Fit for the Job: What Can Workplace Wellness Programs Deliver?

The Evidence Base for Worksite Health Promotion and Disease Prevention ProgramsRon Z. Goetzel, Ph.D. , Emory University and Thomson Reuters HealthcareNational Health Policy ForumReserve Officers Association Friday, November 6, 2009

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U.S. Business Concerns About Healthcare

• The United States spent $2.24 trillion in healthcare in 2007, or $7,421 for every man, woman and child.

• Private employers contributed 77% to health insurance premiums, a 6.1% increase over 2006

• Private sector share of total spending is 53.7%

• National health expenditure growth trends are expected

to average about 6.6% per year through 2015.

• Health expenditures as percent of GDP:

– 7.2 % in 1970 – 16.2 % 2007 – 19.7 % in 2017 (est)– 25.0 % by 2030 (est)

Source: Hartman et al., Health Affairs, 28:1, Jan/Feb, 2009, 246.

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EMPLOYER COSTS ARE RISING RAPIDLY

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WHY IS HEALTH CARE SO EXPENSIVE?

• Rise in spending for treated diseases (37%)– Innovation/advancing technology (pharmacologic, devices,

treatments)• Newborn delivery costs – five-fold increase from 1987-2002

– NICU, incubators, ventilators, C-sections• New/better medicines for treating disease

– Depression –• SSRI introduction -- 45% treated in 1987 to 80% treated in 1997

– Allergies (Claritan, Allegra,…)• New treatment thresholds

– Blood pressure– High blood glucose– Hyperlipidemia

Ken Thorpe

Source: K.E. Thorpe, "The Rise in Health Care Spending and What to Do About It," Health Affairs 24, no. 6 (2005): 1436-1445; and K.E. Thorpe et al., "The Impact of Obesity on Rising Medical Spending," Health Affairs 23, no. 6 (2004): 480-486.

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WHY IS HEALTH CARE SO EXPENSIVE? (THORPE - PART 2)• Rise in the prevalence of disease (63%)

– About ¾ of all health care spending in the U.S. is focused on patients who have one or more chronic health conditions

– Chronically ill patients only receive 56% of clinically recommended preventive health services

• And 27% of the rise in healthcare costs is associated with increases in obesity rates

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No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

OBESITY TRENDS AMONG U.S. ADULTS1986

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No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

OBESITY TRENDS AMONG U.S. ADULTS1987

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No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

OBESITY TRENDS AMONG U.S. ADULTS1988

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No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

OBESITY TRENDS AMONG U.S. ADULTS1989

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No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

OBESITY TRENDS AMONG U.S. ADULTS 1990

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No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

OBESITY TRENDS AMONG U.S. ADULTS 1991

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No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

OBESITY TRENDS AMONG U.S. ADULTS 1992

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No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

OBESITY TRENDS AMONG U.S. ADULTS 1993

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No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

OBESITY TRENDS AMONG U.S. ADULTS 1994

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No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

OBESITY TRENDS AMONG U.S. ADULTS 1995

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No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

OBESITY TRENDS AMONG U.S. ADULTS 1996

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No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

OBESITY TRENDS AMONG U.S. ADULTS 1997

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No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

OBESITY TRENDS AMONG U.S. ADULTS 1998

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No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

OBESITY TRENDS AMONG U.S. ADULTS 1999

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No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

OBESITY TRENDS AMONG U.S. ADULTS 2000

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No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

OBESITY TRENDS AMONG U.S. ADULTS 2001

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No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

OBESITY TRENDS AMONG U.S. ADULTS 2002

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No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

OBESITY TRENDS AMONG U.S. ADULTS 2003

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No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

OBESITY TRENDS AMONG U.S. ADULTS 2004

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No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

OBESITY TRENDS AMONG U.S. ADULTS 2005

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OBESITY TRENDS* AMONG U.S. ADULTSBRFSS, 2006

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

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OBESITY TRENDS* AMONG U.S. ADULTSBRFSS, 2007

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OBESITY TRENDS AMONG U.S. ADULTSBRFSS, 2008

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ENVIRONMENTAL CAUSES OF OBESITY

•More driving• Rise in car ownership• Increase in driving shorter distances• Less walking and bicycling

•At home, more convenience• Increase use of “labor saving” devices• Increase in ready-made foods• Increase in television viewing, computers, and video games

•At work• Sedentary occupational fields (“knowledge workers”)

•In public• More elevators, escalators, automatic doors and moving sidewalks

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• The Centers for Disease Control and Prevention (CDC) estimates…

• 80% of heart disease and stroke• 80% of type 2 diabetes• 40% of cancer

…could be prevented if only Americans were to do three things:

Stop smokingStart eating healthyGet in shape

Bottom Line: The vast majority of chronic disease can be prevented or better managed

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CONVINCE ME…

Why should an employer invest in the health and well-being of its workers?

