Healthy people for health profit

By Martín J Sepúlveda, IBM

If employees are an organization’s most valuable asset, then the success of that business is dependent upon employees’ health and well-being. IBM strives to provide a ‘culture of health’ that assumes healthy living as a company norm, where employees are encouraged and supported in a healthy environment and are challenged to maintain healthy behaviors and be smart consumers of healthcare. This culture of health provides a key competitive element to our company’s leadership, which relies on the commitment, creativity and resilience of IBM employees.

As US healthcare costs rise well in excess of profits, wages and medical price inflation each year, the challenge is to provide effective and efficient health and wellness programs. IBM’s vision for improving healthcare – while keeping costs in check -- focuses upon prevention and primary care, health system reform, and healthy lifestyles. It relies on our ability to apply information technology in ways that enables our employees to be informed, engaged partners in healthcare with technology-enabled healthcare professionals. As an IT company, we recognize this as an opportunity to help transform an industry that currently is immersed in paper records, bureaucratic dysfunction and unnecessary patient errors that harm people and add to the high cost of the system. As a global purchaser of healthcare for our employees, IBM is taking an active role in this transformation in ways that not only improve care for our beneficiaries, but which also promote key system reforms.

Technology is central to the design, promotion, delivery and assessment of all of our health and wellness programs. Consider our global vision for health: “Healthy people for high performance based on partnerships focused on improved health outcomes, personal accountability and sustainable costs. The innovative use of technology is essential to meet these health improvement and financial goals.”

Operating Model
Every year, we establish annual health and well-being objectives and targets aligned with company goals. For example, these include specific health objectives – such as promoting a more physically active workforce – as well as operational objectives, such as preventing injury and managing disability or making it easier for employees to secure prompt and quality medical services and get back on their feet after illness. Our technology-enabled integrated disability management process, for example, delivers a consistently low cost of compensable injury below 15 cents per $100 of payroll in the United States.

Through an online well-being management system, high-level objectives are integrated with bottom-up health priorities from IBM businesses around the world for appropriate follow-through. Use of a centralized database helps plan-owners at country and geographic levels to synchronize their efforts and to ensure consistent delivery of programs. During the past few years, the well-being management system has helped to coordinate more than 500 well-being and health benefit objectives and targets worldwide, and has provided feedback for senior executive review and continuous quality improvement.

Like other employers, IBM focuses upon ways to help employees reduce their health risks and maintain healthy habits. Research indicates there’s a strong tie between employees who engage in unhealthy activities, such as smoking, and higher healthcare costs of up to $250 to $300 per year in the US. Such workers tend to have lower productivity rates due to time lost, have higher rates of absenteeism, and use disability and workers compensation more often than other employees.

At the same time, research demonstrates that by making ‘interventions’, employers can potentially lower future costs by encouraging employees to discontinue unhealthy habits and maintain healthy ones. As an employer, it’s a complex issue to devise ways to successfully affect the health of employees. Simply offering isolated wellness resources for voluntary use by employees is not enough to stimulate significant changes in their behavior. IBM relies on a holistic approach to health and healthcare investments, together with a coordinated delivery infrastructure to multiply the impact of specific initiatives. This holistic approach, coupled with selection of the most state-of-the-art and effective technology tools, allows for maximum reach to our highly distributed and mobile workforce and contributes to the success of the programs.

Wellness for Life
A web-based health management center is the single locus for employee engagement. It includes a wellness for life component, which serves as a central portal for employees to learn about and access all wellness, disability, health and safety offerings. It forms a key component of our wellness for life strategy, and provides a tool for employees with many benefits: it helps employees navigate wellness services; provides specific direction for taking action; enhances the consistency of our program delivery; communicates central health-promotion messages; and provides an integrated online system for delivering and evaluating outcomes.

Using the wellness for life strategy to deliver a coordinated approach provides resources, tools and information on well-being services to help direct employees in determining an appropriate course of action to address their areas of need and to help them manage their health risks. In addition, as the name conveys, a central theme is to foster long-term healthy behavior.

Three core components provide the framework for this model. They are:
Assess: Initial and periodic health screening and assessment offer valuable information to employees about their health status and their areas of need.
Plan: Appropriate planning is key to achieving goals for healthy living. An innovative online tool incorporates feedback on their health assessment, permits personal goal setting, and provides wellness coaching.
Act: Employees can take action through a variety of tools, resources and programs focusing upon changes in health behaviors, informed healthcare consumption and incentives to take action.

