State of Nebraska

Narrative Description of Program

The State of Nebraska was founded in 1890 and has 1.8 million residents across 800 miles. As a municipal employer, the State of Nebraska has over 19,000 employees, ranging from blue collar to professional positions that live in all 93 counties across the state.

Under current state statute, the State of Nebraska contributes 79% of the premium associated with each plan offered to state employees. This factor, along with rapidly rising medical costs, was creating financial challenges to the State’s health insurance program.

Prior to 2009, the State offered a portfolio of health plan options with minimal preventive care benefits. These plans included a low-deductible PPO, a high-deductible PPO, a no-deductible POS and no-deductible HMO. The State of Nebraska health claim costs were far exceeding budget with reserves reaching an all-time low.

As a result, the State developed a new innovative wellness strategy known as ‘wellnessoptions.’ The State of Nebraska became one of the first states to launch a comprehensive plan for health insurance coverage (Wellness PPO health plan) integrated with wellness program participation (‘wellnessoptions’).

In April 2009, the State of Nebraska launched the ‘wellnessoptions’ program, offering the following programs to 19,000+ employees and spouses enrolled in a State health plan:

• Web Platform
• Health Risk Assessment
• Onsite Biometric Screenings
• Health Advising
• Walk this Way
• Feel Like a Million
• EMPOWERED Health Coaching
• Condition Management Coaching

Consistent branding for the wellness program allows easy recognition by employees, and reminds employees that “Wellness is a journey we take together”. In addition, the wellness program provides targeted messaging to those enrolled in a State medical plan to increase preventive screenings (i.e. mammogram, colonoscopy, cholesterol) and chronic condition screenings (i.e. hemoglobin A1C, liver enzymes) to those not compliant based on claims data.

Two primary evaluation methods and results include:

1. Overall ‘wellnessoptions’ Return-On-Investment Analysis

Through a randomized process of matching and using propensity scoring adjustments, participant and non-participant groups were identified. Claims and allowed amounts were examined and matched with the appropriate participant and non-participant groups. A least 3 squares linear regression analysis was performed to assess the treatment years minus the baseline year. The allowed amount between the two groups was analyzed. A simple paid/allowed ratio adjustment (approximately 88%) was made to estimate the employer ROI. Net savings were calculated. This analysis computed the ROI for all above mentioned ‘wellnessoptions’ programs.

Roughly $4.2 million in saving have been realized in reduced claims spending. For every dollar spent on wellness, $2.70 was the documented savings after two years. Wellness program participants saw a claims savings of $934.

2. Targeted Messaging Analysis

Historical medical and pharmaceutical claims were used to track preventive screening utilization. In addition, wellness program participation and Wellness PPO health plan enrollment metrics were used to determine the impact of this communication strategy.

Preventive screening adherence grew by 8.5 percentage points, or a relative increase of 14%. The use of generic prescriptions increased 5%. Overall wellness program participation and the Wellness PPO health plan enrollment increased 10%.

Narrative Description of Evaluation Results

Overall 'wellnessoptions' Return on Investment (ROI) Analysis

Program Year 1 ran from April 20, 2009 through March 31, 2010 and Program Year 2 ran from April 1, 2010 through March 31, 2011. Employees and their spouses (eligible in Program Year 2 only) who were continually covered with benefits were used in the analysis. Incentive costs were not added into the final ROI calculation due to the separate wellness benefit plan being cost neutral to the employer with lower cost premiums. Average allowed amount savings were used to calculate overall medical and pharmacy ROI. A simple paid/allowed ratio adjustment (approximately 88%) was made to further estimate the employer ROI.

