Can holistic well-being programmes change the face of family care

CONNECTING THE DOTS TO EMPLOYEE WELL-BEING

Consider this scenario: You book off work with a pounding headache. You go to your doctor – a general practitioner – who sends you to see a neurologist. The neurologist sends you to get a CAT scan. When the CAT scan shows up nothing, your partner suggests you start seeing a therapist. Four sessions on with your therapist you stop, as this is all your employee assistance programme will cover and you just don’t have the money to continue. What your partner doesn’t know – and what you can’t bring yourself to tell them – is that your unemployed son is quietly pushing you towards financial ruin as he battles with a drug habit, which is why the money is running out before the end of each month. Bottom line: you can’t afford to pay all these people to help you solve problems you can’t seem to find a beginning or end to.

For outsiders to the story, it’s easy to see how interconnected all these elements probably are in this protagonist’s life. Unless the son’s addiction, the financial debt, the secret that’s being kept from the partner, and so on, are addressed, the migraines are likely to continue. But this is not how our care professionals currently engage with us. Our doctors try to help us address health problems; our therapists help us address emotional problems; and our financial advisers help us address financial problems, each in their own exclusive domain. It’s when we connect the dots and look holistically at the problem that the healing can really begin – and this is the critically important insight that employee well-being programmes are beginning to unearth.

Seeing the value of employee well-being programmes

Value to employers

Interestingly, employers have seen value in these concepts for some time. Well-being programmes, and now specifically financial well-being programmes, have emerged as the number-one trend in employee benefits in both the US and the UK. In South Africa, most employers have some form of well-being strategy embedded in their employee engagement initiatives. A number of surveys and studies provide compelling cases for why these programmes add value to maintaining or enhancing productivity in the workplace¹. We can even calculate a return on investment (ROI) employers can hold up to their boards that shows the money spent on these interventions both saves the company money in human capital management costs and adds to the bottom line by increasing productivity. Other potential cost improvements are reductions in group life premiums and reductions in healthcare premiums.

The financial case has been made and the intent of this chapter is not to make it again². From the employer’s perspective, the appeal of these programmes is that they address the ‘care conundrum’: how to ensure that employees maintain financial, physical and mental stability and vitality without the employer becoming overly paternalistic and intrusive. Value to employees From the employees’ perspective, the attraction of these programmes is that they aren’t paternalistic. Rather, they give employees an opportunity to structure what they need, how they need it, while (hopefully) at the same time guarding the integrity of employee data. Employees are beginning to appreciate how unique this value proposition is. For many families, this type of workplace wellness solution is a particularly effective way to access a holistic framework of care. It is this win-win benefit for both the employer and the employee that is making employee well-being programmes the hot commodity that they are becoming. Outside this environment, ‘care’ simply isn’t structured to be addressed this way.

Figure 4: The impact to the employer’s bottom line:
A paper by Greg Ward published by the Society of Actuaries in 2017 showed that when fi nancial wellness improves by just 10%, the projected annual savings for a large employer (1 000 people or more) are as follows:

Questions to consider when constructing a holistic well-being framework

As we cautioned, we are only just starting the journey of discovery in terms of identifying how this framework could best be structured. No one has the complete picture just yet ... but the pieces are coming together fast. Some are being tackled by the healthcare industry, some by the financial services industry, and some by the EAP industry.

Perhaps one reason no one has cracked this servicing model is that these players are trying to tackle the problem through their own operating lenses, whether that be through the lens of their business models, servicing models, or technology and data management models. Therein lies the heart of the problem.

What would it take to make such a powerful concept really take flight? In trying to answer this bigger question, we look at each key component in turn and ask:

• What should a holistic well-being programme strive for?
• What is a sustainable business model?
• How do we measure success, and for whom?
• What is the role of technology and data in delivering these programmes?
• Who should provide these programmes?

1. Proactive support for positive change

What are our expectations of a holistic well-being programme? What would it have to achieve for us to regard it as a success?