Expanded Focus on Prevention
At IBM, we know that investing in prevention and well-being makes sense for our employees and our business. Our work-related injury experience and costs are extremely low, our integrated disability program saves many thousands of lost work days each year, and early analysis of our health promotion initiative for physical activity reveals reductions in healthcare claims cost per individual of approximately US$100 per year. Consequently, IBM has increased its investment in preventive healthcare and wellness in each of the past five years.

This has allowed us to provide most routine health checkups and preventive services no cost in-network in all non-HMO medical options – a commitment shared by only 5 percent of major US employers. Services covered at 100 percent in-network include commonly accepted preventive medical tests and screenings, such as those recommended by the US Preventive Services Task Force, as well as routine physical examinations and wellness checkups. Participants do not need to meet an annual deductible or pay co-insurance. Further, we design our health plans to incentivize people to secure timely primary care exempting all primary care for adults and children from deductibles.

Healthy Living Rebates
In 2003, the company made a unique commitment to further promote healthy living among employees by offering a health benefits premium discount to non-smokers, as well as smokers who were willing to participate in a smoking cessation program. The response was overwhelming. More than 6000 employees who smoked participated in cessation programs. This success gave rise to the healthy living rebate programs in 2004 and 2005, which offered US$150 in cash rebates annually both to non-smokers and those smokers who participated in smoking cessation programs.

The smoke-free rebate program used multiple cessation program options to support smokers in their attempt to quit, while reinforcing abstinence among non-smokers. Before the finanancial incentive was offered only a few hundred employees participated in smoking cessation programs. But since it was introduced more than 9,000 individual employees have participated in at least one of the cessation programs during the past three years. Smokers who agreed to participate in cessation programs reported quit rates of 22-26 percent, compared with nine percent among non-participants.

We also reward regular physical activity through the the physical activity rebate program. To earn a US$150 cash rebate, employees must elect to participate during annual fall benefits enrollment, join our web based virtual fitness center program, and log their minutes of activity online. In 2004 and 2005, participants engaged in at least 20 minutes of physical activity three days per week, for 10 out of 12 consecutive weeks, to qualify for the rebate.

The highly accessible and flexible virtual fitness center tool, combined with the financial incentive and maximum visibility through benefits enrollment, has generated significant reach among the employee population. Monthly usage of the online virtual fitness center rose by 500 percent after a financial incentive was offered, with more than 100,000 individual employees using it during the past two years.

For example, during benefits enrollment in 2004, 71 percent, or 97,000 workers in the eligible US population elected to participate. Of those who enrolled, more than 53,000 employees earned the 2004 rebate by engaging in the required amount of physical activity and logging their activity minutes online. During the 2005 benefits enrollment, 81 percent, or 108,000 employees said they would participate and the number who earned the rebate rose by 21 percent to 64,000 individuals that year.

Analyses revealed that the reported lack of physical activity among IBM employees correlates with $535 greater healthcare claims costs each year, compared with those who achieved at least one day of activity per week.

The preventive care rebate program rewards employees who take steps to identify their preventive care needs and personal health risks. Our objective for this program is to enhance participation in preventive care and quality-driven care consumption. This program allows employees to receive health information and news tailored to their interests, to find information about medical conditions, and to track and store key health information in a personalized health record. In 2006, about 104,000 employees in the US elected to participate in this program during their annual benefits enrollment. Of those, 80,000 employees registered through an online process on the health management center for IBM through WebMD’s web site, and 65,000 employees met an established criterion, earning a US$150 rebate.

Maximizing engagement and fostering behavior change
Our rebate programs have provided significant exposure to wellness initiatives and stimulated positive employee response. Employee engagement relies on creative approaches of this type that maximize visibility and interest. Increasing intervention penetration in this way is the first step in influencing the population. Engagement must also be sustained over the long-term, in part through pervasive messaging at multiple levels. The company incorporates a tiered strategy to deliver key messages and promotions.