Areas that contributed toward reduced costs among wellness program participants include:

• Reduced prescription utilization; in fact, the total number of prescription scripts filled within the Wellness PPO Health plan reduced 3% last plan year
• Reduced ER visits
• Reduced hospital admissions
• Reduced hospital stay

Targeted Messaging Analysis

Based on baseline claims utilization, the State found the preventive and chronic care screening compliance rate was extremely low among all those with health coverage, thus justifying the need to address prevention and early detection. The solution turned to a targeted messaging initiative to increase compliance of evidence based guidelines to result in quality of life and cost savings to the participant, in addition to the State of Nebraska. To accomplish this, persuasive home mailings include relevant information to limit barriers for action and target those individuals by providing:

• Type of screening that is due
• Health Plan coverage information for the screening specific to the participant’s coverage
• Nearest doctor’s office from home if participant does not have a primary doctor

These reminders, which have been proven to increase compliance (Milkman, Beshears, Choi, Laibson & Madrian, 2011), save money by lowering medical costs through prevention, early detection, and early treatment for a variety of medical conditions. The State of Nebraska impact of the targeted messaging engagement strategy are objectively reported based on data driven outcomes from claims data and wellness participation metrics, including:

• Total preventive screening adherence rate has increased 14%
• 10% increase in overall wellness program participation
• 10% increase in Wellness PPO health plan enrollment
• 5% increase in use of generic prescriptions

Program Evaluation Highlights

Wellness Components

• 11.3% who were previously high risk for low levels physical activity are now exercising more than 2 days per week.
• 7.7% who were previously high risk for low fruit/vegetable consumption are now eating more than 3 fruits/vegetables per day.
• Participants reporting they use tobacco decreased from 9.3% to 7.8%.
• Additionally, those at high risk for depression decreased from 11.6 % to 9.6%.
• The overall average number of individual risks significantly declined from PY1 (1.55 risks) to PY2 (1.41 risks).
• The percentage of employees at low-risk status (0-2 risks) increased from 78.4% in PY1 to 81.9% in PY2. Consequently, the percentage of employees at moderate-risk (3-4 risks) decreased from 18.7% to 15.7% and those at high-risk (5+ risks) decreased from 2.9% to 2.4%.
• Compared to other medical plans, the Wellness PPO Health Plan participants had the largest percent of high risk reduction between PY1 and PY2 with a 9.2% reduction.

Wellness Program Interest Survey

• Personal Attitude Towards the Wellness Program
  • 67% are somewhat or very enthusiastic about ‘wellnessoptions’
• Personal Benefits
  • 83.5% indicated the ‘wellnessoptions’ program has somewhat or considerably affected health and well-being positively
• Greatest Attraction
  • 83.8% like the premium savings with the Wellness PPO

Targeted Messaging

• 146,080 reminders were sent from 04/30/2010-04/30/2011.
• Adherence in areas such as cancer screenings, blood pressure & cholesterol screenings, glucose & bone density screenings and chronic conditions has grown by 8.5 percentage points since April 2010. This is a relative increase of 14%.
• As a result of a large increase in preventive screenings, there have been a significant amount of cases in which conditions have been detected in their early stages, with many getting screened for the first time. During the two year period, 514 new cases were detected with an early stage of cancer (mostly colon). Unfortunately, 26 new cases were diagnosed with a late stage of cancer.

• Overview of Evaluation Methods

  Wellness Components Evalutation

  The population was divided into appropriate groups and differentiating characteristics were measured: gender, age, insurance plan, and pregnancy. The participant groups were then matched to non-participants so covariates were equalized. The matching occurred through a randomized process using propensity scoring adjustments. By matching on probabilities between participants and non-participants, the selection bias based on known variables is minimized. After matching, the groups were statistically tested for equivalence.

  A baseline period of 12 months just prior to when the program year started for each group was identified and a Per Member Per Year (PMPY) allowed claims expense was calculated. For each program year identified, 12 months of claims and three months of claims run out were required. These dollars were then adjusted for inflation to match the first program year. Claims savings were computed as the difference between each program year and the baseline.

  A least squares linear regression analysis was performed to assess the treatment years minus the baseline year allowed amount between the two groups. Program costs were identified and adjusted to the baseline year for inflation. The ratio of gross savings to program cost is the return-on-investment for the specified program duration. Net savings are also calculated by subtracting out program costs.

