By Jocelyn Sivalingam, M.D., F.A.C.P. | BenefitsPRO

As employers or benefits consultants, it is critical to ensure that your health plan, advocacy or decision support providers, and other partners that depend on this information to guide their practices and decisions understand and follow current, relevant guidelines.

Employees and their family members frequently face tough questions about their health care: How do I know when it’s time to get a mammogram? When does my child need a vision screening? Is thyroid screening something I should get? If I have high blood pressure or diabetes, what is the best treatment for me?

For the providers who care for them, the key question is: How do we implement appropriate, science-backed treatments for our patients, testing where needed, but avoiding potentially harmful or unnecessary (and expensive) care? The answer is to seek guidance from and use clinical guidelines —along with existing clinical skills — wisely.

Establishing clinical guidelines

Clinical guidelines are sets of science-based recommendations, designed to optimize care for patients in areas such as screening and testing, diagnosis, and treatment. They are developed after a critical review by experts of current scientific data and additional evidence to help inform clinical decisions across a spectrum of specialties.

Based upon this process, guidelines are then released by a number of sources and collaborations, including academic and non-profit health care entities, government organizations, and medical specialty organizations.

From preventive care to treatment protocols for chronic conditions, guidelines provide a framework health care providers use with patients to help guide care. However, it is important to note that clinical guidelines are not rigid substitutes for professional judgment, and not all patient care can be encompassed within guidelines.

The impact on health care and benefits

Clinical guidelines are used in myriad ways across the health care spectrum, and providers are not the only ones who utilize them. Insurers may also use guidelines to develop coverage policies for specific procedures, services, and treatment, which can affect the care your covered population receives.

To illustrate a key example of an intended impact of guidelines on health plan coverage, consider those issued by the U.S. Preventive Services Task Force (USPSTF), whose A and B level recommendations comprise the preventive services now covered at no cost under the mandate of the Affordable Care Act.

As another example, the National Committee for Quality Assurance (NCQA), which accredits health plans and improves the quality of care through its evidence-based measures, uses the American Heart Association guidelines when creating its quality rules for treating high cholesterol with statin drugs.

Other examples exist among commercial coverage policies. For example, some cancer drug reimbursement policies use components from nationally recognized guidelines for cancer care.

The importance of up-to-date guidelines

Because science is rapidly changing, guidelines are often updated, leading insurers to revisit their policies to decide if they will change how services and medications are covered for their members. Providers and health systems may modify processes of patient care in response to major changes in guidelines and/or resultant changes in payer reimbursement.

Not all guidelines are updated on a set schedule, making it even more important for providers and organizations that rely on guidelines to stay on top of changing information, as it can have a direct impact on how they work. Attending conferences, visiting the recently established ECRI Guidelines Trust™ , and regularly reviewing relevant professional association websites and journals can help ensure needed guidelines are current. Lack of current information can affect care decisions and potential outcomes for patients. Those who have access to the most up-to-date, evidence-based information are able to work together to make well-informed healthcare decisions.

The value of clinical guidelines for employers

As employers or benefits consultants, it is critical to ensure that your health plan, advocacy or decision support providers, and other partners that depend on this information to guide their practices and decisions understand and follow current, relevant guidelines.

Further, by combining information from relevant guidelines and data from biometric screenings, health risk assessments, claims and other sources, it is possible for clinical advocacy and other decision support providers to identify employees with gaps in care and generate targeted communications (through a member website and/or mobile app) to help them take action to improve their health.

Clinical guidelines are science distilled into practical recommendations meant to be applied to most patients for quality health care. By maintaining current, relevant guidelines, organizations and providers who work with your covered population can ensure that all parties have the key information they need to make the best decisions for their health.

About the author

Jocelyn Sivalingam, M.D., F.A.C.P., is a Medical Director with West’s Health Advocate Solutions, a company that provides health and well-being solutions for over 12,500 organizations using clinical guidelines to inform preventive screening recommendations as well as ongoing disease management. Dr. Sivalingam is board-certified in Infectious Diseases and leads the Clinical Guidelines working group at Health Advocate. She also serves as a key leader of clinical operations for the Chronic Care Solutions program and provides clinical expertise across a number of areas at Health Advocate.

Wellness Programs Really Do Work

Dr. Abbie Leibowitz | HR Daily Advisor

study published recently in the Journal of the American Medical Association (JAMA) has raised questions about the value of workplace wellness programs.

While the findings confirmed that employees who participate in wellness programs make positive behavior changes, the results of this study indicated that these changes did not influence health outcomes or costs.

For years, research has generated mixed reviews of workplace wellness initiatives. However, it is important to note that many of these studies, including the most recent in the JAMA, are limited in scope and do not account for the best practices successful organizations utilize to maximize their wellness programs and drive engagement, improve health outcomes, and lower costs.