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IT SEEMS SO LOGICAL…

…if you improve the health and well being of your employees…

…quality of life improves

…healthcare utilization is reduced

…disability is controlled

…productivity is enhanced

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THE LOGIC FLOW:

A large proportion of diseases and disorders from which people suffer is preventable;

Modifiable health risk factors are precursors to many diseases and disorders, and premature death;

Many modifiable health risks are associated with increased health care costs and diminished productivity within a relatively short time window;

Modifiable health risks can be improved through effective health promotion and disease prevention programs;

Improvements in the health risk profile of a population can lead to reductions in health costs and improvements in productivity;

Well-designed and well-implemented programs can be cost/beneficial – they can save more money than they cost, thus producing a positive return on investment (ROI).

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• A large proportion of diseases and disorders is preventable. Modifiable health riskfactors are precursors to a large number of diseases and disorders and to prematuredeath (Healthy People 2000, 2010, Amler & Dull, 1987, Breslow, 1993, McGinnis & Foege, 1993, Mokdad et al., 2004).

• Many modifiable health risks are associated with increased health care costs withina relatively short time window (Milliman & Robinson, 1987, Yen et al., 1992, Goetzel,et al., 1998, Anderson et al., 2000, Bertera, 1991, Pronk, 1999).

• Modifiable health risks can be improved through workplace sponsored health promotion and disease prevention programs (Wilson et al., 1996, Heaney & Goetzel, 1997, Pelletier, 1999).

• Improvements in the health risk profile of a population can lead to reductions in healthcosts (Edington et al., 2001, Goetzel et al., 1999).

• Worksite health promotion and disease prevention programs save companies moneyin health care expenditures and produce a positive ROI (Johnson & Johnson 2002,Citibank 1999-2000, Procter and Gamble 1998, Chevron 1998, California Public RetirementSystem 1994, Bank of America 1993, Dupont 1990, Highmark, 2008).

THE EVIDENCE

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Drill down…

• Medical

• Absence/work loss

• Presenteeism

• Risk factors

POOR HEALTH COSTS MONEY

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Medical, Drug, Absence, STD Expenditures (1999 annual $ per eligible),by Component

Source: Goetzel, Hawkins, Ozminkowski, Wang, JOEM 45:1, 5–14, January 2003.

$0 $50 $100 $150 $200 $250

Angina Pectoris, Chronic Maintenance

Essential Hypertension, Chronic Maintenaince

Diabetes Mellitus, Chronic Maintenance

Mechanical Low Back Disor.

Acute Myocardial Infarction

Chronic Obstructive Pulmonary Dis.

Back Disor. Not Specified as Low Back

Trauma to Spine & Spinal Cord

Sinusitis

Dis. of ENT or Mastoid Process NEC

$ per eligible employee

MedicalAbsenceDisability

TOP 10 PHYSICAL HEALTH CONDITIONS

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Using Average Impairment and Prevalence Rates for Presenteeism($23.15/hour wage estimate)

Source: Goetzel, Long, Ozminkowski, et al. JOEM 46:4, April, 2004)

THE BIG PICTURE: OVERALL BURDEN OF ILLNESS BY CONDITION

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Percent Difference in Medical Expenditures: High-Risk versus Lower-Risk Employees

Independent effects after adjustmentN = 46,02670.2

46.334.8

21.4 19.7 14.5 11.7 10.4-9.3-3.0-0.8

-50

-25

0

25

50

75

100

Perc

ent

Dep

ress

ion

Stre

ss

Glu

cose

Wei

ght

Toba

cco-

Past

Toba

cco

Blo

od p

ress

ure

Exer

cise

Cho

lest

erol

Alc

ohol

Eatin

g

INCREMENTAL IMPACT OF TEN MODIFIABLE RISK FACTORS ON MEDICAL EXPENDITURES

Goetzel RZ, Anderson DR, Whitmer RW, Ozminkowski RJ, et al., Journal of Occupational and Environmental Medicine 40 (10) (1998): 843–854.

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HEALTH RISKS AFFECT WORKERS’ PRODUCTIVITY

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EXAMINING RISK FACTORS AND PRESENTEEISM

Indicates a Statistically Significant difference between those with risk and those without risk.

