Editor's note: Clint Davidson will be copresenter of a webinar sponsored by CUPA-HR on the topic, "ROI of Wellness Programs," on May 29, 2008. For more information, go to www.cupa-hr.org.

More than half of the nation's cost for health care stems from chronic disease, resulting primarily from the high risk behaviors of individuals. Recognizing that one of the best remaining options for controlling health-care costs was to create a healthier workforce, thereby reducing the number and per-person cost of filed claims, Duke University launched a new employee health-care program, Duke Prospective Health, in 2003. The program is designed to help identify an individual's risk for developing a disease or chronic condition before it is known or occurs. While Duke expects to see lower claims costs in the future as one measure of success, the program represents an ideological shift in that Duke didn't go into this with cost savings as the sole priority, but rather, with the intention of improving employee wellness and productivity.

Prescription for Success

In identifying an approach to address the needs of the Duke workforce relative to health and wellness, Duke had to figure out an effective strategy for engaging individuals and their health-care providers to work together on preventive practices and disease management. "Duke's strong emphasis with the program is to engage with faculty and staff regarding health and health care," said Clint Davidson, the university's vice president of human resources. While disease-management programs have become prevalent, what is often missing is a sense of partnership between patients and their care providers. One primary focus behind Duke's Prospective Health program centers on ongoing communication with employees and health-care providers, creating compelling arguments for why it is in the interest of employees to be involved in their health care and for providers to become more involved with their patients.

Since many patients often don't get the opportunity to spend quality time with their physicians, Duke developed the concept of health-care coaches and care managers to play an intermediary role with employees and their providers. These health-care coaches and care managers are employees of Duke Prospective Health, a third-party administrator. This relationship ensures employee privacy regarding matters of personal health and treatment. Coaches and care managers are clinically qualified individuals who assist patients with understanding diagnosis and treatment options and who can accompany patients on doctor visits. Their participation helps foster a strong patient-doctor relationship and helps ensure patient follow through on treatment or preventive health management that is tailored to an individual based on his or her current or predisposed risk for developing a condition.

Engaging Employees

Duke's Prospective Health is voluntary, open to all employees covered by a Duke health plan and offered at no additional cost to employees. As a first step, employees must complete a health risk self-assessment. This is a simple questionnaire about lifestyle and daily habits including exercise, nutrition, and stress. In combination with other health-care information, the assessment helps identify potential health risks and is used to develop a personalized health plan.

Depending on an individual's specific health-care needs, support may include assignment to a health-care coach who works on specific issues with a group of participants. An employee might also work one-on-one with a care manager who coordinates care directly with a team of health-care professionals or helps connect the individual with specific Duke health-and-wellness programs that focus on fitness, weight loss and nutrition, cholesterol and blood pressure, or smoking cessation, among others.

Developing a Health Census

Depending on their potential health risks, participants are grouped into one of three categories.

Intensive. These individuals are considered high risk and already have one or more chronic conditions. In addition to working with health-care coaches, they receive monthly calls from their care managers, who coordinate with the individual's primary care physician to help them reach specific goals.

Enhanced. These participants include those at risk for developing chronic conditions and disease. They work with care managers to reduce their specific risk factors.

Core. These participants have the lowest risk for developing chronic conditions or disease. As part of their care plan, these individuals remain connected to their primary physicians and receive regular educational materials, participate in Duke's wellness program, and keep track of progress toward their personal health goals online.

While the intensive and enhanced groups represent the minority of Duke employees—roughly 4,500 among 30,000-plus employees—they account for a much greater percentage of per-person medical claims costs. For instance, costs for the intensive group total more than seven times the cost of participants in the core group, and costs for the enhanced group are more than twice that of the core group. For this reason, Duke focused its initial efforts on increasing the participation of those in the intensive and enhanced groups.

Measurable Outcomes

Duke invested more than $2 million to launch its Prospective Health program. "We soon will reach the five-year anniversary of the program, at which time we plan to engage in a more aggressive analysis of the program. However, early indicators suggest the program is already having a dramatic impact," says Davidson.

• Overall medical expenses of Duke's original intensive population have decreased by more than $1 million since 2003.
• Claims expense for the past four years has been less than the university budgeted and less than the national average. Claims costs have gone down significantly within the intensive group. Per-member, per-month claims costs for these individuals decreased from approximately $510 in 2003 to $377 in 2007.
• Hospital admissions have decreased by 17.9 percent since 2003, at an average savings of $4,343. The overall length of a hospital stay has also decreased by one day since 2003, at an average savings of $1,083 per day. Likewise, emergency room visits, at an average cost of $966, have decreased appropriately in proportion to a rise in urgent care visits, which on average cost only $80.
• Since the program was rolled out, 56 percent of Duke's employees have completed the health risk appraisal. Approximately 50 percent of individuals within the intensive and enhanced groups are actively engaged in care management programs.

To encourage all employees to participate in Duke's Prospective Health program, gift certificates and financial credits are provided for prescription drug co-pays to individuals who are active in the program. In attempts to further create a high level of involvement and focus on wellness, the university plans to introduce financial incentives for employees to remain healthy when they engage in a range of activities to manage their health. These may include going through a tobacco cessation course, or establishing certain goals such as losing weight or reducing cholesterol.

Duke will continue to monitor the success of the program based on various measures, including the percentage of employees who are actively engaged with health coaches; active in preventive care through routine physicals, mammograms, and so forth; and by various utilization metrics such as office visits, hospital and emergency room visits, and total medical costs.

As a result of successful early interventions and engaging all employees in healthier habits, Duke expects to continue to see reduced claims costs from higher-risk employee groups. University leaders believe that will translate not only into greater savings for the institution, but also improved health and productivity for its employees.

Karla Hignite, principal of KH Communication, is editor of NACUBO's HR Horizons; e-mail: karlahignite@msn.com.