4 Healthy Pregnancy and Healthy

Children: Opportunities and

Challenges for Employers

A Case Study on Employee Engagement:

Marriott International, Inc.
Company Background
Marriott International Inc., is a leading lodging company with nearly 2,900 lodging
properties in the United States and 68 countries around the world. Its heritage can be traced
to a root beer stand opened in Washington, DC in 1927.

As a leader in the competitive hospitality industry, Marriott understands the importance

of employee health and productivity. Marriott believes its associates are its greatest asset;
and as a leader in the service industry, Marriott knows that its success rests upon engaging
those associates. Marriott’s robust health
benefits package seeks to engage associates
“We have learned that good health
by meeting the needs of their families. leads to better productivity on the
Jill Berger, Vice President of Marriott’s job. We want to encourage and
Health and Welfare benefits, explains: support our associates and their
“Health benefits are a very important part families in getting the essential
care they need.”
of our compensation package to attract - Rebecca Main,
and retain talent. One of our core values Director, Benefit Plans
is if we take care of our associates, they
will take care of our guests.”

Marriott provides medical, prescription drug, vision, and dental coverage to 150,000 covered
associates and dependents in the United States. Approximately 80% of benefits-eligible
associates are enrolled in Marriott’s medical plans, and most associates have a choice between
a PPO/POS and HMO. Most of Marriott’s medical plans are self-insured.

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 A Case Study on Employee Engagement: Marriott International Inc.

Education and Communication:

The First Steps Toward Engagement Evidence shows that
beneficiaries with
Marriott knows that health education and communication are chronic disease benefit
critical. Effective health communication is particularly important from continuous care
because Marriott’s associates speak many different languages and delivered in a medical
come from diverse backgrounds. “Continuity of care is also a home.
challenge, as too often people wait to get care until they experience
symptoms of an established disease” notes Berger. “We’d like to see more of our associates develop a
relationship with a doctor,” explained Main, “then the point of entry into the healthcare system would not
be the ER.”

Know Your Numbers

To educate beneficiaries on the importance of preventive care, Marriott designed a preventive health
education and communication campaign: “Know Your
Numbers.” The program, launched in 2007, encourages
Six percent (6%) of beneficia-
ries in Marriott’s self-insured all beneficiaries to visit a primary care provider and be
plans generate 60% of claims assessed for four key health indicators: glucose level,
costs. Cardiovascular disease blood pressure, lipids profile, and body mass index
and diabetes are a large part (BMI). These four numbers give a snapshot of a person’s
of these claims.
health status and can predict his/her risk of diabetes,
cardiovascular disease, and obesity.

Marriott developed the Know Your Numbers program in order to encourage beneficiaries to take
charge of their health, know their health risks, and address chronic conditions as early as possible.
The program has three objectives:
1. Educate beneficiaries on the importance of health assessment;
2. Motivate beneficiaries to visit a provider for preventive
care; and
3. Encourage beneficiaries to form a relationship with a For more information
on health literacy and
primary care provider. effective health com-
munication techniques,
The program was championed by the benefits department refer to Fact Sheet
at Marriott’s corporate headquarters in Washington, DC. #1 in Part 5.
Beneficiaries were mailed an informational postcard and
brochure, and Marriott’s newsletter also included stories on the
program. To ensure that program materials were consumer-friendly, Marriott followed its health
literacy guidelines:
• Health communications are simple and actionable and are specifically tailored for people
without a background in health care.
• Support from on-site HR professionals during annual enrollment.
• Access to web-based portals to help associates understand benefits materials and plan
variations during annual enrollment.

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Removing Barriers to Care
The Know Your Numbers campaign is based on knowledge transfer. Marriott, with a keen
understanding of barriers to care, knew it needed to address access and cost issues if the program were
to succeed in getting beneficiaries to the doctor. To remove potential cost barriers, Marriott eliminated
copays on all preventive services effective January 1, 2007, where it could. Marriott’s health plans
decide which preventive services qualify for the zero cost-sharing policy; each year they review the U.S.
Preventive Services Task Force (USPSTF) recommendations and American Medical Association (AMA)
guidelines on clinical preventive services and set their reimbursement algorithms accordingly.

