The Essential Guide to Health Coaching How to plan, implement, promote, and evaluate health coaching within your population health management program
What you ll learn from The Essential Guide to Health Coaching One-on-one coaching has become an established approach to help individuals with health risks change their behaviors and improve their risk factors. But there are so many approaches to integrating health coaching into your overall population health management program and so many elements involved that it can be hard to know where to start. WebMD Health Services Logo Here, you ll find everything you need to know about adding health coaching to your population health management program. We ll cover the basics of what health coaching is and why it s important. We ll help you plan your program and decide on health coaching approaches, modalities, and services. We ll walk you through implementation, including laying the groundwork with Blue your PMS 3005 management team and preparing your Process population, and we ll focus specifically on engagement, which is one of the most important elements for success. Finally, we ll discuss ways to evaluate your program s efficacy and return on investment, and plan for the future. Whether you re in the early stages of your wellness program or have years of effective health management initiatives under your belt, The Essential Guide to Health Coaching is here to help with step-by-step guidance.
The Essential Guide to Health Coaching How to plan, implement, promote, and evaluate health coaching within your population health management program 4 17 32 42 Planning Implementation Engagement Evaluation 5. Why Add Health Coaching? 8. Build Your Culture of Health 10. Integrated Health Management 11. How to Compare Approaches 16. Summary & Best Practices 18. Lay the Groundwork 20. Required Elements 22. Keys to Success 25. A New Approach to Condition Management 27. Virtual & Mobile Coaching 28. Going International 29. Program Sustainability 31. Summary & Best Practices 33. Why Engagement Matters 34. Communications Planning & Development 36. Intrinsic & Extrinsic Rewards 41. Summary & Best Practices 43. What to Measure and Why 44. Implementation Guidelines for Analytics 46. Utilization Metrics 48. Outcomes Metrics 49. Return on Investment 51. Apply What You ve Learned 52. Summary & Best Practices WebMD Health Services Logo Process
Planning Know what you re getting into and why
PLANNING: Why Add Health Coaching? According to the Centers for Disease Control and Prevention (CDC), nearly 50% of Americans live with at least one chronic illness, including conditions such as heart disease, cancer, and diabetes. Treatment for those individuals accounts for more than 75% of the $2 trillion spent annually on medical care in the U.S. 1 The CDC also says that preventable health risks such as tobacco and excessive alcohol use, insufficient physical activity, and poor nutrition contribute to the development and severity of many chronic conditions. The habits that contribute to the prevalence of these conditions can be addressed through effective one-on-one lifestyle improvement programs. Health coaching has been identified as an effective way for employers and health plans to help individuals change health behaviors and improve critical risk factors. At the same time, it can help reduce both the economic and personal burdens of unhealthy lifestyle choices. The importance of employee WebMD Health Services Logo Process 5 Planning
health behaviors Individual lifestyle choices can have a significant impact on population healthcare costs: A long-term study of more than 205,216 employees demonstrates that excessive health claims, lost productivity due to preventable health risks, and unnecessary sick days cost employers an average of $4,043 per employee per year. 2 Each employee who smokes costs employers $1,897 in lost productivity each year. 3 Obesity results in $1,429 more in annual medical costs per person, compared to people with normal weight even without accounting for the costs of absenteeism and loss of productivity. 4 Employees who exercised only occasionally were 50% more likely to report having lower levels of productivity than employees who were regular exercisers. 5 Health coaching works 6 72.6% of high-risk and 61.6% of moderate-risk WebMD coaching completers improved one or more modifiable health risks. 80% of high-risk engaged participants and 88% of moderate-risk engaged participants completed the coaching program. 7 Those who completed the program are projected to have $507 per person, per year in decreased health-related costs. 8 87% of users participating in coaching said coaching sessions motivated them to make healthy changes in their lives. WebMD Health Services Logo Process 6 Planning
I thought coaching was a system where someone would tell me what to do. Now I know it is about support; about giving me information and alternatives. WebMD Health Services Logo Process 7 Planning
PLANNING: Build Your Culture of Health Most people spend the majority of their waking hours at work, which gives employers a unique opportunity to develop a culture of health that positively influences employees and their families. Employers provide the physical environment and processes that keep employees safe and healthy during the workday, and can offer meaningful rewards related to benefits. Elements of a Culture of Health Portal, Tools, & Mobile Apps Worksite Events Contests & Games $ WebMD Health Services Logo Process Leadership Policies & Benefits Strategic Communications & Incentives Communities Biometric Devices Health Coaching 8 Planning
Coaches, as part of an overall wellness program, can help build an organization s culture of health as a result of these factors: Offering one-on-one health coaching is a clear indication to employees that the organization values employee health and is willing to support employees wellness efforts. Onsite health coaches are visible leaders who can support workplace wellness activities (such as lunch-and-learn sessions, health fairs, and health screenings) that reinforce a culture of health. Coached individuals can extend the impact of health coaching through their workplace social networks. Recent research suggests healthy behaviors are significantly influenced by social networks: A coworker in a small firm quits smoking the likelihood you quit smoking increases by 34% 10 A friend becomes obese the likelihood you become obese increases by 57% 11 You are 8.3% more likely to get a flu shot if an additional 10% of your friends get a flu shot 12 Health Coaching Impact on Social Networks Social networks and health behavior A WebMD Health Services study suggests that there is a secondary benefit to telephonic health coaching. Each coached person influences other people around her, providing a secondary impact 2.5 times greater than the primary impact. 9 That means the more people who are engaged in coaching, the broader the potential impact on your overall population both coached and uncoached. WebMD Health Services Logo Process 9 Planning
PLANNING: Integrated Health Management A comprehensive health management program has many moving pieces. Health coaching should be firmly integrated with your other initiatives, and all of it starts with having your population complete a health risk assessment (HRA). HRA results help individuals recognize their health risks, and give employers a picture of their population s health. Results can also be used to identify those who are eligible for coaching and other programs. Ideally, the HRA is offered as part of a broader health management program that combines online and offline resources. Those often include relevant decision-support resources as well as lifestyle and condition management programs that match your population s health needs and interests. An integrated messaging and incentives platform helps participants stay on track and earn rewards for making progress. All of these offered resources should be coordinated with other corporate initiatives such as employee assistance programs (EAPs), disease management programs, wellness challenges, biometric screenings, and remote health-monitoring devices. With an integrated WebMD Health Services Logo foundation in place, participants can share health information and progress with their coaches in real time. And coaches can guide participants to relevant, available resources to support their behavior-change goals. Process 10 Planning
