Incentives and Other Factors Associated With Employee Participation in …€¦ · · 2017-12-05Incentives and Other Factors Associated With Employee Participation in Health

FAST TRACK ARTICLE

Incentives and Other Factors AssociatedWith Employee Participation in HealthRisk Assessments

Michael S. Taitel, PhDVincent Haufle, MPHDebi Heck, MARonald Loeppke, MD, MPHDonald Fetterolf, MD, MBA

Objectives: Investigate factors associated with employee participationrates in health risk assessments. Methods: This cross-sectional studyusing multiple regression analyzed data from 124 employers with882,275 eligible employees who completed 344,825 health and produc-tivity assessments (HPAs). Results: Incentive value and Communica-tions and Organizational Commitment Level (Com/Org Level) were thestrongest predictors of HPA completion rates. Employer size and aGateway Model were also significant predictors. In addition, a correla-tion of variables showed other important relationships. To achieve a50% HPA completion rate, employers with a low Com/Org Level willneed an incentive value of approximately $120 whereas employers witha high Com/Org Level only need approximately $40—a difference of$80 dollars. Conclusion: This applied study offers empirical evidence tohelp employers increase their employees’ participation in health riskassessments. (J Occup Environ Med. 2008;50:863–872)

E mployers are in a unique position topositively influence the health of theUS population because they haveaccess to the employees and depen-dents that make up a large portion ofthe population, and they are respon-sible for paying a majority of thisgroup’s health care expenditures.1

Employers impact health throughtheir control of benefit plan designs,communication channels, corporatepolicies, physical environments, andcorporate culture. They also play animportant role in the prevention ofillness through worksite health pro-motion programs.

A large and expanding body ofhealth research shows that employeeswith multiple modifiable risk factorscost more than other workers and thatincreasing healthy behaviors and de-creasing health risks are associatedwith cost savings.2,3 Furthermore,employers offering health promotionprograms benefit from enhanced cor-porate image and good will, increasedemployee morale, greater employeeretention, reduced absenteeism, andhigher on the job productivity.4

As a result of these and other data,public policymakers are encouragingemployer-based initiatives. For ex-ample, Healthy People 2010 has thegoal of increasing the proportion ofworksites that offer comprehensiveworksite health promotion pro-grams.5 The recently proposed“Healthy Workforce Act 2007”(S.1753), is legislation that wouldprovide tax incentives to employersto stimulate investment in compre-hensive health promotion. Further-

From Alere, Rosemont, IL.All funding for this study was provided by Alere, formerly Matria Healthcare.Address correspondence to: Michael S. Taitel, PhD, Alere, 9500 W. Bryn Mawr Avenue, Suite 500,

Rosemont, IL 60018; E-mail: [email protected] © 2008 by American College of Occupational and Environmental Medicine

DOI: 10.1097/JOM.0b013e3181845fe2

JOEM • Volume 50, Number 8, August 2008 863

more, the Centers for Disease Controland Prevention’s Healthier WorksiteInitiative offers guidance and practicaltools to employers developing healthpromotion programs.6

More and more employers are em-bracing the notion that a healthyworkforce is beneficial to their orga-nization’s productivity and profit-ability.7 They are seeking methods toimprove the overall health of theirworkforce and reduce the cost asso-ciated with treating illness. To thisend, they are taking an active role inpromoting health.

National surveys of employersshow that most offer some form ofhealth promotion. Childress andLindsay8 report that 90% of USworksites with over 50 employeesoffer at least one health promotionprogram. Nevertheless, only a smallproportion of employers offer compre-hensive health promotion programs.Results from the 2004 National Work-site Health Promotion indicate thatonly 6.9% of the responding worksitesoffer a comprehensive health promo-tion program as defined by HealthyPeople 2010, which include the fol-lowing elements: health education,supportive environments, integrationinto organizational structure, links toemployee support services, and healthscreenings.9 Although many employ-ers have stepped up to provide healthpromotion, clearly there is room forimprovement.

Health screenings in the form ofhealth risk assessments (HRAs) arecommonly used by employers as akey element in their health promo-tion programs. A 2007 survey of 573US employers with a total of 11million employees found that 72%offered HRAs.2;p1466 HRAs are self-report surveys that typically includequestions about various medical andlifestyle indicators that have beenshown to relate to preventablechronic health conditions. Medicalrisk indicators may include measuressuch as body mass index, blood pres-sure, and lipid profiles. Lifestyle riskindictors may include measures suchas physical activity levels, smoking

status, nutrition, and stress levels.More recently HRAs are beginningto include measures of health-relatedproductivity.10

HRAs produce reports that serveseveral functions. Individual risk re-ports provide feedback to the re-sponder regarding their relative riskfor various mental and physicalhealth conditions and their overallrisk profile. This feedback, informedby behavior change theories such asProchaska’s Transtheoretical Model11

and Bandura’s Cognitive-SocialModel,12 usually offers tailored rec-ommendations and education to helpthe individual change certain be-haviors to reduce their modifiablerisks. A 2008 Hewitt and Associatessurvey of approximately 30,000 em-ployees indicated that 99% of re-spondents agreed or strongly agreedthat it is important to know theirpersonal health risk to take steps toprevent or treat chronic disease. Inaddition, 60% of respondents reporttaking action on their health based onthe feedback from an HRA. Of the40% not yet taking action, 55% in-dicate they are ready to follow rec-ommendations, 35% plan to take,and 10% do not plan to take action toimprove health based on HRA feed-back.13 There is insufficient empiricalevidence that HRAs by themselveslead to health risk reductions.14,15