In the lengthy literature and research we have produced around well-being (see Benefits Barometer 2014:  'Fine-tuning the employee benefits system' and Benefits Barometer2015: 'Financial Well-being'), what makes well-being programmes distinctively different from employee assistance programmes is that they operate proactively to ensure behavioural change. Unlike employee assistance programmes, which tend to reactively provide support services when employees need them, well-being programmes start with how you are living your life. They focus on behaviours you could change or insights you could gain to increase your and your family’s general stability and well-being.

More than that, these programmes are about equipping individuals to successfully navigate life’s general challenges – whether these challenges are physical, financial, emotional or some combination of all. This is all about a process that helps people to change their thinking and actions around managing debt, their daily consumption needs and ongoing health and physical well-being, creating the basis for a work–life balance, and other actions that help them function optimally and achieve their goals.

From education to action

The only way we will know if the programme is working is if we can actually see actions following insight. That means these programmes need to be more than just educational exercises.

Let’s return to our medical analogies. Medical centres have become a powerful addition to the suite of medical care options. What has made them so successful at changing community-level health (and addressing the logjam of medical care that was being experienced at the general hospital level) is that they have facilitated access to various components of everyday healthcare on an outpatient, walk-in basis, all through one convenient touchpoint. You have access to your GP, your specialist physicians, the various testing labs (X-ray, CAT scan, blood tests, etc.), the pharmacy that will fill your prescription right there and then and, in some centres, an array of community health programmes such as prenatal care or child healthcare.

The point is, by making it easy for individuals to exercise each step in the process of addressing a physical ailment or pursuing proactive healthcare, the success rate for community healthcare increased exponentially.

Financial well-being should work on a similar model. We know that financial education by itself has failed to move the behavioural dial towards better financial capability. In Benefits Barometer 2014: 'Fine-tuning the employee benefits system', we spoke at length about what it would take to move that dial. When it comes to financial capability, the bottom line is that it’s only when an individual feels confident enough about their ability to make effective financial choices that they will take action and do the right thing to address their needs.

An effective workplace well-being programme isn’t just about offering on-site education and counselling. It’s also about making it as easy and cost effective as possible for people to take action that translates insight into outcomes. Actions could range from visiting a debt counsellor and setting up and sticking to a budget, to seeing a financial adviser or buying a financial product. The point is, the action is directly related to the problem the individual is trying to address.

2. Ensuring a sustainable model

Who pays?

Let’s go back to our medical centre example. We would be deeply concerned if we thought our medical centre doctors earned their keep from prescribing medicine through their centre’s pharmacy or stipulating that specific medical tests be conducted by the centre’s labs. By the same token, we should be concerned if the funding of the financial well-being aspect of our programme was also based on the sales of financial products. Yet, this is a business model that many financial services companies follow. It’s a model that, in the long run, will do more to raise concerns about the merits of these programmes than it will to allay them.

The reality is that the best well-being programmes will, by necessity, be particularly demanding of resources – both the human kind, in terms of time and effort required for programme development, interventions and ongoing coaching – and the technological kind, in terms of creating and maintaining the necessary digital delivery for continuous engagement. Who, then, should pay for all of this?

Here are the options – and the issues:

• Financial services company pays (offers it for free)
  How sustainable is that model likely to be without an expectation of products being purchased? There is an argument that the cost of such programmes could be absorbed into a company’s corporate social investment or skills development spend. It may even be argued that shareholders would happily absorb the costs if there were adequate evidence that this translated into more responsible product sales or better client retention. Still, at this point, the model is raising questions for regulators.
   
• Employer pays
  Currently a number of employers will willingly pay monthly, per-member fees for employee assistance programmes that provide limited access to emergency services such as legal, financial and family therapy support. It’s an important starting point, but three problems emerge:
  • These programmes are not designed to provide continuous support and direction. Nor do they address fundamental behavioural change issues that demand a more hands-on approach.
  • The employer may have insight into how often these services are used and by which segments of their employee base, but they have little insight into whether the issues involved were actually resolved.
  • There is no integrated wellness programme reporting results at either the individual or employer level.

A comprehensive programme such as the one we have envisaged here would cost the employer significantly more than a superficial employee assistance programme. This makes the ability to demonstrate that the programme is having an impact that is translating into an ROI that much more important. But another debate here is whether getting stakeholders to commit, whether they be the service sponsor or the service receiver, demands that there be something at risk as well. When we are dealing with sensitive issues that demand behavioural change, a fully funded programme from the employer could open up the potential for moral hazard: why bother to change if your employer is always there to bail you out?