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Pepsi Bottling Group – Cost of Overweight/Obese Employees

Adjusted predicted annual costs for employees by BMI

$0

$2,000

$4,000

$6,000

$8,000

$10,000M

edic

al

STD

WC

Pres

ente

eism

Abs

ence

s

Tota

lAdj

uste

d pr

edic

ted

annu

al c

ost

NormalOverweightClass IClass IIClass III

Difference between combined overweight/obese categories and normal weight is displayed

Diff = 25%, $987

Diff = 10%, $28

Diff = 7%, $49

Diff = 26%, $186*

Diff = 58%, $111*

Diff = 29%, $613*

74% of the sample are overweight or obese

*At least one difference significant at the 0.05 level

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OUTCOMES OF MULTI-COMPONENT WORKSITE HEALTH PROMOTION PROGRAM

Purpose: Critically review evaluation studies of multi-component worksite health promotion programs.

Methods: Comprehensive review of 47 CDC and author generated studies covering the period of 1978-1996.

Findings:• Programs vary tremendously in comprehensiveness, intensity & duration. • Providing opportunities for individualized risk reduction counseling, within the context of comprehensive programming, may be the critical component of effective programs.

Ref: Heaney & Goetzel, 1997, American Journal of Health Promotion, 11:3, January/February, 1997

Literature Review

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EVALUATION OF WORKSITE HEALTH PROMOTION PROGRAMS--

Worksite Health Promotion TeamRobin Soler, PhDDavid Hopkins, MD, MPHSima Razi, MPHKimberly Leeks, PhD, MPHMatt Griffith, MPH

Community Guide

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SUMMARY RESULTS AND TEAM CONSENSUS

OutcomeBody of

EvidenceConsistent

ResultsMagnitude of

Effect Finding

Alcohol Use 7 Yes Variable Sufficient

Fruits & Vegetables

% Fat Intake

711

No

Yes

0.16 serving

+8%

Insufficient

Strong

% Change in Those Physically Active

17 Yes +12.7% Sufficient

Tobacco Use

Prevalence

Cessation

2223 (9)

Yes

Yes

–2.2 pct pt

3.5 pct pt

Strong

Seat Belt Non-Use 10 Yes –35.4% Sufficient

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OutcomeBody of

EvidenceConsistent

Results Magnitude of Effect Finding

Diastolic blood pressure

Systolic blood pressure

Risk prevalence

161811

Yes

Yes

Yes

Diastolic:–1.9 mm Hq

Systolic:–3.0 mm Hg

–3.4 pct pt

Strong

BMI

Weight

% body fat

Risk prevalence

61245

Yes

No

Yes

No

–0.5 pt BMI

–0.56 pounds

–2.2% body fat

–2.2% at risk

Insufficient

Total Cholesterol

HDL Cholesterol

Risk prevalence

18711

Yes

No

Yes

–5.0 mg/dL (total)

+1.1 mg/dL

–6.6 pct pt

Strong

Fitness 5 Yes Small Insufficient

SUMMARY RESULTS AND TEAM CONSENSUS

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SUMMARY RESULTS AND TEAM CONSENSUS

OutcomeBody of

EvidenceConsistent

ResultsMagnitude of

Effect Finding

Estimated Risk 15 Yes Moderate Sufficient

Healthcare Use 6 Yes Moderate Sufficient

Worker Productivity 10 Yes Moderate Strong

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CASE STUDIES

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CITIBANK, N.A.HEALTH MANAGEMENT PROGRAM EVALUATION

• Title: Citibank Health Management Program (HMP)

• Industry: Banking/Finance

• Target Population: 47,838 active employees eligible for medical benefits

• Description:– A comprehensive multi-component health management program– Aims to help employees improve health behaviors, better manage

chronic conditions, and reduce demand for unnecessary and inappropriate health services,

– And, in turn, reduce prevalence of preventable diseases, show significant cost savings, and achieve a positive ROI.

• Citations:• Ozminkowski, R.J., Goetzel, R.Z., Smith, M.W., Cantor, R.I., Shaunghnessy, A., & Harrison, M. (2000).

The Impact of the Citibank, N.A., Health Management Program on Changes in Employee Health Risks Over Time. JOEM, 42(5), 502-511.

• Ozminkowski, R.J., Dunn, R.L., Goetzel, R.Z., Cantor, R.I., Murnane, J., & Harrison, M. (1999). A Return on Investment Evaluation of the Citibank, N.A., Health Management Program. AJHP, 44(1), 31-43.

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Program Components

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Program Participation• All 47,838 active employees were eligible to

participate.

• The participation rate was 54.3 percent.