Nevertheless, there is growing supportthat HRAs coupled with comprehensivehealth promotion programs are associ-ated with health risk reduction.16,17

Aggregate reports summarize apopulation’s health risk and provideessential information needed for pro-gram planning and for measuringchanges in the population’s risk sta-tus over time. Many advanced HRAsintegrate with comprehensive well-ness and disease management pro-grams and serve as a mechanism toidentify individuals for specific healthenhancing interventions.10;p470

Employee participation is the key tomaximizing the value of health promo-tion programming. Achieving highrates of engagement and participationis identified by leading experts as es-

sential to successful worksite healthpromotion programming.18 BecauseHRAs are typically the entry point intothese programs, employers have avested interest in increasing and main-taining high HRA participation rates.Research indicates that employeeswho typically respond to heath riskassessments are different than nonre-sponders.19,20 Consequently, effortsthat are successful at increasing HRAparticipation rates will engage moreindividuals who otherwise would nothave participated in health promotionactivities and produce reports that aremore representative of the whole em-ployee population. Therefore, employ-ers and health promotion providerscontinually seek to improve programparticipation.

We suggest that there are threeessential constructs controlled byemployers that influence health pro-motion participation: communica-tions, organizational commitment,and incentives.

CommunicationsHealth communications may take

the form of mailings, payroll stuffers,web site advertising, worksite posters,phone calls, and e-mails. The contentcan raise awareness of health risks,suggest methods to reduce them, pro-vide the motivation and skills neededto reduce these risks, help direct indi-viduals to supportive environments,and reinforce healthy attitudes.21 Sev-eral benchmarking studies have recog-nized that effective communication isan essential component of disseminat-ing information about worksite healthpromotion programming.18;p114 Othershave found that insufficient or ineffec-tive communications about health pro-motion programs can result in lowlevels of participation because em-ployees are simply unaware of avail-able programs.22

Organizational CommitmentOrganizational commitment is the

structure that supports engagementand dissemination of health promo-tion programs, which includes em-ployee involvement and leadership

864 Employee Participation in Health Risk Assessments • Taitel et al

support. Employee involvement cantake the form of employee advisoryboards (EABs), wellness commit-tees, union representation, and inter-nal champions. Leadership support isdefined by senior leadership andmanagement’s visible advocacy andprogram participation, and by theirallocation of dedicated resources tohealth promotion programming.

Several elements of organizationalcommitment can influence employeeparticipation in health promotionprograms. EABs and employee well-ness committees are importantgroups of representative employeesthat influence the promotion, plan-ning, and development of worksitehealth promotion programs.22,23

They help tailor health promotionprograms to fit the needs and desiresof the employees and, as a result,help create more attractive program-ming that can increase participationrates.20;p401 Evidence suggests thatthe amount of employee involvementin an EAB is positively correlatedwith both the awareness and partici-pation in a worksite health promo-tion campaign.24

Champions have long been recog-nized in the business community as atool to influence others to supportprojects.25,26 Champions are opinionleaders who are recognized by theirpeers and typically have an influentialrelationship with fellow employees.Champions can include employees atall levels: staff, management, and evenexecutive leadership. They are well po-sitioned to influence others to participatein health promotion programming.

Management and leadership sup-port are essential to have a successfulworksite health promotion program.Sloan and Gruman27 found that su-pervisor support was independentlyassociated with participation inhealth promotion programs. Crumpet al28 found that worksite organiza-tional factors (perceived managementsupport, organizational resources, andsupportive social environment) arepredictive of employee participationin health promotion programs in theworksite setting. Further, evidence

suggests that having a staff personexclusively committed to healthpromotion programming is a strongpredictor of a worksite having a com-prehensive health promotion pro-gram.22;p439 The bottom line is thatorganizational commitment representsmuch of the corporate culture andworkplace environment that influencesparticipation and sustainable behaviorchange.

IncentivesIncentives are financial and nonfi-

nancial rewards linked to specificbehaviors. Recently employers (andbenefit consultants) are showing re-newed interest in using rewards orincentives to increase health promo-tion participation rates. A 2004 Na-tional Worksite Health PromotionSurvey indicated that 26% of em-ployers use incentives to promoteparticipation.9;p2 Incentives can ex-trinsically motivate individuals tomodify their behavior by changing thecost and benefits associated with thebehavior. Typically, the higher the av-erage dollar value of an incentive, thehigher the participation levels.29 Incen-tives can take the form of cash, giftcards, coupons, merchandise, time off,awards and recognition, drawings orlotteries, preferred benefit plan de-signs, premium and copay reductions,and contributions to flexible spendingaccounts (FSA), and health savingsaccounts (HSA). The monetary valueof incentives typically ranges from justa few dollars to several hundreds ofdollars.

Cash-based incentives are offeredin the form of taxable dollars, giftcards, and coupons. Merchandise canrange from small inexpensive trinketsto large ticket items like iPods anddigital cameras. Employer-sponsoreddays off from work can include addi-tional vacation days or paid time off.Tax-exempt contributions to FSA orHSA are an increasingly popular choiceamong employers and are a natural fitwith the trend toward consumer-drivenhealth plans. Medical plan premiumreductions and medical and pharmacycopay reductions are a way employers

are tying health promotion participa-tion to medical utilization.

