Financial Incentives and Workplace Wellness-Program Participation

Financial incentives appear to be a crucial factor in bringing unhealthy workers into workplace wellness programs, according to a new analysis by EBRI

Data from a large employer that offered financial incentives to encourage participation in its wellness program are analyzed in this paper. It examines how the characteristics of first-time, wellness-program participants changed with the enhancement of financial incentives for health-risk assessments (HRA) and biometric screenings. Those who completed an HRA or biometric screening in the two years prior to the change in financial incentives (i.e., pre-incentive) are compared to those who completed an HRA or biometric screening in the two years (for HRA) or three years (for biometric screening) after the change in the financial incentives. Findings from this study paint a vivid picture of the type of individual who favorably responds to wellness-program financial incentives—a research contribution with important implementation and evaluation implications.
Demographics—Among employees who first completed an HRA post-incentive, 82.4 percent were male versus 70.2 percent who first completed an HRA pre-incentive. For biometric screenings, the gender comparison was similar. Late adopters also tended to be older. Among those first completing an HRA post-incentive, average age was 50.0 compared to 45.0 among the pre-incentive group. For biometric screenings, average age was 48.7 versus 46.4 for the post- and pre-incentive cohorts, respectively.
Health Status—In general, individuals who first completed the wellness programs during the post-incentive period were less healthy than early adopters. Moreover, prevalence rates of diabetes, high blood pressure and high cholesterol were all higher in the post-incentive groups than in the pre-incentive groups.
Health-Services Utilization—Visits to specialists were higher for the post-incentive cohorts. Prescription drug utilization was higher as well among post-incentive HRA completers (17.0 fills per year) compared to pre-incentive HRA completers (14.2 fills per year), and also greater for post-incentive biometric screening completers (18.7 fills per year) compared to pre-incentive completers (13.3 fills per year). In large part, individuals who first completed HRA and biometric screenings after the financial incentives were introduced were less likely to have consumed preventive care, and they were less likely to have visited a primary care provider.
Health Risks—Individuals who first completed the HRA post-incentive had greater health risk than those first completing it pre-incentive. Employees first completing the HRA post-incentive were more likely than those completing it pre-incentive to be at risk for blood pressure, exercise, glucose, nutrition, smoking, and weight.
Biometrics—Late adopters of biometric screening also had worse biometric values. Over one-third (35.2 percent) of post-incentive biometric screening completers was obese compared with about one-quarter (26.3 percent) of pre-incentive completers. Further, 50.3 percent of post-incentive biometric screening completers were pre-hypertensive, compared to 45.8 percent of early adopters.

typical m Figure References Yen, L, A 6, Biometrics— Health St HRA Ince e Sch Perc chau nisms. The entage of Sam ltz, E Sc atus ntive P—The o hnu sst-incentiv — He When eri Charlso alth Insura p nle Wit ger, the HRA e an h biometric n Comorbidity d D Diabetes, High B nce was first W Edin Portability a scre gton. enin introduced, em Inde g com l"Fi o n x o d Acco (CCI n d ancial Costs Due to Excess Pr pessure, a let ) is ue nrs wer a pr tabi ployees wer li oty Act of n xe d Hi y meas mor gh e e Chol likely 19 ure o offer 96 esterol, by f than e (HIPAA h d Health Risks ea alth $50 ea status der ) rly ado gift prohi Year card Among of b pits discrim ters to to co First HRA ived from Active be obese mplete ina ation n it. A d Paul Fronstin is director of the Health Education and Research Program at the Employee Benefit Research Institute Financial Incentives and Workplace Wellness-Program and diag against i few years th nos Employees of pre- is n hyper Biometric cod divi er duals base eteafter, s ensive. Abo from m a Utility Com Screening Com emp e d o dic lu oyees w na t one health l claims pany." -p thir e let status, re data. d i ins on Relative to Jour (35.2 percent te Th nal but ad given e i of Occu does al ndex th Ye ) a $2 of pation low ar Figure 10 Figure 12 e Figure 3 Figure 8 Figure 5 Figure 1 o post-ince Financia 0-per-mo employ reti al an cally r d Enviro ers to l Incentive n nth discount a tive nges biometr provide from nmental M was 0 to ion re c scr Introduced war the 3 ee7 dic enin id r w s or hea ine ith higher scores g com , 20 lfinanc th insur ................................. 06 p: le ial 8 ters was o ance premi 9 ince 6-905 nindic tives fo . bes ati um e n rs g if 10 (EBRI). M. Christopher Roebuck is president and CEO of RxEconomics, LLC. This Issue Brief was written with assistance Anderson, D R, et al. "The Relationship Between Modifiable Health Risks and Group-Level Health Care Expenditures. Participation Use of Specific Health Blood Percentage Pressure, by To Use A tal verage Charlson Number of Prev Male and Y enti of Health ear Management ve of First Biometric A Serv Comorbidit vera Risks, by ices, ge Ag Programs, by by e, y Y Index, Y by ear of ear Y Screening Completion ear of First HRA by First of First HRA Y Firm Size, ear HRA of * * *2013 compared to employee they complete greater di part sease b ad th icipation bout on ue HRA. rden e-quar in (Cha Th a welln e goa rlson, et a ter (26. ess pro l of 3 the perc l. 1 g c r9am. While en h 87) ange in t) of (Deyo, pre f HIP inan - Ch incAA a entive com erkin cial in llows for i a centives nd Ciol pleters (Figure n 199 was to i centives up 2) (Q nuan, creas 1t1 o et al. ). J e as part umuch st over 20 icipat 05 as 20 perc ). I ion 50 n the percent in th pr e H ent esent of RA o post- f the study, from EBRI Health En ’s research an hancement d Resear editorial staffs. ch Organizat Any views ion (HERO expr ) essed in Research Committ this report ar ee." e t America hose ofn the Journal autho of rs and should Health Promotio not be n Figure 7, Use of Health Care Services, by Year of First HRA and Biometric Screening Completion Relative to Year Completion Relativ and First HRA and Biometric Screening Completion Relativ e Biometric to * Year and Biometric e to Financial Y Screening ear Financial Incentiv Screening Completion Incentiv e was Completion Relativ e Introduced Relativ was eIntroduced e to By Paul Fro nstin, Ph.D., EBRI, and M. Christopher Roebuck, Ph.D., RxEconomics incentive total cost of program. employees biom 90 wh % coo firs etric scre verage, t com a ma enin plet g compl ximum o ed an HRA efters 30 or percent were biometric pre-hypert is no scw l reenin e ensive, com galgs un pos dert PP -in pa c ACA, whic entive red to 45 had h al .8 hi percent o so allows u gher CCI s f ea cpor rly tes o 50 adopters (i. percent e., we (Figu re i ln e sre s ascribed to the officers, trustees, or other sponsors of EBRI, Employee Benefit Research Institute-Education and 15 (2000): 45-52. March 2015 • No. 412 Relativ to Y Ye ear Financial to ear Y Financial ear Financial Incentiv Incentiv Incentiv e e w w as as Introduced eIntroduced was Introduced Endnotes Financial Incentive was Introduced ......................................................................................................... 