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The American Journal of Managed Care August 2014
Personalized Preventive Care Reduces Healthcare Expenditures Among Medicare Advantage Beneficiaries
Shirley Musich, PhD; Andrea Klemes, DO, FACE; Michael A. Kubica, MBA, MS; Sara Wang, PhD; and Kevin Hawkins, PhD
Impact of Hypertension on Healthcare Costs Among Children
Todd P. Gilmer, PhD; Patrick J. O'Connor, MD, MPH; Alan R. Sinaiko, MD; Elyse O. Kharbanda, MD, MPH; David J. Magid, MD, MPH; Nancy E. Sherwood, PhD; Kenneth F. Adams, PhD; Emily D. Parker, MD, PhD; and Karen L. Margolis, MD, MPH
Tracking Spending Among Commercially Insured Beneficiaries Using a Distributed Data Model
Carrie H. Colla, PhD; William L. Schpero, MPH; Daniel J. Gottlieb, MS; Asha B. McClurg, BA; Peter G. Albert, MS; Nancy Baum, PhD; Karl Finison, MA; Luisa Franzini, PhD; Gary Kitching, BS; Sue Knudson, MA; Rohan Parikh, MS; Rebecca Symes, BS; and Elliott S. Fisher, MD
Potential Role of Network Meta-Analysis in Value-Based Insurance Design
James D. Chambers, PhD, MPharm, MSc; Aaron Winn, MPP; Yue Zhong, MD, PhD; Natalia Olchanski, MS; and Michael J. Cangelosi, MA, MPH
Massachusetts Health Reform and Veterans Affairs Health System Enrollment
Edwin S. Wong, PhD; Matthew L. Maciejewski, PhD; Paul L. Hebert, PhD; Christopher L. Bryson, MD, MS; and Chuan-Fen Liu, PhD, MPH
Contemporary Use of Dual Antiplatelet Therapy for Preventing Cardiovascular Events
Andrew M. Goldsweig, MD; Kimberly J. Reid, MS; Kensey Gosch, MS; Fengming Tang, MS; Margaret C. Fang, MD, MPH; Thomas M. Maddox, MD, MSc; Paul S. Chan, MD, MSc; David J. Cohen, MD, MSc; and Jersey Chen, MD, MPH
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Katy B. Kozhimannil, PhD, MPA; Laura B. Attanasio, BA; Judy Jou, MPH; Lauren K. Joarnt; Pamela J. Johnson, PhD; and Dwenda K. Gjerdingen, MD
Synchronization of Coverage, Benefits, and Payment to Drive Innovation
Annemarie V. Wouters, PhD; and Nancy McGee, JD, DrPH
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Arne Beck, PhD; A. Lauren Crain, PhD; Leif I. Solberg, MD; Jürgen Unützer, MD, MPH; Michael V. Maciosek, PhD; Robin R. Whitebird, PhD, MSW; and Rebecca C. Rossom, MD, MSCR
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Optimizing Enrollment in Employer Health Programs: A Comparison of Enrollment Strategies in the Diabetes Health Plan
Lindsay B. Kimbro, MPP; Jinnan Li, MPH; Norman Turk, MS; Susan L. Ettner, PhD; Tannaz Moin, MD, MBA, MSHS; Carol M. Mangione, MD; and O. Kenrik Duru, MD, MSHS
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Shun-Mu Wang, MHA; Pei-Tseng Kung, ScD; Yueh-Hsin Wang, MHA; Kuang-Hua Huang, PhD; and Wen-Chen Tsai, DrPH
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Optimizing Enrollment in Employer Health Programs: A Comparison of Enrollment Strategies in the Diabetes Health Plan

Lindsay B. Kimbro, MPP; Jinnan Li, MPH; Norman Turk, MS; Susan L. Ettner, PhD; Tannaz Moin, MD, MBA, MSHS; Carol M. Mangione, MD; and O. Kenrik Duru, MD, MSHS
An automatic enrollment strategy for health insurance programs may not only increase the total number of enrollees but may also decrease some enrollment disparities.


Many health programs struggle with low enrollment rates.


To compare the characteristics of populations enrolled in a new health plan when employer groups implement voluntary versus automatic enrollment approaches.

Study Design

We analyzed enrollment rates resulting from 2 different strategies: voluntary and automatic enrollment. We used regression modeling to estimate the associations of patient characteristics with the probability of enrolling within each strategy. The subjects were 5014 eligible employees from 11 self-insured employers who had purchased the Diabetes Health Plan (DHP), which offers free or discounted copayments for diabetes related medications, testing supplies, and physician visits. Six employers used voluntary enrollment while 5 used automatic enrollment. The main outcome of interest was enrollment into the DHP. Predictors were gender, age, race/ethnicity, dependent status, household income, education level, number of comorbidities, and employer group.


Overall, the proportion of eligible members who were enrolled within the automatic enrollment strategy was 91%, compared with 35% for voluntary enrollment. Income was a significant predictor for voluntary enrollment but not for automatic enrollment. Within automatic enrollment, covered dependents, Hispanics, and persons with 1 nondiabetes comorbidity were more likely to enroll than other subgroups. Employer group was also a significant correlate of enrollment. Notably, all demographic groups had higher DHP enrollment rates under automatic enrollment than under voluntary enrollment.


