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Health Risk Assessments: What You Don't Know Can Cost You

By Brian Schilling

Employers convinced there is no more low-hanging fruit, with respect to keeping employees healthy and controlling health care costs, may just need to think low-tech. Health risk assessments (HRAs) can help people get needed care when it can do the most good—before problems escalate. But just offering an HRA (as 60% of large employers do) isn't a cure-all.1 To really make a difference, employers must ensure that employees fill out the HRA and then follow up appropriately.

A health risk assessment (also known as a health risk appraisal) is an instrument used to collect health information, typically coupled with a process that includes biometric testing to assess an individual's health status, risks, and habits. Alone, an HRA can do little to improve health or cut costs. But, as part of a broader program to engage employees in their health, shape lifestyle choices, and promote prevention, HRAs can be enormously effective.

"The HRA is really an essential first step in getting health costs under control," said Ray Werntz, senior consultant at benefits consulting firm HPN Worldwide. "It gives you information about the kinds of services or support different employees need, so you can avoid bigger problems down the line. Half the battle is diagnosing diseases and matching patients with programs that can help them. For example, a great diabetes management program doesn't do you any good if your diabetic employees aren't in it."

Although savings estimates vary, successful examples of worksite health promotion programs featuring HRAs are not hard to find:2

  • Monongalia Health System in West Virginia adopted a wellness program in 2002 that required employees to fill HRAs and attend training classes on health care decision-making skills. Data drawn from the HRAs were used to identify problematic health behaviors that were then targeted by initiatives in the areas of nutrition, fitness, weight management, heart care, and smoking cessation. For the next two years, Monongalia experienced level health care claims at a time when most employers were experiencing 12 percent to 13 percent increases.
  • Johnson & Johnson reduced employee medical claims by almost $250 per year per employee over four years after it adopted a company-wide program that required employees to fill out HRAs and offered "benefit credit" incentives of up to $500 for employees to take advantage of various wellness programs.
  • Bank of America, Citibank, Proctor & Gamble, NASA, King County (in Washington State), and the State of Arkansas have all reported similar success stories following the adoption of aggressive HRA programs.

One of the reasons HRA programs work is because so many people aren't being appropriately screened for various conditions. Hence, diseases are often diagnosed later, which tends to raise treatment costs. The statistics can be chilling: 33 percent of breast cancer is not detected until it is late-stage cancer, which costs significantly more to treat. In a 2006 study, early stage breast cancer treatment costs averaged $16,000, compared with $50,000 for stage 4.3 Many conditions routinely go unnoticed: 50 percent of cervical cancer is detected at a late stage and one-third of diabetics do not know they have the disease.4,5

HRAs could help change this, but few people fill them out. According to NBCH's 2010 eValue8 survey results, only about 4 percent of health plan members fill out an HRA annually even though they are commonly offered by even smaller employers. Biometric screening is even less common.

To some, this will come as no surprise. The forms and tests can be intrusive and there is a fairly strong cultural bias in the U.S. against sharing the details of one's health history with anyone but the most trusted personal physician. To help overcome that bias, more and more firms, unions, and municipalities are putting cash on the table.

Fort Smith, Arkansas
In 2005, the city of Fort Smith, Arkansas began giving employees a $30-per-month premium credit incentive to participate in a wellness effort, complete biometric testing, and fill out an HRA. About 800 of Fort Smith's 900 employees opted in.

For four years prior to the program, the city's human resources director, Richard Jones, had been working aggressively to manage costs. Efforts included switching pharmacy benefits managers and plan administrators to reign in prescription costs and improve claims accuracy in 2002, launching cost containment and utilization management programs in 2003, implementing a wellness program in 2004, and revamping benefits package to promote preventive health care and screenings in 2005.

But Jones was convinced that a piece of the puzzle was still missing. "I read about a company that had good results with an HRA program and I knew that that's what I wanted to do with our employees," he said.

Jones was so convinced that an aggressive program to push HRAs and engage employees in their own health could help curb the trend that he launched it without first asking for permission.

"In some cases it's better to ask for forgiveness than permission," said Jones. "But in this case I didn't have to—our total health care spend today is the same as it was in 2006."

Of course, the city council did not budget for flat health care costs, so by 2010, after several years of budgeting for annual increases, Jones and the human resources department found themselves in an unusual position: they were able to give back about $800,000 to the city coffers. He describes that experience as a professional highlight.