11 HRA Completed Pre-Incentive HRA Completed Post-Incentive 12). incentives healthy Diff ) tha erenc for n interventio e those who s in cholester co ns designed to mplete ol leved ls betw either preen t or bot event or r he h o pre fe th duce tobacco - a en we d post-inc llness programs pre use. entive biometric -inc screeni entive. CCI ng coho average rts were d 0.21 not for Small employers Large employers Research Fund (EBRI 0.25 -ERF), or their 82% staffs. Neither EBRI nor EBRI-ERF lobbies or takes positions on specific policy Biometric Screening Completed Pre-Incentive Biometric Screening Completed Post-Incentive 80% 80% HRA Co 70% mpleted Pre-Incentive HRA Completed Post-Incentive HRA Not Completed Biometric Scre 60% ening Incentives—When biometric screenings were first implemented, employees were offered Baicker, Katherine, David Cutler, an d Zirui Song. "Workplace Wellness Programs Can Generate Savings." 78% Health Affairs Where the world turns for the facts 80% on U.S. employee benefits. statistically significant employees with post-ince (Fig nti urve HRAs e 13). and 0.16 among those with pre-incentive HRAs (Figure 5). Mean CCI was 0.22 and proposals. EBRI invites comment on this research. 60% Biometric Screening Completed Pre-Incentive Biometric Screening Completed Post-Incentive Biometric Screening Not Completed Figure 8, Use of Preventive Services, by Year of First HRA and Biometric Screening Completion Relative to Year 1 0.22 incentives Introduction to participate via random drawings for gift cards and movie tickets. Shortly after the $20-per-month This report takes a similar approach to Huskamp and Rose 0.22 nthal (2009) who examined individuals who completed an HRA 29, no. 2 (February 2010): 304-311. 0.15 for the post- and pre-incentive biometric screening groups, respectively. 0.21 Financ 90 ial Incentive was Introduced ......................................................................................................... 12 Figure 7 Preventive reduction in health 60% insurance premiums was introduced for HRAs, employees were also required to complete biometric Prior Literature and Research Limitations Recently, and compared ther 70% e has them against i been growing int ndividuals who abstained fro erest in workplace m participation wellness prog.r ams. The Patient Protection and Affordable Care Retirement and health benefits are at the heart of w 48.5% orkers’, employers’, and our nation’s 50% 47.9% 0.20 82.4% 50.3% 66% office visit 0.19 81.3% 81.1% Copyright Information: This report is copyrighted by the Employee Benefit Research Institute (EBRI). It may be Baxter, Siyan, Kristy Sanderson, Alison J. Venn, Leigh Blizzard, and Andrew J. Palmer. "The Relationship Between 50% screenin Financi Differencgs to es in continue al Incentives and Workplace Wellness-Program health status to receive th between e thos discount. e completing an HRA or biometric screening with and without financial economic security. Founded in 1978, EBRI is the most authoritative and objective source of Act of There is a 2010 small (PPACA) a (and oft U llows se o en controvers femployers to Health C ial), ar e S provide but er gro vi fi c w es nanci in,g bbody o y al inc Year en f l o tives o iterat f Firure th sft as muc HRat has A* an h as d e B v30 aluated vario ioperc metent, ric S up from c urs aspects o eenin 20 perc g f ent, of 80 Figure 9, Prevalence of Health-Risk Status, by Year 75.6% of First HRA Completion Relative to Year Financial Incentive was 2 Established in 1978, the Employee Benefit 45.8% used without permission but citation of the source is required. All wage data are in 2013 dollars. Return on Investment and Quality of Study Methodology in Workplace Health Promotion Programs." American incentives can be explained by differences in prevalence of diabetes, high blood pressure, and high cholesterol. Among information on these critical, complex issues. 60% 50% the total cost of coverage wh C en t omipl ed to etion R participation elative t in o Y a e we arllness Financ program. This ial Incentiv prov e wision of as Introduc PPACA ed is expected to drive workplace wellness programs. Recent reviews include Baicker, Cutler and Song (2010), Baxter, et al. (2014), Goetzel, Participation 70.2% 0.16 Introduced ........................................................................................................................................... 12 Sample— 40% 70 This analysis examined the set of employees who were ages 18–64 and continuously enrolled in the 66.8% Journal of HealR th Promotio esearch Institute (EBRI) is the only n 28, no. 6 (July/August 2014): 347-363. Breast cancer those compl eting an HRA post-incentive, 7 percent were being treated for diabetes, 14 percent for high blood pressure, increase et al. (201 d a 4), do and Mattk ption of finan e, et cial inc al. (2entives, 013). Puand t blishe HRAh d stu ere is al die HR s inclu re Aady de evidenc exam eples o to sufggest t B bot iomet h rsuccessful an ic h at addin Big om we et d unsuccessfu rllness inc ic entiv l es is by 0.15 3 51% 51% 40% 0.15 screening Recommended Citation: Paul Fronstin and M. Christopher Roebuck, “Financial Incentives and Workplace Wellness- Wage levels are relatively high in the working population examined. Wages for union workers from this employer were also By Paul Fro company healtn h pl stin, Ph.D an over th., Em e five-year ploy p eeer Benefit iod 2009 t Rese hrougharch Institute, and M. 2013. Union employees, memb Christopher Roebuck, ers in capitated health 33.2% EBRI focuses solely on employee benefits research — no lobbying or advocacy (wom . en, age and 19 percen 50% t for high cholesterol (Figure 6). In Completed contras Complt, am eted ong thos HRA e who first co Screeninmpleted a g Scrn eeni HR ng A pre-incentive, Biometric far more po EBRI Employe pular amon e Bene 47% fit R g em eseaployers tha rch Institute Isn s a ue B lternative cha rief (ISSN 0887 n ? ges t 137Xh ) is ey pu cbli ould shed m ma ont ke to he hly by the E alth m pl ploy an ee B deen sign efit R s (F esear ron ch s In tin sti 20 tute, 14). programs. Ma Figure 10, Totial Number of n fi 40% ndi independent nonpr ngs in t Health his researc Risks, by Ye h base are often ofit, nonpartisan ar of First HRA Com at odds. For p example, letion Relative two t re ocent reviews examin Year Financial Incentive ed the return- was 60 30.5% >=40) Program Participation,” EBRI Issue Brief, no. 412, (Employee Benefit Research Institute, March 2015). examined. Average annual wages were between about $65,000 and $70,000 when examining the timing of HRA completion. Birnbaum, H G, M E Mattson, S Kashima, and T E Williamson. "Prevalence Rates and Costs of Metabolic Syndrome and plans, as well as spouses, partners, and other dependents were excluded from the analysis. Ph.D 110 ., RxE 0 13th S EBRI c t.onomics NW, S stand uite 8s 78, alone in em Washington, Dpl Coyee , 200 Pr 05 eben -- 4051, efits at $3 Po rese 00 st p - er ar ych ear or i a No s s tan inclinde uded as pend Co pa mp rt le eof n ted t, a m nonprofit, and no ember Csh om ip plsu eted bscri pti on. npa S P crtisan re eeni riodng i- 52.5 5 percent we 30%re being treated for diabetes, 10 percent for high blood pressure, and 15 percent for high cholesterol. 