• Employee pays
  Currently, companies that require their employees to maintain contracts with medical aid schemes have, on average, shifted that burden of cost to the individual. Typically, this cost is embedded in a total cost to company calculation. We have already seen with the medical aid scheme choice that it’s typically the employees who require these services the most that end up opting for the lowest cost options, mainly because of financial constraints. Perversely, this outcome would be the case even more so if employees had to shoulder the full burden of financial wellness programmes.
  
  Charging an individual a per-member, per-month rate to address a wider array of needs (adding financial and mental wellbeing to the physical well-being pot) may make the best sense as this would mean that ownership for the programme would be in the hands of individuals and their families – as opposed to being dependent on an employer. But it may require more time for these programmes to demonstrate their potential value before employees are prepared to shoulder the full cost.
   
• Co-payment
  We believe that until this type of holistic family care model really gets traction, each of the stakeholders – employer, employee, financial services provider, government – should shoulder a portion of the cost (government in the form of tax concession, perhaps).
  
  Co-payment means that everyone has a vested interest in making sure the programme is working:
  • The employer and/or unions need to be committed because these programmes may well require some measure of work time and resource. They also fill a vital need in the realm of meaningful employee benefits.
  • The employee needs to be committed to stick with the programme to ensure the outcome is achieved.
  • Policymakers need to pay attention here because if the working community can get this right, it could take a massive burden off a very stretched fiscus by providing a way to proactively promote and maintain family health and financial stability.
    
    ​​​​​​​There are any number of variations on a copayment model. The share of costs could be determined by how aligned the outcomes might be to the different stakeholders’ interests.

Getting any stakeholder to buy in to the value proposition of such programmes would demand that there were identifiable benefits to such an investment. This then takes us to the next condition for success of a sustainable wellness programme: the feedback mechanism.

3. Feedback mechanism for measuring success

Are we winning? And was it worth the investment?

With each of these stakeholders invested, how will each one know whether the investment has paid off? This is where these programmes can be particularly powerful. For an employer to know that the programme is working, for example, demands better feedback than utilisation rate calculations. And therein lies the challenge. What measures of financial well-being or physical well-being or mental well-being could be used?

Financial well-being at its best is the ability to manage the trade-offs necessitated by existing financial constraints so that an individual can achieve what matters most to them and their families.

Similarly, at the heart of mental well-being lies work–life balance. It’s something our HR departments tell us employees want most. How exactly is that measured, given that this would be interpreted differently by every single South African family?

If we understand and accept these points, we can start assembling bits and pieces of information and data that, when taken collectively, start painting a picture. It’s this collective picture that we can assess over time, on two levels: that of the employer and that of the employee.

The employer level

At one level, the employer needs to see a picture of the de-identified aggregate of their workforce through any number of different lenses and from any number of different perspectives. But the aggregate picture of ‘improvement’ needs to be translatable into a direct return on investment that can be shown to both current and potential shareholders.

The following (quantifiable) factors not only have an impact on lowering human resource costs but can also be measured against yardsticks of increasing productivity:

• To what extent have the programmes reduced the costs of employee turnover, absenteeism and presenteeism?
• To what extent have healthcare costs been optimised?
• How has control of employee debt translated into reduced administration costs from garnishee orders and payday loans?
• To what extent are employees staying engaged with their well-being programmes?
• To what extent have the education and skills development facilities been used, and how has this enhanced the overall resourcing needs of the employer?
• To what extent are employees contributing more to their retirement savings or other (emergency) savings vehicles?
• Has there been better preservation, better annuitisation?
• Has there been a reduction in group life premiums?
• Has there been a reduction in fraud?

Each one these elements not only has an impact on lowering human resource costs but can also be measured against increasing productivity.

