Financial Incentives Improve Diabetes Control and Cardiovascular Risk Factors

Study supports workplace disease management programs

Since 2009, Cleveland Clinic has offered financial incentives to employees for participation in disease management programs. Starting in 2011, additional incentives were offered for achieving clinical goals, including glycosated hemoglobin (HbA1c), low-density lipoprotein (LDL) cholesterol, blood pressure and weight targets.

Whether the employee incentive programs translated to measurable risk reductions was evaluated by a team of Cleveland Clinic investigators headed by Anita Misra-Hebert, MD, MPH, of the Cleveland Clinic Medicine Institute’s Center for Value-Based Care Research. The research findings were published recently in the Journal of General Internal Medicine.

The study found financial incentives were associated with improved cardiovascular risk factors over five years in employees with diabetes compared with a matched group of nonemployees and were particularly pronounced for employees who participated in disease management programs in the first year.

“Our findings show that employee-sponsored financial incentives may be an important vehicle to engage patients and improve diabetes care in large populations,” says Dr. Misra-Hebert.

Unique study design

Most studies investigating the effectiveness of employee incentive programs have compared employees participating in the programs to nonparticipating employees. But Dr. Misra-Hebert points out that such a study design introduces an inherent selection bias: Employees who choose to participate are often a more motivated population, and any benefits found in this group compared to controls may be exaggerated.

This retrospective cohort study looked at 1,092 Cleveland Clinic employees with diabetes (whether or not they actually participated in the program) and compared them with demographically and propensity-matched nonemployees with diabetes who were being cared for by the same group of providers as the study group. Data for analysis were obtained from insurance claims linked with the electronic medical record from January 2008 to December 2012.

Inherent in this study design is the assumption that employee incentive programs may benefit people throughout the workplace, not just program participants.

Study findings

Key findings of the study include:

• With increasing incentives, employee program participation in disease management improved: from 7 percent to 50 percent participation over the five-year study period.
• Over five years, yearly improvement in HbA1c, LDL cholesterol, systolic blood pressure and weight improved in Cleveland Clinic employees more than in nonemployees.
• HbA1c decreased annually in employees by an average of 0.05 percentage points.
• Weight decreased by 2.3 kg in employees who participated in disease management in the first year of participation compared to only 0.1 kg in nonemployees.

Dr. Misra-Hebert notes that the benefits observed, while modest, could have clinically significant impacts if trends continued over many years, and that ongoing study of this population to measure long-term impacts would be interesting. Further areas of interest to her research group are to evaluate other employee health programs, such as for obesity or asthma.

What works best? Unanswered questions

Over the study period, different wellness initiatives were offered by Cleveland Clinic at different times: fixed cash payments of different amounts, health insurance premium discounts for program participation, and further discounts for achieving clinical goals, with potential rewards of more than $1,000 annually. The study was unable to determine which incentive program was the most effective because significant trends could not be discerned in the data when analyzed in increments of two-year periods.

Dr. Misra-Hebert speculates that engaging people to seek regular healthcare may be the most important factor in improved outcomes. An artifact of the study design — which involved using a control arm of people in a primary care practice and selecting for analysis in both groups only those who had at least two consecutive HbA1c measurements — was that everyone in the study received some degree of regular care. The fact that the study demonstrated significant benefits in the first year of program participation and over the full five years but could not attribute benefits to the implementation of particular incentives during the study period supports the notion that obtaining regular care may be the critical factor to improved outcomes.

Dr. Misra-Hebert also notes that employees tended to have well-controlled diabetes at baseline, which may help explain the only modest improvements observed. Enrollment in the program among employees with poorly-controlled diabetes did not increase as much over the years as among employees overall.

“How to make disease management programs more attractive to employees with less well-controlled disease is an ongoing challenge,” says Dr. Misra-Hebert. “What are other ways to engage people?”

Public health implications

According to Dr. Misra-Hebert, studying incentives for health program participation has important implications in the wider realm of public health. Could employee health incentives be extrapolated to other models at a community level? Dr. Misra-Hebert feels that understanding what motivates people is key to designing effective programs. Financial incentives, she speculates, may be most effective as a step to engage employees to obtain regular care.