PLANNING: How to Compare Approaches Not all health coaching programs are created equal. Some differences include coach training and background, identification and engagement methods, coaching approaches and modalities, and the availability of related services to support program success. Coach training and background requirements Health coaches should have at least undergraduate or graduate degrees in related health sciences or health promotion fields and years of experience in the field. There are also numerous nationally recognized certifications to look for, including certifications for specific health risks and interventions such as tobacco treatment and obesity. But health knowledge is only part of the picture. To help someone change an ingrained behavior such as smoking takes more than a health degree. Coaches bring personality attributes that help participants feel respected, empowered, and personally responsible for their goals and actions. Training in approaches such as motivational interviewing expands on those personality traits to help health coaches go beyond mastering health as a science, to understanding WebMD Health Services Logo health as a behavior. Health coaches help individuals place value on health, address ambivalence to change, set goals, own actions, build supportive environments and networks, overcome obstacles, and celebrate successes. Process 11 Planning
Finally, the health coaching program needs clinical oversight to make sure that coaches follow protocols defined by evidence-based guidelines, to review clinical solutions, and to ensure intervention credentialing. Look for a chief medical officer (CMO) and a clinical advisory board with recognized experts from a variety of backgrounds such as medicine, behavior change science, obesity, tobacco cessation, and health analytics. How participants are identified for coaching An important planning decision is how participants will be identified as coachingeligible. Neither behavior nor health status is determined by one factor alone. A combination of the number of risks, acuity of risks, and the impact that each risk has on overall health and healthcare costs more accurately stratifies individuals into the right intensity program. Participants may also be identified for coaching based on their stage of being ready to make a change in their health behaviors. But don t overlook individuals who report being unready to change; most individuals are willing to work on at least one risk factor and coaching may help people become ready to change. Health coach certifications ACE American Council on Exercise Advanced Health and Fitness Specialist ACSM HFS American College of Sports Medicine Health Fitness Specialist ACSM RCEP- American College of Sports Medicine Registered Clinical Exercise Physiologist Advanced Cardiac Life Support American Cancer Society FreshStart AND - Academy of Nutrition and Dietetics Certificate of Training in Adult Weight Management CHES Certified Health Education Specialist CPR, First Aid, Basic Life Support CSCS Certified Strength and Conditioning Specialist CPT Certified Personal Trainer Diabetes Management Distance Certified Counselor EMT Emergency Response Health Cost Management LMHC Licensed Mental Health Counselor NCC National Certified Counselor RD Registered Dietitian RN Registered Nurse Smoking Cessation Facilitator TTS Tobacco Treatment Specialist Wellcoach WebMD Health Services Logo Process 12 Planning
In a WebMD analysis, coaching participants showed a 10.8% net increase in readiness to change. 13 Don t Overlook Those Who are Unready to Change. Unready to change Coaching approaches and modalities A whole-person approach to health coaching takes all of an individual s health risks and conditions into consideration, as opposed to a siloed approach that limits health coaching efforts to one health risk. An employee who is struggling with weight, stress, and a sedentary lifestyle needs one comprehensive coaching program, not three siloed programs. Ready to change Those who are unready to change can represent a significant proportion of your population, but can also offer significant health risk improvements and financial impacts. We also recommend a participant-centered approach, which uses a variety of techniques to help participants find their own motivation to make lasting changes for improved health. These techniques work by helping participants set short-term goals and work toward their long-term goals to move through the stages of change as described in the transtheoretical WebMD Health Services Logo model of behavior change. This isn t a linear process, but participants gain confidence in their ability to change as they set and achieve manageable goals. The belief that they can Process 13 Planning
In an analysis of more than 100,000 WebMD HRA participants, those who moved from being sedentary to 90 minutes/week of physical activity were 65% more likely to quit smoking. 14 perform a behavior to attain a particular goal is their self-efficacy, which can be increased through a cognitive behavioral approach. With the help of their health coach, and using cognitive behavioral strategies such as goal-setting, selfmonitoring, setting realistic expectations, and finding support, participants continue to gain confidence in their ability to change throughout the coaching program. Coaching is part of a broader health management program Effective health coaching is incorporated within a broader population health management initiative that includes a wide range of online and offline, telephonic, and in-person resources everything from mobile health tracking applications to health club memberships. Make sure that your coaching program Participant-centered Approach Whole-Person LONG TERM GOALSModel STAGES OF CHANGE for all risk factors LONG-TERM GOALS SHORT-TERM GOALS MOTIVATIONAL INTERVIEWING SELF-EFFICACY WebMD Health Services Logo Process 14 Planning
leverages robust online and offline capabilities that allow coaches to access and view participants progress. Also ask about onsite health promotion services such as health fair and biometric screening coordination to help launch your program. Additional services to look for in your coaching vendor Health management consulting services to help you design and optimize your health management and wellness programs. Strategic engagement services that include communications and incentives support to encourage the highest possible participation rates. Outcomes reporting and analytics support to demonstrate your program s efficacy to senior management and identify specific opportunities to optimize your programs going forward. WebMD Health Services Logo Process 15 Planning
PLANNING: Summary & Best Practices Health coaching has been identified as an effective way for employers and health plans to help individuals change health behaviors and improve critical risk factors. At the same time, it can help reduce both the economic and personal burdens of unhealthy lifestyle choices. Planning ensures that all elements are in place, and can guide vendor decisions. Best practices checklist Look for a coaching approach that applies proven behavior-change techniques to help individuals set and achieve goals. Ask coaching vendors about clinical oversight processes to make sure coaches follow protocols defined by evidence-based guidelines. Ask about additional available resources to help you build an integrated health management program. Start with a comprehensive health risk assessment and biometric screening to identify those who are eligible for coaching and other programs. Integrate health coaching within other health initiatives as well as messaging and incentives programs that promote engagement. WebMD Health Services Logo Process Stratify coaching participants by number of risks, acuity of risks, and risks impact on overall health and healthcare costs. 16 Planning
Implementation Set your foundation and build on it
IMPLEMENTATION: Lay the Groundwork If health coaching is new to your population, don t move too fast. Prepare people for the change. Help them understand what health coaching is, why you re offering it, and what the benefit is to them. Build trust in your organization s motives for offering health coaching, and make sure people understand the security and privacy safeguards you re putting in place. Be aware of potential barriers to engagement, or even opposition. To anticipate what those might be, analyze your population s response to some of your past initiatives. What were people most worried about? Group meetings before launching your program allow you to listen to people s concerns and then develop communications to address them. Communicating to all levels of management is just as important as communicating to employees. If your managers don t understand your program or how well it s working, they re much less likely to support it. WebMD Health Services Logo Process 18 Implementation
