brings us to our second problem.  Everyone does onsite biometric screenings, but they are not coupled to diagnosis, treatment or medical follow-up.  And here’s how I want you to think about it.  When someone has a problem at their screening, like high blood pressure or high cholesterol…. What do they walk out with?  What’s literally in their hand when they walk out?

They don’t walk out with a solution to the problem, do they?  There is nothing here that solves the problem.  Do you think their blood pressure is now resolved when they get that note that says see your doctor?  Is their cholesterol resolved at the end of that phone call with the coach?  Of course not.   The only way the problem gets solved is if they work with their primary care doctor. 

So we’ve said employers do onsite biometric screenings and participants leave the screening with a piece of paper saying they should talk to their doctor.  And maybe they get a phone call or two from a health coach asking them to work with their doctor.  But do they really work with their doctor and resolve the problem?    It turns out that employee wellness programs have no idea 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.  22% track whether the participants talk to a coach after the screening.  So the vast majority of wellness programs have no way of knowing if people they screened ever went to a doctor or got treatment or resolved the problem. 

And yet.  We asked employers what they SHOULD be tracking.  What’s the best thing to track.  64% of employer said that the best thing to track is whether the participant’s doctor says the issue has been treated and resolved.  Later in this presentation we’ll show you exactly how to track that, and how to put incentives on it.  It makes sense, right?  And it’s the opposite of what employers are doing today, which is our next problem. 

The second big theme of our presentation was to use the smartphone in the wellness program.

And here’s the last problem.  85% of your employees now carry a smartphone in their pocket.   So there is this incredibly powerful tool for measuring steps, physical activity, weight, nutrition, and other things.  Wellness programs designed around accurate smartphone data can really transform your results.   But that’s not the directions employers are going. 

In our employer surveys, we are finding that even in 2016, 90% of employer programs for physical activity allow self-report data.  Even the ones that also allow apps and devices.  What you’re seeing in that pie chart is that only 10% of employer programs require accurate app & devices data only.  That means that ultimately, the programs are designed around the limitations of that paper walking log you see on the slide.

If you have manual daily logging, that means your programs can only run 6 or 8 weeks.  People get tired of logging. 

And if you have inaccurate, self-report data, that means your incentives must be small. 

So that’s how employers still have ineffective programs, even though more than 50% are allowing apps and devices into their programs.

And here’s the last problem.  85% of your employees now carry a smartphone in their pocket.   So there is this incredibly powerful tool for measuring steps, physical activity, weight, nutrition, and other things.  Wellness programs designed around accurate smartphone data can really transform your results.   But that’s not the directions employers are going. 

In our employer surveys, we are finding that even in 2016, 90% of employer programs for physical activity allow self-report data.  Even the ones that also allow apps and devices.  What you’re seeing in that pie chart is that only 10% of employer programs require accurate app & devices data only.  That means that ultimately, the programs are designed around the limitations of that paper walking log you see on the slide.

If you have manual daily logging, that means your programs can only run 6 or 8 weeks.  People get tired of logging. 

And if you have inaccurate, self-report data, that means your incentives must be small. 

So that’s how employers still have ineffective programs, even though more than 50% are allowing apps and devices into their programs.

So here’s what it looks like to participants.

Most program have a significant, annual incentive based on the things on the right.  Did you take the health risk assessment?  Did you go to the biometric screening?  If you’re high-risk, did you complete a coaching program?  Are you a tobacco user?  And in some cases, are your biometrics in the right place.  The message is:  those are the important things.  Lifestyle change is not on the list.

In fact, companies routinely run short-term programs for lifestyle.  They run a 6-week walking challenge.  They have a biggest loser contest.  They have a series of lunch & learns on nutrition.  If anything, there are some water bottles and t-shirts for the winners. Employers are treating lifestyle as if it’s not important. 

And it’s because they are not really using the smartphones. 

Ok, so those are the problems.  In the next section we’ll talk about taking lifestyle seriously by using Apps and Devices in employee wellness.

The good news is that today, accurate and automatic measurement is here.  Both apps and devices can give you accurate measurement for steps and weight. 

Most of you are familiar with FitBits and similar devices.  The same companies that make those devices also make scales that have a wireless connection.  They send your weight up to the cloud so it can be tracked along with your activity.  So the good news is these devices are available everywhere, including your local Target.  The bad news is that these devices cost a lot of money if you buy them for everybody. 

On the other side of the screen, by now 85% of working adults with health insurance now have a smartphone.  Every smartphone built since 2013 has the same kind of sensors built in that are in a FitBit.  So your phone can be your FitBit, and for 85% of the people there’s nothing you have to buy.  Just get an App.  Now take a look at the photo on the right.  This is showing how an App can use the cameras built into the phone to get an accurate weigh in.  The person steps on the scale, and the App gets a picture of the scale readout, and the person’s face.  So the smart phone just turned an ordinary dumb bathroom scale into an accurate, connected data source. 