42% on-investment (ROI) from wellness programs. The 2010 review concluded that medical costs declined an average of Introduced ........................................................................................................................................... 13 50.0 50.2 cals postage rate paid in Washin40% gton, DC, and additional mailing offices. POSTMASTER: Send address changes to: EBRI Issue Brief, 1100 organization committed exclusively to data 48.7 In additio Associated Ris n, similar to organization. k Factors Usin non-unio It analyzes a n emplo g Employ yees, amo nd ees' Inc rep ent Integrat no ig unio vrt es re In n sea ed Laboratory Data c employees, those who first completed an HRA or biometric enti rch ve data Comp without leted and H spin o Pre-Inc ealth r e nt unde iv Ca e rlying re Claims. Post-Ia nc gend ent " iJo ve a. urnal o All fin Not Cfo d m ing ples ted , 50 Cervical 30% 46.4 In 2014, th 40% e Equal Employment Opportunity Commission (EEOC) filed its first-ever legal chal 28.0% lenges to wellness Similar prevalence rates and patterns for these chronic conditions were found when comparing the pre- and post- 13th St. NW, Suite 878, Washington, DC, 20005-4051. Copyright 2015 by Employ 45.0 ee Benefit Research Institute. All ri27.1% ghts reserved. No. 412. about $3.27 for every $1 spent on wellness programs (Baicker, Cutler and Song 2010). The more recent 36% (2014) paper Report Availability: 30% This r 26.2% eport is available on the Internet at www.ebri.org cancer 0.10 35% Overall, HRA Hos c wheth pi otmpletion al inpati er on fi ent was stnan ay exami s ( cial per data, 1,000 ned fo option r 41,030 emplo s, or trends, yees; an are reve d bio aling metric screeni and reliable ng com — the re pletioaso n for n 41, EBRI informatio 649 n is screening post-incentive had 21.6%higher wages than early adopters. Occupational and Environmental Medicine 53 (2011): 27-33. programs, claiming t dissemination, r hat they violated the esear Americans AT A GLAN ch, and education on with Disabilities ACE ct (ADA). A U.S. District Judge sc den reeniin ed EE g OC’s Figure 11, Body Mass Index (BMI), by Year of First Biometric Screening Completion Relative to Year Financial incentive biometric screening groups. found an average ROI of $1.38, whic 22.6% h was lower in high-quality studies and higher in low-quality studies (Baxter, et al. ind 40 ithe vidual gold sta s) ndard fo 18.3% r private analysts a 15.5 nd 18. de 4 cision 26. make 5 rs, gove 14.0 rnment policy 16.7 makers, the media, and 15.2 20% 30% (women, age employees. For each wellness program, three groups were constructed: those who completed an HRA or biometric 30% request to block one of the programs from implementation. Uncertainty regarding the EEOC’s stance and ju >=21) dicial merit Incentive was Introduced ...................................................................................................................... 13 Hospital inpatient days (per 1,000 2014). This re the view a publi economic security and employee benefits lso re c. ported an improvement in study quality ove. r time. 20% Burton, W., C. Chen, D. Conti, A. Schultz, and D. Edington. "Measuring the Relationship Between Employees' Health 20% screening in the two years prior to the change in financial incentives (pre-incentive); those who completed an HRA or Health-Services Utilization—Physician’s office visits for specialists were higher among post-incentive Colorectal completers ? Data from 30 a large employer that offered financial incentives to encourage participation in its wellness program may dampen enthusiasm for expanding financial incentives. However, the excise tax on high-cost health plans, which individual 22% s) The Employ 36.5 ee Benefit Research Institut 49.8 76.6 e (EBRI) was founded in 1978. Its 35.2 40.5 mission is to 50.4 This Issue Brief was conducted through the EBRI Center for Research on Health Benefits Innovation (EBRI CRHBI). The cancer Risk Factors a 0.n 05d Corporate Pharmaceutical Expenditures." Journal of Occupational and Environmental Medicine 45 biometric screening in the three years (for HRA) or two years (for biometric screening) after the change in the financial Figure 12, Blood Pressure, by Yearcontribute to of First Biometric , to encourag Screenin e, an g d to enhanc Completion R e the developmen elative to Year t of sound empl Financial Inceontive yee ben was efit of HRAs an are ana 20 10 d % %biometric scre lyzed in this epaper. I nings retlative exami to the nes ho pre w th -inc e cha entive rac grou teristics ps (Fi of first gure 7 -time, wel ). However, lnes physici s-program an’s of sc pa reenr fice in ticipants g visits for Emergency department visits (per takes ef Many investi fect in gators acknowl 2018, may dri edge th ve furte m her ado ethodologica ption of well l cha nllenges ess incentiv of pro es. Furt gram eva hermore, luation. Per there his a aps t gro he most critica wing body ofl issue following organizations provide the funding for EBRI CRHBI: American Express, Ameriprise, Aon Hewitt, Blue Cross and EBRI explores the breadth of employee benefits and related issues. 20 (20 Who we are 03): 793-802. (age >=50) incentives, but not in the 10% pre-incentive programs and so period; and t und public policy hose that di through objective d not complete an resear HRch and A or biometric education. EBR screeni I is the only ng in any of 1,000 individuals) 122.1 118.4 132.5 118.2 127.8 124.1 primary car Introduc e 10 % were ed .................................................................................................................... lower among post-incentive completers of HRAs and biometric screenings compared to t ....................... 