WebMD clients who have highly engaged senior management have an average HRA completion rate that is 32% higher than those whose senior management is not engaged. 15 An executive champion can make a huge difference. This person believes in the importance of health and wellness, and is in a position to support it. If you design your program to match that person s vision and regularly let him or her know how the program is succeeding, you re much more likely to retain that person s support. Communicating effectively to senior management 1. Find or cultivate your executive champion 2. Provide easy ways for managers to get involved in your wellness program 3. Poll managers for their attitudes toward wellness programs to find natural alignment 4. Listen for and respect other opinions 5. Recognize your supporters and use them as examples 6. Align communications to the cultures and sub-cultures within individual departments 7. Give managers wellness program facts they need in digestible chunks they can use 8. Give them a wellness role to play that s comfortable and visible 9. Show them they re keeping up with their peers (wellness is part of professional WebMD Health development!) Services Logo 10. Recognize managers whose departments meet wellness goals Process 19 Implementation
IMPLEMENTATION: Required Elements There are a few required elements that must be in place before you dive into your health coaching implementation. Annual HRA In order to proactively target and engage the right coaching participants, contact information and health data must be captured and kept current. The best way to do that is with an annual health risk assessment (HRA). For many organizations, the HRA is a required element for participation in any wellness program, and is the only way participants can earn rewards or health insurance premium reductions. If that expectation is already established and accepted, it s that much easier to add lifestyle and behavior management programs including health coaching. Participants should be required to complete a new HRA annually to ensure the most accurate responses are used to target participants for coaching. Biometric screenings Biometric screenings are an excellent way to get accurate, timely health data to identify coaching participants. Screenings should be administered just prior to the launch of the annual HRA event. Participants can upload new biometric data after completing the HRA for the year without impacting their coaching qualifications. Contact information We recommend a combination of outbound calling and messaging to engage participants and keep them motivated over WebMD time Health Services Logo that means having accurate contact information is vital. Talk to your vendor about how they collect contact information, as this can be a critical element in engagement. If your Process 20 Implementation
Evaluation tips Think ahead to the evaluation requirements you ll have at the end of your program year to ensure you ll have all the right data. For more accurate time-over-time health risk reports, the HRA should be offered at roughly the same time each year, and participants should be required to complete the entire assessment each year. Prior to opening the HRA to participants, delete all previous years answers and upload only current biometric screening results so participants aren t influenced by past responses. See the Evaluation section at the end of this e-book for more details. organization has a large offline population (people who don t have access to computers) be sure to capture mailing addresses so you can send coaching materials to eligible participants homes. Integration with other resources Make the best use of all of your health management resources. Make sure coaches are aware of the programs and tools that are available to participants so they can refer them to appropriate resources. Those might be things like employee assistance programs (EAPs), wellness challenges, and health screenings, as well as, onsite resources such as gyms or clinics, or online resources such as health trackers, articles, or message boards. WebMD Health Services Logo Process 21 Implementation
IMPLEMENTATION: Keys to Success When you re ready to get started, look to proven, evidencebased processes to guide your approach. Your coaching vendor should be able to demonstrate what they ve learned from their book of business, and help you identify the best methods for your population. Timing We recommend aligning the coaching enrollment period and the HRA incentive window. Develop communications for these in advance to build awareness and to encourage optimal enrollment. This strategy establishes a sense of urgency and motivates participants to take action during an expected time frame rather than putting it off until later. Participants will get coaching calls close to the time of HRA completion, which creates a connection between the two activities. And the sooner participants engage during a coaching year, the more support they will receive and the longer they have to improve their health during the year. Risk stratification Identifying the appropriate participants for health coaching programs can help you attain maximum outcomes. However, neither behavior nor health WebMD Health Services Logo status is determined by one factor alone, so it s important to look at how health behaviors and health risks interact. Some vendors rely on the number of risk counts to determine if a person Process 22 Implementation
Among WebMD clients who used a proactive, outbound approach for high- and moderate-risk coaching, our book of business engagement rate is 45%. That compares to a 2% engagement rate for organizations who chose an inbound-only method. 16 is at high, moderate, or low risk (for example, 0-2 risks=low, 3-4 risks=moderate, 5+risks=high). Our experience shows that a combination of number of risks, acuity of risks, and the impact that each risk has on overall health and healthcare costs can more accurately stratify an individual into the appropriate intensity program. Readiness to change Participants can also be recognized according to their readiness to change. An inclusive model lets health coaches meet participants wherever they are in the continuum, allowing coaches to foster trust, address risks, and move participants toward the action phase. Opt-in vs. opt-out We recommend proactive engagement, or an opt-out model, to maximize program engagement. When a health coach places a phone call and has an opportunity to speak with the participant, participation rates climb dramatically. Organizations that offer coaching to high- and moderate-risk individuals, should also consider a low-risk program, which may be offered as an opt-in program in some cases. This all-inclusive approach can make it easier for the organization to communicate the program; since the entire population is eligible for participation at some level, communication and incentives can be broad and consistent. WebMD Health Services Logo Process 23 Implementation
Multimodal delivery model There s no single right way to reach every coaching participant, and the best delivery model for any individual may change over time. The most effective health coaching programs rely on a multimodal delivery mix of onsite, telephonic, online, video conference, virtual, and mobile text-based as well as integrated mobile apps. This multimodal approach lets participants engage in the way that is most comfortable or convenient for them. But to work, each delivery method must be fully integrated with the others. Data must pass freely between each mode, so that information from one source consistently reinforces feedback from another, and data remains accessible to both participants and coaches. Additionally, protocols and directives must remain consistent and iterative. As consumers continue to adopt new technologies, health coaching programs can take advantage of these technologies as well, to interact with participants in the ways they re most comfortable. WebMD Health Services Logo Process 24 Implementation
