Retailer L.L. Bean Inc. was ahead of its time 31 years ago when it started an informal Heart Club for employees that was focused on helping them achieve healthy blood pressure and cholesterol levels through better nutrition, exercise, weight loss and relaxation. Of the 75 employees who joined the club back then, 45 reduced their blood pressure and cholesterol within eight months, according to published reports.
Fast-forward to today, and the Freeport, Maine-based company boasts an employee population with a remarkably low incidence of hypertension—largely a result of the evolution of its humble wellness roots and a super-sharp focus on controllable heart-health risks.
"Achieving a healthy blood pressure is definitely one area we’re targeting," says Stephanie Harvie, wellness program administrator at L.L. Bean. "We have a variety of data clearly now showing a significant improvement."
The company rolled out a full-scale wellness program called Healthy Lifestyles in 2007 that is linked to its health insurance plan. To reap health plan premium discounts that can range from $1,000 to $3,400 annually, employees are required to undergo onsite health risk screenings, complete an online health questionnaire and speak with a health coach. The attractive incentive has led 85 percent of the company’s benefits-eligible workforce and family members—or about 4,000 employees and spouses—to participate in the program since 2007.
Thanks to that steady involvement and a host of health and fitness options offered at L.L. Bean, Harvie says the percentage of employees with hypertension fell from 21.8 percent in 2010 to 6.6 percent in 2013—a rate that is considerably below the national average.
Stalking a Silent Killer
L.L. Bean isn’t alone in paying closer attention to hypertension, often dubbed the silent killer because it is largely a symptomless condition. While the elements of any comprehensive wellness plan can help people achieve healthy blood pressure, HR professionals at many companies are using a variety of drill-down strategies to get more employees screened, better identify those at risk and drive healthier outcomes by pushing high-risk workers to get the care they need.
Employers appear confident that part of the solution lies in the use of greater financial incentives—specifically, penalties (such as higher premiums and deductibles) and outcome-based incentives—to hold employees accountable for better health measures. The use of rewards or penalties for biometric outcomes based on health-contingent targets (such as for blood pressure, cholesterol and body mass index, which many companies assess in health risk appraisals) will dramatically increase from 26 percent in 2014 to 68 percent in 2015-16, according to a 2013 survey of 892 employers by Towers Watson and the National Business Group on Health (NBGH).
"It’s an attempt to pay for performance, if you will," says Michael Wood, senior consultant in health management at Towers Watson. "And it’s a bit of a blunt instrument: Employers are increasingly saying to employees, ‘We’ll pay more if you really try and succeed in getting these things under control.’ "
Yet while increasing participation in health risk appraisals and biometric screenings is the key first step to discovering a problem, getting employees to take that next step—treating and controlling their hypertension over time—presents some unique challenges.
"Employees typically don’t see or feel hypertension, so it’s an even harder condition to get them really engaged with and to address something so invisible," notes Shari Davidson, vice president at the NBGH.
Tough Problem to Solve
The incidence of uncontrolled high blood pressure is alarming, according to a recent advisory from the American Heart Association (AHA), the American College of Cardiology and the Centers for Disease Control and Prevention.
The latest annual estimates by the AHA show that 77.9 million adults in the U.S., or one in every three, have high blood pressure—defined as a reading at or above 140 over 90. About half of them (52.5 percent) have it under control, and about half (47.5 percent) do not. Amazingly, these figures include people who have insurance, are being treated with medicine and have seen a doctor at least twice in the past year. Meanwhile, almost 30 percent of American adults fall in the pre-hypertension range, with readings of between 120 and 139 over 80 to 89.
Projections show that by 2030 the prevalence of hypertension will increase 7.2 percent from these 2013 estimates, the AHA reports.
"Achieving success in hypertension control is still a challenge," says Dr. Alan S. Go, lead author of the advisory and director of the Comprehensive Clinical Research Unit at Kaiser Permanente Northern California. "But it’s not just about an individual patient or an individual doctor or provider; there’s no single explanation for poor hypertension control."
There is no single solution, either.
Go believes that blood pressure management is multifaceted and requires much more coordinated engagement of patients, families, providers and health care delivery systems, communities, and employers. This includes patient and physician awareness, lifestyle modifications, access to care, evidence-based treatment, medication adherence, and follow-up.
It Takes a Village
Over the past decade, Kaiser Permanente has tried to follow this approach. In 2001, just 44 percent of Kaiser patients in Northern California had their blood pressure under control.
So the health system with 3 million members decided to try five things: create an electronic registry of patients with hypertension, use that registry to alert doctors as to which patients have out-of-control blood pressure, write guidelines that make it easy for doctors to tailor treatment, use medical assistants to help patients monitor their blood pressure, and put multiple drugs in a single pill so adherence to treatment is easier.
It worked. From 2001 to 2011, Kaiser increased the number of patients meeting blood pressure goals from 44 percent to 87 percent, Go says.