Drawings or lotteries are per-ceived as a way to administer anincentive at a relatively low cost.Drawings give the appearance of alarge incentive but may, in reality, bea low-cost way for employer’s todeliver an incentive. Nevertheless,research on the effectiveness of lot-teries suggests that they may notwork well to influence behavior.30

Preferred benefit plan designs, whichare usually enhanced medical carecoverage, are another way employerscan reward individuals who partici-pate in health promotion program-ming. A very economical incentivethat is frequently used among em-ployers is the use of awards andrecognitions. For example, employ-ees who participate in health promo-tion programming are recognized bymanagement and praised in front oftheir peers. For some employees, com-petition to receive recognition drivesparticipation more than compensation.

Employers considering the use ofincentives should be aware of theHealth Insurance Portability and Ac-countability Act, Americans withDisability Act, state law, and taxpolicies that may impact the use ofincentives. In general, incentives of-fered to a whole employee popula-tion are not limited other than certaintax liabilities. Nevertheless, incen-tives directed to subpopulations,such as smokers or the obese, orincentives directed at specific behav-ior change, or biometric results aremore regulated.31

Employers have a strong interestin improving the health of theirworkforce by offering health promo-tion programs. They want to achievehigh participation rates to maximizethe value of these offerings. Never-theless, there is little empirical evi-dence from the applied setting toguide employers on selecting thebest factors to drive participation. Asan initial contribution, we investi-gated several factors that are likely tobe associated with employee partici-pation rates in HRAs.


Study Data and MethodsIn this cross-sectional study, we

analyzed data from 124 employerswith 882,275 incentive-eligible em-ployees who completed 344,825HRAs. These employers varied insize (Table 1) and represented a widedistribution of business, government,and industry sectors (Table 2). Onecommonality is that they all engagedAlere to provide a variety of inte-grated population health improve-ment initiatives, and all relied onAlere’s “health and productivity as-sessment” (HPA), a web (and occa-sionally paper)-based HRA used tomeasure health risks, worker produc-tivity, and modifiable behaviors.

Alere’s health improvement pro-grams are supported by a standard-ized technology infrastructure thathosts and tracks participation inHPAs, preventive care screenings,and Healthy Living Programs, whichare personalized on-line modulesthat help employees take important

steps to reduce their health risks andimprove overall health. Once an em-ployee completes their assessment,an algorithm triggers the programsbest tailored to their risk profile andstage of readiness for change. Theseprograms address weight loss, physicalactivity, nutritional management,stress relief, heart health, diabetes pre-vention, smoking cessation, healthyaging, and cancer prevention. Employ-ees may also self-select to participatein any of the programs regardless oftheir HPA results.

Employees also have access toon-line seminars that cover a widevariety of health and wellness top-ics. The program offers participa-tory interventions that includephysical activity, healthy weightmanagement, nutrition and stressmanagement. In addition, programsmay include telephonic healthcoaching. The fundamental compo-nents to these interventions are thatthey provide the tools for the par-

ticipant to set personal goals, de-velop action plans, and trackprogress.

The data for this study were ob-tained from Alere’s informationsystem that tracks program participa-tion. We also collected data by ab-stracting administrative recordsmaintained by Alere’s WellnessConsultants who are experts inhealth promotion program designand are responsible for supportingthe employers’ health promotionprograms. The abstracts includeprogram campaign dates, number ofeligible employees, wellness pro-gramming structures and activities,marketing and communication cam-paigns, incentive structures, incen-tive types and monetary values.

Measures

Dependent VariableThe dependent variable used to

measure participation in HRAs wasthe HPA completion rate. Through-out this article, we will refer to thegeneral concept of participation as“HRA participation,” and we willrefer to the operational measure ofparticipation as “HPA completion.”The HPA completion rate was de-fined as the ratio of the number ofemployees who completed the HPAto the total number of employeeseligible for the incentive program forthe time period the HPA was acces-sible to employees. The assessmentperiods varied depending on the em-ployers’ predefined preferences, al-though, most assessment periodslasted approximately 9 to 12 months.

Independent VariablesAs an applied study, we relied on

available information that the litera-ture and expertise suggested wouldimpact participation rates. Some ofthese factors include the level of anemployer’s communication and or-ganizational commitment to healthpromotion programming, employerand employee characteristics, and theuse of incentives. Incentives have

TABLE 1Frequency Distribution by Employer Size (n � 124)

Employer Size Frequency Percent

Less than 1000 employees 14 11.31000–4999 employees 58 46.85000–10,000 employees 29 23.4Greater than 10,000 employees 23 18.6

TABLE 2Frequency Distribution by Industry Types (n � 124)

2007 NAICS US Titles Frequency Percent

Accommodation and Food Services 4 3.2Administrative and Support and Waste Management and

Remediation Services5 4.0

Construction 4 3.2Educational Services 6 4.8Finance and Insurance 9 7.3Health Care and Social Assistance 18 14.5Information 6 4.8Manufacturing 23 18.6Mining, Quarrying, and Oil and Gas Extraction 4 3.2Other Services (except Public Administration) 4 3.2Professional, Scientific, and Technical Services 13 10.5Public Administration 4 3.2Retail Trade 12 9.7Utilities 6 4.8Wholesale Trade 6 4.8


multiple elements including struc-ture, type, and monetary value.