14 he early changed with the enhancement of financial incentives for health-risk assessments (HRA) and biometric evidence that workplac The Institute seeks to advance the public’ e wellness programs may reduce health care costs, although s, the extant literature on this topic is derives from the voluntary nature of workplace wellness programs. Employees who volunteer to take part in HRA or Blue Shield Association, Boe EBRI studies the worl ing, Deseret d of health and retirement ben Mutual, Federal Reserve Em efit ployee B s — issue enefits s such a System, Ge s 401(k)s, neral Mills, H IRAs, retire ealth ment ways, private, nonprofit, nonpartisan, Washington, DC-based organization committed exclusively to the years under inv Specialist of estigatio fice visitn s. 1.2 1.5 1.4 1.5 1.7 1.2 10% adopters. screenin gs. Those who completed an HRA or biometric screening in the two years prior to the change in 10 income adequacy, consumer-driven benefits, Social Security, tax treatment of both retirement and health not wit biometric hout its screenin limitations, gs are likely to be as will be diff discus erent from sed in gr those eater who detaildo not below. opt in. Econom ists call this selection bias. If these public policy research and education on economic security and employee benefit issues. IBM, JPMorgan Chase, Mercer, and Pfizer. Charlson, M. E 0% ., P. Pompei, K. L. Ales, and C. R. MacKenzie. "A New Method of Classifying Prognostic Comorbidity in the media’s and policymakers’ knowledge Primary care provider office visits 2.5 1.9 1.7 2.2 2.1 1.6 Figure 13, Total Chol - esterol, by Year of First Biometric Screening Completion Relative to Year Financial Incentive was 0% Zero–Two Three–Four Five+ benefits, cost management, worker and employer attitudes, policy reform proposals, and pension assets financial incentives (i.e., prEBRI’s member e-incentive) ar ship includes a e compared to cross-section of those who co pension funds; businesses; trade associations mpleted an HRA or biometric screenin; g in differing characteristics are c HRA Compl orrelated eted HRA Co with mpleoutcomes of interest such a ted HRA Not s health Biometr -servic ic es utili Biometr zation ic an Bid omworker etric Longitudinal Studies: Development and Validation." Journal of Chronic Disease 40, no. 5 (1987): 373-83. Pre 0% scription druHRA g fills HRA HRA 14 No .2 t 17.0 Biom 16etr .5ic Biometr1 ic3.3 Biometric 18.7 14.4 0 Post-inceIntroduc ntive HRA com ed .................................................................................................................... pleters had 17.0 prescription drug fills compared to 14.2 prescription drug fi....................... 14 lls among pre- and fundi and under ng. Pre-IThere is wi ncentivestanding of employee benefits and labor un Posde t-Incspread ent ions; h ive ealth re Cocog car mplee prov te nd ition iders and insur that if employee be ers; Scgovernment org reeningnefits Sc data exist, EBRI kno re aen nizations; ing Scand service firms. reening Not ws it. This paper an 0% alyzes data from a large employer that enhanced financial incentives to encourage participation in its Completed Pre- Completed Completed Screening Screening Screening Not the two years Norm(for al (D HRA) or t iastolic<80 & Sy h sree y tolic<12e 0ars ) (fo Pre- r biomet hypertensioric scr n (Diastole icenin 80-89 o g) a r Syfst ter t olic h Hy e ch perteange i nsion (Dia n s t tolh ice 90financ + or Systial olic 14 in0+ centives. ) % Male Number of Health Risks Average Age productivity, naïve observational analysis of wellness-program impacts will yield incorrect estimates. In the absence of a Source: Employee Benefit Research Institute analysis of administrative claims data. Completed Pre- Completed Post- Completed End-of-life case Case management Disease Nurse advice line Health advocate Lifestyle Health assessment Incentive Post-Incentive Completed Pre- Completed Completed Participation in the Program 120-139) incentive HRA completers. Similarly, prescription drug utilization was also higher (18.7 fills) for late adopters of Incentive Incentive workplace wellness pro management grams. The researcma h objectiv nagement e is to compare characteristics of employ management ees who first participated Fin*d H in eal gs from th reimbur this study sement arpain rangem t a vivi ent. d picture of the type In of in centiv divi e dual Post- w Incent ho favora ive bly responds to wellness- Deyo, R. A., D. C. Ch their importance to our nation’ erkin, and M. A. Ciol. "Adapting a Clinical s economy Comorbi. dity Index for Use with ICD-9-CM Administrative randomized, controlled trial, the analyst might employ advanced econometric techniques in an attempt to correct for Table of Contents Source: Employee Benefit Research Institute analysis of administrative claims data. Source: Employ Source:Employee ee Benefit Benefit R Research Instit esearch Institute EBRI’s work advances knowledge and unders ute analy analys sis is of of administrativ administrative e c claims data. laims data. tanding of emplo 1 yee benefits and their EBRI delive HRA particripat s a stead ion—In th y e t stream of invaluable research and anal wo years prior to the introduction of the $20-per-mo ysis. nth, premium discount, 30,574 biometric scre Source: Employ ening relative ee Benefit R to members w esearch Institute analy h so opt is of administrativ ed for ebiometric scre claims data. ening prior to the change in financial incentives Source: Employee Benefit Research Institute analysis of administrative claims data. prior to these enhancements, to individuals who first participated after they were in place. Results describe the type of * Health risk assessment. program * Health fi risk nan assessmen cial in t.centives—a research contribution with important implementation and evaluation Databases." * Healh Jro isk urnal o assessment f Cl . inical Epidemiology 45, no. 6 (June 1992): 613-9. this selection * H bias, but u ealth risk assessmen nde t. rstanding the differences between volunteers and non-volunteers is of great importance in Source: page 13 in http://www.nvbgh.org/wp-content/uploads/Making-Wellness-Work-Mercer.pdf Introduction .......................................................................................................................................................... 4 importance to the nation’s economy among policymakers, the news media, and the public. It EBRI publications include in-depth coverage of key issues and trends; summaries of research employees (75 percent) had completed the HRA (Figure 2). During the three years after the introduction of the financial (13.3 fills). individual who favorably responds to wellness-program financial incentives, and this represents a significant implications. does this by conducting and publishing policy research, analysis, and special reports on such pursuits. What we do findings and policy developments; timely factsheets on hot topics; regular updates on legislative and Background o incentive, anon ther 9,77 Wellness Pr 7 em ograms ployees (2 ............................................................................................... 