The employee level
The employee also needs to be given a picture of achievement, which can be assessed in the following ways:

• Have they acted on the recommendations they have been given for addressing what matters to them?
• Are they getting to where they have said they needed to go?
• Do they feel secure in the path they have chosen?
• Have they developed the confidence that they have the means to cope with whatever life throws at them?
• Have they got their debt under control and is their credit rating improving?
• Are they making the most efficient choices about their medical scheme options?
• Have they established an adequately funded emergency savings fund?
• Do they have adequate protection for their perceived risks?

These lists can go on and on as we capture more data sources for rounding out our insights into an individual’s degree of well-being for both themselves and their families.

Where the feedback becomes vital
Feedback provides oil that greases the ongoing machinery of well-being. It’s our verification and validation starting point. We are not just using feedback to measure success but also to provide an ongoing assessment of whether our engagements and interventions are translating into actions, so that we can constantly improve on our delivery.

4. A technological interface that deals with continuous engagement and data integration

What is the mechanism of engagement? Who owns and has access to the data?
An effective employee well-being programme lives and dies by both its mechanism of engagement and the data that can be sourced and aggregated to provide the basis for this engagement. This, too, is a work in progress for many companies, particularly at a time when regulations such as the Protection of Personal Information Act (PoPI) mean that this data must be protected at all costs. What makes this particularly difficult is the pace at which technology is developing better solutions to these security issues.

We’ve spoken at length about how technology will be changing the way we work. Technological developments such as blockchain will also challenge where personal data and information will be stored and who will have the ultimate control over who can access it. This is one debate that the consumer might actually end up winning. We are rapidly moving towards a world where personal data will no longer sit with a service provider such as your bank, medical aid, insurance company or financial services company, and be aggregated by ‘scraping tools’ that collect this information into one place for analysis. Instead, we will likely see a model where the individual owns all their data and allows access to it only at the request of the service provider (except when there is a legal requirement for the service provider to have such access).

Say what you wish about how long this conversion of data ownership is likely to take ... the one thing we know for certain about technological development is that it’s happening much faster than we ever imagined. Watch this space.

Alongside the great leaps forward in data aggregation are the advances we are making in understanding how people learn and what keeps them engaged with that learning process. The bad news is that we know we each learn in very different ways and respond to very different stimuli (and those aren’t differences that can be neatly categorised into generational bands).

This is a key insight for well-being programmes. Making these programmes scalable demands that we use some form of digital engagement. Developing an interaction framework that learns what the learner responds to then expands the engagement to incorporate this new insight is where these programmes must go. In Skills development – a new approach we delve further into one way that Alexander Forbes is already developing solutions in this area.

5. Putting it all together

Who is best positioned to provide these programmes to the employer?

On one level, we should be heartened to see how many players in the financial services industry see financial well-being programmes and even holistic employee well-being programmes as important additions to their servicing capabilities. What this suggests is that the industry is finally seeing value in placing the client at the centre of focus. This should only be good news for the consumer. But let’s explore that premise a bit further.

Most financial services companies have evolved over the last 30 or 40 years to become more product-centric. With that product-centricity comes the legacy business model, data access and technology architecture models.

Potentially better positioned are companies that exist in the consulting and advice space. Here, an interesting model that is emerging is one where the consulting group works with the employer to assess what the workplace well-being needs would be for their specific employee population and industry. The consulting group then takes the responsibility for sourcing the most appropriate and cost-effective solutions or external partners required to meet the company’s range of needs. Further, they take responsibility for overall programme monitoring, for both the employer and the employees, to ensure that what has been recommended is delivering.

We think this may be the model of the future for well-being programmes. It’s a model that Mercer has been employing in the US and the UK, and employers appear to feel that it ticks all the right governance boxes. It also has the potential to produce outcomes that employee assistance programmes can’t address.

Most importantly, a model like this can provide the basis for delivering the vision we articulated at the beginning of this chapter: could employee well-being programmes not change the face of what it means to provide holistic family care?

Summary

Well-being programmes make intuitive sense as an employee support and engagement model. More importantly, if employers are going to offer a broad range of benefits options to employees, (something that we will describe in more detail in Part 4), a well-being programme becomes an essential component, if only because it helps employees determine how to assess which benefit options provide the greatest value to them and their families. Think of holistic wellness programmes as providing a guidance and educational framework for decision-making.

