After Teresa Roe lost 85 pounds in 2006, the encouragement for her to maintain a healthy lifestyle came from an unexpected place - her employer.
"I have a very bad history in my family ... diabetes, congestive heart failure, all of that," Roe said. "I know I have a lot of factors against me, and the more education I have, the more power I have."
Roe is a 15-year employee of Jefferson City Medical Group, which introduced its first employee wellness program in 2006. In the years since its inception, JCMG's wellness program has maintained an 80-percent participation rate, offering incentives and support for employees to form healthy habits.
JCMG's program is part of a larger trend, where businesses are encouraging healthy choices as a way to decrease health-insurance claim costs over time while developing a healthier, happier and more productive workforce.
"With us being a health-care organization, we thought it would be good for us to be out on the leading edge to help our employees take control of their lifestyle so that they could live a healthier life, reduce their stress and improve their quality of life with good health," said Louise Hune, director of human resources at JCMG. "We wanted to set an example for the community that we serve."
Hune helped launch the wellness program, which has earned the American Heart Association's Fit Friendly Award for the past seven years.
Jumpstarting wellness
Formulas for employee wellness programs vary, and the best way to foster healthy lifestyles for employees at a particular company is to ask the employees what they want, according to Jefferson City's Wallstreet Insurance Group, which has been helping clients design wellness programs for about seven years.
"It's not a one-size-fits-all," said Lee Wilbers, Wallstreet Insurance Group owner. "It's really what is best for that company. I firmly believe that the individual company has to look at their people."
JCMG, a Wallstreet client, started with a committee of 10 members from departments across the company. Focus groups of employees guided the beginning stages.
"Most of the time, we'll go in and do a five-year plan: At the end of the day, what would we want, and how do we get there?" Wilbers said.
He also said programs should direct effort toward encouraging people who are lukewarm about their health habits - those who don't have critical conditions but do have some health risks and do not necessarily eat nutritiously or stay active - for the most economic impact.
"You really can't help the people who are critical do anything; it's that group in the middle. With that group in the middle, what you're trying to do is reduce risks," Wilbers said. "If you reduce the risks, it reduces claims."
That's the approach of another large-scale employee wellness initiative, the Missouri Consolidated Health Care Program's Strive for Wellness program, which launched in its current form in fall 2012. The insurance plan serves 39,000 state employees, 25,000 of whom participate in the wellness program.
"As with any large employer group, our membership has a fair number of lifestyle conditions. We have high rates of diabetes, high blood pressure, heart disease. We have a significant amount of obesity and overweight issues that can be affected by a lifestyle change," said Judith Muck, MCHCP executive director. "We know that individuals with health risks have higher health-care costs, so we need to bend that curve."
A fledgling program might begin by simply encouraging employees to participate in healthy activities.
"Those things are really to get people engaged and to make it easy, fun," Wilbers said. "The great thing about those is people get excited about it, they do it, and that's probably the first step in a wellness program."
JCMG started with a "Route 66 Walking Challenge." The wellness committee calculated the mileage between each stop on old Route 66 and challenged employees to walk the distance - more than 2,000 miles - over 18 months. Reaching milestones earned incentives like vacation time or gift cards.
They also tried to make the challenge easy to accomplish.
"We mapped out the mileage route here in the building for bad-weather days or employees who wanted to stay in during the winter months," Hune said. They also offered a list of other activities - yoga, bicycling, playing basketball, etc. - along with calculations for what constituted a mile for each alternative exercise.
Upping the ante
Results-based programs offer a more intensive approach, offering incentives only for employees who meet or make progress toward specific health-improvement goals.
"It's points-based. They really penalize the people that aren't doing the right things," Wilbers said. "That is probably where wellness is going long-term. It's trying to get people to change a behavior and trying to get people to change that risk."
Twenty-three percent of large employers used outcomes-based incentives in wellness programs in 2014, up from 20 percent in 2013, according to Mercer's December 2014 National Survey of Employer-Sponsored Health Plans.
Wallstreet's own employee wellness program is results-based, using biometric measurements and health risks assessments to keep track of participating employees' health progress.
"If you score above a certain point value, we pay all your health insurance and we give you the full HSA contribution. If you score in the middle, then you have to pay a part of your premium and we pay less HSA," Wilbers said. "It kind of goes down from there."