4 percent) completed it. Only 689 employees (2 percent) had n .......................... 4 ever completed EBRI’s mission is to contribute to, to contributio Fronstin, Paul. n to "What the knowl to Ex edge base pect Duemplo rin wg ith im O yee benef pen-Enrol portant im its issues; holding educational br lment ple Se mentation ason: Fi and evaluatio ndings From th iefings for EBRI memb n im e SHRM/EBRI plications. 2 For ers, congressional and 014 thcoming rese Health Benefits arch Conclusion regulatory developments; comprehensive reference resources on benefit programs and workforce There were no statistically signif icant differences in inpatients stays, inpatient days, or emergency department visits an HRA by the end of the five years. federal agen cy staff, and the news media; and sponsoring public opinion surveys on employee ? Demographics—Among employees who first completed an HRA post-incentive, 82.4 percent were male versus Survey." EBRI Notes 35, no. 12 (Employee Benefit Research Institute, December 2014). will Many studi examine es tshare anot he impact o her f financial limitation, sm incentiall sampl ves on partici e sizep s. Evaluations ation rates, as well as based on too healtfew o h and pro bservatio ductiv ns are o ity outcomes ften Prior Literature and Research Limitations ................................................................................................................ 5 This paper examined administrative health insurance claims, wellness-program participation, and data collected from issue encour s; and age major survey , and to enhance the development s of public attitudes. benefit issues. EBRI’s Education and Research Fund (EBRI-ERF) performs the charitable, between the pre-incentive and post-incentive groups. 70.2 percent who first completed an HRA pre-incentive. For biometric screenings, the gender comparison was associated with the wellness programs themselves. underpowere d, whic EBRI h leads tmeetings o few statistic present an ally sign d explore i ificans t sues results. with Furth thou ermore, a ght leade naly rs s from all se es on subpopulations ctors. (e.g., health-risk assessments and Biometric screening biometric participation screenin —In th gs. It r e two years eports dis prior tinct to the differ intro ences duction of between the in $ divi 20du -per-mo als who nth, parti premium cipated educational, and scientific functions of the Institute. EBRI-ERF is a tax-exempt organization Data ..................................................................................................................................................................... 5 of sound employee benefit prFigure 13 Figure 1 ogr Figure 4 Figure 2 Figure 9 ams and 1 Figure 6 Goetzel, R Z, D R Anderson, R W Whitmer, R J Ozminkowski, R L Dunn, and J Wasserman. "The Relationship Between similar. Late adopters also tended to be older. Among those first completing an HRA post-incentive, average EBRI regularly provides congressional testimony, and briefs policymakers, member organizations, patients with chronic conditions) suffer the same fate. Finally, investigations that only examine one employer do not supported by contributions and grants. prior to the enhancement of financial incentives and those who first participated after the new incentives were in place. discount, 12,239 (29 percent) had taken part in a biometric screening. During the two years after the financial incentive In general, post-incentive HRA and biometric screening completers used less preventive care than pre-incentive ToCompletion tal Cholesterol, by Body Prev Mass Index (BMI), alence Average of HRA of Health-Risk An Y * nual ear and Biometric of Income, by by First Year Status, Biometric Screening Completion of First Biometric Screenings Year by Y of ear First of First HRA Relativ HRA Screening * e to * Year Percentage of Sample With Diabetes, High Blood Pressure, and High Modifiable Health Risks and Health Care Expenditures: An Analysis of the Multi-Employer HERO Health Risk and Participation in the Pro and the medi gram .................................................................................................. a on employer benefits. ................................. 6 age was 50.0 compared sound public policy thr to 45.0 among the ough objective pre-incentive group. For biometric screenings, average age was generate results that are generaliz able to broader populations. Inde was p ed, ut into emplo ply ace, anot ees who d her ela 26,9 yed com 12 emp pletio loyn of ees (65 an H pe RA a rcent) re nd/or ceived biometri biometric c screeni screenin ng were mor gs. Nearly e likel 2,500 employees y to be male, older, completers. Employees with a first HRA Completion Completion Cholesterol, Financial Relativ and Relativ Relativ e Incentiv Biometric Screening Completion to in by th Y Y e ear e eear post-inc to to e w Financial of First HRA Y Yas ear ear en Introduced, Financial Financial tive period w Incentiv * and Incentiv Incentiv W e e re less l Biometric o w rkers as e e Introduced Relativ w w iA kely t as as ges 18–64 Screening Introduced Introduced o e have had a preventive office visit EBRI issues press releases on newsworthy developments, and is among the most widely quoted Cost Database." Journal of Occupational and Environmental Medicine 40 (1998): 843-854. Background on Wellness Programs 48.7 versus 46.4 for the po EBRI Issue Briefs st- and pre-incentive co is a monthly horts, respect periodical with ively. in-depth evaluation of employee benefit issues Characteristics of Wellness-Program Participants Pre- and Post-Incentive .................................................................. 6 higher wage earners, and in poorer to Y healt ear h—as evidenced Financial Incentiv by higher e w C as Introduced harlson Comorbidity Index scores; and to have (6 percent) never compl resear eCompletion ted a ch and education. biometric Relativ screenin e to g Y dur ear ing the study Financial Incentiv period. e was Introduced than the pre-incentive group; or to have had a screening for breast cancer, cervical cancer, or colorectal cancer (Figure B Biiom ometr etriic S c Sc cr re eeni ening ng Com Compl pleted eted Pr Pre e- -In Ince centi ntiv ve e B Biiom ometr etriic S c Sc cr re eeni ening ng Com Comp plle eted ted Po Post st- -I Inc ncenti entiv ve e sources on employee be HRA ne Co fits mpleby all media. ted Pre-Incentive HRA Completed Post-Incentive and trends, as well as critical analyses of employee benefit policies and proposals. EBRI The timing of the evaluation is also an issue. Sometimes, workplace wellness programs are studied too soon after Our Employers of all sizes utilize various types of health management solutions. These include wellness programs designed $140,000 HRA Completed Pre-Incentive HRA Completed Post-Incentive HRA Not Completed higher prevalence rates of obesity, diabetes, pre-hypertension, high blood pressure, and high cholesterol. Moreover, 8). Among in d ividuals EBRI CHECK OUT EBRI’S WEBSITE! who direct cos mplete membe d bio rs m and etric s other constit creening, thos uencie e fis rst to receivin the informatio g it post-incentiv n they need an e were l d eunde ss likely rtakes than new Conclusion .................................................................................................................... Goetzel, Ron Z., et 100% al. "Do Workpla Notes ce He is a monthly alth Promotio period n (Wel ical pr lness) Pr oviding curr ograms ent in Work?" formation on a variety Journal o ...................................... 