Top-Tier Health Plans and Wellness Programs for People with Diabetes – An Employer's Handbook
By Karena Yan
By Karena Yan
Millions of people either with diabetes or at risk of developing diabetes are covered by an employer-based healthcare plan. Employers should think about choosing the best health plans and wellness programs that will maximize productivity and allow their employees to live happy and healthy lives.
Editor's Note: Updated on March 4, 2021
People with diabetes make up a significant portion of the workforce in the US. Over 34 million Americans have type 1 or type 2 diabetes – roughly 10.5% of the adult population – and an additional 88 million have prediabetes – about 34.5% of US adults. Furthermore, over 157 million people in America get health insurance through their employer, that means about 45% of them, or 70 million, have diabetes or prediabetes.
The COVID-19 pandemic has exposed many inequities in our system, and many employers may be looking for better ways to invest in the health of their employees, contractors, and community members. If you are such an employer, this article is for you. If you work at a company that might be in need of information like this, then we hope you will take this article to your employer and start a conversation with them about which of the following recommendations might fit your workplace.
Undermanaged diabetes can lead to challenging and expensive health complications, including conditions like severe hypoglycemia, DKA, heart attacks, strokes, heart failure, kidney failure, amputations and blindness. For the sake of employee health and productivity, it’s critical that employers choose health plans and wellness programs that provide not only proper coverage and care for people with diabetes but smart care that helps to avoid these preventable and expensive complications.
People with diabetes are at an increased risk of developing both short-term and long-term complications if they don’t have sufficient and affordable access to medications, technology, healthcare visits, as well as optimal and understandable data that drives health success. A health-conscious work environment is integral to this process. With access to plans that provide easy paths to the best care, people with diabetes and employers can forge successful partnerships together.
In “The Costs of Diabetes,” the ADA explains that diabetes accounts for $327 billion of spending in the US each year – $90 billion of which comes from lost productivity. Inadequate diabetes care can be improved, with the help of employers, so that people with diabetes have better health and the entire system spends less! This is especially true for short-term costs – like complications from severe hypoglycemia and hyperglycemia that result in lost productivity and absenteeism – that have a direct impact on a company’s bottom line.
Below, you will find diaTribe’s recommendations for top-tier employer health plans and wellness programs. These guidelines outline the type of coverage people need to optimally manage their diabetes and maintain happy and productive lives, both personally and professionally. Additionally, these recommendations apply to health plans that cover employees with diabetes as well as their dependents, such as their spouse or children, whose health significantly affects an employee’s productivity and well-being as well.
If you’re an employer, we strongly encourage you to incorporate these components into your company health plans to give your employees with diabetes the best opportunities to stay healthy, maintain productivity, and lower overall plan costs.
If you’re a person with diabetes, we urge you to share this article with your employer and HR department to alert them to what people with diabetes need in an insurance plan, and how these health and wellness programs can benefit companies and employees alike.
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Top-Tier Health Plans for People with Type 1 Diabetes and Type 2 Diabetes – a Dozen Ways to Imagine Better Employer Coverage
To provide the best healthcare coverage for people with type 1 or type 2 diabetes, employers should consider including the following components in their health plans for both their employees and their employees’ dependents. These are listed roughly in order of impact, and almost all can be accomplished through negotiating with your health plan’s Pharmacy Benefit Manager (PBM).
1. Add insulin to the preventive drug list.
Insulin is a life-sustaining medicine for all people with type 1 diabetes and many with type 2. In fact, one in five people with diabetes use insulin every day.
In July 2019, the IRS ruled that chronic disease management can be covered pre-deductible in high deductible health plans. This paved the way for insulin to be added to a plan’s preventive drug list because it helps prevent or slow the progression of diabetes-related complications and death.
By labeling it as a preventive medicine, employers exempt insulin from the annual deductible. This means that when an employee submits a prescription for insulin, it will be covered as if they have already met the deductible, so they will only be responsible for paying either a copayment or coinsurance. In the best-case scenario, employers can completely eliminate employee cost-sharing for insulin, making it free for the employee.
2. Directly pass rebates and discounts to individuals – or better yet, move away from rebates entirely.
The list price of a drug is the drug price set by the manufacturer. The net price, on the other hand, is the price after rebates and discounts are subtracted from the list price. These rebates and discounts are negotiated with the manufacturer by the Pharmacy Benefit Manager (PBM) on behalf of an insurance plan or employer.