• Participants received a $10 credit toward Citibank’s Choices benefit plan enrollment for the following year.

• Approximately 3,000 employees participated in the high risk program each year it was offered.

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CITIBANK RESULTS

Number and Percent of Program Participants at High Risk at First and Last HRA by Risk Category (N=9,234 employees tracked over an average of two years)

Ozminkowski, R.J., Goetzel, R.Z., et al., Journal of Occupational and Environmental Medicine42: 5, May, 2000, 502–511.

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CITIBANK RESULTS

*Net Improvement refers to the number of categories in which risk improved minus number of categories in which risk stayed the same or worsened.

**Impact = change in expenditures for net improvers minus change for others. Negative values imply program savings, since expenditures did not increase as much over time for those who improved, compared to all others

† p < 0.05, ‡ p < 0.01

Unadjusted Impact**

Adjusted Impact**

Net improvement* of at least 1 category versus others(N = 1,706)

-$1.86† -$1.91

Net improvement* of at least 2 categories versus others (N = 391)

-$5.34 -$3.06

Net improvement* of at least 3 categories versus others (N = 62)

-$146.87† -$145.77 ‡

Impact of improvement in risk categories on medical expenditures per month

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CITIBANK: MEDICAL SAVINGS-ADJUSTED MEAN NET PAYMENTS

$170

$212

$180

$257

$0

$50

$100

$150

$200

$250

$300

$350

Pre-HRA Post-HRA

Time Period

All Participantsn=11,219

Non-Participantsn=11,714

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CITIBANK HEALTH MANAGEMENT PROGRAM ROI• Program costs = $1.9 million*

• Program benefits = $8.9 million*

• Program savings = $7.0 million*

ROI = $4.7 in benefits for every $1 in costs

Notes:

• 1996 dollars @ 0 percent discount

• Slightly lower ROI estimates after discounting by either 3% or 5% per year.

• Results very similar to RCT conducted of same Healthtrac program, by Fries, et al.

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JOHNSON & JOHNSONHEALTH AND WELLNESS PROGRAM EVALUATION

• Title: J & J Health and Wellness Program (H & W) • Industry: Healthcare• Target Population: 43,000 U.S. based employees• Description:

– Comprehensive, multi-component worksite health promotion program

– Evolved from LIVE FOR LIFE in 1979

• Citations:• Goetzel, R.Z., Ozminkowski, R.J., Bruno, J.A., Rutter, K.R., Isaac, F., & Wang, S. (2002).

The Long-term Impact of Johnson & Johnson’s Health & Wellness Program on Employee Health Risks. JOEM, 44(5), 417-424.

• Ozminkowski, R.J., Ling, D., Goetzel, R.Z., Bruno, J.A., Rutter, K.R., Isaac, F., & Wang, S. (2002). Long-term Impact of Johnson & Johnson’s Health & Wellness Program on Health Care Utilization and Expenditures. JOEM, 44(1), 21-29.

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Lifestyle Benefit Incentive

• All employees offered Health Profile

• Employees assessed to be at risk for smoking, blood pressure or cholesterol were invited to participate in a health management program

• Health care prices discounted by $500

• Employees not participating in Health Profile or follow-up health improvement program lose the $500 discount

• Result: 94% Participation Rate

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HEALTH & WELLNESS PROGRAM IMPACT ON EMPLOYEE HEALTH RISKS (N=4,586)

66.2%

43.2%

49.6%

41.0%

45.8%

35.1%32.7%

23.9%

9.7%

1.3%4.5%

2.7% 3.5%2.9%

0%

10%

20%

30%

40%

50%

60%

70%

HighCholes.

Low FiberIntake

PoorExerciseHabits

CigaretteSmoking

High BP Seat Beltuse

Drinking& Driving

Time 1 Health ProfileTime 2 Health Profile

High Risk Group

After an average of 2¾ years, risks were reduced in eight categories but increased in four related categories: body weight, dietary fat consumption, risk for diabetes, and cigar use.