Results
Because the program is so new, reliable outcome data is not yet available. In a few years, Marriott
expects its claims data will show that the program led to an:
• Increase in preventive care (office visits, procedures, and medications/immunizations);
• Decrease in ER visits; and an
• Increase in the number of associates who select a primary care provider and see that provider
at least once per year.

Employee feedback has been positive. Associates like the way Marriott has communicated the
program; they feel it is easy to understand, straightforward, and actionable. They particularly like
the case-study approach that features the stories of real people who went to the doctor, identified a
risk or problem, and prevented serious illness through relatively simple lifestyle changes.

Unanticipated Challenges
As could be expected with any complex benefit change, Marriott encountered challenges in
administration and implementation. Jill Berger notes, “Administering the program has been a bit
challenging. For years, copays went up and up and now they are going away. It’s a culture change,
not just for us and for our associates, but for the health plans and providers as well.”

Marriott instructs its beneficiaries on what to say and do when a provider balks at the $0-copay for
preventive services. Aetna, one of the first Marriott-sponsored plans to promote the Know Your
Numbers program, redesigned their standard beneficiary identification card. “Preventive service
office visit copay: $0” is clearly marked on the front of the card. Marriott hopes that as more
employers adopt zero cost-sharing policies for preventive care, health plans and providers can resolve
the administrative hurdles.

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 A Case Study on Employee Engagement: Marriott International Inc.

Cost-Effectiveness
Marriott considered cost-savings and cost-offsets in its
“We know that if we can
decision to launch the Know Your Numbers program and get more associates to
the zero cost-sharing policy, and expects to see a positive engage in preventive
return on investment in just a few years time. care and form a relation-
ship with a primary care
provider, we will improve
Next on the Horizon
quality and save money for
The Know Your Numbers program is just one of many both the company and the
innovative benefit programs at Marriott. associate.”
• In November, 2006, Marriott released a - Jill Berger, Vice President,
Health and Welfare
comprehensive, free smoking cessation program for
associates and dependents.
• In 2007, Marriott introduced a personal health
record (PHR) through ActiveHealth Management for beneficiaries in all of its self-insured
plans. The PHR will be promoted during this year’s annual enrollment.
Next, Marriott hopes to expand its value-based purchasing strategies. Currently, Marriott offers copay
reductions for certain drugs for highly prevalent chronic conditions such as hypertension and diabetes.

Advice from Marriott

Marriott’s programs address the unique characteristics of their population. Yet the goals of health
communication, employee engagement, and quality are universal. Marriott suggests that employers
interested in promoting essential preventive care follow these action steps:

1. Examine claims and enrollment data in order to identify your top problem areas. Look for:
• Access. How many beneficiaries have not selected a primary care provider? What percent
of your beneficiaries do not see a primary care provider in the course of a year? How many
beneficiaries have a claim for an ER visit yet do not have a claim for follow-up care?
• Excess costs or major changes in cost from one year to the next. What are your highest-cost
conditions or diagnoses? Are any of these conditions preventable (e.g., influenza) or
modifiable (e.g., diabetes)?
• Utilization metrics. Compare your utilization metrics to the HEDIS metrics. For example,
what percent of your child beneficiaries receive routine well-child care? What percent of your
pregnant beneficiaries receive early (first trimester) prenatal care?
2. Contract with health plans that are willing to support your healthcare strategies.
3. Develop a business case for investing in prevention and health promotion. Use your own data and
look to the literature to estimate cost-savings.
4. Don’t forget about administration. Sometimes the most difficult challenges are administrative; be
sure to coach your plans to advise and educate providers and facilities on benefit changes.

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4 Healthy Pregnancy and Healthy
Children: Opportunities and
Challenges for Employers

AOL’s WellBaby Program:

An Employer Case Study
Company Background
AOL, a large media company located just outside AOL recognizes that healthy
of Washington, DC, takes a proactive approach mothers and babies result from
to controlling pregnancy-related healthcare costs good preventive care that
by offering all employees and their families access begins before conception and
extends into early childhood.
to a comprehensive well-baby program.

AOL’s WellBaby Program provides preconception, healthy pregnancy, and lactation programs
that promote optimal health behaviors through awareness, education, counseling, and
incentives. This program has helped AOL reduce or control its pregnancy-related health costs
in a number of key areas.

