Employers around the country evaluate their company benefits package every year in the hopes of finding solutions to the ever-rising costs of health insurance premiums. For many business executives, however, the only logical choice is to pass along those increased costs to the employee. This is a matter of simple economics, especially when we consider that health insurance expenses are the fastest growing cost component for employers.1 "Health insurance premiums have increased rapidly over the recent past, growing a cumulative 78% between 2001 and 2007 and far outpacing cumulative wage growth of 19% over the same period."1 The price of health insurance can be a heavy burden for families, as premiums for employer-sponsored health insurance in the United States have been rising 4 times faster on average than workers' earnings since 2000.2 In Delaware alone, as an employer the state paid approximately $433 million in healthcare expenditures for fiscal year 2008.3
Not only is the cost of health insurance premiums increasing exponentially, but more Americans are dealing with chronic and sometimes preventable conditions.4 We have all read the headlines regarding the nation's obesity epidemic, and as our waistlines are expanding, more Americans are dealing with the consequences of living an unhealthy lifestyle. This is evident by the rise in high-risk diseases such as asthma, congestive heart failure, and coronary artery disease.4
As employers, we need to do our part to come up with innovative solutions to drive down the cost of health insurance premiums while encouraging our employees to live a healthy and active lifestyle. We embarked on such a program based on the assumption that if our employees become more involved in their healthcare, they will take the steps to reduce their risk factors and improve their health. Our motto has been, "Although it may seem an unusual business investment to pay for healthcare before the need arises, in Delaware we concluded that this makes perfect sense." Employer-initiated pilot programs are beginning to emerge in this country and in other countries, representing a new approach to improving health outcomes and controlling costs.5-7
The State as the Largest Employer
The State of Delaware, as an employer, is unique, because we employ more people than any other organization from the public or private sectors in Delaware. The state covers approximately 110,000 individuals—state workers, their families, and those who have retired from state service. Therefore, driving down the cost of healthcare represents not only a benefit to our employees but also an expectation held by every taxpaying citizen of the state.
Although cost is a major component of benefit development, we recognize that it is only one aspect of the total picture. Many conventional employee wellness programs—such as disease management programs— target people who already have been diagnosed with a certain condition. These programs can be beneficial, but they ignore the fact that people often have risk factors or conditions that have not been diagnosed. If ignored, these risk factors may develop into a serious or chronic disease that can quickly become more serious and expensive to treat. The goal of the State of Delaware as an employer has been to educate, motivate, and inspire employees to get involved in their own wellness journey and to be aware of any possible risk factors in their own lives.
For private companies or public entities, it can often be difficult and cost-prohibitive to embark on an ambitious new benefit program. How do you get decision makers to buy into the idea of spending money on keeping employees healthy, especially when America has favored a system that addresses the needs of those who are sick or injured instead of addressing potential risk factors before a patient becomes symptomatic?
To help overcome these hurdles, we instituted from the beginning a phased-in approach to our employee wellness program. Although it is difficult to have a paradigm shift in state government, we moved forward based on the assumption that change could happen through demonstrated success and research results. This allowed us to effectively meet the needs of our target participants, while using the results from our pilot programs (see below) to garner support from lawmakers. Throughout the process, we reviewed the concept and strategy at each phase, making adjustments when necessary.
The Initial Pilot Program
In 2003, the State of Delaware partnered with its health insurance carrier, Blue Cross Blue Shield of Delaware, to launch its first 100-person feasibility pilot after looking at some successful private sector programs. Our goal was to show that it is possible to motivate people to take responsibility for their health and wellness if they are provided with the necessary tools. Pilot participants underwent a health assessment, which was comprised of:
Complete health history
Resting and exercise blood pressure
Cholesterol level check
Immediate results revealed that some participants may already have high-risk conditions (ie, elevated blood pressure, elevated cholesterol levels) that have not yet been detected. All participants also received recommendations on an exercise regimen to improve their physical outcomes in all risk areas. They all received feedback and were reassessed after 1 year.
We wanted to motivate participants to take a more active role in their health by educating them on their own cardiometabolic risk factors, and then give them an opportunity to make lifestyle changes in an effort to improve their overall health. Throughout the pilot, we used a process that involved evaluating, educating, motivating, and reevaluating participants.
The results of the initial pilot were encouraging. Not only did participants improve their health in the short-term, including reductions in hypertension and emergency department visits, but most also opted to make healthier lifestyle choices as a direct result of their involvement in the program. That was great news for our participants, but the bigger news for lawmakers was that these health-related changes had resulted in immediate direct savings of more than $62,000, which were calculated based on savings from blood pressure reductions and fewer visits to the emergency department. This success gave us the momentum we needed to broaden the scope and number of participants in subsequent phases of the program.
