We have reached a health and wellness tipping point. After years of struggling to find solutions to rising health care costs, the majority of the nation's employers agree that health programs aimed at promoting better health and delaying or preventing the onset of costly chronic illnesses are essential to their profitability and survival. The popularity of wellness programs is powerfully demonstrated in a recently released survey by the Integrated Benefits Institute with Harris Interactive, which found that 98 percent of responding employers offered health promotion programs. 1

However, as employers have enthusiastically embraced the concept of prevention and have begun rolling out wellness programs aimed at identifying and addressing health risks prevalent within their employee populations they have encountered another challenge - participant engagement. While employers are getting positive results in risk reduction and lower health care costs from their wellness programs, many are challenged with achieving the enrollment and engagement rates necessary to generate the desired clinical and financial outcomes.

What's behind the challenge to get participants engaged?

Research on the issue has yielded some compelling answers. In many cases, employers are not providing comprehensive programs with a wide enough range of offerings to facilitate individualized care. Many employees may join programs but then not get the guidance and support that meets their specific health needs.

If they feel unsatisfied or overwhelmed by standard interventions, they are more likely to become frustrated and drop out of the programs.

Lack of consistent organizational support, communication, and encouragement is another factor influencing whether employees feel motivated to join or sustain their enrollment in programs. Employers may provide state of the art programs but not adequately promote the programs to the employees or communicate the importance of the programs.

Another factor influencing participation is the reluctance of many employees to take on the difficult challenge of changing unhealthy lifestyle behaviors. They may be suffering from feelings of powerlessness and thus think that they are unable to change. Awareness that there are health programs available to assist them may not be enough to inspire them to reach out for help. They need the right kind of encouragement and a strong support system to help them transform their lives.

While the level of employer involvement is encouraging and studies and results are showing that wellness programs work, the fact remains that even more needs to be done to increase employee participation. To secure maximum value from programs, employers must find ways to maximize employee participation.

The rate of employee participation and sustained involvement in health and wellness programs varies widely depending upon a number of factors.2 Ultimately, the key to achieving maximum long term participation will involve a combination of strategies, including:

Creating a Culture of Health

As employee participation is the key to maximizing the value of wellness programs, high rates of engagement and participation are required to achieve successful worksite health promotion programs.

Results from a study published in the August 2008 issue of the Journal of Occupational and Environmental Medicine UOEM) show that a healthy workforce culture with good communications, employee involvement, and senior leadership support is essential if organizations want to achieve high participation rates and maximize the impact of the program incentives.3 The study, "Incentives and Other Factors Associated with Employee Participation in Health Risk Assessments," examined the various factors that influence participation in health risk assessments(HRA), which are the gateway to other health programs.

Creating a workforce culture of health requires top executives to "walk the talk" by overtly participating in programs and practicing healthy behaviors. In addition, they must develop policies that encourage and support employee participation in programs. Examples include the provision of time off or flextime to participate in exercise programs or weight management meetings, healthy snacks in vending machines, and healthy food choices in cafeterias. And, they could create a physical environment that facilitates more walking or use of stairs instead of elevators.

Several forward-thinking companies offer a wide range of programs to employees, such as a customized weight management and smoking cessation assistance, stress management, health coaching, and healthier food choices in the cafeteria. They offer health programs that provide strong incentives for employees to join and company wide health and wellness challenges that sometimes involve competitions between teams of people, which serve to help motivate people to stay engaged.

While specific wellness program elements vary, what these companies share is top leadership who exemplify the ideals and who are fully committed to their organizations' wellness programs. Their executives live by example and have also worked diligently to create a culture of health within their respective organizations.

Intangible and often subjective elements are also critical in creating a culture of health, including fostering an environment where employees and managers feel cared for and where management and fellow employees are supportive of participation in wellness programs.

Companies that build a healthier workforce strategy into their mission and communicate their vision to employees will reap rewards in the future. On a macro level, this involves understanding that wellness is an investment. From a micro standpoint, it means building wellness participation into the daily routine, even down to performance reviews. Not every employee and manager needs to be the ideal specimen of health; however, every employee should be encouraged and recognized for participation.

Tailoring Programs to Individual Needs

Motivating employee participation begins with offering personalized health support programs with a person-centric approach to care characterized by guidance and support based on individual needs, desires, and psychological, emotional, and cultural status. Targeted behavior changes are recommended based on the individual's health status, comfort level and readiness to make the specific change as opposed to standard interventions applied across the board.