IMPLEMENTATION: A New Approach to Condition Management The health management industry is beginning to look at condition management in new ways. Whole-person health coaching offers a new approach to managing health risks, including lifestyle choices that can lead to or exacerbate chronic conditions and diseases. The health coach and the coaching participant are at the center of this new, whole-person approach to condition management, which takes all of an individual s health risks and conditions into consideration. A health coach helps individuals define and set goals not just around their conditions, but also around eating, exercise, and managing stress. In this way, we can build on the strengths of health coaching to change the paradigm of disease management (DM) as well. Look for a vendor who addresses all three key aspects of condition self-management lifestyle, medication, and monitoring through both a human element (the health coach) as well as innovative technology that helps them costeffectively impact more people. By keeping these elements in balance, coaches can help individuals better manage their WebMD health Health Services Logo conditions as well as the lifestyle behaviors that impact their health risks. Process 25 Implementation
Multimodal experience Look for condition management approaches that are delivered through a variety of modalities to meet individual preferences. That includes telephonic, online, or in-person coaching, plus support from relevant, personalized resources, including virtual online coaching applications and mobile-enabled apps that let participants see and manage their data anywhere. Other elements that support condition selfmanagement include remote-monitoring devices that automatically upload and share condition data with the health coach, such as glucose readings for diabetes, weight for CHF, or blood pressure for CAD. Transparency One of the challenges of leveraging focused condition management programs across larger populations is transparency providing accurate reporting on the number of contacts, the interventions delivered, the cost per participant, and ultimately the outcomes methodology. A per-participant pricing model provides better transparency than pricing against an entire population, which doesn t give a realistic view of return on investment. WebMD Health Services Logo Process 26 Implementation
IMPLEMENTATION: Virtual & Mobile Coaching New technologies bring new opportunities for innovative health coaching approaches. One to watch is the advent of virtual coaching applications that can also be implemented as mobile apps. These applications provide an online experience that s designed to emulate what happens in a one-to-one coaching session, but that is accessible to a much larger population. Participants can select long-term goals that are suggested for them based on their risks and conditions, and then create a weekly plan made up of coach-suggested short-term goals or activities. They re reminded to come back at least weekly to update their plan, and are presented with content so they can learn more about their risks and conditions. Virtual and mobile coaching applications can also integrate with home biometric devices and can be an additional tool to support human coaches, who can be given access to participants goals, activities, and trackers. WebMD Health Services Logo WebMD s Mobile Digital Health Assistant provides an online experience that emulates what happens in a one-to-one health coaching session. Users choose long-term goals that are suggested for them based on their risks and conditions, then track short-term goals and activities either at home or on the go, using mobile health tracking applications. Process 27 Implementation
IMPLEMENTATION: Going International Common North American health risks obesity, stress, low physical activity, and poor nutrition are now prevalent worldwide. Many companies want to understand the health risks and productivity impacts across their entire population, not just certain geographies. Today, 54% of multinational employers have a global health management program strategy, up from 41% the previous year. 17 As these global programs grow, many organizations are evaluating how health coaching can be integrated into an international strategy. Consider using professional consultants to help you work through the many nuances of global health coaching, which include: Localized HRAs that are sensitive to local cultures, mores, and compliance standards Broad language localization that supports a single, global rollout to all multinational locations Personal data storage that complies with strict global standards Resources such as incentives and communications WebMD Health Services Logo that meet local customs and standards Process 28 Implementation
IMPLEMENTATION: Program Sustainability You ve launched your health coaching program and the initial results are positive. You re seeing reductions in employee health risks and engagement is high. But after the initial excitement has ebbed and organizational priorities shift, how do you sustain and improve results? Every element of your health coaching program needs to have a planned evolution to keep it fresh and innovative. Health management consultants offer expertise to help you plan ahead. Your incentive plan is a key element that requires a phased strategy: what motivates people once may not be enough to keep them interested in following years. But don t just adjust rewards your population should also do more to earn rewards in subsequent years. Program measurement and analysis will help you make appropriate adjustments over time, but also solicit feedback through focus groups and surveys to understand your population s perceptions. Consider incorporating new technologies such as mobile or virtual coaching, or remote monitoring devices to drive engagement and success. And WebMD Health Services Logo keep communications campaigns fresh, fun, and creative. Process 29 Implementation
Key Elements for Sustainability & Evolution Common pitfalls to program sustainability: Value Incentives Leadership change-over $ Lack of program innovation Incentives that don t grow with the program Communications become stale Leadership Sustainable Program Design Environment No metrics in place for evaluating ROI Culture that doesn t support wellness Lack of communication back to management Communication Culture Innovation Every element of your health coaching program needs to have a planned evolution to keep it fresh and innovative. WebMD Health Services Logo Process 30 Implementation
IMPLEMENTATION: Summary & Best Practices Health coaching implementation is complex. Take the time to research options and new approaches and analyze the required elements. Plan and execute communications to get your population and leaders on board. And think ahead to long-range plans such as global coaching, new technologies, and how you ll sustain your program for the long run. Best practices checklist Communication is key. Explain the program to management to get their support, and build trust across your organization so your population is willing to participate. Think ahead to what you ll need to evaluate your program at the end of the year and put those processes in place up front. Offer coaching to everyone: high- and moderate-risk coaching should be opt-out, while low-risk coaching can be offered as opt-in to control costs. Build an integrated, multimodal delivery model that shares information across sources while engaging participants in ways that are most convenient and compelling. Build in program evolution to keep it fresh and engaging, and to ensure ongoing success. Make sure required elements such as HRA, biometric screenings, coach training, and communication and incentive plan are in place before you begin. WebMD Health Services Logo Process 31 Implementation
Engagement Communicate and reward participation
ENGAGEMENT: Why Engagement Matters The best coaching program in the world won t initiate change unless people know about it and use it. Engagement including communications and incentives programs is one of the most important elements for health coaching success. Engagement rates are driven by: Trust People pick up the phone because they understand and believe in your reasons for offering health coaching The right contact information Phone numbers are collected from the HRA that was completed (in many cases) just days before Leveraging the teachable moment Individuals are made aware of coaching eligibility immediately upon completing the HRA Timely and effective outreach Initial contact is made on the preferred day and time listed by the participant Quality of coaches Highly qualified coaches bring specialized training and skills to guide behavior change Personalized messaging Ongoing, motivational messaging, both online and offline, that explains the value of health coaching and encourages participation Relevant incentives WebMD Health Services Logo Individuals are rewarded for taking action, working toward health goals, and improving their health Process 33 Engagement