Most programs focusing on health behavior areas provide one-size-fits-all solutions. Even if individuals are assessed and grouped based on health needs, they still may not benefit from the identical intervention approach. Knowing this, we are striving to target intervention strategies based on employees’ readiness to make health-related behavior changes. This stage of change model allows the specific needs of the individual to be addressed based on their unique range of circumstances. The first stage requires behavioral assessment of employees in the context of specific health behavior areas. Then, exposing participants to targeted intervention approaches and messaging at the appropriate times allows them to more successfully advance along the readiness to change continuum.

Transforming healthcare – looking to the future
By using the intranet and internet, IBM has been able to offer a comprehensive set of health and wellness programs tailored to individual employees. With prevention the goal of everything we do, we’ve seen participation increase dramatically if we offer monetary rebates. We’ve also demonstrated how the successful use of technology can help make a difference in our employees’ lives.

Going forward, one of the top priorities for IBM in healthcare is to rally employers around the urgent need to resuscitate and transform primary care from general practitioners, pediatricians, family practice and general internists. In the United States, a delivery system built on specialty care creates unnatural medical fragmentation of individuals and, in aggregate, results in much poorer health outcomes and much greater per-capita costs than systems where care is centered on the individual as a whole. These healthcare systems provide a single point of first contact, continuous and comprehensive care, i.e., primary care.

International data from many countries, including the US, has repeatedly shown over 25 years that more emphasis on primary care results in lower mortality, better preventive care, better health outcomes for babies and children, better chronic disease management, higher satisfaction with healthcare systems, and much lower costs. IBM wants to buy this type of care for its beneficiaries and is actively working with physicians to create practices that have the technology infrastructure to enable primary care specialists to do what they were trained to do.

Reviving primary care includes supporting primary care doctors with technology that enables them to fulfill this role more effectively. ‘Connected healthcare’ would permit the instantaneous access and exchange of information between doctors, hospitals, pharmacies and insurers, giving doctors access to complete computerized medical records and up-to-date clinical decision-making information when they interact with patients.

For example, IBM is participating in Bridges to Excellence (B2E), a nonprofit effort to encourage a more uniform and efficient level of primary care by rewarding providers who follow ‘best practices’ from the National Committee for Quality Assurance. IBM is also a leading employer in the Taconic Health Information Network and Community in upstate New York where physicians, hospitals and pharmacies are electronically connected to facilitate comprehensive care by physicians.

Ultimately, this vision of primary care creates a ‘medical home’ for each patient to receive comprehensive, holistic and long-term care from primary care practitioners with technology that promotes best practices, use of standards for care supported by current science and provides complete medical information based upon electronic health records. Networked ‘connected healthcare’ communities permit exchange and access to information among doctors, hospitals, pharmacies, patients and insurers – with tremendous potential for delivering better care, reducing duplication of tests and medical errors, improving access for patients, and reducing cost for individuals, employers and governments.

If a patient’s complete health records were stored electronically, for example, physicians and other healthcare providers would have complete medication records, a new prescription could be checked automatically against allergies or for interactions it could have with prescription drugs the patient is already taking. Likewise, connecting healthcare providers with an information network creates further opportunities. Instant transmission of test results from a laboratory to a doctor, for example, can save critical time in making a diagnosis and starting or modifying treatment.

Systems like this already exist in countries including Denmark and Singapore, but wider adoption in places such as the United States will take time, effort, and bold leadership by employers. Employer initiatives have led to widespread changes in healthcare in the United States, including the promotion and diffusion of chronic disease management in their workforces, health promotion and preventive care, and quality initiatives involving measuring, reporting and reimbursing performance by caregivers that conforms to recommended medical science and standards of care. As private employers, we must rise to the challenge of not just reviving, but recreating and transforming primary care that matters.

Martín-J. Sepúlveda, M.D., FACP, is the Vice President of Global Well-being Services & Health Benefits for the IBM Corporation. He leads a global shared services organization providing global solutions to employee well being and health benefits business requirements.

Dr. Sepúlveda is a graduate of Yale University and the Harvard Medical School. He trained in the Epidemic Intelligence Service of the Centers for Disease Control and Prevention, and completed residencies in internal medicine at the University of California-San Francisco Hospitals and Clinics, and in occupational medicine at the National Institute of Occupational Safety & Health. He also completed a fellowship in internal medicine at the University of Iowa Hospitals and Clinics. He is board certified and holds the rank of fellow in both the American College of Physicians (internal medicine) and the American College of Occupational & Environmental Medicine (occupational medicine).