To identify those factors, employers need to start with the building block of a strong wellness program - the health risk assessment. HRA's use nationally accepted criteria for risk identification to stratify key health factors, such as age, weight, use of alcohol and tobacco, physical activity, and nutrition into risk levels. Effective HRA's also include:

Other important components of an effective HRA are the use of self-reporting tools. They provide insight not available in standard medical and pharmacy claims data and help employers understand the cost drivers and functional outcomes related to productivity. For example, being overweight or obese rarely shows up in medical claims. Yet, employers need this kind of information to develop targeted and useful programs.

HRA's produce reports that serve several functions. Employees receive secure online tailored risk reports that provide feedback regarding their relative risk for various mental and physical health conditions and link to educational resources that employees can use to learn how to reduce their risks. Employers receive aggregated reports that identify the characteristics of their population and prevalence of various risks. This information is useful for developing program offerings.

HRA information should be captured and presented to the employer as a part of a thorough analysis and plan of action. However, the best HRA's go well beyond simply providing data on current health status. HRA's provide a unique and teachable moment for employees. They should be used as a strategy to help fuel participation in available programs. For example, employees taking an HRA online who indicate an interest in weight loss or smoking cessation should be immediately linked to information about available resources and programs.

Encouraging participation in the HRA is often the first step in determining interest and ensuring participation in the wellness program as a whole. According to the JOEM study, the top factors influencing HRA participation include the monetary value of incentives, strong, effective communications, and organizational commitment.

Implementing Well Designed Incentives

Incentives are a key component of both HRA participation and a successful wellness program. They provide the "carrot" necessary for some employees to feel motivated to take the first step toward improving their health. While a wide variety of incentives have been implemented successfully, a "panacea" incentive that works for all organizations has yet to be discovered. Because of cultural differences, what may work well in one organization may not work as well in another.

Organizations will have more success with incentives if they evaluate their individual populations to determine what types of incentives have the highest perceived value and then design incentives programs that match the perceived effort to earn the reward with the perceived value of the reward.

In the JOEM study, which included 124 employers, the monetary value of incentives and the organization's level of communication and organizational commitment (Com/Grg) were the strongest predictors of participation in health risk assessments. Results also showed that the dollar value of incentives required to engage employees was lower for organizations with a higher Com/Grg level, demonstrating the value of building a culture of health.

While many companies have experienced success with cash and merchandise incentives, a trend is emerging among companies to integrate the wellness incentive with the company's overall benefits strategy. The purpose is to communicate that the organization is willing to help those who are accountable for their own health.

Types of Benefits

This table includes a list of commonly used incentives and some advantages and disadvantages of each. The following are additional incentive decisions to consider:

Incentive Tax Issues

Be aware of the tax implications of your incentives. Some of those listed in the table are tax neutral for the employer and employee.

However, if you use cash or gift certificates above certain values, the reward could be treated as taxable income.

When carefully planned and communicated, this strategy can be very effective, as well as be cost neutral. When providing monetary rewards, there are basic criteria to keep in mind:

• The reward cannot be more than 20 percent of the cost of employee only coverage under the plan;
• The program must be reasonably designed to promote health or prevent disease; and
• All individuals must be provided with a reasonable opportunity to qualify for the reward.

Issues/Challenges

While it is critical to create programs that incent and encourage employee participation, employers do need to be aware of key regulatory and legal guidelines. Legislation regarding wellness programs continues to change. As of February 2010, there were several proposals within health care reform to provide incentives and tax breaks to employers offering wellness programs.

A broad range of employers, unions, associations, legislators, and health advocates recognize the value of wellness programs. There are few who would want to limit programs created to help employees become healthier and more productive. However, some concerns have arisen over issues related to access, privacy, and fairness.

To ensure compliance, there are a number of regulatory and legal issues for employers to consider when creating wellness programs. A few laws that employers must be mindful of when creating wellness programs include:

GINA was designed to prevent discrimination against employees with potential genetic predispositions for certain diseases. The ADEA protects individuals from discrimination with respect to "compensation, terms, conditions, or privileges of employment." The ADA provides protections from discrimination to people with certain disabilities.

The issue of privacy, regulated under HIPAA, has also emerged as a key area for employers. For example, some employees may be concerned that when taking an HRA private health information may be communicated back to their employer and can potentially lead to disclosure of private health information. The use of third party vendors, specifically companies specializing in wellness, can help address these concerns. There are strong firewalls and HIPAA guidelines protecting employee information. Specific employee information is never shared by the vendor with the employer. The creation of a culture of trust - where employees have assurances that employers are using HRA's and subsequent wellness programs to improve health, outcomes, and manage costs - can help to assure employees that their health information will be kept private and secure.

The employer's internal human resources staff, wellness provider, and consultants can help provide optimal insights, and counseling into legal and regulatory issues related to wellness program development.