No single health factor can keep an employee from scoring in the highest level in Wallstreet's program, except for tobacco use.
"So when you start looking at risks, it's a combination of risks that drop you down," Wilbers said.
Penalizing tobacco use more heavily is becoming more common - 26 percent of large employers contributed less to employees' health-insurance premiums if they use tobacco products, or discouraged tobacco use in some other way, in 2014, up from 23 percent in 2013, according to the Mercer survey.
MCHCP's Strive for Wellness program offers a $40 insurance premium reduction for tobacco-free employees, but even employees who cannot attest to being tobacco-free can still earn the incentive by agreeing to attend tobacco-cessation classes provided by the program.
JCMG adapted to results-based wellness in 2014, re-branding its initiative as the Healthy Initiatives Program.
"Everybody was having so much fun with it, and we decided it was time to make sure that we hold our employees accountable," Hune said.
Participating employees undergo a biometric screening that evaluates body mass index, blood pressure, cholesterol and glucose levels; complete a health risk assessment; and sign a patient agreement.
Adding individual medical screenings into the equation does increase the cost to a company, compared to a simpler activity-based program. Wallstreet's program costs about $100 per person each year, not including what the company contributes to health-insurance premiums, Wilbers said.
Making it count
The other primary cost associated with wellness programs is the incentives used to encourage employees' healthy behavior. The types of incentives used are another aspect to consider through committees and focus groups. "Everybody's motivated a different way," Wilbers said.
Fifty-six percent of large employers with wellness programs offered financial incentives in 2014, according to the Mercer survey.
That's the direction JCMG turned when it boosted its wellness efforts last year. Employees who met their health goals for the first year received a monetary award of $150.
"This year, they go through the same process," Hune said. "But, if they had improved in those four categories, then they would get an additional $25 for each category that they improved in. So they could get up to a $250 rebate."
To employees like Roe, who used her award this year to go horseback riding on the beach while on vacation with other JCMG employees, the financial incentive is just enough to keep her on track.
"It holds me, at least year to year, accountable," Roe said. "When I know where I was last year ... I know that time is ticking if I want to get that incentive."
Like at Wallstreet, MCHCP's Strive for Wellness program offers decreased insurance premiums ($25 a month) for employees who agree to health assessments and annual wellness exams. Based on the health assessments, the program connects employees with behavioral health coaching to help them reduce their particular health risks.
Other potential additions to wellness programs vary by workplace. Wallstreet has a gym at the office that employees use before and after work and over breaks. MCHCP recently added the Strive for Wellness Health Center in the Truman Building to offer state employees convenient access to treatment for minor illnesses and things like flu shots.
"We're piloting that to see if we can get people to access care at an early moment where they won't need urgent care or emergency care down the road," Muck said.
Measures of success
Employee wellness programs are still new enough that it's difficult for companies to measure their success in improving health and lowering insurance claim costs.
At JCMG, employee insurance premiums didn't increase for four years, and the fifth year's increase was minimal, Hune said.
"It's hard to put the dollar on it," Wilbers said. "In larger groups, what you have to look at is ... how have we changed if we look at five years ago?"
While MCHCP's current program is only a year old, a previous, less-robust program offers some insight.
"Over a five-year period, we had some slight reductions in population health risks," Muck said. For example, MCHCP saw a 2-percent decrease in the number of participants with six or more health risks, a 4-percent decrease in participants' overall number of health risks and a 6-percent decrease in tobacco use. "We're hoping to see better results with our new, improved program, but it's just too early for us to make that initial assessment."
Until that time, companies may see other benefits of encouraging their employees to adopt healthier lifestyles.
"Our focus is improving our members' health status," Muck said. "We hope the byproduct will be a reduction in trend that will help save us money, but our primary focus is improving the overall health of our population."
"If I've got healthy employees at work every day, they miss less time," Wilbers said. "If they're healthier, they're better employees."
For Roe, the results are more personal, and the encouragement keeps her looking forward.
"In 2006, my cholesterol was high, my blood pressure was high," Roe said. "With medication, my blood pressure is normal now. ... My goal is to not be on medication through my activities and lifestyle. That is my goal for next year."