ENGAGEMENT: Communications Planning & Development One of the first steps in a strategic communication plan is to evaluate all the ways you can reach your population so you can identify those that are most appropriate and effective. A capabilities assessment and channel audit let you evaluate all of your current and future communications touch points, including face-toface meetings, intranet portals, e-mail, newsletters, mailings, bulletin boards, social media, etc. Make note of the available communication channels, the responsible functions and stakeholders, the production and review processes and associated timelines, and each channel s relative efficiency and performance. Assessment and segmentation Segmentation lets you organize your population into discrete groups based on their shared demographic characteristics, attitudes, and beliefs. Then you can make educated guesses about individuals needs, communication preferences, messages that resonate, and relevant calls-to-action that will improve response rates. Multimodal plan development Make use of both online and offline modes of delivery. Online media includes e-mail, webinars, e-cards, e-newsletters, microsites, WebMD Health Services and Logo PRINT social PANTONE VERSION media. Traditional offline media vehicles include champion letters, printed brochures, newsletters, posters, and direct mail. Each form of media requires a different level of investment, each Process 34 Engagement
generates a different level of response, and as a result, the economics can change dramatically based on how they are allocated. Focus communication first on health management program enrollment and portal registration. Once individuals are enrolled and registered, encourage health assessment and biometric screening completion, and promote risk awareness and health education in order to activate those individuals. When those steps are complete, move to health coaching enrollment and participation. Measurement, testing, and refinement A test-and-refine approach to engagement lets you explore opportunities to re-allocate the media mix using A/B testing and lets you experiment with incentives to find the sweet spot. You can also use a variety of forums to extend the health coaching message, such as site champion networks, onsite facilities, health fairs, grassroots or local networks, etc. You should be able to see and prove the performance of communication efforts, both in terms of their relative efficiency and their aggregate contribution to health coaching engagement. Tips for communicating about health coaching Position it as a free benefit and make it feel personal Promote it in launch and welcome materials Repeat key messages Send reminder e-mails to those who have not scheduled a call but are eligible Remind people of their scheduled appointments and goals (using integrated system tools) Send motivational messages to encourage participants throughout their programs WebMD Health Services Logo Process 35 Engagement
ENGAGEMENT: Intrinsic & Extrinsic Rewards More and more employers are recognizing the importance of incentives to engage employees in health management programs. And while the use of wellness incentives is well-established to encourage periodic activities such as HRA completion, the use of incentives for long-term health coaching engagement is not as well-understood. We believe that although change ultimately has to be driven through intrinsic motivation, extrinsic motivation through rewards is an important tool for raising awareness and introducing employees to tools and resources they can use to change their health behaviors. Look for extrinsic rewards that complement ongoing intrinsic motivation. By pulling different incentive levers over time, you can create an effective feedback loop that keeps participants engaged long past the receipt of a short-term reward. Engagement using stages of change Stage of change is an important element of health coaching, but it should be used primarily to guide engagement, not as a WebMD filter Health Services for Logo enrollment. The stages of change framework was developed to guide communication with people at different Process 36 Engagement
levels of readiness. In a multi-client study 18 covering 14,392 of our coaching participants we found: Few people are completely unwilling to change any of their risks. A person may be unwilling to quit smoking, but may be willing to eat better; 81% of our engaged population were ready to change a behavior. Coaching effectively helps unready people to change. People at a lower stage of readiness to change actually had greater health risk improvements in six of the 11 risk areas we studied, in comparison to people who indicated that they were at a higher stage of readiness to change. There is approximately equal medical cost savings for people who are highly ready to change and those who are less ready. Even when people don t improve risks, they increase readiness to change. Within people who did not improve their risks, we found a net increase of 5.67% in the action and maintenance categories, which suggests opportunity for ongoing health improvement in year two and over time. Incentives Over Time Both incentives and communications need to evolve over time to remain fresh, to capture new audiences, and to motivate people to use appropriate health management programs and move down the health risk continuum. The bar should constantly be raised, and rewarded actions must be aligned with organizational goals as they change as well. Beginning: Participation Begin by rewarding for participating in at least one coaching session. This helps strengthen overall wellness culture and builds on the broader psychology of behavior change on both the individuals being coached as well as other people in their social circles. Intermediate: Completion Beginning: Participation Intermediate: Completion Advanced: Outcomes Advanced: Outcomes Begin by rewarding for At the next stage, reward based Mature programs often move participating At the next in at stage, least one reward based on on completing a required Mature number programs to outcomes-based often move rewards, in coaching completing session. a This required helps number of coaching sessions, to typically outcomes-based which rewards, individuals in earn which rewards strengthen sessions, overall typically wellness based on risk based stratification. risk stratification. individuals This earn for rewards demonstrating for demonstrating measurable culture and builds on the broader stage may be ramped up over a progress, towards changing their This stage may be ramped up over a couple measurable progress toward changing their psychology of behavior change couple of program years, requiring of program years, requiring more on both the individuals being more coaching coaching sessions health or a status over exercising time, such regularly, as exercising losing an coached sessions as well or as a other longer people commitment longer at each commitment at regularly, each stage, losing established an established number number of pounds, of in their stage, social along circles. with new incentive along design. with new incentive pounds, design. or meeting or meeting specific specific biometric biometric values. values. health status over WebMD Health time, Services such Logo as Process 37 Engagement