Initial Impetus
AOL created the company’s WellBaby Program out of concern for the health and well-being
of their beneficiaries. An analysis of healthcare cost data identified the need to reduce high-
risk pregnancies and sick-baby claims. AOL recognized that early intervention and health
promoting activities (e.g., new parent education, breastfeeding education) have the ability to
improve health and reduce healthcare costs.

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 AOL’s WellBaby Program

AOL’s Pregnancy-Related Cost Concerns

• Costs associated with preterm birth.

• Costs associated with low-birthweight babies.
• Absenteeism due to disability and complications.
• Job retention.
• Sick-baby care in the first year of life.

Business Case
Containing high healthcare costs, minimizing absenteeism due to pregnancy complications and
episodic childhood illness, and retaining employees following the birth of a child drive the business
case for AOL’s WellBaby Program. The program’s return on investment (ROI) is realized from both
direct and indirect costs-savings.

Direct Cost-Savings:
• Reduced utilization of high-cost pregnancy care.
• Fewer neonatal intensive care unit (NICU) days: AOL saved an estimated $782,584 in
NICU costs in 2005.
• Shorter hospital stays for mother and baby.
• Fewer sick-baby visits to the pediatrician.
• Fewer pregnancy-related short-term disability claims.

Indirect Cost-Savings:
• Reduced absenteeism and presenteeism.
• Improved retention (reduced turnover).
• Increased breastfeeding rate and duration.

History
AOL’s WellBaby Program was launched in 2003 when AOL identified the need for an intensive health
promotion program for expectant mothers. Prior to 2003, AOL provided contracted telephonic
counseling and health education services for pregnant women, and sponsored a few classes per year for
expectant and lactating mothers, usually off-site. In 2003, the company established a working relationship
with Inova HealthSource of the Inova Health System. Inova staff agreed to provide on-site programming
to give the WellBaby Program a more visible presence. AOL was able to leverage the Inova staff’s
institutional knowledge, understanding of company culture, and existing relationships with employees.
Together, AOL and Inova substantially revised the existing program to include a higher level of personal
interaction, additional classes and content areas, expanded counseling services, and greater availability.

AOL human resource staff developed the WellBaby Program over a 3-month period with the
following goals in mind:
• Lower the healthcare costs related to pregnancy and childbirth.
• Focus on preconception, prenatal, pregnancy, and lactation issues facing employees and their
partners.
• Increase timely, appropriate, proactive interventions to decrease costly utilization.
• Increase employee productivity by decreasing absenteeism and impairment.
• Provide incentives for participants to engage in health promoting activities.
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 Maternal Health at AOL: A Snapshot

Large female population:

38% of benefit-eligible employees at AOL are women.

38%

Women
62%
Men

Young population:
The average AOL employee is 38 years old; spouses are a few years younger.

41.5
41
38 40.8
40.5
40
39.5
39
Years

38.5
38
37.5
37
36.5
AOL Employees National Average

Growing average family size: The average family size grew by 2.5% in 2006, an upward trend
consistent with prior years.

Many high-risk pregnancies: 86% of program participants are categorized as high-risk.

14%

High-Risk Pregnancy
86%
Healthy Pregnancy

Due to the availability of an infertility benefit, which allows older women and women with preexisting
health problems to become pregnant, AOL has a higher-than-average rate of high-risk pregnancies.

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 AOL’s WellBaby Program

Description of the Program

AOL’s WellBaby program includes three components: a
The WellBaby Program
preconception program, a pregnancy program, and a lactation provides a high-touch,
program. Each program addresses the specific health issues and high-tech approach to
topics relevant to having a healthy baby. pregnancy health
promotion.
Preconception Program
AOL’s preconception program is intended for couples planning a
pregnancy, as well as those planning to undergo infertility treatment. A care manager assigned to the
woman and her partner assesses the woman’s health history and makes individual recommendations
and referrals. As a part of the preconception program, AOL provides a monthly newsletter, free and
confidential webinars on key issues, and private consultations on the following topics:
• The science of getting pregnant.
• Preconception planning.
• Pregnancy.
• Nutrition and healthy lifestyle choices.
• Infertility treatment.
• Financial and emotional considerations.