  This analysis framework was used to compute the ROI among all of the following ‘wellnessoptions’ programs:

• Web platform utilization
• Health Risk Appraisal
• Onsite biometric screenings
• Health advising
• Walk This Way
• Feel Like a Million
• EMPOWERED health coaching
• Condition Management

• Targeted Messaging EvaluationThe wellness program determines which State of Nebraska members are due for evidence based preventive and/or chronic care based on age, gender and medical history including medical and pharmacy claims. These members are sent personalized reminders to encourage the completion of the recommended preventive care. The wellness program receives monthly and refreshed medical and pharmacy claims from the State of Nebraska health plan and pharmacy benefit management supplier. The claims data is mined to determine, based on diagnostic and treatment codes, whether the member completed preventive and/or chronic care. If there is a corresponding code(s) for the recommended care, test, screening, procedure or medication, then the participant is considered adherent to care.

• Erratum Statement: Nebraska

The following are verbatim remarks made by the reviewers:

A

• Integration of program into wellness-branded low-cost health plan that supports wellness and preventive care
• Comprehensive, well-designed and integrated program
• Targeted preventive care outreach strategy very effective in increasing rates of preventive screening and early identification of health issues
• Grassroots (champion network) and senior leadership support including very active support and involvement by Governor
• Participant recognition program supported by Governor
• Environmental changes supporting wellness strategy
• Very positive changes in health care cost trend in every post-implementation year, with annual trend improvements since program implemented
• Favorable health care trend aligns with rigorous differences-in-differences, matched control, propensity adjusted savings analysis comparing participants and non-participants, together providing strong evidence of program savings
• ROI of $2.70:1 over the first two years of program implementation, based on rigorous evaluation methodology, compares favorably with ROI benchmarks in the peer-reviewed literature
• Overall risk reduction of 9% based on reduction in number of risks among repeat HRA participants provides health improvement evidence supporting savings analysis

B

• Web resources, HRA, biometrics, health coaching
• $4.2 million in saving from reduced claims spending
• ROI of 2.7:1 after two years
• Wellness program participants saw claims savings of $934
• After double-digit increases prior to implementation of wellness program, saw recent decrease of 8%
• Coaching approach includes aspects of motivational interviewing, positive psychology, readiness to change, and social cognitive theory.
• Condition management program for Coronary Artery Disease, Heart Failure, Diabetes, Back Pain, Asthma, COPD, Depression and Healthy Pregnancy
• 30% of eligible in low-premium wellness PPO plan
• Leadership support
• Wellness champions
• Recognition
• Primary-level interventions
• 42% participation rate
• Quasi-Experimental Design with Controls. Matched sample with propensity score adjustment
• Reduced ER and hospital use
• Preventive screening adherence rate has increased 14%
• Improvements in physical activity, consumption of vegetables and fruits, tobacco, stress and depression
• Overall health risk reduction 1.55 to 1.41

C

• Well-documented application with program description and history.
• Comprehensive program
• Good branding
• VBBD connected to wellness program
• Senior leadership support including the governor
• Staff commitment
• Recognition program
• Environmental and individual interventions
• Participation rates around 40% (not great)
• Good evaluation methods
• Medical trend down

D

• Program offerings seem comprehensive, especially for a state government.
• Integrating the wellness program into the health plan design is wise.
• Requiring spouses to meet the participation criteria for the Wellness PPO is wise.
• Providing a photo with the governor for people who are successful in health changes is innovative. It is probably also provides the governor with additional visibility, which in turn enhances his commitment to the program.
• Providing a wellness incentive that is cost neutral to the employer is wise.

E

• Governor’s support
• 19,000 employees and spouses
• Reported $ 4.2 M in savings and ROI of 2.70:1
• 8% reduction in medical cost trends vs the State of Nebraska overall
• Incentives of $ 525.36 per individual with up to $ 1,865.76 for a family
• ROI of 2.70:1 after 2 years
• Wellness program participants with claims savings of $ 934

F

• Comprehensive services
• Integrated wellness with benefit design
• Health advising session with health assessment and biometrics
• Targeted communications
• Premium discount for program participation – If family, spouse must participate
• Wellness champions, leadership support, environmental support
• Good spouse participation
• Rigorous savings calculation methodologies / Multiple methods using to build directional confirmation
• Risk migration analysis
• Positive savings (2.7:1.0) ROI
• Good impact on preventive screening activity

G

• Program being ingrained in culture of university
• Very good basket of tools utilized
• Good approach to begin by identification of health/wellness issues
• Impressive spouse participation