Sometimes, employers or PBMs will pocket the rebates and discounts themselves. However, better health plans pass on the rebates and discounts directly to the individual at the pharmacy counter, meaning that the person’s out-of-pocket costs reflect the lower net price rather than the inflated list price.
If the health plan’s cost-sharing mechanism is coinsurance, passing on rebates will save people money. Coinsurances are a percentage of the drug’s price, so passing on rebates means the coinsurance (AKA the out-of-pocket costs for the drug) will be calculated based on the net price rather than the list price.
If the health plan uses copays instead of coinsurance, the out-of-pocket cost will always be a fixed amount, regardless of whether rebates are passed through and whether the net price or list price is used. In other words, plans that use copays make the rebate model irrelevant – the best case scenario for patients.
3. Cover the full range of FDA-approved insulin pumps and continuous glucose monitors (CGM).
People who use insulin make dosing decisions throughout the day based on their carbohydrate intake, physical activity, and stress levels, among other variables. It is essential that they have access to the full range of tools to support their blood sugar management efforts. Insulin pumps and CGMs can make monitoring blood glucose and injecting insulin significantly easier, but these devices are not “one size fits all.” By covering the full range of these devices, employees will be able to have freedom of choice and use the device that best meets their needs, thus improving diabetes management.
While insulin pumps are used only by people with diabetes who take mealtime insulin, CGM can benefit all people with diabetes. CGM provides users with real-time glucose levels and trends, and alerts when glucose levels drop or rise below a preset threshold – all of which is very helpful to staying healthy and in range. If the person experiences hypoglycemia or severe hypoglycemia, access to CGM can help determine ways to reduce the hypoglycemia.
If you’re an employer, you can negotiate with your PBM to ensure open access to CGMs and BGMs for your employees. For insulin pumps, negotiate with your major medical insurance network, which is responsible for durable medical equipment.
4. Set cost sharing as a low, fixed dollar copayment instead of coinsurance percentages.
If a drug, such as insulin, is exempt from the deductible, employers can either share the cost of the drug with the employee – through a copay or coinsurance – or pay the full cost themselves. On the other hand, if a drug is not exempt from the deductible, employees must pay for the full price of their medication until the deductible is met, after which they will transition to sharing the costs.
Regardless of whether a medication is exempt from the deductible, copays are a better option for the person because they are more predictable. Whereas copays are a flat fee that an individual pays per prescription, coinsurance is a percentage of the drug’s price, which is subject to large fluctuations, especially if rebates and discounts aren’t passed through.
5. Cover all FDA-approved SGLT-2 inhibitors, GLP-1 agonists, and DPP-4 inhibitors for people with type 2 diabetes.
These glucose-lowering medications are approved for type 2 diabetes. Because each has different side effects and different efficacies depending on the user, it is important for employers to cover the full range of therapies so employees can work with their healthcare team to find the most effective treatment. Moreover, SGLT-2s and GLP-1s are cardio-protective and renal-protective, meaning they decrease the risk of developing costly complications like heart and kidney disease.
Most health plans today cover only one or two drugs in each category (SGLT-2, GLP-1, and DPP-4) in their formulary, which is a list that dictates the coverage and out-of-pocket costs for medications. This is not ideal for patients for two reasons. First, if a health plan changes formularies, patients may be forced to switch medications – this is called non-medical switching. For example, if a plan originally covered Jardiance as their SGLT-2 inhibitor but then switches to Invokana, people who were familiar with and stable on Jardiance will be forced to change medications. Second, many plans will require that a person fail to improve on metformin before allowing them to change to the more expensive alternatives.
“This may make sense on the surface until you realize that this happens when people change employers and now have to go back to a drug that failed them 5 years ago. In both of these cases, we need to move back to prescriber prevails. The doctor should be able to prescribe what is best for the patient and not what is best for the insurance company,” says George Huntley, COO of Theoris and CEO of the Diabetes Leadership Council.
Thus, health plans should cover the full-range of SGLT-2s, GLP-1s, and DPP-4s to provide stability for people with diabetes and allow them to find the best fit for them. Moreover, this will save employers money by ensuring a healthier and more productive workforce and by reducing the costs of diabetes complications due to noncompliance.