The Expanded Pilot Program
In 2004, with the support of Governor Ruth Ann Minner and the State Employee Benefits Committee, we launched the second wellness program pilot, which included 1500 state employees. The employees in this expanded pilot underwent the same initial health assessment as in the 100-person pilot.
Participants were randomized into 3 intervention groups, with very similar demographics (Table 1) and comorbidities (Table 2).
In addition, we collected information on the participants' average healthcare costs before and after the pilot (Table 3) and (Table 4) to be used as a baseline measure to assess the program's effectiveness.
The groups were set up in the following manner: Group A had pre- and postassessments, with "fit stops." Group B also had the pre- and postassessments, with fit stops, plus regular e-mails. Finally, group C underwent the pre- and postassessments, with fit stops, and they were also offered a $100 financial incentive for achieving or maintaining 5 of 6 goals. These fit stops consisted of 2 personalized sessions with an exercise physiologist, with each session targeting a specific cardiometabolic risk factor. All employees were welcomed to participate in fit stops.
The results from this expanded program, which ran from September 2004 through March 2006, were even more impressive than the initial pilot. In addition to realizing significant reductions in their body fat percentage, participants also improved their overall fitness levels substantially, and their blood pressure and cholesterol levels were reduced (Table 5) and (Table 6).
As can be seen in Table 5, group C was the only negative short-term net margin group. Our assumption is that the incentive payment may have motivated the group C employees to seek more extensive care to reach goals earlier than the other 2 groups. We realize that reevaluation of the program on an annual basis will be necessary to confirm persistency of short-term net margin and to evaluate intermediate- and longterm program impact. We estimate that we will require 4 or 5 years of analyses before we can measure a consistent trend.
Even so, these preliminary findings from the pilot program are very encouraging. In addition to the improved health of the participants, the program has also resulted in a trended healthcare savings of approximately $450,000 for the state (Table 7) and (Figure)
In April 2007, armed with the data proving the success of the wellness initiative, we had the justification and enthusiasm we needed to push forward with our comprehensive wellness program—DelaWELL. This program uses the same basic concept as the pilot program but is tailored to appeal to a broader group of more than 40,000 state employees. We decided to use a confidential online health risk assessment (HRA), which is followed by personalized lifestyle and disease management tools, to target individuals based on their own specific risk factors. Using an electronic HRA allowed participants to immediately receive feedback about potential health risks in an anonymous and nonthreatening manner. To encourage participation, a $75 incentive was offered to the first 6000 participants to fill out their HRA.
After completing the HRA, participants with 2 or more risk factors (eg, smoking, obesity) received behavior coaching. Those with 3 or more risk factors received more intensive intervention, including a comprehensive physical examination and a cardiometabolic screening, to give them detailed information about their health. All eligible participants were able to access online resources on topics such as living with chronic conditions, a drug reference guide, and health resources for different demographics—men, women, children, older adults, and pregnant women.
In the first year, nearly 9000 employees took advantage of the HRA, approximately 23,000 visited the online site, and more than 500 attended educational seminars.
The DelaWELL program encourages participants to take an active role in their personal health. To drive that message home, we wanted to show participants that management "walked the walk, and talked the talk" regarding health and fitness. On May 30, 2007, with the support of our governor, we held our first-ever Governor's Cup 5K Run/Walk (Photo). The event was so successful that we had to close down registration early and set up a second walk for later in the year to accommodate all of the state employees who wanted to participate. The 2 walks accommodated staff in 2 counties in Delaware and approximately 1000 walkers and runners participated in the events. We are planning to incorporate more events like this as an annual component of DelaWELL.
Employees' Input: Weight Management
As we embark on year 2 of the DelaWELL program, we have incorporated suggestions we received from participants in an effort to best meet the needs of our target population. Partici pants told us they would like to have options available for managing their weight. As a result, we have added Weight Watchers® offerings to our program. We chose Weight Watchers® because they had the resources necessary to accommodate the anticipated number of participants, and their program helped support the DelaWELL mission but did not require participants to buy special meals like some of the other programs.
Our partnership with Weight Watchers® provides membership reimbursements for employees, pensioners, and their dependents older than age 18 years. Participants receive support materials at a reduced rate, with a potential 100% reimbursement through our health insurance vendors. To make this option available to as many participants as possible, we offer the meetings in state offices for groups of 15 or more. The results have been very encouraging. In fact, one group with 40 participants has reported a more than 485-lb combined loss since the program started in February 2008. And in just more than 4 months, 729 members participating in "at-work" meetings had a combined weight loss of 5162 lb.