For WebMD s 2010 book of business, clients who used a premium reduction realized a 12.5% higher HRA completion rate than other incentives offered (such as cash or gifts). 19 Types of incentives Carrot vs. stick The concept of carrots vs. sticks refers to using an incentive as a reward (carrot), or as a penalty (stick). For example, rewarding people with a premium reduction for completing an HRA is a carrot, while charging a higher premium for not completing an HRA is a stick. Either approach can be effective, although behavioral economics says that people like to gain more than they like to lose. It s important to know the population you are working with to determine which approach to use. Some key questions to help make the determination include: Will your population respond better to positive reinforcement for action or a potential take-away of something for non-action? How negative might the reaction be to a stick approach? Are there other organizational events that might indicate if the timing is appropriate for triggering a potential negative reaction? How does a stick approach fit with your organization s culture? Cash vs. premium reduction Programs have been equally successful through use of cash and premium-based rewards. Many organizations are moving toward a premiumbased reward because it offers tax advantages to the organization and the participant, can be designed as a cost-neutral approach, and solidifies the message that individuals health behavior impacts their health spending. For cash rewards to be successful, the amount of the reward has to be seen as valuable, and that WebMD Health Services Logo amount may need to be increased year over year to keep populations engaged. Process 38 Engagement
Cost-neutral reward calculation For a cost-neutral, premium-based reward, start by estimating participants vs. non-participants, determine the budget available to fund incentives, and adjust premiums accordingly. For example, with a premium reduction of $100 on completion of the HRA and estimates that 45% of a population of 10,000 will participate, the incentive cost will be $450,000. If we adjust premiums to cover that expense, the premiums paid by the non-participating 55% of the population offsets the incentive investment and the cost to the organization can be neutral. Work with those responsible for setting premium rates to determine the most cost-effective approach and to ensure compliance with HIPAA, ADA, ERISA, and other regulatory agencies. Reward fulfillment Employees respond better when they are given deadlines. We recommend that the HRA be promoted and completion rewarded at the beginning of a program year for at least four weeks and no more than eight weeks, and that behavior-change interventions such as coaching start at the same time. It s important, however, that while the HRA is rewarded in a given time frame, it remains available for people to update and refer to throughout the year. It can also be available for new hires to be rewarded within a certain time from their hire dates. When rewarding for engagement in coaching, results are best when incentives are applied to a defined call-completion rate, such as completing three or more calls for moderate- to high-risk individuals. An appropriate option for low-risk individuals is rewarding for completion of one call. WebMD Health Services Logo Process 39 Engagement
Outcomes-based rewards Employers with mature programs are starting to evolve their incentive program designs around outcomes-based rewards, which means that individuals are rewarded based on meeting an in-range value for certain biometrics or behaviors. While this approach exemplifies the purpose of health management programs, it can also make it harder for participants to earn rewards, which can affect engagement. For example, healthy ranges may not be achievable by all employees. Consider rewarding individuals as long as they re working toward improving their health or staying healthy. For example, reward an individual for setting a goal and making progress toward that goal, not just for reaching a certain biometric value. Keep in mind that biometric screenings will be required, which must also be budgeted, planned, and communicated. Are outcomes-based rewards right for you? How long has your incentive program been in place? Have you reached participation, engagement rate, and outcomes targets? If not, is it the incentive design? Is it the communication approach? Are there other competing priorities? Will requiring individuals to meet a certain biometric value or range be seen as doable, or as a larger barrier to participation? Is there ample budget for screenings? Can the screening vendor bill for screenings as a plan cost rather than a separate investment? Can you manage reasonable alternatives for individuals who cannot and will not be able to meet the goals? WebMD Health Services Logo Process 40 Engagement
ENGAGEMENT: Summary & Best Practices Engagement including communications and incentives programs is one of the most important elements for health coaching success. Communication educates, creates excitement, and encourages participation. A combination of intrinsic motivation with extrinsic rewards creates effective feedback loops that keep participants engaged over the long run. Best practices checklist Develop an annual communications plan that uses a broad range of online and offline delivery modes. Develop a long-term incentives strategy that evolves from rewarding for participation to outcomes-based rewards over time. Work with your health plan to develop premium-based rewards that are cost-neutral. Reward for HRA completion as a gateway for earning other rewards. Align coaching enrollment with the HRA incentive window to take advantage of the teachable moment. Test and refine communications and incentives to find the sweet spot for engagement. Use the stages of change framework to guide communications to different audience segments. WebMD Health Services Logo Process 41 Engagement
Evaluation Measure, refine, & optimize
Evaluation: What to Measure and Why The most successful coaching programs track utilization, outcome metrics, and return on investment over time. The data will help you identify opportunities to optimize programs going forward, prove your program s efficacy, and further engage your population by communicating how their actions are making a difference. When to apply what you learn Behavior change doesn t happen overnight. As you analyze your coaching program, you ll apply what you learn to make program changes to following years, not the current program year. If you make changes during a program year, you won t have given yourself time to see what s working or not, and you won t have time to analyze the implications of making changes. Accumulate data for the full program year so you can demonstrate the clear impact of carefully thought-out changes. How to use leading indicators Claims analysis data takes time to accumulate; usually about 18 months. In the meantime, use leading indicators to gain understanding. Are participants taking coaching calls? Are they completing recommended activities? Get feedback from participants to understand who is and isn t participating and why. Use WebMD Health Services Logo that information to guide communications during the program year. The more participation you can encourage during the year, the better your data will be at the end. Process 43 Evaluation
Evaluation: Implementation Guidelines for Analytics Evaluation requirements need to be considered well before you implement your coaching program. Otherwise, you may find yourself at the end of the year without the data you need to make important decisions. Timing guidelines While health management program roll-outs can occur at any time of year, the incentive year and coaching year should always be aligned so you can clearly track the impact of the incentive. HRA and biometric screening activities used for coaching qualification should also take place at the same time each year. That will make sure that you have 12 months worth of data to track year-over-year results, and will avoid gaps in intervention. Establish a communications and rewards program strategy that drives HRA completion and coaching eligibility to enroll the majority of coaching participants at the same time. While you don t want to prevent latecomers or new hires from participating, valid analytics require that the majority of your population has the same amount to time for interventions. You also want a clean stop date at the end of the program year to start analyzing that WebMD Health Services Logo year s results. Process 44 Evaluation
HRA guidelines Implement an annual HRA event at roughly the same time each year, and offer an incentive to complete the HRA within a reasonably short period of time. This will help ensure that the majority of your population is on the same coaching schedule and that they are eligible for coaching services for the maximum amount of time each year. With this approach, you ll have better apples to apples data to analyze. Biometric screenings guidelines If you plan to offer biometric screenings, hold the screening events and upload the resulting data before you open the HRA. Then wipe all previous years answers (except for new biometrics) from last year s HRA before the new annual HRA event. These guidelines ensure that you see an accurate measurement of participants current health during each HRA event. We have found that if prior-year answers are not removed, participants are much more likely to click through the questionnaire without making any updates. This can result in under-reporting improvements they may have seen during the year. WebMD Health Services Logo Process 45 Evaluation