Pregnancy Program
The pregnancy program is designed to educate and support pregnant employees, beneficiaries, and
non-beneficiary dependants and their families. This program supports improved birth outcomes
for the AOL family by combining education on health benefit offerings with health screenings, and
guidance on preventive care.

Care managers provide support to improve the adoption of healthy behaviors, and increase prenatal
and postpartum treatment compliance. They also work to improve the comprehension and retention of
health information provided by the program and the woman’s personal physician. For example, pregnant
women receive same day or next-day phone calls if the care manager is aware of a problem (e.g., missed
appointment, test result indicating a problem with the fetus). WellBaby staff assess the problem, and
if needed, make sure the participant contacts her physician for additional information. Care managers
immediately answer any questions about the care or treatment recommended by the woman’s physician.
In some cases (and with the woman’s permission), the care manager schedules appointments and contacts
her healthcare provider to make sure the woman gets necessary follow-up care.

Lactation Program
The lactation program assists employees and their infants in breastfeeding as long as possible.
Women are enrolled in the program for as long as they breastfeed, and participation often
continues through an infant’s first year of life. The program provides worksite lactation benefits,
comprehensive on- and off-site lactation counseling, group lactation classes, and tailored support.

Worksite lactation benefits include lactation rooms in every building on the AOL campus, two
types of hospital-grade breast pumps in each room, and flexible break times to pump throughout
the workday. Participants are also eligible to receive in-person consultations on breastfeeding and
breastfeeding techniques in their homes or at the worksite.

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Health education and support messages on breastfeeding are sent through Instant Messenger (AIM),
emails, telephone calls, and the monthly WellBaby newsletter. In addition to breastfeeding support,
the education messages include information on incorporating solid food into a baby’s diet, and
weaning the baby from breast milk. Helpful tips are also provided on working while breastfeeding.

Outline of WellBaby Program Components

Registration
• A WellBaby Program staff member gathers basic information from the beneficiary:
m Name
m Email
m Phone number--both home and work
• A welcome email and overview of the program is sent to the participant.
• An initial welcome phone call is placed and the participant is screened for pregnancy risk factors.

Tailored Support and Health Education

• A care manager contacts each participant.
• Referrals to “physicians/centers-of-excellence” are provided on an as needed basis:
m Physicians with extensive cultural knowledge for various groups.
m Fertility centers with responsible implantation practices.

m Maternal-fetal specialists for participants with a high-risk assessment.

• A monthly newsletter that includes health education information on a variety of pregnancy-related topics is sent to all
participants; materials are also available at an on-site office.
m Information from the March of Dimes and the Centers for Disease Control and Prevention (CDC).
m Materials developed specifically for participants by program staff.
• Participants are invited to attended education classes in-person, by conference call, or in webinar format on
preconception, prenatal, postpartum/new baby care, and a new parents group.

Follow-Up
• Care managers contact each participant immediately after the birth of their child:
m In hospital for participants delivering at local hospitals.
m Visits to high-risk perinatal/ NICU babies at local hospitals.
m Phone call for patients delivering at other area hospitals.
m Participants are encouraged to contact their care manager whenever needed.
• Care managers contact each participant 2 months after the delivery of their child. At this time, care managers:
m Screen for postpartum depression.
m Provide lactation support.
m Assess treatment compliance.
m Discuss the participant’s postpartum visit and the importance of follow-up treatment for conditions identified during
pregnancy.
m Provide advice on family planning.

Lactation Support
m A lactation room is provided in every building and includes two types of breast pumps.
m Lactation classes are available.

m Certified lactation consultants are available to assist participants on- or off-site.

Program Incentives
• Participants earn points for participation in activities. Points can purchase gift cards at baby stores or a high-quality
breast pump for use at home.

Program Outreach
m Advertisements for WellBaby classes are posted and placed on a company-wide schedule of events.
m Advertisements are also sent out via email.
m Instant Messenger (AIM) and the telephone are used for direct communication with participants.
m Benefits packet fliers distributed during open enrollment include WellBaby program information.

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 AOL’s WellBaby Program

Program Achievements
AOL analyzes the following data points annually in order to access the achievements of the WellBaby
program:
m Number of women enrolled in the program.

m Number of prenatal visits.

m Number of prenatal prescriptions filled.

m Number of cesarean deliveries.

m Number of preterm births.

m Number of NICU days.

m Breastfeeding rate.

m Utilization of pregnancy-related healthcare services.