Communications and Organiza-tional Commitment. Recognizingthat communication, employee in-volvement, and leadership supportare influential on program participa-tion, we created an ordinal metriccombining many of these elements.We engaged Alere’s Wellness Con-sultants to subjectively assess eachemployer’s Communications and Or-ganizational Commitment Level(Com/Org Level) using the follow-ing criteria:

Low: Program advertised 1 to 3times throughout the campaign pe-riod. This advertisement includes abasic announcement, typically ator around program launch. Theseadvertisements are in one or moreplaces such as open enrollmentmaterials, launch brochure, and/orflyer. In addition, one to two othercommunications occur during theprogram period. Limited client re-sources (personnel time) are allo-cated to the program (�10% of aFTE).

Medium: Program advertised 4 to 10times throughout the campaign pe-riod. A series of communicationsoccur throughout the program pe-riod, in multiple mediums, such asopen enrollment materials, bro-chures and/or flyers, emails, posters,postcards, and employee meetings.Some executive/management sup-port for program is shown, a fewestablished wellness committees,but overall culture does not stronglysupport or adapt to the program.Moderate client resources (person-nel time) are allocated to the pro-gram (�50% of an FTE).

High: Program advertised 10 or moretimes throughout the campaign pe-riod. Multiple communications oc-cur throughout the program period,in multiple mediums, such as openenrollment materials, brochures and/or flyers, emails, posters, postcards,and employee meetings. WellnessChampions are established for “mostprograms.” Strong, visible execu-

tive/management support is shown,and established wellness commit-tees and regular dedicated clientresources (personnel time) are allo-cated to the program (�50% of aFTE).

Employer and Employee Charac-teristics. As a proxy for the potentialinfluence of employer size, we reliedon Alere’s employer size groupings(�1000, 1000 to 4999, 5000 to10,000, and �10,000) to categorizethe number of incentive-eligibleemployees. We then evaluated theimpact of employer size on HPAcompletion rates. We also evaluatedif the average age and gender ofthe HPA respondents correlated withthe completion rate. Finally, to deter-mine if HPA completion rate isrelated to participation in other well-ness programming, we created anEngagement Score by calculating theratio of the median total wellnesspoints (a measure of health programparticipation) to the 95th percentileof the maximum wellness pointsachieved per employer. We selectedthe median total wellness points andthe 95th percentile of the maximumto minimize the influence of outlierscores that may skew the ratio. TheEngagement Score was based onwellness points from HPA respond-ers only. We used this EngagementScore in further analyses.

Incentive Structure. In this study,incentive structures are measured bya set of dichotomous variables thatindicate the presence or absence of awellness point system, incented inde-pendently, a Gateway Model, man-datory biometrics, and the use ofmultiple incentive types.

A Wellness Points System is indi-cated when employees that completea wellness activity (eg, HPA, annualphysical examination, weight lossprogram) receive an employer-specific, predefined number of pointsfor that activity. For example, anemployee completing an HPA re-ceives five points; they receive threeadditional points when they attend ahealthy living seminar. On the basis

of the various activities that an em-ployee completed, they will haveaccumulated a total number ofpoints. An incentive is providedwhen their total number of pointsmeets or exceeds a predeterminedpoints threshold. Some employersuse a tiered incentive structure wherean employee can earn a more valu-able incentive as their total numberof points reaches a higher level. It isimportant to note that employees areinformed of the total points neededto achieve the various incentives andunderstand each activity’s relativecontribution to the total.

The incented independently incen-tive structure is indicated when theincentive is provided exclusively forHPA completion; this incentive isindependent from other programincentives. The Gateway Model isindicated when employees mustcomplete the HPA to be eligible toearn an incentive for participating inother health promotion activities.Mandatory Biometrics is indicatedwhen biometrics (eg, body mass index,blood pressure, high-density lipopro-tein) are required for the participant toachieve an incentive. The final incen-tive structure assessed, multiple incen-tive types, is indicated when more thanone incentive type is provided for HPAcompletion. For example, employeesreceive a gift card and a pharmacycopayment wavier for completing theHPA.

Incentive Type. Incentive types arethe various modes used to deliverincentives. These include awards/recognition, merchandise, cash/giftcard, drawings, FSA or HSA contri-bution, preferred benefit plan, timeoff from work and cost sharingthat may include medical insurancepremium reduction, medical or phar-macy deductible reduction, and med-ical or pharmacy copayment waiver.The distribution of the various incen-tive types offered by the employersin our sample is very similar to thedistribution reported in a survey ofmajor US employers.32

Monetary Value of Incentive. Totest the influence of incentives value


on HPA completion rate, we devel-oped a methodology that allows us tomonetize different incentives typesuniformly across employers. Formost incentive types, the incentivesvalue was straight forward andclearly identified by the employer.For example, if completing an HPAis worth 10 points and the totalpoints needed to achieve the firstincentive level is 30 points, thencompletion of the HPA contributesto 33% of the incentive value. There-fore, if 30 total points achieves $120in cash, the HPA is worth approxi-mately $40. In a tiered incentivestructure, we limited the monetiza-tion of the incentive for HPA com-pletion to its relative contribution toachieving the first possible incentivelevel. If the HPA was incented inde-pendently, the entire value of theincentive was applied. On the otherhand, some incentive types weremore complicated and required addi-tional attention.

Awards/recognition have inher-ent value, but due to the limiteddata available regarding the type ofawards and their delivery, we de-termined that there was not a reli-able way to assign a dollar value.Therefore, we did not monetize thevalue of awards/recognition in thisanalysis.

Some employers issued an incen-tive in the form of time off fromwork. We converted time off fromwork into dollars by calculating theaverage hourly salary ([averageyearly salary/250 workdays]/8 hoursworkday) and multiplied hourlysalary by the number of hours oftime off.