Evaluation: Utilization Metrics Utilization metrics provide statistics on who is eligible for coaching, who engages, and who drops out and, coupled with other metrics, can help you figure out why. These metrics provide leading indicators on how the program is doing and what changes should be considered to improve the approach for the next year s program. Begin tracking participation in your coaching program early, and continue throughout the program year. This lets you assess the responsiveness of your population to coaching outreach and incentives, and lets you make adjustments to communications if participation is lower than expected. Track the following utilization metrics monthly for the first two to three months of your program year and quarterly thereafter: Qualification and stratification Which programs are individuals in your population qualifying for? Is your population more or less healthy than anticipated WebMD Health Services Logo based on its demographic profile? Process Engagement Are those individuals who qualify for coaching actually engaging with a coach? 46 Evaluation
Outreach status Of those who don t engage, why? Is it lack of valid phone numbers? People not answering the phone calls? Are individuals actively requesting removal from the program? Of those who do engage, who subsequently requests removal from the program or is made ineligible? Call attempts and reach rates How many times do coaches attempt to contact qualified participants? How frequently do call attempts result in an actual coaching session? Track the following utilization metrics quarterly: Interim behavior change Are participants who started in lower stages of change migrating to higher stages of change? Are participants reporting increases in good behaviors (i.e., increased exercise, better nutrition, reduced tobacco usage, etc.)? Satisfaction Are participants who are offered a satisfaction survey agreeing to complete it? Do those who complete the survey report high levels of satisfaction with their experience and the knowledge of their coaches? Coaching session distributions Of those who engage in the program, how many complete any given number of coaching sessions? What is the average number of coaching sessions completed by engaged individuals? Health behaviors What areas of health are being discussed by engaged participants? (The areas in which the population is most frequently engaged will likely be the areas that demonstrate the most improvement down the road.) Goal progression In what health areas are goals being set? What progress are participants making toward achieving those goals? WebMD Health Services Logo Process 47 Evaluation
Evaluation: Outcomes Metrics Outcomes metrics can help prove the success of a program. They include impact on medical claims, changes in absenteeism and presenteeism rates, impacts on life and work satisfaction, and impacts on self-assessment of health. Outcomes data may not be available for several months to as much as a year after the end of a program year. However, this analysis provides long-term proof of efficacy, and can be used to guide year-over-year program changes. Population health profile changes Population health profile changes can be assessed using time-over-time HRA data, available about eight weeks after the launch of the next annual HRA event. This allows time for a representative HRA cohort to accumulate (participants who complete the HRA in both the baseline and follow-up program years). Track these outcomes metrics annually: Modifiable risk prevalence rates Track the change in risk prevalence from baseline HRA (prior to coaching) to follow-up HRA (after the intervention). For populations with low baseline awareness of their biometric values, prevalence for those risks may appear to increase for the first couple of years as individuals become aware of those values. Risk distribution WebMD Health Services Logo Track the change in the percentage of the population with each given number of risk factors between baseline and follow-up HRAs. Process 48 Evaluation
Evaluation: Return on Investment There are several ways to assess financial impact of a health coaching program. The length of time for delivery and the costs associated with the different methodologies can vary substantially. Carefully weigh the pros and cons of each option in order to determine which one best meets your needs and budget. Risk-based estimates of financial impact Track the estimated costs associated with the baseline modifiable risk prevalence and the follow-up modifiable risk prevalence. The difference in estimated costs can provide a high-level directional or indicative measure of program savings for the population. These types of financial estimates are generalized based on the results of previously published research and do not necessarily represent a hard dollar estimate of savings. However, they are beneficial in that they are immediately available once an HRA cohort has been accumulated. They are also available to WebMD Health Services Logo organizations of all sizes even those whose population is too small to support a claimsbased analysis. And they can typically be conducted without additional evaluation fees. Process 49 Evaluation
Claims-based savings calculations Claims analyses are typically not available until six to eight months following the close of a program year to allow for run-out on claims incurred during the year. Note that there are several methodologies commonly used to assess program return on investment using claims data. Those include participant-matched control or pre-post trend evaluation. Analysis methodologies In order to ensure that you receive a valid and reliable estimate of return on investment (ROI), evaluate the proposed analysis methodology for the following: Your vendor should proactively evaluate your program and determine that an actuarially sound analysis can be conducted. Criteria include the size of the eligible population, program participation rates, quality/quantity of available data, program design, and analysis budget. Analysis should account for potentially confounding factors. Those can include differing levels of baseline health, demographic profiles, differences or changes in benefits plan offerings during the analysis period, non-relevant episodes of care, and concurrent participation in other health management programs during the analysis period. Methodology and results should be reviewed, preferably by an independent third party such as respected consulting firms or by a dedicated healthcare analytics organization, or the vendor s approach should be vetted and endorsed by a third-party industry expert without bias. Final reports should provide clear and transparent results. This should include full documentation and justification of all analysis assumptions applied, details of all calculations conducted, source of the program costs, and an assessment of the generalizability of the results to participants excluded from the final analysis sample. How to use benchmarks Market segment benchmarking is a great way to gauge your success with respect to your peers. Ask your coaching vendor for information so you can compare your results to their other clients that have similar demographic makeup and are a similar size and industry type. Make sure your coaching vendor provides complete transparency on how they re WebMD Health Services Logo defining the metrics they provide. And be careful trying to apply external, third-party benchmarks, or to compare across vendors. Definitions can vary significantly, even if they re described essentially the same way. Process 50 Evaluation
