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Evive Health and Workplace Influenza Vaccinations

Prashant Srivastava, co-founder and Chief Operating Officer of Evive Health, and Jennifer Lindner, Creative Director of Evive Health, paced around a small conference room at their company's Chicago offices, tossing around ideas. It was September 2009, the beginning of a flu season, and Evive was gearing up for its yearly outreach to encourage clients' employees to obtain influenza vaccinations (flu shots). Here was an opportunity for Evive not only to deploy its novel approach for increasing consumer engagement in health care, but also to prove that its techniques were effective at driving better health behaviors.

Evive Health

Srivastava founded Evive Health in 2007 with Chief Executive Officer Peter Saravis because they saw a way to address major shortcomings in the way that Americans used the health care system. The medical profession provided clear guidance that patients should adopt a range of health-promoting behaviorsfrom getting screened for serious illnesses to engaging in preventive health measures to taking prescription medications as directed. However, even though these recommended behaviors improved health and quality of life, many individuals failed to follow the recommendations. For example, Centers for Disease Control and Prevention (CDC) guidelines indicated that all adults who were at least 50 years old should be screened regularly for colorectal cancer, but about one-third of this population did not follow the guidelines, despite the fact that early detection enables highly effective treatment.1 "When you looked at the data, the numbers were shocking," said Srivastava. "In one area after another, people were falling far short of best practices in their health behaviors. The problem wasn't that companies were not offering good health benefits; the problem was that employees simply weren't taking advantage of what was available to them. The main reason for this was in the messaging from the employers. It was too generic and wasn't resonating in a way that motivated action."

Evive addressed the problem of poor health behavior by harnessing two emerging trends in the health care sector: the "big data" revolution and the application of behavioral economics to the health setting. The company built a platform to ingest the large volumes of administrative data that are

1Centers for Disease Control and Prevention, "Colorectal Cancer Screening Rates Remain Low," November 5, 2013, http://www.cdc.gov/media/releases/2013/p1105-colorectal-cancer-screening.html, accessed February 20, 2016.

Professor John Beshears prepared this case. It was reviewed and approved before publication by a company designate. Funding for the development of this case was provided by Harvard Business School and not by the company. HBS cases are developed solely as the basis for class discussion. Cases are not intended to serve as endorsements, sources of primary data, or illustrations of effective or ineffective management.

Copyright 2016 President and Fellows of Harvard College. To order copies or request permission to reproduce materials, call 1-800-545-7685, write Harvard Business School Publishing, Boston, MA 02163, or go to www.hbsp.harvard.edu. This publication may not be digitized, photocopied, or otherwise reproduced, posted, or transmitted, without the permission of Harvard Business School.

916-044Evive Health and Workplace Influenza Vaccinations

created by each health care provider for the primary purpose of facilitating payments from health insurers. The platform decoded this information to construct each individual's health history for use in messaging interventions. By applying evidence-based rules, Evive was able to identify targets for each recommended health behavior. Then, when communicating with individuals (for example via email or mailed letter), Evive designed the message using the principles of behavioral economicsthe field that combines insights from economics and psychology to understand how people make choices, why they sometimes make mistakes, and what can be done to produce better decisions. Finally, the regular receipt of health care data enabled Evive to evaluate the effectiveness of individual interventions.

Lindner described the benefits of Evive's approach:

First, the analytics enable us to get the timing right, and timing is critical. If you send someone a health-related message when that message doesn't apply, you've wasted an opportunity to change that person's behavior. Second, the behavioral science insights help us maximize the impact from the brief moments when we have someone's attention. To give a quick example, people respond much more to a message framed as a letter from a doctor than they respond to a message framed as an informational brochure, even when both messages explain the same facts. Finally, the analytics complement the behavioral economics. We know that different demographic groups respond more to different behavioral messaging, and as we learn about a person, we can even tailor the behavioral messaging to be most compelling to that individual. Personalization matters a lot for the ultimate effect on behavior.