This chapter has attempted to take the conversation a bit further by helping employers appreciate that there are important qualitative differences in how these programmes could be structured, and they need to be clear on the distinctions.

An important message is that unless these programmes provide properly integrated feedback to both employers and employees, the result can be a considerable waste of time, resource and money. In the next section we zero in on the healthcare component of a well-being programme as a case in point.

Case study/lesson

The merits of employee wellness have been largely accepted by organisations worldwide. There is an acknowledgement of the interrelatedness between employee health and organisational health. Healthy employees are generally more productive, have lower rates of absenteeism, and are more engaged. They’re also better able to manage stress and change, have higher job satisfaction and a positive morale.

Organisations that focus on employee well-being seek to reap the rewards associated with a healthy workforce: lower absenteeism, fewer workers’ compensation claims, reduced disabilities, and greater workplace safety, productivity and performance – all of which contribute to a competitive and sustainable organisation.

A lot of time, energy and financial resources go into workplace wellness. In large companies, you often find a plethora of employee health management (EHM) programmes and employee-health-related costs, some of which include:

• medical scheme(s)
• IAS19 valuations
• primary care programmes
• occupational health programmes
• primary care nurse, doctor or on-site clinic
• employee assistance programme
• gap product cover, hospital cash plan, accident policy
• expatriate cover
• wellness programme(s)
• executive wellness programme
• sickness and absenteeism management
• incapacity management
• workers’ compensation
• death benefits
• funeral benefits

Owing to the magnitude of the employee health management portfolio, it is often divided among different areas within the organisation. Human Resources may deal with health policies, employee engagement and the psycho-social aspects of health; Benefits and Compensation may deal with health programmes, death and funeral benefits; occupational health and safety may sit in a different department and employee wellness and education in yet another. As a result, there is seldom any integration of data from the various EHM programmes.

Benefits of measuring employee health management programmes

Is your organisation reaping the benefi ts of the basket of EHM programmes offered? Are your workers healthier, happier, less stressed, and more engaged and productive as a result of your time, effort and expenditure? Are their health and well-being improving or deteriorating over time?

With the Protection of Personal Information Act, it is often very difficult to effectively integrate the data from EHM programmes in order to measure their relative success at an individual level. However, the data received from these programmes can be used to create a dashboard that provides the organisation with a big-picture view on employee well-being.

Integrating available EHM data with organisational metrics on employee engagement, absenteeism, disability cases and productivity will assist the organisation in better answering some of these questions. It will also assist with:

• understanding the health and well-being issues that employees are grappling with, and their impact on the health and well-being of the organisation
• showing the impact of the organisation’s policies, culture and environment on the health and well-being of its employees
• identifying both short- and long-term strategic objectives for employee and organisational health
• identifying where targeted interventions are required
• providing insight into the duplication of benefit offerings, enabling greater cost efficiencies within EHM programmes
• identifying the efficiencies and effectiveness of EHM programmes to ascertain whether these programmes are achieving the desired outcomes and if they are the most efficient mechanism for doing so 

If organisations don’t integrate this data, it’s likely that EHM data won’t be used at all. For example, medical scheme wellness reports provide information on the many aspects of employees’ physical and lifestyle health. However, if the organisation doesn’t understand the impact this is having on the business, very little is done with this data.

What to measure

There are many measurement models available to guide organisations on what to measure with respect to their EHM programmes. The Health Enhancement Research Organization (HERO) and Population Health Alliance (PHA) have developed a model which incorporates the following metrics:

• Financial outcomes: This metric seeks to measure the savings derived from implementing EHM programmes.
  
  This is not always easy to do, particularly in the case of programmes that operate within a community rating framework, such as medical schemes where contributions are not risk rated for the organisation. For example, the organisation may have implemented successful initiatives to reduce body mass index, resulting in fewer claims from the medical scheme, which could in turn reduce the costs of medical scheme contributions for all members ... but this would not be realised as an immediate cost reduction for the employer exclusively.
  
  Some risk-rated insurance products may result in reduced contributions for the organisation thanks to the improved health of its employees. Such programmes are easier to measure under this metric. For example, reduced BMI may result in fewer employees with high cholesterol, which may result in fewer heart attacks and could yield lower group death cover rates³.
   