Wellness Program Best Practices

Developing wellness programs that encourage and sustain participation begins with each organization identifying the approaches and programs that will best meet the needs of their organization. Best practices that have emerged from successful programs include:

Concept of Wellness Champions

This approach involves the development of teams of coworkers who encourage colleagues to participate in wellness programs and who actively support their efforts. This single approach has proven to be a significant factor in ensuring program success.

Creation of an Attractive and Safe Environment

One way to increase exercise levels is to ensure there are safe and accessible locations near the work-place. One company wanted more employees to take the stairs, but recognized stairwells were dark and unattractive. The company painted the stairwells an attractive color, put up artwork, and even piped in music. Many companies offer onsite gymnasiums; still others provide walking paths and access to other activities.

Flexibility and Support for a Variety of Options

Improving health can involve a number of activities targeted to employee interest and capabilities. For instance, an employee may not be able to or want to use stairs, but he or she could commit to increased walking, eating a healthier diet, or taking a stress management class.

Provision of Healthy Eating Options

Wellness programs can only go so far if employees face temptations at work. Consider providing healthier snack options in the vending machine and cafeteria or having healthy snacks at office meetings as opposed to donuts or other sweets.

Involvement of Employees in Wellness Initiatives

When developing wellness programs do not forget to access the most important source of ideas and insights - employees. Encourage workers to offer their ideas on appropriate programs and the best way to engage employees. Consider the development of a culture of wellness committee. Do not rely on consultants and HR alone - there are potential good ideas to be found at every level of an organization.

Gradual Implementation of Wellness Plans

Employers have found that immediate changes to benefit programs typically do not work. A long term strategy - perhaps three to five years - is recommended for the development of an effective wellness initiative.

Creation of "Sticky" Programs

Once the basic program is in place, ensure that employees have a wide range of engaging information and resources to obtain additional guidance and support. Many employers use the concept of "sticky" marketing for their own products and services - the same approach should be adopted for wellness programs. Interactive health portals with engaging programs, routine e-mails, and online or print newsletters will help to reinforce wellness messages.

Development of Meaningful Programs

Health care advocates believe that one of the likely outcomes of healthcare reform - primarily because of the perception that "my tax dollars are paying for your health care" - will be an increased awareness of the role of personal responsibility.

Recognizing the role of personal responsibility is an important task for employers, employees, and the nation as a whole. However, if an emphasis is to be placed on the individual, equal recognition must be given to the reality that to make meaningful changes in health, many people will need support. It is estimated that about 90 percent of people who lose weight through diet, gain all or most back within one year. Recidivism rates for smoking cessation and exercise, among other activities, are often also high. However -and this is critical for employers - it is not the individual alone who fails. Rather, it is often the structure of the program and the lack of support and help provided to the individual.

Because of the need to encourage and sustain change, personal health coaches should be a core component of corporate wellness programs. Personal health support programs are clinically developed and proven approaches designed to help employees make meaningful health related changes in their lives.

Optimal personal health support programs include health coaches - typically trained nurses, dieticians, or exercise physiologists that can help provide the individual support and program needed to help encourage sustainable behavioral changes. These individuals should be accessible to employees at the time and in the manner most convenient - from e-mail, to cell phone, to Internet - whatever makes participation easiest for the employee.

Coaches begin by looking at the employee's HRA to better understand the "whole" person. The goal is also to find out more about each person's emotional and psychological state as well as each individual's culture and home environment.

To be successful, these programs must also engage employees with"personalized" benefits that are relevant to each person. Instead of focusing immediately on the person's unhealthy lifestyle behaviors, such as smoking or failure to refill a prescription, effective programs must initiate a dialog about what is important to that person on that day. For example, often an employee is unwilling to stop a behavior such as smoking immediately, but they will commit to a basic exercise program - even as little as five minutes a day can make a difference in getting a person motivated to make more lasting changes. Once success is achieved in one area, most employees are more willing to expand their efforts to another area of improvement.

Wellness is Well Worth the Effort

Wellness programs can no longer be thought of as "nice to have if we can afford it." Properly developed and implemented, wellness programs should become strategic business initiatives designed to address cost, productivity, and even global competitiveness.

A recent study reports that for every dollar spent on wellness programs there are $3.37 dollars returned in reduced medical costs and $2.73 returned in reduced absenteeism.4

Wellness is clearly well worth the effort. Employers that take the time to develop comprehensive, integrated and engaging programs will be able to increase participation, maximize the value of their programs and ultimately improve both the health and bottom line for their organizations. So what are you doing to motivate employees to participate in your health and wellness programs?

Notes

Gordon Norman, M.D., M.B.A., is Chief Innovation Officer for Alere, a provider of health management services to employers and health plans. Michael Taitel, Ph.D., is a researcher, author, and lecturer on topics related to employee health and wellness plans.