We also learned from the HRAs that a large majority of our employees did not know their blood pressure, cholesterol, or glucose levels, and were therefore unable to provide that information on the HRA. In response, as of January 15, 2008, the State of Delaware began offering free onsite biometric health screenings at work locations for employees, pensioners, and their dependents. The screenings gave employees important information about their health (eg, their height, weight, body mass index, blood pressure, total and high-density lipoprotein cholesterols, and glucose level).
Another lesson we have learned is that incentives work. In DelaWELL year 2, all employees who completed their HRA and biometric health screening by May 30, 2008, became eligible for a $100 pretax incentive. Providing an incentive helped to motivate our employees to become active and involved in their own wellness journey. We have also provided gifts for participating in DelaWELL activities, including water bottles, beach towels, and T-shirts.
In the end, an incentive is a small cost for an employer when the goal is maintaining its biggest investment—its workforce. As an employer, our priority in Delaware has always been to protect and empower our most valuable asset, our employees, and we are reaping the rewards of this philosophy today.
Incorporating Entire Family
Finally, to increase the success of our program and in an effort to reach more of our target market, in January 2008, we have incorporated the entire family into our DelaWELL initiative. The program is currently available to approximately 68,000 state employees, retirees younger than age 65 years, and their families.
Current Scope of the Program
At a time when many companies are faced with skyrocketing insurance premiums, we have managed an almost unprecedented feat. The savings we have realized from this program have allowed us to maintain employee contributions to the state's health insurance at the same level for the past 3 years.
To date, more than 10,000 participants completed an HRA, and more than 9000 participants had a biometric screening. In addition, we extended invitations to individuals who had 2 or more risk factors identified by their HRA to participate in our NextSteps program. In this program, participants can choose from telephone coaching; mail-based options that include personalized letters, brochures, and help in setting goals and building skills; or online options, in which participants receive a self-paced, personalized online NextSteps program.
So far this year, we have more than 1500 employees enrolled in NextSteps. We also have approximately 1500 participants in various Weight Watchers® offerings, including local meetings, at-work programs, and online offerings. We are anticipating an even greater participation rate as we await reimbursement requests by individuals who elected to use the monthly pass option, where participants sign up online and pay 1 fee for all monthly Weight Watchers® meetings.
We are in the process of launching DelaWELL University—a series of free health seminars for employees focusing on topics such as the Active Workday, Managing Your Weight, Stress and Your Workday, and Eating for Performance and Health.
Our program is receiving national attention and in July 2008 was awarded the Eugene H. Rooney Award, given out annually by the National Association of State Personnel Executives. This award recognizes innovative human resource management practices that ensure access and equity while enhancing productivity and service delivery.
It is too early to know the long-term financial results of our DelaWELL program, but we are encouraged by the evidence we have seen to date. It will take several years of collecting data on the program before we have benchmarks in place to accurately assess the return on investment. However, the feedback we have received in the second year of DelaWELL has been overwhelmingly positive. Our employees know that we are doing our part to help them invest in their personal health by making these tools as convenient and accessible as possible.
As employers, we are all facing the same predicament of rising health insurance premiums and out-of-control costs. Delaware may be a small state, but we have come up with a big idea toward solving a substantial healthcare dilemma. With the support and leadership of innovative leaders like our governor, we have designed a comprehensive wellness program that saves money for the state while helping our employees live healthier, happier lives. A healthy workforce is a more productive workforce. It is our hope that our program may offer other employers a model for enhancing their employees' health and reducing overall healthcare costs.
The Henry J. Kaiser Family Foundation. Employer Health Insurance Costs and Worker Compensation. March 2008. http://www.kff.org/insurance/snapshot/chcm030808oth.cfm. Accessed August 6, 2008.
The Henry J. Kaiser Family Foundation and Health Research & Educational Trust. Employee Health Benefits: 2007 Annual Survey. http://www.kff.org/insurance/7672/index.cfm. Accessed July 30, 2008.
Data on file. State of Delaware.
Wu S, Green A. Projection of Chronic Illness Prevalence and Cost Inflation. Santa Monica, CA: RAND Health; October 2000.
Harris JR, Cross J, Hannon PA, et al. Employer adoption of evidencebased chronic disease prevention practices: a pilot study. Prev Chronic Dis. 2008;5:A92.
Renaud L, Kishchuk N, Juneau M, et al. Implementation and outcomes of a comprehensive worksite health promotion program. Can J Public Health. 2008;99:73-77.
Oberlinner C, Lang S, Germann C, et al. Prevention of overweight and obesity in the workplace. BASF-health promotion campaign "Trim Down the Pounds—Losing Weight Without Losing Your Mind." Gesundheitswesen. 2007;69:385-392.