• Health impact: This metric assesses the impact of EHM programmes on the overall health and well-being of targeted populations. It includes an assessment of physical, mental and emotional health as well as the behaviours that affect these dimensions of health.
  
  This metric also includes a review of the prevalence of health factors across all EHM programmes. Over time, any initiatives instituted by the organisation to improve aspects of health should be reflected in this metric.
   
• Participation: It is important to measure the uptake and ongoing use of EHM programmes by employees. Without adequate employee participation, the efficacy of these programmes is diluted and their cost effectiveness comes into question. This measure also assists organisations in understanding the effectiveness of the communication strategy for their EHM programmes.
   
• Satisfaction: This metric measures how satisfied both the organisation and its employees are with the benefits and services of the EHM programme. This assists in refining the benefit offering and improving the service delivery of the providers.
   
• Organisational support: This metric measures the level of organisational support for each of the EHM programmes. It looks at policies, procedures and facilities that make it easier for employees to make healthier choices.
   
• Productivity and performance: It is not always easy for employers to measure the productivity of their employees, especially in the service industry. In the absence of a definitive productivity metric for an organisation, these metrics often review absenteeism, disability and employee engagement ratios.
   
• Value on investment: This metric seeks to measure the value received (as opposed to savings derived, measured under the financial metric) by the organisation for each rand spent. It tracks the cost of EHM programmes, and the improvement and deterioration of health, satisfaction levels, employee engagement and productivity scores over time.

The evolution of employee health management programmes

Whatever metrics an organisation uses to review its EHM programmes they should assist in establishing a greater understanding of what works, what doesn’t, and which aspects of health to focus on to enable the organisation to achieve its strategic objectives with regard to employee health.

EHM programmes are dynamic, and successful EHM programmes go through a cycle similar to that depicted in Figure 5, which encompass the following steps⁴:

• Mobilise: For EHM programmes to succeed, buy-in from leadership (shareholders, executives, unions, operational management) within the organisation is paramount, as it demonstrates organisational support. Employee wellness and well-being should form part of the organisation’s DNA, incorporated in its policies, and aligned with its mission, values, objectives, operations and cultural norms.
• Assemble: Effective EHM programmes use collaboration as a means of driving the programmes. Break down silos by creating a committee that incorporates all stakeholders, including unions and employee representatives.
• Assess: The committee’s first responsibility should be to assess the present levels of employee and organisational health, then to compare this to the desired levels of employee and organisational health. There are many tools to assist in this endeavour, including the metrics listed above.
• Prioritise: The committee should agree on priorities that would benefit the organisation and its employees. Once again, collaboration is key to obtaining buy-in from all stakeholders.
• Plan: This is where the plan of action is established. The plan should include short-term goals (current year) and long-term goals (three to five years). The plan should be drawn up for each of the priorities and should include the policy changes required, if any; budget requirements; processes; and any resources required.
• Do: This stage includes assigning responsibilities and rolling out the programme.
• Evaluate: We have looked at the importance of evaluating the EHM programme in this section; establishing what works, what does not, and what is impeding the success of the programme. This exercise establishes the gap between the planned objectives and the actual results.
• Improve: If gaps are identified or there is a need to adjust priorities, this is the time to review the plan and repeat the cycle.

We’ve heard that the cost of healthcare is prohibitive. But has your organisation adopted a strategic and structured approach to implementing and running an employee health management programme? Measuring the effectiveness and efficiencies of EHM programmes is key to developing the right structure and refining your strategy to ensure it the programmes deliver maximum benefits to both employer and employees.

If you’re not already doing this, now is the best time to start.

References

1 See Benefits Barometer 2015 and PwC. (2017). Employee Financial Wellness Survey, 2017 results.
2 Robison, J. 2010. The business case for wellbeing, Gallup Business Journal (June 9, 2010) Foundation for Financial Wellness. Financial wellness: enabling a productive and healthy workforce.
3 Health Enhancement Research Organization; Population Health Alliance. 2015. Program measurement and evaluation guide: core metrics for employee health management.
4 Burton, J. WHO healthy workplace framework and model: background and supporting literature and practices. World Health Organization.