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JOHNSON & JOHNSON HEALTH & WELLNESS PROGRAM IMPACT ON MEDICAL COSTS

$224.66

$118.67

$70.89

$45.17

($10.87)

($50.00) $0.00 $50.00 $100.00 $150.00 $200.00 $250.00

OVERALL SAVINGS

Inpatient Days

Mental Health Visits

Outpatient/Doctor OfficeVisits

ER Visits

$225 Annual Medical Savings/ Employee/Year

since 1995

N=18,331 – Ozminkowski et al, 2002

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Per Employee Per Year, 1995 – 1999 -- Weighted by sample sizes that range from N = 8,927 – 18,331, depending upon years analyzed

$(100.00)

$-

$100.00

$200.00

$300.00

$400.00

$500.00

IP daysMH visitsOP visitsER visits

IP days $60.76 $94.25 $164.72 $195.80 MH visits $78.42 $55.05 $51.49 $103.43 OP visits $1.54 $23.57 $186.03 $181.27 ER visits $(12.15) $(14.43) $(7.27) $(8.06)

1 2 3 4

Years Post Implementation

INFLATION-ADJUSTED, DISCOUNTED HEALTH AND WELLNESS PROGRAM CUMULATIVE SAVINGS

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PROCTER & GAMBLE

0200400600800

10001200140016001800

Year 1 Year 2 Year 3

Participants Non-Participants

Adjusted for age and gender; Significant at p < .05*In year 3 participant costs were 29% lower producing an ROI of 1.49 to 1.00

Ref: Goetzel, R.Z., Jacobson, B.H., Aldana, S.G., Vardell, K., and Yee, L. Journal of Occupational and Environmental Medicine, 40:4, April, 1998.

Total Annual Medical Costs For Participants and Non-Participants In Health Check (1990 - 1992)

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HIGHMARK ROI STUDY

• Regional health plan with approximately 12,000 workers

• Headquartered in Pittsburgh, with a major operating facility in Camp Hill, PA and other locations in Johnstown, Erie, and Williamsport, PA.

• Worksite Health Promotion Program (introduced in 2002)– health risk assessments (HRAs)– online programs in nutrition, weight management and stress management– tobacco cessation programs– on-site nutrition and stress classes– individual nutrition and tobacco cessation coaching– biometric screenings– six- to twelve-week campaigns to increase fitness participation and

awareness of disease prevention strategies– state-of-the-art fitness centers (Pittsburgh and Camp Hill, PA)

Source: Naydeck, Pearson, Ozminkowski, Day, Goetzel. The Impact of the Highmark Employee Wellness Programs on Four-Year Healthcare Costs. JOEM, 50:2, February 2008

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Annual growth in net payments –for matched-participants and non-participants over four years – resulting in crude savings of ~$200/employee/year

Annual Growth in Costs, Highmark

0

500

1000

1500

2000

2500

3000

3500

2001 2002 2003 2004 2005

Net

pay,

in $

2005

Participants Controls

Start of Pgm

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Cost-Benefit (ROI) Analysis

Wellness Program Costs, Highmark, inflation-adjusted to 2005 dollars

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So, what is important to employers? • Financial outcomes

– Cost savings, return on investment (ROI) and net present value (NPV)

– Where to find savings:• Medical costs• Absenteeism • Short term disability (STD)• Presenteeism

• Health outcomes– Adherence to evidence based medicine– Behavior change, risk reduction, health improvement

• Quality of life (humanistic) and productivity outcomes– Improvement in quality of life– Improved “functioning” and productivity

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Policy Implications• Pass Tom Harkin’s Healthy Workforce Act (S.1753)

– Companies that spend $400 per employee on wellness would earn a tax credit of up to $200 per employee for the first 200 employees and $100 per employee for the rest of the payroll.

• Provide wellness program tax credits for employers and employees (HR 853, Knollenberg; HR 3717/S 1753/S 1754, Udall/Harkin; S 158, Collins).

• Sponsor venues for public recognition of exemplary programs and business leaders supporting these programs (e.g., Koop Awards).

• Identify and disseminate best practices.

• Establish public-private technical assistance and consulting services to support employer efforts.

• Increase funding of “real world” research demonstrations.

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Other Policy Options• Introduce federal legislation promoting workers’ health, e.g.,

smoke-free workplace policies.

• Initiate pilot studies at local/state/federal agencies that test innovative models of health promotion among public employers.

• Make available tools and resources that employers can use to run programs, e.g., evaluation instruments, financial modeling programs.

• Establish ongoing measurement and performance tracking systems specific to workplace health promotion and reporting relevant metrics related to employer efforts, e.g., “healthiest places to work.”

• Assure a clear focus on workplaces as an important venue for health system reform.

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Summary

Focusing on improving the health and quality of people’s lives will improve the productivity and competitiveness of our workers and citizens.

A growing body of scientific literature suggests that well-designed, evidence-based workplace health promotion programs can

Improve the health of workers and lower their risk for disease;

Save businesses money by reducing health-related losses and limiting absence and disability;

Heighten worker morale and work relations;

Improve worker productivity; and

Improve the financial performance of organizations instituting these programs.