Health Risk Appraisals
The 1999 National Survey of Worksite Health Promotion Activities indicated that among all companies, 35% offered health risk appraisals (HRAs), either directly or through their health insurance programs; 57% of companies with more than 750 employees offered HRAs.1 It is very possible that this percentage has increased in the years since the survey; more current data are pending the results of the 2004 National Worksite Health Promotion Survey.
While HRAs are widely used in workforce wellness programs, the impact of their use on health risk behavior change and related health indicators such as body composition and cholesterol levels, is not well-understood scientifically. The Guide to Community Preventive Services is currently undergoing a thorough review of the scientific literature to identify evidence for the appropriate use of HRAs in the workforce. However, the most recently published literature review on the use of workplace-based HRAs, conducted by D. Anderson and M. Staufacker in 1996, found "suggestive evidence for the effectiveness of HRA when it is used in a comprehensive worksite health promotion program."2
The Health Care Financing Administration (formerly HCFA, now Centers for Medicare and Medicaid or CMS) describes HRA as follows: "Health risk appraisal is a systematic approach to collecting information from individuals that identifies risk factors, provides individualized feedback, and links the person with at least one intervention to promote health, sustain function and/or prevent disease. A typical HRA instrument obtains information on demographic characteristics (e.g., sex, age), lifestyle (e.g., smoking, exercise, alcohol consumption, diet), personal medical history, and family medical history. In some cases, physiological data (e.g., height, weight, blood pressure, cholesterol levels) are also obtained."3 The term health risk assessment is sometimes used interchangeably with health risk appraisal. However, Anderson and Staufacker differentiate the two: "…HRA formally refers only to the instrument whereas health risk assessment refers to the overall process (e.g., orientation, screening, interpretation, counseling) in which the HRA instrument is used."1
Before selecting an HRA tool and implementing the appraisal among your employees, it is important to define objectives for doing so. Clearly-defined objectives can guide selection of an appropriate tool from the many commercially available HRAs, and help assure proper data collection and use. For example, an HRA specific to diabetes might be used as part of a health education or counseling program on lowering risks for diabetes, whereas a broader HRA tool would be required if an objective for implementing the HRA is to supply population data to guide the design of a comprehensive workforce health promotion program.
Below are various reasons that employers might implement an HRA. It is possible that more than one of the following are relevant to your company's goals.
Strategic Planning/Design of Workforce Health Promotion Program — Assessing collective risk factors of the population and segmenting the population by certain risk factors and conditions can help program planners target often limited resources. Programs and incentives can be designed to address the modifiable health risks factors that are most prominent in their workforce and to achieve goals specific to employees at various risk levels (e.g., maintenance for those with low-risk, helping those at higher risk move into lower risk categories). HRAs can be part of the baseline data to inform program design and can be repeated periodically to measure progress.
Cardiovascular Screening for Physical Activity Program Participation — For safety and company risk-management purposes, employers with on-site fitness facilitates sometimes require employees to participate in an HRA or health screening prior to exercising at the fitness center.
Individual Health Awareness, Education and Intervention — An HRA might be used to increase employee awareness of personal health risk factors for making appropriate lifestyle changes on their own or with the support of a workforce health promotion program or more intensive counseling services. Repeated HRAs allow the employee to monitor their risk factors.
Identifying of Individuals for Disease Management Services — The American College of Sports Medicine (ACSM) points out that, while the primary objectives of workforce HRAs include identifying the health risks of the population, "A more recent development in HRA programs is an emphasis on individuals with chronic conditions or who are at risk for becoming high medical care utilizers."4 Through wellness programs and health benefit plans, some companies offer personalized disease management services to assist these employees in reducing health risks.
Guidance for Refining Health Plan Services — Population data resulting from an HRA can be used in combination with other data, such as health plan use, to help identify the need for targeted health plan services for preventive benefits, disease management, or other key services that an employer might choose to negotiate as strategies to decrease morbidity and sick care costs.
Yes, in addition to selecting the right HRA tool to meet your company's objectives, HRA planners should be aware of the following:
Ethics — Examples of ethical aspects of HRA are data security, confidentiality, and proper employee communications to explain individual results and the concept of risk. For more, see Ethics Guidelines for the Development and Use of Health Assessments by the Society for Prospective Medicine.
Technical Features — Ask questions of the vendor to determine if the HRA has technology and content that meet your specifications as defined by your objectives. Examples include basis of and date of last risk protocol update, report options for group data and participant reports, option for sending reports to employees' physicians, inclusion of biometrics and blood test data, features such as Stages of Change measurement, inclusion of individualized health education materials with participant reports, data that include tracking of HRA results over time, level of customization available, on-line capability, methods for preventing confidentiality breech, and features included in the base price and those that cost extra.
Mode of Administration — Choices include personal interview, telephone interview, paper-and-pencil tools (on-site completion/submission, mailing for completion and submission from home), and online completion. Implementation might be done by internal workforce health promotion staff, an HRA vendor, or the employees' health plan.
Incentives for HRA Participation — Employers that can and want to provide incentives must determine what type and level of incentives are appropriate to motivate HRA participation among their employees. Incentives can range from one-time items such as water bottles or tee-shirts to ongoing rewards that are integrated into benefit plan design. For the later, employers might consult human resources and legal professionals who are well-versed in Health Insurance Portability and Accountability Act (HIPAA) regulations. Business health councils and coalitions can often be a resource for guidance on incentives, HIPAA, and other health promotion topics for their members.
Type of Feedback — HRA products vary in the design of the feedback format and method (written reports, online reports, and instant kiosk-produced reports) so it is up to the planners to select the one most appropriate for their workforce. Feedback may be provided immediately or might require processing time. The information could be provided by mail or online delivery to the employee at home or work, personal interpretation through meetings with each employee at work or at a physician's office, or group feedback sessions with employees following along in their individualized reports.
Who Provides Participant Feedback — Deciding who will present HRA results to employees depends on the level of follow-up being provided. Options include health professionals, heath educators, or specially-trained staff members. These individuals might be in-house, provided by the vendor or contractor, or be health plan employees.
Level of Follow-up — This will vary based on the stated HRA objectives: feedback only, feedback plus counseling, feedback plus health promotion programs, or referral for individual counseling of high-risk employees or those with existing chronic conditions.
1Anderson, D & Staufacker, M. (1996). The Impact of Worksite-based Health Risk Appraisal on Health-related Outcomes: A Review of the Literature. American Journal of Health Promotion, 10(6), 499–508.
21999 National Worksite Health Promotion Survey: Conducted by the Association for Worksite Health Promotion; William M. Mercer, Incorporated; and the US Department of Health and Human Services, Office of Disease Prevention and Health Promotion; 1999.
3Rubenstein L, Shekelle P, Tucker J, Maglione M, Morton S, Roth E, Chao B, Rhodes S, Wu S, & Newberry S. Health Risk Appraisals and Medicare. Evidence Report prepared for the US Department of Health and Human Services, Health Care Financing Administration, 7500 Security Blvd., Baltimore MD. 21244-1850, Contract No. 500–98–0281.
4Cox, CC. (Ed.). (2003). ACSM's Worksite Health Promotion Manual: A Guide to Building and Sustaining Healthy Worksites. Champaign, IL: Human Kinetics.