The monetizing of drawings re-quired us to consider the economicconcept of expected value to accountfor the discounted value of the re-ward. Expected value is the facevalue of the incentive multiplied bythe probability of winning.33 For ex-ample, the expected value of a draw-ing with a 0.1% chance of winning$500 is $0.50. By using this ap-proach, we could have looked retro-spectively at each employer that

offered a drawing and determinedthe average chance of winning thedrawing based on number of incen-tive-eligible HPA respondents andcalculate the expected value. Never-theless, this methodology is prob-lematic because it is very difficult foran individual to calculate their oddsof winning or the expected value ofthe incentive when they do not knowhow many others will complete theHPA. This methodology also doesnot account for the psychologicalvalue of this incentive, such as expe-riencing the thrill of the gamble orthe fantasy of winning a big prize. Asa result, the strict expected value willunder-represent the actual value ofthe incentive.

We needed to develop a method-ology for monetizing the impact of adrawing incentive, taking into ac-count both the expected value andthe psychological value of the incen-tive. Nevertheless, we did not findsufficient empirical literature to pro-vide guidance. Therefore, taking intoaccount the range of face and ex-pected values, we determined thatmultiplying the face value of theincentives by 1% would be a reason-able estimate of the incentive valueto each employee. For example, ifthe face value of the drawing is$3000, then the incentives dollarvalue would be $30 from the em-ployee’s perspective.

AnalysisWe examined the bivariate rela-

tionship between the HPA comple-tion rate and all of the independentmeasures using a Spearman rankorder correlation. Multivariate lin-ear regression analysis was used toexplore the relationship betweenemployee participation in the HPAand all independent variables. Allanalyses were conducted using SAS9.1 software (Copyright © 2002–2003by SAS Institute Inc, Cary, NC) andMicrosoft Excel 2003 (Copyright©1985–2003 Microsoft Corporation).

Since no a priori hypotheses hadbeen made to determine the order

of entry of the predictor variables,we used a forward stepwise multi-ple regression analysis to predictHPA completion rate. A P-value ofless than 0.05 was considered sig-nificant for the results of all statis-tical analyses.

Results

Descriptive ResultsTable 3 presents the means and

standard deviations for the averageage of the HPA respondents, incen-tive value, engagement score, gen-der, and HPA completion rates.

Table 4 displays the frequencydistribution of the incentive struc-tures and the Com/Org Level. Wefind that 75.8% of employers offeredWellness Points; 37.9% incentedindependently; and 22.6% used aGateway Model whereas only 8.1%

TABLE 4Frequency Distribution of IncentiveStructures and Com/Org Levels(n � 124)

Frequency Percent

Gateway Model 96 77.4Wellness points 94 75.8Incented

independently47 37.9

MandatoryBiometrics

10 8.1

Multiple incentivetypes

No incentives 2 1.6One incentive 84 67.7Two incentives 35 28.2Three incentives 3 2.4

Com/Org LevelLow 23 18.6Medium 58 46.8High 43 34.7

TABLE 3Mean and Standard Deviation (SD) ofContinuous Variables

Mean SD

Average age (yrs) 42.5 2.8Incentive value

(US dollars)$57.35 $69.49

Engagement score 0.40 0.18Gender (% female) 59.8% 18.3%HPA completion rate 39.1% 27.0%


required Mandatory Biometrics.Most employers (96.0%) offered oneor two incentives for the HPA. Em-ployers in this study demonstrated arange of Com/Org Levels: 18.6%had low Com/Org Level; 46.8% hadmedium Com/Org Level; and 34.7%had high Com/Org Level.

Table 5 displays the frequency dis-tribution of the various incentivestypes and the mean incentive value foreach type offered by the employers.Cash/gift card, cost sharing, and mer-chandise were the most frequentlyused incentive types among these em-ployers. Preferred benefit plan, costsharing and drawings are the top threeincentive types with the highest aver-age incentive values.

Bivariate Analysis ResultsAll of the independent variables

analyzed are listed in Tables 3–5.Table 6 displays the Spearman rankcorrelations between HPA comple-tion rate and the significant predictor

variables and the correlations amongthemselves. Several measures werepositively correlated with HPA com-pletion: Incentive value (r � 0.681,P � �0.0001), Com/Org Level (r �0.507, P � �0.0001), cost sharing(r � 0.288, P � 0.001), GatewayModel (r � 0.273, P � 0.002),Multiple incentive types (r � 0.226,P � 0.01), and incented indepen-dently (r � 0.190, P � 0.03). Em-ployer size (r � �0.195, P � 0.03)was negatively correlated with HPAcompletion rate. In addition, incen-tive value correlated with Com/OrgLevel, cost sharing, Gateway Modeland incented independently (P �0.05). Further, Com/Org Level cor-related with multiple incentive types;and incented independently corre-lated with Gateway Model and em-ployer size (P � 0.05).

Multivariate Regression ResultsMultivariate regression results are

shown in Table 7. The incentive

value (which ranged from $0 to $480per participating employee), Com/Org Level, employer size, and theuse of a Gateway Model accountedfor approximately 55% of the vari-ance in HPA completion rates, F(4,119) � 36.83, P � 0.0001.

In recognition of the possible col-linearity between the incentive valueand other predictors, we also ran aregression model removing incentivevalue so as to better understand thecontribution of these other predictorvariables in the model. Use of costsharing and incented independentlywere significant in the model but werenot sufficiently influential to be con-sidered for inclusion in the finalmodel. Incentive value had a muchstronger relationship to HPA comple-tion rate as compared to the othercorrelates and therefore stayed in thefinal model.

