Author: Peter Mead

Imagine employees who provide their ownhealth benefits, their own assistance program and pay up to $5,900 of their ownfirst-year salary through two tax incentives. That’s the federal Ticket to Workand Self-Sufficiency Program.

    Ticket is in thefirst year of a three-year rollout and takes advantage of several pre-existingprograms.

    EmployedSupplemental Security Income (SSI) beneficiaries can get extended Medicaidhealth benefits or use Medicaid “buy-in” programs in some states.Employed Social Security Disability Income (SSDI) beneficiaries can get extendedMedicare health benefits. Companies that employ SSI or SSDI beneficiaries mayqualify for tax credits (see below).

    Social Securitydisability beneficiaries already are using these and other program supports toseek employment or keep working. Approximately 276,000 SSI recipients wereworking in December 2000, and 55,000 to 60,000 SSDI beneficiaries enter theworkforce annually, according to the Social Security Administration (SSA). Thosenumbers could increase substantially.

    Ticket is alsocreating an enlarged public/private employment network, including vocationalrehabilitation services. In 2001, Ticket is scheduled to roll out its fullprogram in 13 states: New York, Florida, Illinois, Massachusetts, Wisconsin,Arizona, Colorado, South Carolina, Oklahoma, Oregon, Iowa, Delaware and Vermont.

    Approximately 2.2million SSA disability beneficiaries in these states will receive Tickets toaccess this expanded employment support network. In other states, the existingstate vocational rehabilitation programs and other support services could bebusier as Ticket gets media coverage.

    By 2004, when Ticketemployment networks are rolled out nationwide, the SSA estimates 138,000 peoplewill be using the program.

For more information:

• Maximus, under contract to SSA toadminister Ticket programs, toll free at 866/968-7842.

• SocialSecurity Administration, including SSATicket contacts.

• IRS,800/829-1040, dial 2, 1, wait, 5, 4, and ask for the Work Opportunity TaxCredit and Welfare to Work Tax Credit then leave a message for a returncall. Publication 954 describes these credits, but is not updated to includeTicket.

The first generationof eHealth simply replacesexisting communication functions originally performed on printed material. Thisis illustrated by a recent WorldatWork e-mail survey of 387 employers that usethe Internet for the following functions:

Provider Directories	65%
Company Newsletters	61%
Links to OtherResources	57%
Summary PlanDescriptions	45%
Online Open Enrollment	26%
Online PrescriptionDrug Services	23%
Employer or InsuranceCarriers Accept E-signatures	16%
Employer or InsuranceCarriers Track Major Life Events	11%

    Therate of provider directories, at 65 percent, is the highest-use e-healthfunction, highlighting the Internet’s strength at disseminating frequentlyupdated information. It also illustrates the growth potential for onlineself-enrollment, currently at only 26 percent.

    Ina typical self-enrollment, employees use the Internet and/or phone call centersto research competing health plans, evaluate their options and record theirselection. This greatly eliminates manual processing chores for the benefitsstaff, making it possible for employers to offer a broader selection of healthplans and providers.

    Whatcan an employer expect from self-enrollment? In the WorldatWork survey, 74percent of employers who had chosen online self-enrollment reported increasedemployee satisfaction. Although 81 percent reported improved administrativeefficiency, only 39 percent reported lower costs. This could result from severalcauses: 

• Theparticular service used might not have a clear cost-reduction strategy

• Reducingbenefits staff was not yet appropriate, and staff hours re-assigned to otherHR needs might not have been recorded as “savings.” 

• Employeesinitially needed extensive telephone or staff support to enroll due toliteracy problems, lack of Internet access, or difficulties in learning Webnavigation

    Evenin high-tech companies, 100 percent employee use of online enrollment may nothappen. In Sageo’s early experience providing self-enrollment services, about70 percent are using the Internet to enroll, with 30 percent relying primarilyon telephone support, said Tom Beauregard, chief strategist of Minneapolis-basedSageo.

    Forhigh-tech employers, Internet use might go as high as 98 percent, and formanufacturers where lack of access or literacy might be a problem, Internet usecould go as low as 55 percent, Beauregard says.

    Turningopen enrollment from a paperwork nightmare to an Internet self-service functioncan also reduce employees’ dissatisfaction with shortcomings in customerservice. These advantages make it easy to forget that Web sites must alsoservice the individual client’s healthcare decisions after enrollment.According to Catherine Cather, a total health management consultant with HRconsulting firm Towers Perrin, employees can go through four stages during andafter self-enrollment:

CoverageFocus	TreatmentFocus
Consumer/Purchaser:	Consumer/Patient:
Drivenby purchasing concerns: price, convenience, accessibility of benefit andease of administration.	Drivenby illness concerns:  Breadthof coverage, appropriate treatment, timely access to preferred providersand patient support groups.
Consumer/Member:	Consumer/Caregiver:
Drivenby membership concerns: rapid turnaround on requests by phone or e-mail,timely documentation of provider changes.	Drivenby needs of family member: Breadth of coverage, appropriate treatment,timely access to preferred providers and caregiver support groups.

    A Web site that focuses exclusively onenrollment (the upper left quadrant) gains only the immediate cost savingsavailable from efficient enrollment administration. A Web site that supportsemployees through all four quadrants helps realize the full cost savingsavailable from a consumer-driven healthcare system.