Note: all plans should also cover metformin, and this is almost always already the case.
6. Give people with diabetes access to mental health counseling.
People with diabetes have an increased risk of developing depression. In turn, depression and diabetes distress can also make it more difficult for people to successfully manage their condition and prevent diabetes complications. Thus, health plans that cover mental health visits can improve both the emotional and physical well-being of employees.
7. Provide people with diabetes access to nutrition counseling.
While eating a healthy diet and staying active is important for everyone, food and exercise play an even greater role in managing day-to-day health for people with diabetes. Nutrition counseling with a dietician at least once a year can help people with diabetes figure out culturally-relevant meals and diets that help them manage their blood sugar, blood pressure, and cholesterol, while also working within their preferences, budget, and schedule.
Nutrition counseling can also be incorporated into a workplace wellness program.
8. Offer the Diabetes Prevention Program (DPP) as a covered benefit to people at risk for prediabetes and type 2 diabetes.
Employers can play an active role in prevention, which is key to keeping all employees healthy and reducing healthcare costs. The DPP is a CDC-recognized lifestyle change program that can help prevent or delay the onset of type 2 diabetes. In people with prediabetes, the DPP has been shown to reduce their risk of developing type 2 diabetes by 58% (71% for people over 60 years old).
Moreover, one study found that DPP participants who received coverage for the program through their health plan achieved better outcomes in attendance and average weight loss than did those who paid out of pocket or through a grant. DPP programs can be offered at in-person community gatherings, online, and even at the workplace, where coaches can deliver sessions.
9. Offer mobile diabetes coaching services.
Mobile coaching services offer another way for employers to engage in diabetes prevention and management. Found online or as apps, these services help connect people with diabetes to healthcare professionals virtually, in real time. Mobile coaching can provide health, nutrition, exercise, weight management, and mental health support through remote, 24/7 care.
Many coaching services help improve health outcomes. In a study of more than 2,000 adults at risk for type 2 diabetes, Livongo’s digital Diabetes Prevention Program led to an average weight loss of 5.1% (about ten pounds) after one year using the program. In a study of 262 participants with type 2 diabetes using Virta Health’s program, 54% achieved “diabetes reversal” (defined by Virta as an A1C below 6.5% and no diabetes medications other than metformin).
There are many more companies that provide these services, some of which are offered directly to the patient (no insurance necessary) and others that are offered through a health plan. Many programs are offered in multiple languages, and some include unlimited test strips with their service.
10. Cover emergency glucagon for people with type 1 diabetes or people with type 2 diabetes on insulin.
Glucagon, which helps convert stored energy in the body to blood glucose, can be lifesaving during severe hypoglycemia. It is essential for people who use insulin to have glucagon on hand in case of an emergency.
Recent advances in glucagon have made it significantly easier to administer in emergency situations, including glucagon in the form of autoinjector pens and nasal sprays. Health plans should cover all forms of glucagon, especially the newer versions, to reduce the risks of untreated severe hypoglycemia.
11. Cover FDA-approved blood glucose meters (BGM) and unlimited glucose test strips, as well as other diabetes supplies such as alcohol swabs, lancets, syringes, needles, and gauze.
Especially if CGM is not covered for people with type 1 and type 2 diabetes, health plans should cover blood glucose meters, unlimited test strips, and other diabetes supplies used alongside insulin. Providing unlimited test strips removes any potential burden of rationing strips and gives people the freedom to frequently check their blood sugar levels to better avoid hyperglycemia and hypoglycemia.
12. Cover A1C checks, blood pressure and cholesterol checks, eye screenings, kidney screenings, and foot checks.
While almost all health plans cover these screenings and checks today, they are still important to note. High blood sugar can damage the body’s blood vessels and nerves, so people with diabetes are at increased risk of eye disease (diabetes-related retinopathy), kidney disease (nephropathy), foot damage, and heart disease. To avoid these life-changing and costly complications, health plans should cover these annual – if not more frequent – screenings for people with diabetes:
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A1C checks
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Blood pressure checks
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Cholesterol and triglyceride screenings
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Dilated eye exams
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Blood and urine kidney screenings (to measure their urine albumin-to-creatinine ratio, UACR, and estimated glomerular filtration rate, eGFR)
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Foot checks
Top-Tier Workplace Wellness Programs for People with Type 1 Diabetes and Type 2 Diabetes
Workplace wellness programs are designed to promote healthy behaviors and improved health outcomes. While these programs benefit all employees, initiatives that support exercise, healthy eating, and stress management are particularly important for people with diabetes.