To help validate the model, wetested the assumptions of multiplelinear regression and found them tobe within acceptable limits.

In Figs. 1, 2, we highlight therelationships among incentive value,Com/Org Level, and HPA comple-tion rate. Figure 1 shows a scatter

TABLE 5Frequency Distribution and Mean Incentive Value by Incentive Type (n � 124)

Frequency Percent*Mean

(dollars) SD

Cost sharing 50 40.3 $79.14 $84.24Cash/gift card 42 33.9 $47.82 $47.53Merchandise 26 21.0 $44.60 $67.03Flexible spending account (FSA) or health

savings account (HSA) contribution17 13.7 $43.39 $24.23

Drawings 15 12.1 $65.05 $84.38Time off from work 6 4.8 $30.55 $18.30Awards/recognition 5 4.0 $30.83 $28.80Preferred benefit plan 2 1.6 $205.00 $113.14

*Some employers offered more than one incentive type and some employers did not offerany incentives.

TABLE 6Spearman Rank Correlations

HPA CompletionRate

IncentiveValue

Com/OrgLevel

CostSharing

GatewayModel

MultipleIncentive Types

EmployerSize

Incentive value 0.681*Com/Org Level 0.507* 0.344*Cost sharing 0.288* 0.353* 0.118Gateway Model 0.273* 0.313* 0.152 0.169Multiple incentive types 0.226* 0.092 0.304* 0.006 0.023Employer size �0.195* 0.118 0.059 �0.044 0.165 �0.054Incented independently 0.190* 0.427* 0.160 0.002 0.263* 0.128 0.401*

*P � 0.05.

TABLE 7Multiple Regression Results

Variables F Statistic P

Intercept 2.30 0.15Incentive value 58.58 �0.0001Com/Org Level 61.14 �0.0001Employer size 16.59 �0.0001Gateway Model 5.09 �0.05

R2 � 0.55; F � 36.83; P � 0.0001.


plot of the HPA completion rate bythe incentive value. A 2nd orderpolynomial regression line was fittedto the data (R2 � 0.453) to drawattention to the relationship betweenincentive value and HPA completionrate. Figure 2 shows the HPA com-pletion rate by incentive value strat-ified by the three Com/Org Levels.We found that a 2nd order polyno-mial regression line best fit the lowCom/Org Level, a linear regressionline best fit the medium Com/OrgLevel, and a logarithmic regressionline best fit the high Com/Org Level.Figure 2 clearly shows that thehigher the Com/Org Level, thehigher the HPA completion rate. Forexample, to achieve a 50% HPAcompletion rate, employers with alow Com/Org Level need an incen-

tive value of approximately $120,whereas employers with a high Com/Org Level only need approximately$40; this is a difference of $80 dollars.

DiscussionThis study explored the various

factors that potentially influence em-ployee participation rates in HRAs.We relied on data from the realworld experience of employers offer-ing HPAs as part of their integratedpopulation health improvement initi-atives with Alere. As indicated ear-lier, these employers represented awide distribution of industry typesand sizes. These employers experi-enced a range of participation rates,and they exhibited a variety of fac-tors that impacted their workforces’participation.

Our most notable finding from theregression analysis is that incentivevalue and Com/Org Level were thestrongest predictors of HPA comple-tion rate. The analysis also showedthat employer size and a GatewayModel were significant predictors. Inaddition, a correlation of variablesshowed other important relation-ships. For example, multiple incen-tive types, incented independently,and cost sharing each significantlycorrelated with HPA completionrate. Although they did not remain inthe regression model due to theircovariance with other more signifi-cant predictors, their independent ef-fects should be recognized.

On the basis of these findings, weconfirm basic behavioral theory thathigher incentive values are associ-ated with higher participation rates.Nevertheless, our data suggest thatthis is strongly influenced by Com/Org Levels. Employers seeking toachieve high HRA participation ratesneed to consider both incentive valueand Com/Org Level. Furthermore,employers should consider the cost-effectiveness of investing in incen-tives versus communications andorganizational commitment. Re-search has shown that investment inkey elements of communications andorganizational commitment willhave positive effects beyond healthpromotions, such as improved em-ployee relations, improved retention andturnover, and increased productivity.34

Employer size was included as oneof the characteristics of the studysample. It proved to be significantpredictor of HPA completion rate.Clearly, size has some impact whichmay be due to a variety of factors notmeasured in this study, such as work-group size or corporate culture.

Employers should consider using aGateway Model to increase partici-pation. The Gateway Model requiresemployees to complete the HPA tobe eligible to earn an incentive forparticipating in other health promo-tion activities. Its predictive value inthe regression analysis along with itspositive correlation with HPA com-

Fig. 1. HPA completion rate by incentive value (n � 123).

Fig. 2. HPA completion rate by incentive value and com/org level (n � 123).


pletion rate and its lack of correlationwith the engagement score suggeststhat the Gateway model has a posi-tive impact on HPA completionwithout negatively impacting subse-quent health promotion participation.

We can also learn from the lack ofsignificant relationship between vari-ables that we expected to correlate.With the exception of cost sharing,we did not find any other indepen-dent effects of incentive types onHPA completion rate. We take this tomean that the type of incentive doesnot matter; the important aspect isthe total monetary value of the incen-tive. Therefore, those selecting theincentive types for their programshave a wide range of options. Aslong as the incentive has sufficientmonetary value to most employees,program designers can considerother criteria for their decisions, suchas employee preference, ease of in-centive administration, or leveragingother healthful behaviors.