EVALUATION: Apply What You ve Learned Even though your health management team understands the evaluation process, your population and your senior management may not. Clearly set expectations up front on when you ll have data, what it will consist of, and how (and when) you ll be able to apply it. During the course of the program year, use indicators to inform your communications strategy. Analytics can be especially powerful if you use the data to break down the whole into meaningful sub-groups. Think about what those are for your organization. It might be business units, geographical locations, or business processes, such as retail or manufacturing employees versus corporate. Look at coaching utilization and compare the differences to understand how you can tailor communications effectively to different populations. Don t make program changes mid-year, such as incentives or eligibility criteria. Be patient, wait out the program year, and then make wellthought-out adjustments. Finally, when you re ready to report back to senior management, keep it simple. Show benchmarks where you can, highlight successes, WebMD Health Services Logo own up to challenges, and be ready with a plan to address them. Process 51 Evaluation
EVALUATION: Summary & Best Practices Evaluation requirements need to be considered well before you implement your coaching program. Otherwise, you may find yourself at the end of the year without the data you need to make important decisions. The most successful coaching programs track utilization and outcome metrics over time, as well as year-over-year financial impacts. Best practices checklist Accumulate data for the full program year before making program changes. Use leading indicators to guide communications changes during the program year. new HRA event to ensure accurate responses. Hold biometric screenings before the HRA event and upload resulting data before opening the HRA. Track program outcomes annually to prove efficacy and to guide year-over-year program changes. Use proven analysis methodologies and have ROI results reviewed by an independent third party. Ask for benchmark data to gauge your success compared to similar organizations. Implement HRA and biometric screening activities at the same time each year so you have 12 full months of data to track year-overyear results. WebMD Health Services Logo Process Align the incentive year and coaching year so you can clearly track the impact of the incentive. Wipe previous year s HRA responses before the 52 Evaluation
EVALUATION: Conclusion Brought to You by the Experts at WebMD Health Services Our health coaching experts have helped more than 436,000 participants learn to take control of their health during more than 1.2 million coaching sessions, using a whole-person approach that addresses multiple conditions and behavior-change needs. Matt Donaldson Senior Vice President of Health Coaching Dr. Tim Moore Chief Medical Officer Catherine Macpherson, M.S., R.D. Senior Director of Product Strategy Steve Merryman Director of Analytics Missy Jaeger Senior Director of Health Management Consulting Content Contributors: Matthew Ferguson, Coaching Program Manager; Katie Hollister, Vice President of Client Services; Krista Jansen, Business Analyst; Paul Turner, Vice President of Operations; Rachel Vleck, Health Coaching Center Manager; Ann Whalen, Implementation Consultants Manager We ve given you an in-depth look at how to plan, implement, promote, and evaluate health coaching, but it s a complex undertaking. If you still have questions, we d be happy to talk with WebMD you. Health Services Logo You can contact us at whsinfo@webmd.net Process 53
Medscape logo CMYK VERSION WebMD Health Corp. NASDAQ: WBMD The Most Trusted Brand in Healthcare Blue c 100 m 34 y 0 k 2 c 0 m 0 y 0 k 100 The leading brand of Consumer Health Information More than 86 million unique visitors each month 1 in every 2 U.S. adults, 95% of all adults seeking health information, 5 of top 10 health-related web searches Most trusted consumer brand (Millward Brown) Leading healthcare brand for consumer privacy (TRUSTe) Most recommended by physicians The leading brand of Health Information for Physicians 8 of 10 physicians who write 85% of all Rx s and see 60 million patients per week Over 2 million physician visits each month 1.5 million CME credits completed per quarter The leading brand of Health & Benefits Management More than 250 clients operating in 30 different industries and sectors Large employers, including 4 of the top 20 Fortune 500 Leading national and regional health plans 4 million active PHR users, 6.6 million HQ assessments completed, and 1.2 million coaching sessions For more information about WebMD Health Services, contact us at WHSinfo@webmd.net or visit. Learn More WebMD Health Services Logo Process 54 Evaluation
EVALUATION: Endnotes 1 Centers for Disease Control and Prevention, Chronic Disease Prevention and Health Promotion. Healthy Communities: Preventing Chronic Disease by Activating Grassroots Change At A Glance 2011. http://www.cdc.gov/chronicdisease/resources/publications/aag/healthy_communities.htm 2 Amos, C. Occupational Health and Safety Crisis 2011. http://authorityempire.com/occupational-health-and-safety-crisis-2011/225645 3 Centers for Disease Control and Prevention. Annual smoking-attributable mortality, years of potential life lost, and productivity losses United States, 1997-2001. MMWR 2005; 54(25): 625-628 4 Centers for Disease Control and Prevention. Vital Signs: State-Specific Obesity Prevalence Among Adults United States, 2009. MMWR. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm59e0803a1.htm 5 Merrill, RM, et al. Presenteeism According to Health Behaviors, Physical Health, and Work Environment. Population Health Management October 2012; Vol. 15, No. 5: 293-301 http://www.the-hero.org/research/studies.htm#presenteeism_according_to_health_behaviors,_physical_health,_ and_work_environment 6 Risk mitigation and financial impact assessment using changes in HRA responses over time for a cohort of individuals who completed the HRA in 2010, completed high- or moderate-risk coaching program, and completed a follow-up HRA in 2011. 7 Completed defined as user participating in one coaching call (for those enrolled in low-risk coaching programs), or moderate/ high-risk participants reaching the end of their 12-month enrollment period without de-enrolling from coaching. WebMD Health Services Logo 8 Estimated financial impact includes decreased medical claims, absenteeism, and presenteeism costs as well as the avoidance of expected cost increases due to aging. Process 9 Social Networks webinar, 2010. Based on a WebMD study of a coaching client with a large population (>35,000), with complete eligibility and location data, using the same HRA for two years to study the financial impacts for engagement rates on the whole population and non-coached population. 55
10 Christakis, NA, Fowler, JA. The Collective Dynamics of Smoking in a Large Social Network. New England Journal of Medicine 2008; 358: 2249-2258. 11 Christakis, NA, Fowler, JA. The Spread of Obesity in a Large Social Network Over 32 Years. New England Journal of Medicine 2007; 357: 370-379. 12 Federal Reserve Bank of Boston. Social Networks and Vaccination Decisions. Working paper, 2007. 13 Assessed using changes in HRA responses for a cohort of individuals who completed the HRA in in 2010, completed a high- or moderate-risk coaching program, and returned to complete a follow-up HRA in 2011. 14 Based on a matched cohort study based on WebMD users who completed the HRA in period one and two (analysis timeframe: 6/1/2008-5/31/2010). The study group also completed an exercise lifestyle improvement program (LIP) between the two HRA dates; the control group did not start the exercise LIP and matched the study group population based on market, exercise risk, cardio exercise stage of change, gender, overall health rating, age, education level, ethnicity, and WebMD coaching engagement. 15 Study population of 1,746,680 employees from 52 WebMD employer/government clients during analysis time frame of calendar year 2010. 16 2010-2011 WebMD book of business. 17 Buck Consultants. WORKING WELL: A Global Survey of Health Promotion and Workplace Wellness Strategies. November 2010. http://www.huschblackwell.com/files/event/834bd3fb-27eb-4e79-96f0-b776c74492a6/presentation/ EventAttachment/607fc436-c994-4769-b279-3199b0177e9f/Global%20Wellness%202010_ExecSummary.pdf 18 Multi-client study of individuals who completed an HRA in year one and year two of programming, qualified for high- or moderate-risk coaching based on year one HRA responses, and engaged in at least one coaching session between year one and year two HRAs. 19 Study population of 1,746,680 employees from 52 WebMD employer/government clients during calendar year 2010. WebMD Health Services Logo Process 56