For their part, employers also are devising workplace strategies to help employees control hypertension, including:
Risk stratification. In 1996, American Cast Iron Pipe Co., based in Birmingham, Ala., created the WellBody Club. Participating employees are assigned to one of four "clubs" based on the results of an annual health assessment and biometric measures, including blood pressure, body mass index, waist circumference, exercise frequency and tobacco use. Employees volunteer to participate, and they sign a Health Insurance Portability and Accountability Act release form to allow a health coach to obtain blood work results.
The clubs’ levels—200, 50, 25 and 10—represent employees’ health risks. Club 10 is for workers with very high risk, for example, and club 200 is for those with low risk, explains Sheri Snow, wellness manager for the 3,000-employee company. Employees receive cash incentives each year they participate in the program. At the company’s headquarters, 80 percent of the 1,650 eligible workers voluntarily complete the tests.
"Think of it as triaging people into appropriate follow-up interventions based on their risk so that the right tools are offered to the healthy, unhealthy and at-risk employees," Snow says.
The health risks of the company’s employees mirror those of the southern U.S., where hypertension is more prevalent than in other regions of the country. "We realized we needed to give employees what they really needed—a way for them to home in on their biggest health priorities," Snow says.
She and her team are proactive about the plan: They regularly put on hard hats and go to the company’s plants to encourage employees to learn more about their health. "We do a lot of outreach, including Wellness Wednesdays, where we head out to every department to offer blood pressure checks," Snow says.
The approach is working: In 1996, 15 percent of employees were considered to be at low risk (club 200), 53 percent were at moderate risk (club 50), 29 percent were at high risk (club 25), and 3 percent were at very high risk (club 10).
Seventeen years later, the numbers have improved to 45 percent in the low-risk group, 45 percent in the moderate risk group, 10 percent in the high-risk group and zero in the very high risk group.
A focus on high-risk locations. L.L. Bean assesses health risks by corporate department and location. That allows the company to specifically chart all risks and aim its health, wellness and prevention efforts at those who need them most.
After an analysis of health screening results for about a dozen biometric measures showed that its Bangor, Maine, call center’s 112 employees had greater risk factors than employees in any other areas of the company, L.L. Bean designed Bean Strong, a pilot program targeting health improvement at that location.
Three components of this voluntary one-year program, which concluded in 2012, included nutrition education classes every two weeks, weekly exercise classes and a monthly emotional well-being class.
"We went there and showed employees the risks, plain and simple," Harvie says. "It wasn’t at all a ‘shame on you’ approach but instead a message that said, ‘Here’s what we’re going to do for you.’ "
From 2010 to 2013, the percentage of employees with hypertension fell from 19.8 percent to 7.1 percent, and improvements in almost every health measure were achieved, including a nearly 5 percent decline in the number of employees who smoked and a 2.5 percent rise in the number of employees who exercised 90 minutes a week.
"It was a very high-touch, high-intensity experience, but it hands-down improved lives," Harvie says.
She and the wellness team have embarked on another Bean Strong pilot at the company’s Lewiston, Maine, call center, where nearly 10 percent of 214 employees have high blood pressure and 52 percent are pre-hypertensive. The team hopes to replicate the success of its yearlong experiment in Bangor.
"Our efforts are very focused on where we see the biggest risk," Harvie says. "There’s no one answer for what works for everyone, but we know that impact—and health improvement—spreads."
Wider wellness efforts. Employers, especially smaller organizations, can access free or low-cost resources offered by local hospitals, public health agencies, recreation centers, or association and industry trade group chapters. Activities might include holding regular health fairs, subsidizing heart-health education classes, directing employees to AHA online resources, and putting up self-monitoring stations or blood pressure screening kiosks in the workplace.
Standard Textile Co. Inc. in Cincinnati uses health champions within the company as examples and mentors. A company video features 10 employees who lowered their blood pressure, cholesterol or glucose after participating in the company’s annual blood screening. The video encourages other employees and family members to do the same. Since the company began offering screenings in 2008, it has achieved a 27 percent improvement in the number of employees with high blood pressure and a 37 percent improvement in the incidence of those with high cholesterol.
Health coaches and doctor referrals.Jane Ruppert, vice president of health services at Interactive Health, a Schaumburg, Ill.-based wellness and health management consulting company, is an advocate of immediate health coaching at the time of a health appraisal and screening, along with signed authorizations from employees to send results to their physicians right away. Immediate outreach for hypertension, elevated cholesterol, prediabetes and diabetes can quickly address newly discovered and out-of-control cases before they progress to a more advanced state, she says. This is especially important for employees who may be reluctant to follow up on their own in a timely way.
"A lot of people know they should probably do something, but they’re not ready to act," Ruppert says. "Triggers to action can be different for each person, but employers can help provide some triggers, coupled with the prompt feedback and necessary follow-up resources to get them there."
Susan J. Wells, a contributing editor of HR Magazine, is a business journalist based in the Washington, D.C., area.