So not only can the smartphone be your step tracker, it can also replace the expensive wireless scale. 

So if most people aren’t using a device to track today, why not just buy them one? 

That’s a really big investment / 10,000 people = $1mm

And it turns out that it’s not even a very effective strategy. 

OK, so if devices are too expensive and people stop using them, why not just get people to download an App?  That’s free right?

Well…15% of the consumer apps are only used once.

Only about 35% are used more than 10 times

So what can wellness programs do?  Actually, you can do better than those consumer number because you have a bigger set of tools.  You can integrate apps and devices with wellness programs and incentives.  And that’s the solution. 

So here’s what we advocate.  In your wellness program, use ONLY the accurate data from apps and devices.  No self report allowed.   The most common approach is to have an online wellness portal that has an App and connects to one or more devices. 

Now your data logging is automatic.  That means you can run longer programs that cover the whole year.  We are real fans of Team and Social Challenge programs.   These are more fun and more engaging than a simple tracking program.

Since you have accurate data, now you can start using more powerful incentives.  So instead of a t-shirt or a water bottle, you can have incentives that are as big as your incentive for the health assessment or biometric screening. 

So here’s an example of a lifestyle incentive that makes sense to us.     

So let’s read through it.  The Quarter 1 goal is 5,000 steps per day as measured with a fitness device or App that brings data into the wellness portal.  That’s enough to get the sedentary people moving, but not so difficult that it’s going to discourage anyone. Most sedentary people get about 1500 steps a day, so 5,000 is a big improvement. If you meet the goal, then you keep your lifestyle incentive dollars for next quarter. 

If you’re overweight, you have another choice.  You can lose 5 lbs per quarter and meet the incentive that way.  5lbs is a pretty good target since it’s large enough that it’s not just going to be a day to day variation.  But it’s small enough to be achievable.  The goal keeps moving, so you can’t just lose the same 5 pounds over and over. 

5lbs or 5,000 steps – this is easy for participants to remember and understand.  If you give people a goal based on losting a percentage of their bodyweight – you’d be amazed at how many of them just cannot do the math correctly.  These are quarterly incentives.  Long enough for people to make some real progress, but short enough to help them stay motivated.  And it works for your payroll department - payroll only has to change the incentive list four times a year.

Because lifestyle is REALLY important.  This chart is from a famous study in the New England Journal of Medicine.  This was a large group of middle-aged, mostly overweight adults with pre-diabetes.  They were testing a lifestyle intervention against a medication approach, using the medication called metformin.  On this chart, lower is better.  So the placebo is at the top – not effective at all.  People’s A1C keeps going up over time.  Look at medication versus lifestyle.  Lifestyle is actually working better than medication at reducing A1C and preventing diabetes. 

In other words, Lifestyle is really important.  Physical activity, and moving your BMI in the right direction are really important.   

Reduction in the Incidence of Type 2 Diabetes with Lifestyle Intervention or Metformin

Diabetes Prevention Program Research Group

N Engl J Med 2002; 346:393-403 February 7, 2002 DOI: 10.1056/NEJMoa012512

We think face to face coaching is part of this next practice.  Here’s why. 

There was a famous study done by Albert Mehrabian and his collaborators at the University of California.  What they found was that only 7% of the credibility and effectiveness of communication came from the words themselves.  It’s not what you say, it’s how you say it.  38% of the effectiveness came from the voice and the tone – the things you get from a telephone call.  But fully 55% of the impact came from body language and facial expression.  So here’s what that means for coaching.  When you can see someone’s face it’s more than twice as credible and effective as a voice alone.   Seeing someone’s face is a big, big deal when you’re establishing a trusted relationship. 

And with almost 85% of employees now having smartphones, it’s possible to have these face to face coaching sessions at the same price as a phone call. 

Here are the keys to lifestyle change. 

Using the smartphone is important because lifestyle is REALLY important.  This chart is from a famous study in the New England Journal of Medicine.  This was a large group of middle-aged, mostly overweight adults with pre-diabetes.  They were testing a lifestyle intervention against a medication approach, using the medication called metformin.  On this chart, lower is better.  So the placebo is at the top – not effective at all.  People’s A1C keeps going up over time.  Look at medication versus lifestyle.  Lifestyle is actually working better than medication at reducing A1C and preventing diabetes. 

In other words, Lifestyle is really important.  Physical activity, and moving your BMI in the right direction are really important.   