Since 2005, Jones has tinkered with the incentive payment every year, typically increasing it a bit. It's now $67 per month for employees. Today, about 850 employees and dependents participate and, as of late 2010, overall health care costs were on target to decrease, compared with the prior year. The success of the program is not lost on city employees who last year saw a 10 percent reduction in their contributions to health care costs.

For Jones, though, the real value of the program goes beyond saving money. "I used to see 10 to 15 smokers outside the building every day during lunch hour. Today it's three, maybe. We've also detected five pending heart attacks and one serious colon cancer that would have gone undiagnosed in the short term, if it weren't for the program. That kind of thing makes you feel good at the end of the day."

CIGNA Steps Up
Health plans, which have long recognized the value of HRAs, are especially hard-pressed to get members to fill them out. "People are generally much more likely to want to participate in an HRA effort if it's an employer-driven effort rather than a health plan-driven program," said Laurie Gondek, senior director of health advocacy product solutions at CIGNA.

In response, CIGNA recently launched the Better Health Guarantee program, which is designed to help mid-sized employers promote HRAs among their employees. At the core of the effort is a guarantee, by CIGNA, to reduce the overall "health risk level" among participating employers' workforces, commensurate with participation in the HRA program. For example, if 75 percent of an employer's workers participate, CIGNA guarantees that within a year, 30 percent of participating employees will reduce their level of health risk from high to moderate or from moderate to low.

If employee health doesn't improve in 14 months, the employer is compensated with $1,100 (paid to a health promotion fund) for each participating member who does not reduce his or her health risk. The only potential downside is that at-risk employees might not succeed in improving their health.

Gondek dismisses that possibility. "We're confident that given the opportunity and the information to really manage people's health, we can make a big difference," she said. While it's too early for conclusive results, early indications are very promising, Gondek said.

Fifteen employers are enrolled in the trial program, but CIGNA expects to roll the program out to a wider audience over the course of the next year.

For more information about implementing an HRA program, see Health Risk Appraisals at the Worksite: Basics for HRA Decision Making, available at

Aspects of an Effective HRA Program

A Suitable Delivery Mode. There is no wrong way to administer an HRA: on paper, via the Web, using office-based kiosks, via phone interviews, and through various hybrids. Matching the workforce to the method is the key consideration

The Questionnaire. Many different HRA tools exist, some more expansive than others. Topics that should be considered include:

  • chronic diseases—asthma, cancer, diabetes;
  • infectious diseases—sexually transmitted diseases;
  • health conditions—disability or pregnancy;
  • injury/safety—use of alcohol or seat belts;
  • lifestyle—physical activity, diet, tobacco use, sleep;
  • occupation—heavy lifting, ergonomics, chemical exposure;
  • medical history—family medical history;
  • emotional/mental health— stress, depression, anxiety;
  • prevention—use of screenings; and
  • health literacy—knowledge of resources.

Biometric Screening. Ideally, the HRA will be followed by some collection of basic biometric indicators such as blood pressure, body mass, cholesterol level, blood sugar, bone density, and cardiovascular health. Data from these tests can help validate HRA results, identify health issues, and match employees with needed services, screenings, and programs.

Reports. The point of an HRA program is to translate the data collected into beneficial actions. Doing so requires timely, accurate, and comprehensible reports. At a minimum, a good HRA vendor should be able to provide personalized, clear reports for employees about their own health risks. Employers may also want to look for reports that include health education tips or referrals to specific services. The vendor should also supply aggregated reports to support planning and evaluation.

1 National Business Coalition on Health, Health Risk Appraisals at the Worksite: Basics for HRA Decision Making, (Wash., D.C.: NBCH, 2008).
2 Ibid.
3 California Breast Cancer Research Program, grant to Wendy Max, The Cost of Breast Cancer in California, University of California, 2006.
4 S. J. Henley, J. B. King, R. R. German et al., Surveillance of Screening-Detected Cancers: Colon and Rectum, Breast, and Cervix, United States, 2004–2006, (Atlanta: Centers for Disease Control and Prevention, Nov. 26, 2010).
5 J. P. Boyle, T. J. Thompson, E. W. Gregg et al., "Projection of the Year 2050 Burden of Diabetes in the US Adult Population: Dynamic Modeling of Incidence, Mortality, and Prediabetes Prevalence," Population Health Metrics, Oct. 22, 2010 8:29.

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