11 f Occupation of employal a ee ben nd efit 80% 45% ? Health St Biometriatus— c ScreeniIn genera ng Completed Pr l, i en -In divi centiduals ve Bwh iometr o first com ic Screening Com plet pe led t ted Po he st-wel Incenti lnes ve s programs Biometric Screeni du ngring the Not Comple post-i ted ncentive implementation. Use of health services and related spending may be expected to increase during year one of a wellness to promote health and prevent disease, as well as disease management interventions, which are designed to manage patients first completin reseag rch anon a HRA and/or n ongoi topics. ng bi EBRIef ometric scree basis. is a week ning ly rou post-ince ndup of EBRI r ntive haed search grea and ter use insights, as well of specialist visits, a as updates on nd 41.8% those completing it pre-incentive to have had a screening for breast cancer or cervical cancer. The two groups were publications 2% Environmental Medicine 56, no. 9 (September 2014): 927-934. Characteristics of Wellness-Program Part 25% icipants Pre- and Post-Incentive period were less healthy than early adopters. Moreover, prevale 40.6% nce rates of diabetes, high blood pressure and program, References wh ............................................................................................................................... en health issues are first identified and treatments and/or preventive services are soug ........................... 15 ht. Goetzel, et al. 87% patients with chronic co 90EBRI has earned widespr % nditions. Among surveys, studi larger es, employ litig ead r ation ers, about ,egar legisld as ation and r four-fifths use egulation affe case ct managem ing employ ee nt, e benef disease it plans, while EBRI maintains an 68.8% 69.1% d analyzes the most comprehensive database of 401(k)-type programs in the $120,000 prescription drugs; and were less likely to use preventive services, such as preventive office visits, breast cancer, 70 40 % % $113,750 equally likely to have received a colorectal cancer screening, and the post-incentive biometric screening cohort was $112,926 83% 82% $111,361 high cholesterol were all higher in the post-incentive groups than in the pre-incentive groups. In this sect EBRI’s website is easy to use and packe ion, the characteristics of em EBRI’s Blog ployees who supplements our regular publications first compl d with useful information! Look for eted an HRA or biom , off etric screen ering $109,562 commentar ing after t y onh questions e change in (2014) and Grossmeier, et al. (2012) suggest that three or more years may be needed in order to detect population world. Its computer simulation analyses on Social Security reform and retirement income adequacy management, nurse advice lines, and health assessments (Figure 1), with about one-half offering employees financial Endnotes ............................................................................................................................................................ 16 Goetz cervical ca el, Ro ncer, and colorect n Z., et al. "The Relationshi al cancer screenin p Betwee g. In n Mo shor difiable t, the Health employ Riesk Factors an es who had a d Medical E bstained from xpe nditur particies, pating in the an organization that “tells it like it is,” somewhat more likely to have had a preventive office visit. 80% received from news reporters, policymakers, and others. The EBRI Databook 35.2% on Employee 76% incentives are HRA compared to t Completed hose who com 76% pleted them 75% beforehand. Employees $100,376 who abstained fro 24% m HRA or biometric health effects. Nyce, are et uni al. que. (2012) submit that it may take a year or more for health spending patterns to change after 20% incentives these special features: for participation. $98,510 Smaller firms also employ health management solutions, although they are less likely than 35% 60% workplac Absentee e welism, lness pro $100, Short-T 000 gram erm s were Disability, an Benefits likely th is d e on a sta Presenteeism es in tistic ne al red o efer A enc fm th eong Em work on em em moploy st. The ploye ees at signi e ben Novarti ficantly i efit prog s." n rams and work force-related Journal creased of Occupational & financial incentive ? Health-Service 20% s Utilization—Visits to specialists were higher for the post-incentive cohorts. Prescription drug 32.0% based on the facts. As the Bylaws state: 19% 68% 68% screening during the five-year study period are also included in the Figures, but are not discussed below. Generally, the worker health risks are impacted. 70% larger employers to do so. In addition to their employees, employers may also include spouses in these offerings. issues. Health Risks—It has been shown that health risks are associated with medical spending (Anderson, et al., appeEnvironmental ars to have be Medicine en effective at 51, no encour . 4 (Ap arg iling 200 th 9eir part ): 487-49 icipation. 9. While results from this study cannot shed light on the • utilizatio EBRI’s entire library of re n was higher as well among post-i search publications starts at ncentive HRA completers the m (1a 7.0 in W fills eb page. Click on per year) compared EBRI to pre- EBRI make 30% s information freely available to all. characteristics of individuals not completing an HRA or biometric screening are similar to those of the post-incentive Figures 50% “In all its activities, the Institute shall 2000) (Goetzel, et al. 1998) (Birnbaum, et al. 2011) (Goetzel, et al. 2009) (Yen, et al. 2006) (Burton, et al. 2003), and magnitude of financial incentives necessary to suff 58% iciently bolster participation, a greater proportion of employees $860 0,0 % 00 57% 16% incentive HRA completers (14.2 fills per year), and also greater for post-incentive biometric screening Issue Briefs EBRI assume and s EBRI Notes a public service re for our in-depth and 56% sponsibility to make nonpartisan pe its findings co riodicals. mpletely 26.3% accessible at www.ebri.org Finally, the existing literature is replete with problems of incomplete data. In some ca 15%ses, prescription drug claims were Wellness programs usually include health-risk assessments (HRAs) and biometric screenings. An HRA is a questionnaire groups. Unless otherwise noted, only statistically significant differences between the pre- and post-incentive groups are Contact EBRI Publications, (202) 659-0670; fax publication orders to (202) 775-6312. Grossmeier, Jessica, Paul E. Terry, David R. Anderson, and David Wright. 