Since 2003, the program has succeeded in:

• Increasing program enrollment and re-enrollment for subsequent pregnancies.
• Reducing the number of premature births.
• Reducing the number of low-birthweight babies.
• Reducing child morbidity.
• Increasing the use of prenatal care.
• Increasing the fill/re-fill rate of prenatal prescriptions.
• Increasing the breastfeeding rate. In 2005, 80% of participants breastfed; in 2006 84% breastfed.

Lessons Learned
AOL continually revises its WellBaby program to meet the needs of participants. Since the program’s
re-design in 2003, AOL has learned the following key lessons:
• Be visible. Let beneficiaries know the program is available.
• Utilize independent contractors. Anticipate privacy concerns and provide an extra layer
between the employee and company management.
• Follow-up. Circle back with participants to clarify recommended treatment and increase
treatment compliance.
• Value high-touch care. Both male and female employees respond well to in-person and
personalized communication. Participants appreciate communication customized to their
specific needs.
• Enlist key players in program development activities, such as:
m Pregnant and lactating employees.

m Spouses and family members of pregnant women.

m WellBaby staff.

m Benefits staff.

m Employee assistance program (EAP) staff.

m Local physicians, nurses, and counselors.

m Local hospitals.

m Disability managers.

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Program Success
The success of the WellBaby program is based on the close relationships between the WellBaby
coach, individual care managers, and program participants.

Care managers provide individualized care and tailor the program to each participant’s unique
needs. Through regular, proactive contact, the care manager continually assesses the woman’s needs,
addresses challenges, and encourages healthy behaviors. Additionally, the care manager assists with
problem-solving as issues arise. This in-depth interaction ensures participant engagement. AOL’s visible
commitment to the program and to the health of all beneficiaries further promotes engagement.

Tips for Overcoming Barriers to Success

AOL’s WellBaby program has been tremendously successful, but it did face challenges. Below is a list
of these challenges and the solutions AOL developed to ensure continued program success.

Language/Cultural Challenges: • Distribute health literature from reliable sources in multiple languages.
Pregnant women may not understand prenatal • Select program providers with cultural understanding and experience.
care recommendations because they do not speak • Employ providers with foreign language competencies.
English. • Maintain a backup translator list.

Privacy Concerns: • Use contractors to build an extra layer between employee and
Pregnant women may not use counseling or management for pregnancy issues.
education services because they fear pregnancy • Advise participants of HIPAA compliance.
discrimination from their employer. • Create a pregnancy-friendly corporate culture.

Participant Compliance: • Set protocols for contact intervals.

Pregnant women may not follow care • Keep record of recommendations given.
recommendations because they experience barriers • Follow-up the next day after appointments or pregnancy-related events.
to getting the recommended care/treatment.

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 AOL’s WellBaby
Wellbaby Program
Program

Conclusion
AOL’s experience shows that providing high-quality education, tailored counseling and support
services, and incentives encourages beneficiaries to take a more proactive role in pregnancy and
infant health. By promoting and supporting self-care, AOL is able to control direct and indirect
costs, and improve the health of the entire AOL family.

Answering the following questions can help your company understand the benefits of investing in
pregnancy health.

Key Questions to ask when Considering a Well-Baby Program

• What percent of your company’s health claims are pregnancy-related?
• What percent of your company’s employee population are women of childbearing-age
(women aged 18 to 44 years)?
• How many women of childbearing-age are enrolled in your company’s health plans?
• What percent of beneficiaries give birth to low-birthweight babies? Is this number higher
than the national average of 8% per year?
• What percent of beneficiaries give birth prematurely? Is this number higher than the national
average of 12.5% per year? (Prematurity is defined by the March of Dimes as birth before 37
weeks gestation.)
• What is your retention rate for women following the birth of a child? Is retention following
birth a concern to your company?
• Are you seeing high claims for sick-baby care in the first year of life?
• Are sick babies keeping your employees out of work?
• Would a well-baby program attract highly-skilled workers?
• Under what circumstance might a well-baby program add value to your organization?

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