In addition to improving health, well-designed wellness programs can lead to cost savings and improved business performance by lowering healthcare costs, reducing absenteeism, and improving productivity. For example, Harvard researchers found that for every dollar spent on employee wellness, medical costs fell $3.27, and absenteeism dropped $2.73 – a 6-to-1 return on investment.
While these savings are significant, the success of a wellness program – which depends on employee participation and improvement in overall health – relies on its design. A 2015 survey found that while four out of five employers (80.6%) provided wellness programs to their employees, fewer than half of the employees surveyed (45.0%) reported having access to these programs. This may suggest that the program offerings were not adequately robust or that communications about the programs were not effective. In either case, low levels of awareness and engagement weaken the programs’ ability to improve workforce health.
Employers must carefully craft their wellness programs to promote widespread participation within the company and produce a significant impact on employee well-being and healthcare cost savings. Below are the best practices for employers when creating their workplace wellness programs.
1. Offer voluntary biometric screenings and health risk assessments (HRAs).
Biometric screenings and HRAs evaluate a person’s health and risk factors by taking measurements such as height, weight, blood pressure, cholesterol, and blood glucose. The outcomes of these assessments can inform the design and focus of workplace wellness programs, and they can help employees detect health problems early on and identify their personal opportunities for improvement and intervention. Moreover, by following the screening results with education, program resources, and action items to improve health, employers can generate immediate buy-in into their wellness programs.
It is important to couple screenings and assessments with healthcare professional follow-up and health literacy education to ensure individuals understand their results. Without ample follow-up and education, employees may not know the next steps after the assessments.
2. Establish methods to assess employee needs and gather feedback.
In addition to having biometric assessments and HRAs inform the wellness programming, employers should conduct a needs assessment through surveys or focus groups and establish pathways to gather program feedback. Taking these measures will help assess progress within the program and determine strategic changes that need to be made, understand the changing needs and profile of your workforce, and identify organizational barriers that may be counterproductive to the success of the program.
3. Offer enticing incentives for program participation and health screenings.
Offering incentives, or disincentives, is a proven method of encouraging enrollment, participation, and completion of workplace wellness programs and biometric screenings and HRAs. Whether employees respond more to programs that reward healthy behaviors or penalize unhealthy behaviors depends on each organization’s culture.
The American Heart Association found that the most effective incentive programs are generally monetary ones that reward healthy habits or improvements in health metrics in the form of cash or lower health insurance premiums. However, incentives can come in many forms, including:
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Reimbursement for all or part of the cost of a membership in a fitness center
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Reward for participating in a diagnostic testing program
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Waiving an otherwise applicable deductible or copayment to encourage preventive care
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Reimbursing the costs of smoking cessation programs
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Reward for attending a monthly health education class
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Recognition in company-wide communications or on a wellness “wall of fame”
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Competitions among individuals or company departments or business units
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Allowing company time for participation in wellness activities
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Token giveaways recognizing wellness achievements
Regulations require workplace wellness programs to offer reasonable alternatives to employees who cannot meet standards for participation due to health conditions or disabilities. Employers may defer to the individual’s healthcare professional when determining reasonable alternative standards, which could be lowering the threshold of the existing standard or substituting or waiving the standard.
4. Create supportive physical and social environments.
While incentives can activate employees to learn about health and engage in wellness offerings, incentives alone cannot sustain improvements in workforce health. Successful wellness programs must integrate wellness into the company and worksite culture to promote long-term behavioral change.
Organizational policies can be implemented to make healthy behaviors the easy, convenient, and encouraged choice. Common strategies to create a supportive environment include providing healthy food options in kitchens and at company meetings, considering ergonomics in workstation design, improving workplace structures to promote activity (such as providing treadmill desks or better lighting in stairwells), and offering gym and fitness facilities. Some workplaces also provide stress management and sleep promotion tools, such as “nap rooms” and on-site mental health counseling.
