Minnesota HealthShare: Carrots or Sticks to Support Wellness?

Would you rather be rewarded for achieving a health-related goal, or penalized for not achieving it? Or maybe a combination of both would motivate you best? Much has been written about what works to change behavior, and the literature is inconclusive as to whether carrots or sticks are a better motivator. In Minnesota, the HealthShare local access to care program experimented with two approaches to wellness, and found that, for the population they serve, carrots are the more effective approach.

HealthShare is a multishare health plan that provides coverage to employees of small businesses that employ 50 or fewer employees and pay a median wage equal to or less than 350 percent FPL for a single person. The employer pays $60 per month per employee. The employee share is $67 per month for the Standard Option or $53 per month for the Wellness Rewards Option. Both options include primary, specialty, hospital, and emergency care, as well as pharmacy benefits.

There are three requirements for the Wellness Rewards Option:

1. Enrollees must meet with a nurse care manager to set up wellness goals for the year.
2. Enrollees must contact the nurse care manager within 12 weeks of this initial meeting to provide a progress update on their established goals.
3. Enrollees must annually participate in at least two health-related classes, or two health-related activities, or one of each.

When HealthShare launched, members were given the choice at enrollment to choose either the Wellness Option or the Standard Option. The majority – 79 percent – chose the Wellness Option, primarily because of its lower monthly premium, lower co-payment rates, and higher dollar limit for pharmacy claims. Members who chose the Wellness Option but did not meet the three Wellness Option requirements were switched to the Standard Option.

The resulting churn from Wellness Option to Standard Option imposed a large administrative burden on HealthShare; records had to be updated to note each member’s proper plan enrollment. The nurse case manager faced missed appointments. Staff sent multiple reminders warning of the impending switch and explaining the requirements. Despite this, HealthShare staff fielded phone calls from members who were unhappy when they learned they were no longer qualified for the Wellness Option.

Based on this experience, HealthShare switched the default enrollment option to the Standard Option. Members then have the opportunity to earn enrollment in the newly renamed Wellness Rewards Option by completing the three wellness requirements. Although a lower proportion of members are now enrolled in the Wellness Option – approximately 50 percent of members – those who are enrolled are more likely to complete the requirements. As of the last quarter of 2011, HealthShare has seen a trend of a strong number of enrollees moving to the Wellness Rewards Option. HealthShare’s administrative costs have also dropped as fewer reminder notices must be sent and fewer members must be switched between options.

HealthShare staff shared two lessons from their experience. First, health behavior change is difficult, and people who are engaged in wellness programs are most successful when they have some internal motivation for change; financial incentives alone are not enough to change behavior. Second, it is important for coverage programs to maintain a positive customer experience. By using wellness programs as a carrot, rather than a stick, HealthShare is able to engage those members who are ready for change in a positive environment that supports their success.

Many thanks to Layla Lang, Jenny Peterson, and Dan Svendsen of HealthShare for sharing their experiences with us, and to Cara Bailey at the Minnesota Department of Human Services for her assistance with background information and editorial review.

Sometimes It’s Who You Know: Community-Based Outreach in Colorado

Colorado has long struggled to reach individuals eligible for but not enrolled in health coverage and other social programs. In an effort to reach populations who are often not aware of their coverage options, the Colorado SHAP program awarded Maximizing Outreach Retention and Enrollment (MORE) grants to fund outreach and marketing targeted toward those eligible but not enrolled in coverage expansions. Based on a needs assessment, Colorado decided to employ a “trusted hand” model to conduct this outreach. The MORE grants, totaling $1,696,510, were awarded competitively over three rounds to 39 community-based organizations around the state; each proposed its own targeted outreach strategies.

As a result, the community-based organizations participating in this outreach employ a range of strategies to identify and engage potentially eligible clients and to provide education regarding public health coverage options. For example, one group works through schools, and another targets apartment complexes popular with various ethnic groups. An organization that provides prenatal education added enrollment assistance services to its curriculum. Another organization provides education to high school students and others in the community to de-stigmatize public coverage options.

One MORE grantee that uses the community well in their outreach effort was the Colorado Coalition for the Medically Underserved, which chose to conduct its outreach at family-owned ethnic restaurants in Denver. Within their communities, restaurant owners are often recognized as informal leaders, and thus are ideal partners for disseminating information to others. A volunteer from the Coalition’s partner, Aurora Health Access, visits restaurant owners to provide information on the availability of Medicaid and CHP+ (the state’s Children’s Health Insurance Program). Restaurant owners then pass this information on to both their workers and their customers. The Coalition has designed and distributed linguistically appropriate informational materials that can be customized with each restaurant’s name. Materials include: window clings, posters for employee break rooms, inserts for to-go menus, table tents, and printed placemats.

The 39 community-based organizations conducting outreach have been successful in finding individuals eligible for coverage who are not yet enrolled. As of December 2011, over 9,000 people had been contacted and educated about Medicaid and CHP+, and 4,614 new clients have been enrolled as a result of this outreach. In addition, Colorado’s Medicaid staff is providing training to the community-based organizations, as well as feedback when an application is denied, so that the organizations can follow-up. Organizations are encouraged to continue assisting the applicant when possible; for example, they can assist applicants gather missing information so the application can be resubmitted.

Many thanks to Megan Wood and Cindi Terra at the Colorado Department of Health Care Policy and Financing and to Joe Campe and Art Heredia at the Colorado Coalition for the Medically Underserved for giving generously of their time to share their outreach strategies with us.