In 2015, Quest Diagnostics—which has a self-insured employee benefits team—set out on a new path to try to control healthcare costs while maintaining program quality and promoting population health for its employees.
After almost four years, the results of Quest’s group health insurance program were reported in Population Health Management, outlining the collaboration with a health plan and pharmacy benefits manager to practice the “triple aim” of improving the patient healthcare experience, boosting population health and reducing per capita healthcare spending.
The program had a big impact. Through proactive changes, physician executive leadership, health plan collaboration, disease-specific population health initiatives and plan design, Quest’s annual healthcare costs steadily improved. In 2015, the company's per member per year annual trend was 5.7%, and from 2017 to 2018, that number dropped to just 0.3%.
Steven Goldberg, M.D., vice president of medical affairs for population health and chief health officer, health and wellness, at Quest, was one of the lead architects of the company's employee health benefits program.
When Goldberg looked at what was needed to improve the well-being of the company’s 60,000 employees, he looked for a solution to drive optimal experience and outcomes, he told FierceHealthcare in an interview. Throughout the process, Goldberg adhered to the well-quoted theory: Every system is perfectly designed to yield the exact results it produces. In other words, positive results are not just a byproduct of a perfect design, but also a perfect execution (and vice versa).
And the results of this theory are speaking for themselves. Quest measures results using three types of metrics.
First, they measure the annual spend for employees. Goldberg says the average cost trend in the industry for self-insured employers is 5% a year on healthcare. At Quest, that amounts to about $375 million to $400 million spent by employees on premiums and out of pocket expenses and the company on claims and health savings account contributions. The company needs about $15 million to $20 million per year in efficiency just to stay flat.
“It’s so exciting that we were able to see see the value of the program and we reduced cost per member in the first year of the program,” Goldberg said. The company went from 5.7% in 2015, to -1% in 2017 and 0.3% in 2018.
The second key metric that Quest uses to measure success is data for population health. Quest relies on partner Aetna to collect and measure these data through its Active Health Index—which measures impactable and non-impactable results. Quest reports a 4.2% improvement or reduction in impactable opportunities per the course of the program.
The third metric is engagement. Quest uses multiple channels for soliciting feedback from its employees.
“We were able to control employee out-of-pocket and, in fact, we measured it and our out-of-pocket over the past 12 months has gone down,” Goldberg said.
The company has also added many solutions such as a pre-diabetes program, a diabetes program, a smoking cessation program and an enhanced behavioral health solution.
Along with the payer system, Quest is working to manage how its employees shop for care. For example, the company tries to make it more attractive for employees to stay in-network then to go out-of-network for medical services and make it optimal to seek second opinions before making decisions about surgery.
“We worked with Aetna to create processes so that high-cost conditions can be engaged early instead of late,” he added.
When looking at the larger context of wellness and how it pertains to healthcare costs, Goldberg does not view social determinants of health as a new concept. Quest has been offering a blueprint for wellness for about 10 years, and more than 35,000 people participate every year, completing a health risk assessment, a laboratory panel and biophysical measurements (over 100 data points), with between 75% and 80% participation from the entire staff.
The goal for the team at Quest is to find what employees need and take actionable results. And Goldberg noted the program has helped employees identify health issues they did not know about such as chronic kidney disease, hypertension and more.
“For every 1,000 people, we generate 300 actionable insights for opportunities,” Goldberg said.
“If you say to me, 'Steve, how much of the wellness piece drove your overall results?'—we humbly say we just don’t know,” he said. “But it provided me the dashboard to know where to focus based on geography, condition and so forth.”
When asked about the recent study published in JAMA, Goldberg said that his experience is that wellness programs will actually not yield positive results unless the programs get very specific to the individual.
“The more specific they are and the sooner upstream the issues are identified, the higher likelihood that it will have value,” he said.
But again, these may not be quantifiable return on investment results. Still, Goldberg believes that if they identify and engage employees, there will be fewer advanced cases of kidney disease and diabetes and other illnesses.
There still remain ongoing challenges for Quest and other companies looking to implement wellness programs. The first challenge is making sure that employees are comfortable. People want to know what information you will be collecting and how it will be used in order to maintain some privacy.
Goldberg says another challenge is to make sure the culture around the office is supportive of the wellness initiative. It’s up to managers and leaders to embrace the mindset so that employees will want to join and feel taken care of by their superiors.
And finally, the wellness program and initiatives cannot be too complex. The tasks must be clear and convenient to get employees to engage.
Sometimes programs are trial and error, and Goldberg was surprised by the success of some new company-wide initiatives this year. A group known as the Healthy Quest leaders helps decide how to allocate the funds for the employee wellness projects.
And recently, the company opened up ideas to the greater employee base. There were 12 projects submitted, and some of the ideas were unique to anything Goldberg would’ve thought of himself. For example, one idea was to subsidize the cost of salads in the lunchroom. After the program was put in place, there was a noticeable lift in salad consumption.
Goldberg notes that industry spend is at a 5% increase year over year, with about 1% to 2% of all individuals driving 30% to 35% of the spend. And he believes that by doing the surveillance, its an easy opportunity to engage with people before they are too far down the stream to fix their health and economics.
“I’m not going to say our screening caused our results, but they are a component of our strategy and without it, we don’t get the results we want,” he said. “We need to manage for today and tomorrow, all at the same time.”