Reduction in the Incidence of Type 2 Diabetes with Lifestyle Intervention or Metformin

Diabetes Prevention Program Research Group

N Engl J Med 2002; 346:393-403 February 7, 2002 DOI: 10.1056/NEJMoa012512

So here’s a simplified 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.  You don’t need an onsite biometric screening anymore, you replacing that with the visit to the Primary Care Doctor.  At the Annual Wellness Visit, some patients will get everything accomplished, and no followup is needed.  But for other patients the doctor will require a followup appointment for biometrics.  Or the doctor will refer them to a specialist to get a preventive test like a colonoscopy done.   So Participants will complete the follow-up their doctor recommends.

But then the ACA happened.  And now there is a standardized Annual Wellness Visit.  It’s based on the guidelines of the US Preventive Services Task Force, or USPSTF.  The ACA says anything rated A or B by the USPSTF must be covered by every health plan, and offered at no cost to the participant. .   So doctors, patients and health insurance are all on the same page about what will be done and how it will be paid.

So at the end of the Annual Wellness visit, the goal is for the patient to be 100% up to date on what they need.  And that’s why sending your employees to their doctor can be really beneficial. 

So, here’s an update to our slide.  Now we have the Annual Wellness Visit, and then some participants will need to do the follow-up their doctor recommends.    This is still pretty simple, right? 

But a lot of other patients go to their annual wellness visit and find out they have high blood pressure.  Or some other biometric problem.  And their doctor will give them a prescription and schedule a followup appointment to see if the problem is resolved.  Right?  And here’s what you are doing as a wellness program.  When their doctor says the problem is resolved, then you pay them an incentive. I’ll say it again.  When their doctor says the problem is resolved, then you pay them an incentive. That’s how you improve biometrics.  It really makes sense. 

Some patients will find out they were supposed to have a mammogram or colonoscopy or some other prevention item.  And the primary care doctor will write them a referral to get that done.  And when the specialist says they got that done then the wellness program pays them an incentive.  I’ll say it again.  When all their prevention gaps are closed, you pay them an incentive.   And that’s how you get prevention gaps closed.  It really makes sense. 

This is a SIMPLE and POWERFUL framework for the wellness program to put participants into the right relationship with their doctor.  To improve biometrics and close prevention gaps.  This is a powerful approach for getting results.   But, of course if you want to pay your incentives this way you need to collect the right data.  Let’s talk about that.

The key to this process is that it builds on the doctor’s existing process.  It fits within what the doctor already does.  It’s a three step process.

Here’s step one.  The Annual Preventive Visit replaces your onsite screenings.  You will send participants to that appointment with a short, simple form called the Annual Visit Form.  The form asks about four things, as you see below.

It asks about Key Biometrics such as Blood Pressure, Cholesterol and Glucose.  It also includes height, weight and BMI.  And, it asks if they are already being treated to manage those numbers. 

Then, it asks if the doctor is flagging the person based on their biometrics.  Will the doctor start or change treatment for those key biometrics.  If the doctor flags the person, then the wellness program knows the person is supposed to follow up. 

The form asks about Prevention status:  Whether the participant is up to date with the USPSTF recommendations for preventive services.  Whether any gaps were closed on this visit.  Whether the doctor made any referrals to a specialist to get things like a colonoscopy or mammogram done. 

And finally, the form asks if the person is   Cleared for Exercise / Weight loss.  Can the participant meet the wellness program’s goals for physical activity or weight loss.

So how do you collect the data from the doctor visit?  We’d love to tell you it’s a fully digital process.  But here’s how it really works.  You send participants to the doctor with a paper physician form.  The doctor fills it out and FAXes it to the wellness vendor.  Then you get all the same data you get from an onsite screening.  This process works, across thousands of participants our experience has been that 98% of doctors return the completed form on the first try.

Step 2 is that you gather data from follow-up visits.   Just like in Step 1, the patient brings a form to the visit. 

Remember, in Step 1 we already had the doctor flag the people who need to follow up, based on their biometrics.  We already had the doctor flag the people who need to complete preventive services.   So the wellness program knows who is supposed to send in these forms, and it can compare that against the list of those who actually did follow up.    This is really important, you know who was supposed to follow up and whether they did. 

For biometric followup – things like cholesterol and blood pressure, here’s what the doctor put into the followup form.  First, they put in the retest information.  What do the numbers look like after treatment.  Second, they say whether the doctor considers the problem resolved, or whether they will order another round of treatment and followup. 

If the doctor flagged someone as needing to go to a specialist for preventive services, then the patient brings a specialist form to that appointment.  The specialist notes what services were performed and sends to the wellness program. 

So let me say it one more time.  Between step 1 and step 2, you know who was supposed to follow up, and also who actually did the followup their doctor ordered.  That’s really powerful information for a wellness program.

Now we come to step 3 in our three step process.  In Step 3 the wellness program uses incentives to engage the employees.  There are probably a lot of ways to use incentives in a physician-based program, but here’s one way that we think works well.   It really dovetails with the forms we just talked about. 