Furthermore, although not a for-mal hypothesis, we expected thatHPA completion rate would also beassociated with overall health pro-motion participation measured by theEngagement Score. Nevertheless,this study shows them to be indepen-dent of each other. This lack ofrelationship may mean that HRAparticipation and health promotionparticipation need to be measuredindependently and that HRA partici-pation may not be a proxy for totalhealth promotion participation. Ad-ditional work is needed to furtherexplore this relationship.

This applied study included a con-venient yet reasonably comprehen-sive set of measures. Nevertheless,there are a number of variables andconcepts that may be important butwere not included, such as the influ-ence of delayed gratification versusimmediate reward; newer versus es-tablished programs; HRA accessibil-ity; the content of communications;competitions; and selection of incen-tives based on employee preference.In addition, different employees whoare offered the same incentive types

and structures may receive differentactual and/or perceived value. Forexample, a drug copay reduction willhave varied monetary value depend-ing on the employees’ drug utiliza-tion or if they are on a spouses’health plan. A merchandise incentivemay be valued more or less depend-ing on whether the employee pos-sesses or desires the merchandise.Finally, a cash incentive of $50 maybe worth more to a minimum wageworker than to a corporate executive.

Recently, there has been interest inmeasuring the concept of corporateculture as it relates to the health of aworkforce and participation in work-site health promotion programs.35,36

Although not explicitly measured,we believe that the construct of Com/Org Level has many similarities andwould correlate highly with mea-sures of corporate culture.

In conclusion, this applied studyoffers empirical evidence for variousmodifiable factors that impact em-ployee participation rates in HRAs.Employers should consider thesefactors when designing their healthpromotion programs. We found themonetary value of incentives stronglyimpacted participation rates. Further-more, the Com/Org Level that includescommunication frequency and modal-ity, employee involvement in wellnesscommittees, wellness champions, re-source allocation, and leadershipsupport were equally important. In ad-dition, use of a Gateway model, in-centing an HRA independently andusing multiple incentives contributedto participation rates. Finally, employ-ers can use the exhibit of the relation-ship of incentive value and Com/OrgLevel to HPA completion rate (Fig. 2)as a guide to estimate their programs’expected participation rate given theirinvestment in incentives and communi-cations and organizational commitment.

LimitationsThere were several limitations to

this study. The HPA was offered aspart of each employer’s health im-provement initiatives, which mayhave included a varied set of mod-

ules and activities. Although not in-cluded as an independent measure,the available set of health promotioninterventions and their incentive de-sign may have also played a role inthe employees’ decision to completethe HPA. In addition, the Alere HPAand total population health improve-ment platform used in this study maynot be representative of HRAs andhealth promotion offerings used inother settings. To the extent that otherHRAs vary from an on-line, theory-driven, branching logic tool that isintegrated into a total populationhealth improvement platform thenthe generalizability of these resultsmay be limited. Also, the methodol-ogy used to monetize the drawingincentive was based on expert opin-ion. Further research is needed in thisarea to further develop and validatethis methodology.

As an applied cross-sectional study,we observed levels and grouping ofvariables as they naturally occurredamong employers. Some may suggestthat a randomized controlled study isnecessary to understand the factorsthat impact participation rates or thata dose-response design is needed tomore fully isolate and understandthis impact of varied incentive typesor incentive value. This may be true;however, we believe that our designand results are appropriate and suffi-cient to make informed business de-cisions by employers interested inenhancing the health and productiv-ity of their workforce.

About AlereAlere is a leading provider of

integrated comprehensive health im-provement programs to health plans,employers, and government agencies.Alere is dedicated to developing bettereducated, motivated, and self-enabledhealth care consumers and supportingclinicians in managing the care of theirpatients. The company manages majorchronic diseases and episodic condi-tions including diabetes, congestiveheart failure, coronary artery disease,asthma, chronic obstructive pulmonarydisease, high-risk obstetrics, cancer,


musculoskeletal and chronic pain, de-pression, obesity, and other conditions.Alere delivers programs that addresswellness, healthy living, productivityimprovement and navigation of thehealth care system, and provides casemanagement of acute and catastrophicconditions. Alere’s mission is to lever-age technology to improve health careone person at a time.

AcknowledgmentsThe authors thank Gordon Kaplan, PhD,

Phillip Youngblood, and the Alere team ofWellness Consultants for their contribution tothis manuscript.

References1. Claxton G, Gabel JR, DiJulio B, et al.

Health benefits in 2007: premium in-creases fall to an eight-year low, whileoffer rates and enrollment remain stable.Health Aff (Millwood). 2007;26:1407–1416.

2. Okie S. The employer as health coach.N Engl J Med. 2007;357:1465–1469.

3. Yen L, McDonald T, Hirschland D, Ed-ington DW. Association between well-ness score from a health risk appraisaland prospective medical claims costs.J Occup Environ Med. 2003;45:1049–1057.

4. Warner KE. Wellness at the worksite.Health Aff (Millwood). 1990;9:63–79.

5. US Department of Health and HumanServices. Healthy People 2010: TrackingHealthy People 2010. 2nd ed. Washing-ton, DC: US Government Printing Of-fice; 2000.

6. Centers for Disease Control and Preven-tion. Healthier Worksite Initiative. Avail-able at: http://www.cdc.gov/nccdphp/dnpa/hwi/index.htm; 2008.