R

eelingfrom managed care sticker shock, employers are using a growing army of e-Healthvendors and consultants to redesign the corporate health cost structure.

   Theimmediate payoff is lower administrative costs, or at least improved efficiency,in wellness and health benefits. But getting Joe to surf on over to the healthplan enrollment site and fill out an electronic enrollment form is only thefirst step.

   Bymaking self-service convenient and rewarding, employers are trying “toreposition their relationships with employees around benefits,” says CatherineCather, a total health management consultant with HR consulting firm TowersPerrin.

   Thegoal is to shift employees from unaccountable consumers into the role ofinformed consumers with the tools to plan and manage their own health care.

   “Ifconsumerism can be brought to bear on the health market, it has the potential toreduce costs,” Cather says.

   Liabilityfor violating HIPAA privacy regulations gives self-service another boost.

   “It’sno longer enough to guarantee only proper use of employee medicalinformation,” Cather says. “Now it’s a violation just to be in possessionof it without specific releases.”

   Asa result, employers are re-thinking the cost of building in-house wellness ordisease management programs that might be hamstrung by HIPAA regulations. Costand privacy concerns together are pushing employers toward self-service e-healthusing Web-based vendors. 

From newsletter to wellness
    Self-servicewill come to most workplaces in increments. A prime example is the companynewsletter, which first migrated from print to Web site and now is evolving intoa gateway for more sophisticated functions like wellness and disease management.

   Inthe past, an employer might have printed its own newsletter one month andcirculated a wellness-promotion newsletter the next. Now an employer can buyaccess to a wellness Web site for employees and also post its own content on thesite. Most wellness Web sites charge per member (employee) per year. The costcompares to buying a printed wellness newsletter, but opens up several newpossibilities. 

    Depth of content isgreater and new content is added frequently, so members are virtually assured offinding articles that hit their exact need or interest. Some sites such asWellMed provide links to specialized content on other Web sites. Other sitessuch as MyDailyHealth and StayWell develop or contract for their own content.

   Thechallenge now is to deliver content that members want, and content promotinghealthier lifestyles, without stimulating endless surfing on company time.Unlike Healtheon/WebMD, which has around 25,000 pages, MDH has around 1,500pages and is developing a scorecard system to keep readers moving throughbriskly. Although MDH doesn’t release data on the viewing habits ofindividuals, members access average 2.2 visits per week and about 11 minutes pervisit, says CEO Joe Woodman. 

    Interactivitycan engage readers, identifying when they are ready to change behavior andreduce health risks. Most wellness sites provide a health risk assessment (HRA)questionnaire. Some are using “push” technologies that draw information fromthe HRA to send members a periodic e-mail witha customized table of contents for Web site updates, built around eachindividual’s preferences.

   GordianHealth uses its HRA as the front end of a multi-layered intervention formembers, with voluntary access to telephonic coaching from counselors. Keycontent areas for Gordian are smoking cessation, low back pain, managing chronicconditions such as diabetes and asthma, and managing health risks such asweight, cholesterol, blood pressure or stress.

   Unlikesome e-health vendors, Gordianbegan as a traditional wellness program, and charges on a fee-for-service basis.They will add full Web site interactivity and e-mail coaching this spring inpartnership with MDH. They believe their intense coaching produces betteroutcomes in reducing high-risk lifestyles and medical claims. Their combinedInternet/telephonic approach works well for clients like Murata Electronics, amanufacturer with a high proportion of employees lacking Internet access. 

    Incentivescan be built into Web site use, creating more pull into interventions andreduction of health risks. (Seethe HIPAA sidebar for late-breaking developments that could affect use ofincentives.) Compaq uses MDH as its wellness home site, sometimes updatingcontent weekly. The site is also the gateway to related programs such asFitness, where some employees log their workouts to receive fitness centerreimbursements.

   Compaqhas had the MDH program for more than a year, and soon will evaluate incentivesfor participating on the site.

   “Rightnow we’re not so concerned about user statistics as we are about content andfunctionality of the site, to give our employees a good experience,” saysPatricia Travers, Compaq corporate health strategies manager. She structurestheir e-health program to protectthe privacy of personal user data, and has no access to that informationherself. “I want people to feel it’s safe to use MyDailyHealth.”

   Muratanow adds $2 per week to the paycheck, for two years, for employees who gothrough Gordian’s HRA exam. It is a comprehensive instrument including 10health metrics, which are administered by health and wellness director DianaFrantz, R.N., or her staff nurse. Frantz sends completed HRAs to Gordian forgroup health risk analysis; about 40 percent of employees at their plantparticipate. Frantz plans to lobby management for a second incentive foremployees who go through a complete round of Gordian coaching.

   Atthe heart of e-health is theInternet’s ability to capture an individual’s attention when he or she isready to change. Cather sums it up in a word, “stickiness.” 

• How longdo people stay on a Web site? 

• Howoften do they come back? 

• Do theyclick through to deeper layers for more information? 

• Aftergetting answers, can they make a transaction to support change, such asstarting a migraine diary or asking for coaching? 
  

   Asticky Web site provides an engaging visit and new ideas for casual viewers,with immediate reinforcement for the person who feels impelled to take action.It turns self-service into an engaging and rewarding experience. A Web sitecould begin as a wellness newsletter and evolve into the front end of aneffective, confidential and personalized wellness intervention.