For employer-based programs that struggle with low enrollment rates, especially among certain employee subgroups, an automatic enrollment strategy may not only increase the total number of enrollees but may also decrease some enrollment disparities.

Am J Manag Care. 2014;20(8):e311-e319

The Diabetes Health Plan included variation in enrollment strategy across employer groups, with some using voluntary enrollment and others using automatic enrollment.

• Utilizing voluntary enrollment, 35% of eligible employees were enrolled, and annual income ≥$125,000 and black race were associated with much higher rates of enrollment.

• Utilizing automatic enrollment, 91% of eligible employees were enrolled, and dependents and employees of Hispanic ethnicity were somewhat more likely to be enrolled than other employees.

• Automatic enrollment strategies can increase overall enrollment and provide participants with the opportunity to “opt out,” and may also decrease some enrollment disparities.

Despite extensive recruitment efforts by health plans, state and local governments, and other stakeholders, many eligible individuals do not voluntarily enroll in health promotion or insurance benefit programs designed to improve health outcomes.1 Employers are increasingly sponsoring wellness programs as a way to possibly decrease costs and increase productivity across a large component of the workforce.2 However, despite the use of various approaches, enrollment in wellness programs often remains low.3-5 Although many of these programs and benefits may improve access and outcomes among the subset of persons who are enrolled, with limited reach they are unlikely to improve the health of the overall targeted population.6

Many employer health programs use a voluntary enrollment approach, which employees must actively join in order to be enrolled. However, voluntary program enrollees may have different demographic characteristics than the underlying population, in terms of gender, age, race/ethnicity, income, risk for chronic conditions or disability, and other factors.7 Voluntary program enrollees may also have different clinical characteristics than the underlying population, potentially representing either the “worried well” who may have less need for services or a sicker subgroup motivated to enroll because of the severity of their underlying condition. A recent review of enrollment into a variety of public benefit programs identified multiple barriers to voluntary enrollment and suggested automatic enrollment of all eligible participants as a preferential strategy.8 There is little current, “real-world” data on patient-level differences comparing “voluntary” and “automatic” enrollment approaches. Such information may be useful in the design of future health promotion or insurance benefit programs.

Data from the rollout of the SHP at 11 self-insured employers of the Diabetes Health Plan (DHP)—the first disease-specific health insurance plan for employees and their covered dependents with diabetes or prediabetes—provides a unique opportunity to assess the effectiveness of these 2 enrollment strategies. The DHP is offered by different employer groups, some using a voluntary enrollment approach requiring employees to sign up, others an automatic enrollment approach that directly enrolls all eligible employees. We hypothesized that the automatic enrollment strategy would enroll a larger and more representative sample of the underlying population, compared with the voluntary enrollment strategy.


Study Design, Setting, and Participants

The Diabetes Health Plan (DHP), initiated in 2009, represents an innovative approach to care for individuals with diabetes or prediabetes.9 Purchased by several medium and large self-insured employers across the United States, the DHP eliminates or reduces co-payments for medications and physician visits in order to incentivize evidence-based care. Eligible employees and their eligible covered dependents have the option of maintaining their standard plan or switching to a DHP plan. The latter adds DHP benefits to the standard plan while maintaining the same premium cost to the employee. The DHP also includes enhanced access to wellness programs at no additional cost to the employee. Table 1 shows the variations in features between the DHP and the standard plan.

In addition to these program benefits, the DHP was originally designed by the health plan to include several requirements to be met each year in order to maintain enrollment for the following year. These “compliance criteria” were ultimately determined by each employer, but potentially included a combination of the following: laboratory evaluations such as biannual A1C testing, annual cholesterol blood testing and/or annual microalbuminuria screening, biannual primary care visits, annual retinal exams, biannual mammography, and/or colon cancer screening for persons aged 50 years or more. Required tests were offered free to the enrolled DHP member.

Although the DHP enrolled both employees with diabetes and prediabetes, the current analysis is limited to the sample with diabetes. In order to be considered eligible for the DHP, an employee (or dependent) with diabetes had to meet at least 1 of the following criteria during the prior 1 year: (1) 1 or more medical claims with an International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis code of 250.xx from a doctor’s office, clinic visit, or inpatient hospital stay; (2) any glycated hemoglobin (A1C) value of ≥6.5%, fasting plasma glucose >125 mg/dL, or 2-hour oral glucose tolerance test ≥200 mg/dL; (3) any prescription filled for insulin or an oral antiglycemic agent other than metformin; (4) direct referral from a medical provider or as a result of onsite biometric screenings.

When the DHP was first introduced in early 2009, all participating employer groups offered the plan under a voluntary enrollment strategy. Some employers limited DHP eligibility to persons who had existing diagnoses of diabetes and these persons could voluntarily enroll. Other employers offered on-site biometric screenings to detect new cases of diabetes, and allowed those with either new or existing diagnoses to voluntarily enroll.

Employer groups initially offering the DHP in late 2009 and 2010 had the option to enroll employees using an automatic enrollment approach. Each employer identified the eligible employees based on the criteria described above and notified them of their eligibility. Eligible individuals were automatically enrolled in the DHP at the beginning of the next enrollment period unless they made an active decision to opt out in favor of having a standard health plan. The opt-out process was relatively simple for individuals who preferred to remain in the standard health plan, usually involving a short form that could be returned to their designated DHP representative.

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