7. Parry T, Molmen W, Jinnett K. Employ-ers Managing Health and Productivity: AResearch Update. San Francisco: Inte-grated Benefits Institute; 2006:1–17.

8. Childress J, Lindsay G. National indica-tions of increasing investment in work-place health promotion programs by largeand medium size companies. N C Med J.2006;67:449–452.

9. Linnan L, Bowling M, Childress J, et al.Results of the 2004 National WorksiteHealth Promotion Survey. Am J PublicHealth. 2007;98:1–7.

10. Wang PS, Simon GE, Kessler RC. Mak-ing the business case for enhanced de-

pression care: the National Institute ofMental Health—Harvard work outcomesresearch and cost-effectiveness study.J Occup Environ Med. 2008;50:468–475.

11. Prochaska JO, Velicer WF. The transtheo-retical model of health behavior Change.Am J Health Promot. 1997;12:38–48.

12. Bandura A. Self-efficacy: toward a uni-fying theory of behavioral change. Psy-chol Rev. 1977;84:191–215.

13. Hewitt Associates LLC. Two Roads Di-verged: Hewitt’s Annual Health CareSurvey. Lincolnshire, IL: Hewitt Associ-ates; 2008.

14. Goetzel RZ, Ozminkowski RJ. Thehealth and cost benefits of work sitehealth-promotion programs. Annu RevPublic Health. 2008;29:303–323.

15. Schoenbach VJ, Wagner EH, Beery WL.Health risk appraisal: review of evidencefor effectiveness. Health Serv Res. 1987;22:553–580.

16. Task Force Community Preventive Ser-vices. Proceedings of the Task ForceMeeting: Worksite Reviews. Atlanta, GA:Centers for Disease Control and Preven-tion; 2007.

17. Musich S, McDonald T, Hirschland D,Edington DW. Examination of risk statustransitions among active employees in acomprehensive worksite promotion pro-gram. J Occup Environ Med. 2003;45:393–399.

18. Goetzel RZ, Shechter D, OzminkowskiRJ, Marmet P, Tabrizi MJ, Roemer EC.Promising practices in employer healthand productivity management efforts:findings from a benchmarking study.J Occup Environ Med. 2007;48:111–130.

19. Lynch WD, Golaszewski TJ, Clearie A,Vickery DM. characteristics of self-selected responders to a health risk ap-praisal: generalizability of corporatehealth assessments. Am J Public Health.1989;79:887–888.

20. Glasgow RE, McCaul KD, Fisher KJ.Participation in worksite health promo-tion: a critique of the literature and rec-ommendations for future practice. HealthEduc Q. 1993;20:391–408.

21. US Department of Health and HumanServices. Healthy People 2010: Under-standing and Improving Health. 2nd ed.Washington, DC: US Government Print-ing Office; 2000.

22. Birken BE, Linnan L. Implementationchallenges in worksite health promotionprograms. N C Med J. 2006;67:438–441.

23. Sorensen G, Hsieh J, Hunt MK, MorrisDH, Harris DR, Fitzgerald G. Employee

advisory boards as a vehicle for organiz-ing worksite health promotion programs.Am J Health Promot. 1992;6:443–450.

24. Hunt MK, Lederman R, Potter S, Stod-dard A, Sorensen G. Results of employeeinvolvement in planning and implement-ing the treatwell 5-a-Day Work-SiteStudy. Health Educ Behav. 2000;27:223–231.

25. Schon D. Invention and the Evolution ofIdeas. London: Tavistock; 1967.

26. Frost PJ, Egri CP. “Appreciating execu-tive action,” in the power of positivethought & action in organizations. SanFrancisco: Jossey Bass; 1990:284–332.

27. Sloan RP, Gruman JC. Participation inworkplace health promotion programs:the contribution of health and organiza-tional factors. Health Educ Q. 1998;15:269–288.

28. Crump CE, Earp JL, Kozman CM, Hertz-Picciotto I. Effect of organizational-levelvariables on different employee partici-pation in 10 federal worksite health pro-motion programs. Health Educ Behav.1996;23:204–223.

29. Chapman L. Employee participation inworkplace health promotion and wellnessprograms. N C Med J. 2006;67:431–432.

30. Roberts LM, Wilson S, Roalfe A, BridgeP. A randomized controlled trial to deter-mine the effect on response of includinga lottery incentive in health surveys.BMC Health Serv Res. 2004;4:1–8.

31. Simon T, Symons W. Wellness ProgramIncentives—What’s Allowed, What’s Not.Mercer Health & Benefits; 2007:1–4.

32. Capps K, Harkey JB. Employee Healthand Productivity Management Pro-grams: The Use of Incentives. Lyndhurst,NJ: IncentOne; 2007.

33. Wikipedia. Expected Value. Available at:http://en.wikipedia.org/wiki/Expected_value; 2008.

34. Edelman. Finding Wealth Through Well-ness: How Engaging Employees in Pre-ventive Care Can Reduce HealthcareCosts. Chicago: Edelman; 2006:1–25.

35. Della L, DeJoy DM, Goetzel RZ,Ozminkowski RJ, Wilson M. Assessingmanagement support for worksite healthpromotion: psychometric analysis of theleading by example instrument. Am JHealth Promot. 2008;22:359–367.

36. DeJoy DM, Wilson MG, Goetzel RZ, etal. Development of the EnvironmentalAssessment Tool (EAT) to measure or-ganizational physical and social supportfor worksite obesity prevention pro-grams. J Occup Environ Med. 2008;50:126–137.


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