A Narrow View Doesn’t Show the Full Picture

The study published in the JAMA analyzed results among employees participating in an 18-month-long, stand-alone wellness program. While this narrow focus may be necessary for a scientific study, it does not necessarily consider other factors at play in most organizations’ wellness programs. For example, participation rates were relatively low, at about 35%, which may have skewed the results. As the study authors acknowledge, employees participating in the program tended to be in good health already.

There are obviously benefits to having healthy workers engaged in a wellness program, but there is more potential impact to be made among the segment of the population in less-than-ideal health. This study did not examine some of the strategies organizations use to drive participation among this group.

Providing incentives is one way to achieve this participation. In the study, program participants received an incentive of about $250. While this is about average among most employers, higher incentives are more effective at motivating participation, which, in turn, can generate better results.

Additionally, the study did not mention what other population health initiatives the organization had in place. Enthusiastic support from management is important to the success of any program. A wellness program integrated into an overall culture of health is more likely to be more successful. This may include offering biometric screenings to help identify employees at risk or a chronic condition management program to further support their health goals.

Providing access to expert support from wellness coaches and others can also make a positive impact versus an online program alone. Wellness in a silo is not as effective as an integrated program, which could skew the results when compared with the broader, more holistic approach many organizations are now implementing.

Finally, looking for short-term “savings” from a wellness program is a mistake. Behavior change takes time, and it is premature to anticipate sweeping shifts in cost trends and outcomes in such a short window. The 3-year results the study authors plan to revisit may be more telling, but true return and value on investment in a wellness program are long-term realities that are not accounted for in this particular study.

Strategies for Optimal Wellness Programs

In order to widen the focus of workplace wellness beyond a narrow, siloed approach, there are a number of best practices proven to drive engagement and achieve successful outcomes.

  • Utilize data to inform the design of a meaningful program. Data, such as health risk assessments, claims data, and biometric screening results, can provide a more detailed picture of the specific needs of a population and enable the employer to tailor the program accordingly.
  • Address the full spectrum of population health needs. Providing multiple touch points to meet people where they are based on their health status, risk level, and readiness to change can ensure that employees will be able to access the right support at the right time to reach their personal health and well-being goals.
  • Energize participation, and make it fun! Weave the organization’s culture into the program with unique activities, incentives, success stories, and challenges.
  • Demonstrate internal support. Build a culture of wellness, incorporating both employee input and executive participation.
  • Create visibility. Work with a wellness expert to create an effective and impactful communications strategy so employees are aware of the benefits and resources available to them.
  • Make the program easy to access via technology and personal support. This includes taking advantage of telephonic support, health coaching, an easy-to-use website and mobile app, and personalized e-mails and notifications to drive awareness and utilization.
  • Integrate health and well-being programs for greater impact and engagement. Provide a streamlined, simplified, all-inclusive program to reduce confusion and maximize participation.

Implementing one or more of these strategies into workplace wellness programs can have a major impact on both employee participation and results.

The Value of a Holistic Approach to Wellness

Integrating wellness with other related health and benefits programs is one of the most effective ways to generate measurable results. For example, biometric screenings can establish a strong starting point for employees’ wellness journeys. Oftentimes, employees learn about a potential condition like hypertension or hyperlipidemia during a screening, prompting them to seek treatment from their physician and support from a wellness program. Furthermore, a better understanding of the health of an organization’s employees can help the employer customize the wellness program to meet their needs, increasing the odds of participation and success.

A recent analysis of a cohort of nine companies utilizing Health Advocate’s wellness program demonstrates that best practices like this make a difference. Each of the participating groups offered wellness coaching and strong incentives of $300 or greater, access to online workshops, and wellness information, as well as integrated biometric screenings. The research assessed changes in high-risk participants over 3 years. Of the 16,741 employees who participated in biometric screenings, 9,689 participated all 3 years. Among this group, 1,674 members (17%) reduced their risk level from high risk to normal or borderline risk within 3 years for the following conditions:

Hypertension

  • 1,497 people identified as high risk for hypertension
  • 76% reduced to normal or borderline within 3 years = 1,138 people
  • Potential savings of up to $1,378 pp./y x 1,138 = $1,568,164

Diabetes

  • 425 people identified as high risk for diabetes
  • 49% reduced to normal or borderline within 3 years = 208 people
  • Potential savings of up to $1,653 pp./y x 208 = $343,824

Obesity

  • 3,775 people identified as obese
  • 9% were no longer obese and improved their health within 3 years = 340 people
  • Potential savings of up to $1,090 pp./y x 340 = $370,600

The savings estimates are based on data looking at the cost of medical care needed by people with these conditions. As these results show, when compared with a stand-alone program, utilizing best practices, including integrating a wellness program with on-site health screenings, will amplify the effects. By incorporating best practices into workplace wellness, it is possible to realize both improved health outcomes and cost savings, as well as maximize the impact of the overall program.