Evive's customershealth insurance plans and large self-insured employersbore the financial costs of poor health behavior among their populations, namely expensive treatments for potentially avoidable conditions. To combat this, Evive deployed its communication strategies through a variety of channels (emails, text messages, letters in the mail) and sometimes incorporated additional items, such as magnets to be placed on refrigerators or sticky notes (small pieces of paper with adhesive on the back), to serve as reminders. These strategies were successful at encouraging recommended behaviors and thus helped individuals avoid costly health conditions, creating a win-win-win scenario for those individuals, their health plan or employer, and Evive. After deploying an intervention, Evive conducted data analysis and reported back to the client on the response to the intervention and the financial savings that resulted from avoided medical costs. "The follow-up analysis allows us to show our client that we're driving improvements in behavior, cost savings, and better health outcomes," explained Srivastava. "At the same time, it allows us to learn what is working and what isn't, which informs our next campaign, especially when we work with the same company again."

The Challenge

Srivastava and Lindner were thrilled when one of their clients, a large utility company located in the Midwest, asked Evive to lead the campaign encouraging employees to obtain flu shots for the 2009- 2010 flu season.

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In the United States, influenza causes more than 8,000 deaths per year2 and more than 200,000 hospitalizations per year.3 Flu shots reduce the incidence of mortality, hospitalization, and other negative health effects.4 Despite the benefits of vaccination, however, many employees of the utility company failed to obtain flu shots. During the 2008-2009 flu season, only approximately one-third of employees received flu shots at workplace vaccination clinics, even though the clinics offered these flu shots free of charge.

The utility company was eager to increase the take-up of flu shots. Winter storms in the Midwest often knocked down electrical power lines, and employee absences due to illness made it challenging for the company to restore power and provide other services to customers. Approximately 10,000 employees worked at the company, and more than 3,000 of those employees were in the group for whom the CDC guidelines recommended vaccination. The company asked Evive to focus particular attention on promoting flu shot take-up among that group.

The company was again offering free flu shot clinics for the upcoming flu season, with the clinics scheduled to take place at 62 different office locations. At the company's headquarters and at other offices with large numbers of employees, the clinics would be open for several days during business hours. For the offices with the fewest employees, the clinics would be available only for a few hours on a particular day. If employees missed the workplace clinics or did not wish to obtain flu shots there, they could pay a small fee to obtain a flu shot at a pharmacy or at a doctor's office, and the company's health insurance plans would cover the rest of the cost.

Srivastava and Lindner focused on two objectives as they discussed possible designs for the flu shot campaign. They wanted to incorporate ideas from behavioral economics to drive higher attendance rates at the workplace clinics, and they wanted to implement the campaign in a way that would allow them to develop unique insights that would inform future interventions (for flu shots and beyond). Success on both of these dimensions would strengthen Evive's relationship with the utility company and would help Srivastava and Lindner demonstrate the value of Evive's expertise to other potential clients and for other projects.

Many possible approaches came to mind, but Srivastava and Lindner had to decide: What approach should they use to increase flu shot take-up, and how should they roll out the intervention so that they can measure the success of the approach and learn how to make future interventions even more impactful?

2William W. Thompson, David K. Shay, Eric Weintraub, Lynnette Brammer, Nancy Cox, Larry J. Anderson, Keiji Fukuda, "Mortality Associated With Influenza and Respiratory Syncytial Virus in the United States," JAMA: The Journal of the American Medical Association 289 (January 8, 2003): 182.

3William W. Thompson, David K. Shay, Eric Weintraub, Lynnette Brammer, Carolyn B. Bridges, Nancy J. Cox, Keiji Fukuda, "Influenza-Associated Hospitalizations in the United States," JAMA: The Journal of the American Medical Association 292 (September 15, 2004): 1335.

4 Peter A. Gross, Alicia W. Hermogenes, Henry S. Sacks, Joseph Lau, Roland A. Levandowski, "The Efficacy of Influenza Vaccine in Elderly Persons," Annals of Internal Medicine 123 (October 1, 1995): 518.

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