15%"Financial Impact of Population Health Figure 1, Use of Specific Health Management Programs, by Firm Size, 2013 ............................................................ 7 that reducing these risks may result i 24.2% n lower health care costs (see (Nyce, et al. 2012) and citations 18–25 within). The remained unscreene 15% d for biometrics under the financial in 14% centive than the fraction of the population without a function strictly in an objective and Pre-Incentive Post-Incentive Not Completed 25 — % so that all decisions that relate to employee benefits, whether made in Congress or board rooms or completers (18.7 fills per year) compared to pre-incentive completers (13.3 fills per year). In large part, 14% 14% not available, and reversals and adSubscriptions to justments occurrin EBRIg Issue Bri after claims w efs are included ere submitte as part of d were EBRI not r membership, or as part of econciled. One study a did that in discussed dividual . 40% s can complete to evaluate their health risks and quality of life. It collects data on health status and 50% Management Programs: Reevaluating the Literature." Population Health Management 15, no. 3 (2012): 129-134. Orders/ HRA was used to derive risk indicators for alcohol, blood pressure, cholesterol, depression, exercise, glucose, nutrition, families’ homes, are based on the highest quality, most dependable information. EBRI’s Web site posts complete • Visit EBRI’s blog. d HRA. The differential may be due to the time required to complete each, for which the individual may incur $199 annual subscription to EBRI Notes and EBRI Issue Briefs. Change of Address: 12% EBRI, individuals who first completed HRA and biometric screenings after the financial incentives were introduced $60,000 not have health care claims so average spending was imputed based on util 12% ization. And, in some studies, HRA and unbiased manner and not as an advocate behavior, as well as medical history details, including those of the individual’s family. It is common practice for Figure 2, Completion of HRA and Biometric Screenings Relative to Year Financial Incentive was Introduced, Workers 20% all research findings, publications, and news alerts. EBRI also extends its education and public service smoking, and weight. Employees first com 1100 13th St. NW, Suite 878, Washington, pleting the HRA post-incentive w DC, 20005-4051, (202) 659-0670; fax number, ere more likely than those completing it pre- opportunity co Demogra sts.p Support hics—Employees for this thwho eory i first com s providped leted a by th ne fact that HRA or biomet higher ric incom screeni e earners ng post-incentive were older an were more likely to forgo d 40% were less likely to have consumed preventive care, and they were less likely to have visited a primary care Subscriptions 35% biometric scre 30% ening data were often missing. Huskamp, Hai employers to contract w den A., anid M th te hird parti redith B.e Ros s toe admi nthal. nister th "Health e HRA Risk A in or pprais dea r to rec ls: How M eiveuc de h Do -identif They In ied res fluence ults on t Employ heir ees' Ages 18–64 .................................................................................................................... 10% ........................ 7 role to improving Ameri (202) 775-6312 cans’ financial ; e-mail: knowle 25.7% subs dge criptions@ebr through its a i.org w ardMe -win mbe ning rship Information: public service cam Inquiries paign 10%or opponent of any position.” • EBRI’s reliable health and retirement surveys are just a click away through the topic boxes at incentive to be at risk for blood pr 9% essure, exercise, glucose, nutrition, smoking, and weight (Figure 9). However, those more likely to be male relative to those opting in earlier. Of the HRA 24.1% post-incentive group, 82.4 percent were male, the wellness programs. 9% provider. ® 29% $40,000 regarding EBRI membership and/or contributions to EBRI-ERF should be directed to EBRI employees Health Behavi in 15 r % eturn. or?" The Health A information coll ffairs 28, no. ected 5 (S iseptem used to ber provi /October de cus 20 tom fe 09): 15 ed32 ba-1 ck to 540. partic ipants about their current ChoosetoSave 30% and the companio 8% n site www.choosetosave.org 7% 8% the top of the page. completing the HRA pre-incentive were more than or just as likely as those completing it post-incentive to be at risk for compared to 70.2 percent of the HRA pre-incentive group (Figure 3). Similarly, 75.6 percent were male among those B 20 iom %etric Screening President Dallas Salisbury at the above address, (202) 659-0670; e-mail: salisbury@ebri.org Figure 3, Percentage Male and Average Age, by Year of First HRA and Biometric Screening Completion Relative to 29% 65% 6% health risks, and an action plan for addressing them. Completed Firms offering wellness programs should expect to have to employ financial and other incentives to encourage member alcohol, cholesterol, and depression. who first ? Health Risks— completed biometr Individuals ic screen who firs ings post-ince t completn ed t tive he H compared to RA post-incen 66.8 percent tive had greater of the biometric health risk tha screeni n those first ngs pre- 20% Data 10% Mattke, Soeren, et al. Workplace Wellness Programs Study: Final Report. Santa Monica: RAND Corporation, 2013. Year Financial Incentive 5% was Introduced ................................................................................................... 9 EBRI is supported by organizations from all industries and sectors that appreciate the value of $20,000 • Need a number? 5% Check out the EBRI Databook on Employee Benefits. partici Editorial Bo pation. Relatively ard: Dallas L low . Salisbur financi y, publisher al rewar ; Stephen Blakely ds may attract , editor the . Any young an views expr d w essed in this p ell. Higher ublicat financi ion and th al i12% ncen ose o tives—while f the authors sho m uo ld re completin 10% g it pre-incentive. Employees first 4% completing the HRA post-incentive were more likely than those incentive cohort. Average age was higher in both of the post-incentive groups (50.0 for HRA; 48.7 for biometric 6.7% Biometric screening programs collect information on physical characteristics of the individual such as height, weight, This study utilized data from a large manufacturing employer headquartered in the Midwest, 5.4% with employees located unbiased, reliable information on employee benefits. Visit www.ebri.org/about/join/ for more. not be ascribed to the officers, 7% trustees, members, or other sponsors of the Employee Benefit Research Institute, the EBRI Education and 10% 6% Number of health risks was grouped into categories