5. Improve program reach by using effective communications strategies.
Effective communication strategies can increase the awareness, appeal, and engagement of workplace wellness programs. To personalize communications to target audiences, employers can survey employees to better understand their interests, needs, and goals before tailoring messages accordingly. In addition, effective messaging employs multiple delivery channels – ranging from work emails and social media posts to building signage – and varied and sustained communications over time. Messaging should not only be simple, meaningful, and fun for your audience, but it should also provide actionable information and clear instructions for accessing program resources.
6. Make programs culturally relevant, and customize them to different health and fitness levels.
Wellness programs can only be sustainable if they accommodate each person’s health needs, backgrounds, and goals. For example, whereas some people are already in the process of making healthy lifestyle changes and are comfortable performing high-intensity workouts, others may be beginning to adopt healthy behaviors and prefer more manageable goals, such as reaching a certain number of daily steps through walking. Similarly, while some individuals may find nutritional advice straightforward and easy to incorporate into their daily meals, others may be more comfortable with foods from their own cultures that aren’t highlighted in a program’s educational efforts.
7. Garner managerial support and buy-in.
Company leadership heavily influences the culture and priorities of a company. To set the tone for a supportive culture of health, senior and midlevel managers should be vocal program advocates, actively engage in program initiatives, and personally encourage their direct reports to participate. If this is not happening in your work environment, ask your manager if you can discuss this with them.
To ensure that managers are knowledgeable enough to speak about wellness, companies should ideally provide them with training on healthy behaviors and encourage managers to pilot wellness programs to better understand the services offered. Here are a few resources that provide free training on workplace wellness:
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Centers for Disease Control and Prevention (CDC) provides a free employer-training program to promote worksite wellness through employer education and financial and technical assistance. The initiative employs certified trainers to teach employers how to start a worksite health program, from planning to evaluation, and how to engage and deliver training to other managers and company executives.
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The Art and Science of Health Promotion Institute provides free books for employers to help them launch successful wellness programs. The Institute’s goal is to use research-based methods to improve health outcomes of individuals and make the organizations they serve more successful.
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The Corporate Health and Wellness Association (CH&WA) is a national non-profit that provides many free articles on topics like the business of well-being, fitness and nutrition programs, and worksite wellness. CH&WA also provides a paid certification program in corporate wellness.
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In response to the COVID-19 pandemic, the American Heart Association also offers free employer resources for a changing workplace.
If you’re an employer, consider capitalizing on these resources to promote good health in the workplace and thereby improve the productivity and competitiveness of your company.
8. Provide comprehensive health education, including the Diabetes Prevention Program (DPP).
The best wellness programs address multiple health risks and health conditions. Programs should be designed to focus on developing healthy habits and implementing lifestyle behavior change tailored to employees’ personal needs.
To help delay or prevent the development of type 2 diabetes specifically, companies can hire digital (or when possible, on-site) DPP coaches to teach people lifestyle changes that promote healthy eating and physical activity. Other examples for education include maintaining a health bulletin board, offering cooking classes, and hiring a registered dietician to work with employees.
9. Partner with nonprofits and community health organizations.
Many health and wellness programs exist through local organizations and nonprofits. Community programs through health departments, local fitness facilities, YMCAs, and health clinics can help inform and complement your worksite offerings – see more here for some examples. Employers can also take advantage of the free resources provided by many national nonprofit organizations. For example, the American Diabetes Association offers a free, 60-second Type 2 Diabetes Risk Test online; Aunt Bertha connects people with verified free or reduced cost services (such as medical care, food delivery, job training) in their communities; The diaTribe Foundation provides many free educational resources that teach people about diabetes drugs, devices, and lifestyle tips.
Case Studies: Companies That Are Excelling at Health Plans and Wellness Programs
The following health plans and workplace wellness programs are exemplary case studies that employ many of diaTribe’s recommended components. Also recognized through various sources, including the Centers for Disease Control and Prevention (CDC) and the American Heart Association, the following health plans and programs have significant benefits for people with diabetes.
Health Plans
Kentucky Employees Health Plan (KEHP)’s Diabetes Value Benefit (DVB) Program
KEHP provides health insurance to nearly 300,000 public employees, retirees and their families – 6.6% of the state’s population. Recognizing that diabetes was one of the state’s most costly medical conditions, KEHP implemented DVB in 2016 to improve diabetes management, drug adherence, and regular healthcare visits.