This is a badge-based system.  The first one is the annual visit badge. It’s earned when the participant’s data arrives from the doctor’s office.  When the FAX arrives, they earn the badge. 

Now let’s look at the Prevention badge. That’s earned when the doctor says the participant is up to date on all the recommended screenings and prevention.  So now we’re using incentives to close those prevention gaps. 

Now let’s look at the Biometrics badge.  This is earned when doctor says your blood pressure, cholesterol and glucose are under control.  So notice that it’s already tailored for each person.  That’s why you never have to process appeals and exceptions.  And it doesn’t matter if you get there on your first visit, or your followup visit. 

So you can see, we’re using incentives to build the doctor / patient relationship.  We’re using incentives to close gaps in prevention.  We’re using incentives to make sure people take their medications and go to their followup appointment.  Isn’t that amazing?  When you bring the doctor into the wellness program, you can start putting incentives on the right things.

And we’re actually not done.  Here are two other badges we recommend using. 

On your physician form, you are asking the doctor if this person is OK to do physical activity and lose weight if needed.  So now you can put incentives on physical activity and weight loss, knowing all your participants have been pre-cleared by their doctor.  And you can use the modern apps and devices to make sure you get accurate data on steps and weight.

Finally, almost everyone offers a discount for participants who are tobacco free.

You can do whatever you want for discount amounts, but here’s a simple example.  $100 / month discount if they earn all 5 badges, $75/mo if they earn 4 badges, and $50 a month if they only earn 3 badges.  That’s pretty simple and easy to understand.  So what you’re seeing on these two slides is a way to use the better data we get from the doctor to drive a better set of incentives.  And you can start to put incentives on outcomes without becoming the biometrics police and processing a bunch of appeals. 

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.  

Wellness programs can move people along the path, from not having a doctor at all, or only seeing their doctor when they are sick, into a true primary care relationship where they work with their doctor on prevention.  

We saw an example of how to do this.  Send everyone to their primary care doctor for an annual wellness visit, and put incentives behind it.  If the doctor says they need treatment and followup, put incentives behind it so people do what their doctor recommends.   Wellness programs can and should be designed to move people along this path. 

So this is the flip side of the slide we saw earlier.  People who have a primary care doctor are

•       More likely to receive recommended preventive services

•       Better Quality of Care

•       Greater Satisfaction with their healthcare

•       Lower Utilization overall

•       Lower Cost of Care

•       Lower rates of ER / Emergency Department Use

And beyond that, there’s been a lot of research in the last 5 years on what happens when doctors and patients work together on prevention.   (Discuss). 

These are big numbers and big results. 

12% reduction in Emergency Dept. Use (UCLA)

9.4% reduction in Hospitalizations (PACTs)

2.5% reduction in Specialty Visits

18.5% reduction in Urgent Care Visits

 7.9% reduction in Emergency Dept Use (Colorado)

$4.11 PMPM Reduction due to ED reduction

$4.00 PMPM reduction in overall spend (BCBS Michigan)

$5.44 PMPM savings for pediatric patients

Drug Spend decreased $11.75 PMPM (Rochester)

So here’s the summary. 

Employee Wellness programs have several problems that are caused by not including the doctor.   First, there are many participants who don’t have a doctor / patient relationship.   That means costs go up and health outcomes go down.  Second, screenings are disconnected from medical diagnosis and treatment.  A lot of people who are screened never get their problem treated and resolved.  Third, only about 25% of your employees are up to date on all their prevention.  Fourth, employers who use incentives for outcomes have to use some very unfriendly designs.  And last, employers are paying twice – for an onsite screening as well as a lot of physician visits where the same tests can be given.

Now is the time. Changes in the medical field due to the ACA and new payment models make it practical to include the doctor.  When you send employees to the doctor for an annual preventive visit, everyone knows what to do and how to bill for it.

Wellness programs today are working successfully with employees’ doctors.  Across thousands of participants this year, we’ve had a 98% success rate in the process we showed you today.  There are three steps to this process.  First, replace your onsite screenings with an annual preventive visit.  Collect biometrics and other data using a short, simple Annual Visit Form.  Second, when employees go to Follow-Up visits, collect the Follow-up data using another short, simple form.  Third, use a simple set of incentives to encourage your employees to work with their doctor, do all the recommended prevention, and follow-up on biometrics. 

There are 5 Reasons why your Employee Wellness Program should include the doctor.  It builds and strengthens the primary care relationship.  It will increase your rates of prevention compliance.  It couples screening with diagnosis, treatment and follow-up.  And it allows you to use powerful incentive designs to get results while being friendly to employees.  Finally, it gives you access to better data.