of 0–2, 3–4, and 5 or more to examine the relationship between costly for the employer in the short-run—may bring in o 5%lder, less healthy employees who are consuming more health 5% 4% s Nyce, creenin Stephen completin gs) compared , Jessica g it pre- to t Grossmeier, ince he pre ntive t -inco David entive be at r R. Anderson, groups isk for bloo (45.0d f Paul E. o pr r HRA; 4 essu Terry, re, e 6.4 x ercise, f and or biometr Bruce glucose, nutr Ke ic s lley. "Associatio creeni itings on, smoking, ). n Betw and een C wei hg anges ht. Figure 4, Average Annual In3% come, by Year of First HRA and Biometric Screening Completion Relative Research Fund, or their staffs. Nothing herein is to be construed as an attempt to aid or hinder the adoption of any pending legislation, regulation, body mas throughout th s inde Unite ex, blood d State presss. Health ure, cholinsur esterol, an ance-enrollm d glucoesn e level. t information The sc , medic reening al a is us nd ed to prescript identi ion-dr fy indivi ug cduals laims, an at hd igh • Instantly get e-mail noti?cations of the latest EBRI data, surveys, publications, and meetings $0 overall risk level and timing of HRA participation. While it appears that individuals first completing the HRA post- services, and 0% accounting for a large proportion of health care spending. If wellness programs are effective at improving or interpretative rule, or as legal, accounting, actuarial, or other such professional advice. www.ebri.org 0% in Health Risk Status and Changes in Future Health Care Costs." Journal of Occupational and Environmental to Year Financial Inc HRA Coe mpl ntive was Introduc eted HRA Completed ed HRA .................................................................................... Not Biometric Biometric Biometric ........... 9 risk for chronic conditions such as diabetes, high blood pressure (hypertension), and heart disease. wellness-program-partic 0% ipation data <200 were provided covering 200–239 the period 2009-2013. The emp 24 loyer 0+ had been offering a and seminars by clicking on the “Notify Me” or “RSS” buttons at the top of our home page. 0% Alcohol Blood Cholesterol Depression Exercise Glucose Nutrition Smoking Weight incentive ? Biometrics— had more he Late ado alth r Pre-Iinc sks than those p enti ters o ve f biometric Post-Incent compl ive screenin eCo ting it mpleg te dpr also ha e-inced ntive, worse the biom dif Scre fetric valu ere eningnces were es. O Screen not v iner one g statistically sign Sc-rthir eening N d (35.2 ot p ifiecant r- Employees patient health, who first com positive longer-term, pleted an HRA return or biometric s-on-investme screenin nt (ROI) may g post-incsupport t entive had hi he use of gher wages tha high finann cial in earlycentives. adopters 0% 10 Diabe % tes 20% 30% 40% High Blood 50 Pr %essure 60% 70% 80 Hi % gh Choles 90 ter %ol 100% Medicine 54, no. 11 (November 2012): 1364-1373. Normal weight or underpr we es igh sur t (e BMI <24.9) Overweight (BMI 25–29.9) Obese (BMI 30+) Completed Pre- Completed Post- Completed health-risk assessment (HRA) since at least 2004 and introduced biometric screenings in 2007. Answers that EBRI Issue Brief is registered in the U.S. Patent and Trademark Office. ISSN: 0887 ?137X/90 0887 ?137X/90 $ .50+.50 2 (Figure 10). Total Cholesterol (Figure 4 cent) of ). This post-i suggests th ncentive at biom employ etric scre ers may nee ening compl d to coe nsider ters was obese com incentive lev Ine ce ls rel p nti ared ve ativ with e to i Inabout one-quart centi ncome, s ve ince ter (26. he 3 per- Forthcomin Figure 5, Aver g re age search Charlson will in Comorbidity vestigate th I e n im dex, by pact of Yea these w r of First HRA a ellness prongd rams on Biometric heal Screening Com th-services util pization letion Relativ and e to Since participation is voluntary, employers sometimes offer fi nancial incentives, which can be provided in a number of Source: Employee Benefit Research Institute analysis of administrative claims data. participants provided in the HRA, as well as information from the biometric screenings, were also used. Source: Employee Benefit Research Institute analysis of administrative claims data. Source: Employee Benefit Research Institute analysis of administrativ There’s lo e claims data. ts more! th Source: Employee Benefit Research Institute analysis of administrative claims data. cent) of * H Source: Employ ealth pre risk -in assessmen centive ee Benefit R t. compl esearch Instit eters. Further, ute analysis of administrativ 50.3 eperce claims data. nt of post-incentive biometric screening completers were spendi opportu Quan, H., ng, nity co as et a well lst of time . "Co as work ding Al wer ill gorithms for pro enter ductivity. into iDe n difinin viduals’ w g Comor ellne bid ss- ities i program n ICD-9 -pa-rticipation CM and ICD deci -10 A sion. That dministrat is, ive Data. higher earners " Medi wil cal l Year Financial Incentive was Introduced ....................................................................................... 1100 13 Street NW · Suite 878 .......... 10 ** H H ealth ealth risk risk assessmen assessmen t.t. different ways. Discounts and Source: Employee Benefit surcharg Research Institute es t analy o premi sis of administrativ ums, re ecductio laims data. ns in cost sharing (such as deductibles and * Health risk assessment. 3 © 2015, Employee Benefit Research Institute Washington, DC ?Education and Re 20005 search Fund. All rights reserved. requir Care e pre-hypert great 43, n er incentives as o. 11 ensi (Nve, compar ovemb compensation er 2ed 005 to 45. ): 1130 8 for t percen -9. heirt of time early a spent com dopters. pleting an HRA or receiving a biometric screening. Visit EBRI online today: www.ebri.org copayments), gift cards, giveaways (such as movie tickets), and contributions to health savings accounts (HSAs) are (202) 659-0670 www.ebri.org www.choosetosave.org ebri.org ebri.org ebri.org ebri.org ebri.org ebri.org ebri.org ebri.org ebri.org A monthl ebri.org Issue Brief • March 2015 • No. 412 ebri.org Issue Brief • March 2015 • No. 412 ebri.org Issue Brief • March 2015 • No. 412 ebri.org Issue Brief • March 2015 • No. 412 ebri.org ebri.org Issue Brief • March 2015 • No. 412 Issue Bri Issue Bri Issue Bri Issue Bri Issue Bri Issue Bri Issue Bri Issue Bri Issue Bri y resea Issue rch report f e e e e e e e e efffffffff • March 2015 • March 2015 • March 2015 • March 2015 • March 2015 • March 2015 • March 2015 • March 2015 • March 2015 Brief • r March om the EBRI Education and Re • No. 412 • No. 412 • No. 412 • No. 412 • No. 412 • No. 412 • No. 412 • No. 412 • No. 412 2015 • No. 412 search Fund © 2 015 Em ployee Benefit Research Institute 14 13 12 10 7 9 16 11 15 2 3 5 4 8 6 Use of Preventive Services Average Annual Income Charlson Comorbidity Index Percentage With Diabetes Prevalenc , Hye per oftens Health ion, Ris and High Choles k Status terol