The DVB program provides diabetes drugs and supplies (such as test strips) for free or at a reduced copay or coinsurance, with no deductible. In addition, KHEP provides 100% coverage of the national Diabetes Prevention Program (DPP) and coverage for the Diabetes Self-Management Education and Support (DSMES) program. Moreover, KEHP recognizes that full health requires well-being outside of diabetes management, so the health plan also includes several initiatives that focus on the physical, mental, social, and financial health of its members.
The health plan has already improved diabetes outcomes for its members. Medical costs, emergency room visits, clinical visits, acute admissions, and length of hospital stay have all decreased since DVB’s implementation. In addition KEHP saw adherence to diabetes medications increase by 8% between 2015 and 2019. This not only means that daily management of diabetes improved, but also that members were more likely to ward off complications and the need for additional medications. In fact, increased adherence is estimated to save KEHP $5-5.5 million each year.
Wellness Programs
Macy’s is a national retailer with over 120,000 employees, and its Live Healthy Program, as noted by the American Heart Association, provides a terrific example of a comprehensive wellness program.
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The program provides a $50 incentive to all employees and, if they have a partner, their enrolled partners who complete at least one of five preventive screenings, all of which are completely covered under the health plan: routine physical examination;
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annual well-woman preventive exam;
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mammogram;
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cervical cancer screening; and
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colon cancer screening.
Similarly, employees can earn a $300 incentive by completing Macy’s on-site biometric screening and health risk assessment that examines height, weight, blood pressure, cholesterol, body mass index, waist circumference, and blood sugar levels. If any result identifies a health risk, Macy’s connects the employee to a nurse who can help with chronic disease management.
Macy’s also partners with Omada Health to host a program designed to help individuals lose weight through nutrition, activity, and behavioral changes. Completion of the program is rewarded with a $300 incentive. The Live Healthy Program also provides participants the opportunity to work one-on-one with virtual health coaches 24/7 to address their specific needs, whether it be diabetes management, weight loss, tobacco cessation, or otherwise.
The Starr Group Workplace Wellness Program
The Starr Group is an insurance and risk-management agency that offers a comprehensive approach to supporting a healthy workplace.
In addition to offering biometric screenings, HRAs, and ongoing health coaching, the Starr Group places a heavy emphasis on education through their “Lunch and Learn” program. The program provides tools, classes, and nutrition and activity challenges to engage employees around topics like diabetes prevention and healthy eating.
The Starr Group generates managerial buy-in through their Wellness Committee, which includes the Executive Vice President of Starr Group, a Certified Wellness Coach, and the organization’s Wellness Coordinator. The Wellness Committee designs, tests, and implements the Group’s wellness programming to ensure that all levels of management are engaged in the health of employees.
Moreover, the Starr Group is committed to continuously improving its programs. It administers annual Culture Audits, Presenteeism Studies, Q12 Engagement Surveys, and Employee Satisfaction and Interest Surveys to track the feedback and progress of wellness programs. The results inform programming and strategy changes to best suit the employee population.
Deloitte is a multinational professional services network, and its wellness program takes a holistic, personalized approach for each of its employees.
Similar to other wellness programs, Deloitte offers a $500 annual well-being subsidy that can be used toward a number of health activities, including gym memberships and meditation classes.
However, Deloitte also uses an innovative system called Vitals, which tracks paid time off (PTO), hours worked, and business travel time. This system yields a more complete picture of an individual’s overall well-being, beyond physical health, because it allows managers to identify people at risk of burnout and intervene to help with work and stress management. Vitals allows employees to have biweekly well-being check-ins with their managers and connects individuals to counselors if they need more support.
By using systems that emphasize constructive communication and holistic well-being, Deloitte signals to employees that their health is of utmost importance.
The Bottom Line
Due to the growing diabetes epidemic, the workforce will continue to have an increasing number of people with the condition. Employers must be mindful of how their policies affect their employees’ overall health. Diabetes can be an expensive and debilitating condition, particularly when it is undermanaged or lacking proper healthcare treatment. However, with the right support and healthcare coverage from employers, every person with diabetes is capable of living happy, healthy, and successful lives.
While we recognize that not every employer may be able to include all the components on these lists, we believe that diabetes coverage should be a top healthcare priority for every business. Not only can comprehensive health plans and wellness programs help employees develop healthier lifestyles and succeed in their jobs, but a healthier workforce can also lead to fewer sick days, better productivity, increased job satisfaction, and more cost savings for employers.
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