Transcript THOMSON REUTERS PRESENTATION TEMPLATE

Evaluating Worksite Health Promotion Programs:
Are They Cost-Beneficial?
Ron Z. Goetzel, Ph.D., Emory University and Thomson Reuters Healthcare
©2008 Thomson Reuters
©2009
Employee Health Promotion: Opportunity and Challenge for Massachusetts
AstraZeneca Corporation R&D Center, Weston MA - Friday, April 30, 2010
1
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.
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• 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.
2
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
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Ken Thorpe
– Blood pressure
– High blood glucose
– Hyperlipidemia
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.
3
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
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And 27% of the rise in healthcare
costs is associated with
increases in obesity rates…
4
ENVIRONMENTAL CORRELATES 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”)
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In public
• More elevators, escalators, automatic doors and moving
sidewalks
5
AWAY-FROM-HOME FOOD CONSUMPTION HAS DOUBLED
Share of total food expenditures
Calories Consumed
75%
50%
65%
40%
55%
30%
20%
45%
10%
35%
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25%
1962 1967
0%
1972 1977
Food at home
1982 1987 1992
1978
1997 2002
Food away from home
Source: Food Consumption (per capita) Data Sysytem, USDA, Economic
Research Service
6
1995
LEADING CAUSES OF DEATH IN THE U.S. (2000)*
Cause of Death
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Heart Disease
Malignant Neoplasm
Cereberovascular Disease
Chronic Lower Respiratory Tract Disease
Unintentional Injuries
Diabetes
Influenza / Pneumonia
Alzheimers
Nephritis
Septicemia
Other
Total
*Source: Mokdad et al., JAMA,291:10, March, 2004
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# of Deaths
Percentage
710,760
30%
553,091
167,661
122,009
97,900
69,301
65,313
49,558
37,251
31,224
499,283
2,403,351
23%
7%
5%
4%
3%
3%
2%
2%
1%
21%
100%
% OF ADULT POPULATION TREATED, BY MEDICAL CONDITION
1987-2005: RAPID RISE IN DISEASE PREVALENCE
Medical Condition
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Mental Disorders
Hyperlipidemia
Hypertension
Diabetes
Pulmonary Conditions (OPD, Asthma)
Lupus / Other Related
Arthritis
Back Problems
Upper GI
Heart Disease
Source: ????
8
1987
2005
5.5%
1.5%
13.6%
4.0%
9.5%
4.8%
7.8%
5.4%
3.8%
8.1%
18.8%
14.4%
22.0%
8.0%
18.4%
6.0%
13.6%
13.2%
10.7%
9.5%
DISEASES CAUSED (AT LEAST PARTIALLY)
BY LIFESTYLE
• Obesity: Cholesystitis/Cholelithiasis, Coronary Artery Disease, Diabetes, Hypertension,
Lipid Metabolism Disorders, Osteoarthritis, Sleep Apnea, Venous Embolism/Thrombosis,
Cancers (Breast, Cervix, Colorectal, Gallbladder, Biliary Tract, Ovary, Prostate)
• Tobacco Use: Cerebrovascular Disease, Coronary Artery Disease, Osteoporosis,
Peripheral Vascular Disease, Asthma, Acute Bronchitis, COPD, Pneumonia, Cancers
(Bladder, Kidney, Urinary, Larynx, Lip, Oral Cavity, Pharynx, Pancreas, Trachea, Bronchus,
Lung)
• Lack of Exercise: Coronary Artery Disease, Diabetes, Hypertension, Obesity, Osteoporosis
• Poor Nutrition: Cerebrovascular Disease, Coronary Artery Disease, Diabetes, Diverticular
Disease, Hypertension, Oral Disease, Osteoporosis, Cancers (Breast, Colorectal, Prostate)
• Alcohol Use: Liver Damage, Alcohol Psychosis, Pancreatitis, Hypertension,
Cerebrovascular Disease, Cancers (Breast, Esophagus, Larynx, Liver)
• Stress, Anxiety, Depression: Coronary Artery Disease, Hypertension
• Uncontrolled Hypertension: Coronary Artery Disease, Cerebrovascular Disease,
Peripheral Vascular Disease
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• Uncontrolled Lipids: Coronary Artery Disease, Lipid Metabolism Disorders, Pancreatitis,
Peripheral Vascular Disease
9
ACTUAL CAUSES OF DEATH IN THE U.S. (2000)
in thousands
450
400
350
300
250
200
150
100
50
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0
Tobacco
Use
Diet &
Inactivity
Alcohol
Misuse
Microbial
Agents
Toxic
Agents
Source: Mokdad, et al
10
Motor
Vehicles
Firearms
Sexual
Behavior
Illicit Drug
use
BOTTOM LINE: THE VAST MAJORITY OF CHRONIC DISEASE CAN
BE PREVENTED OR BETTER MANAGED
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:
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• Stop smoking
• Start eating healthy
• Get in shape
11
CONVINCE ME…
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Why should an employer (or government)
invest in the health and well-being of
workers?
12
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
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…productivity is enhanced
13
©2008 Thomson Reuters
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THE LOGIC FLOW
1
A large proportion of diseases and disorders from which people suffer is preventable
2
Modifiable health risk factors are precursors to many diseases and disorders, and premature death.
3
Many modifiable health risks are associated with increased health care costs
and diminished productivity within a relatively short time window.
4
Modifiable health risks can be improved through effective health promotion
and disease prevention programs.
5
Improvements in the health risk profile of a population can lead to reductions in health costs
and improvements in productivity.
6
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).
14
THE EVIDENCE
• A large proportion of diseases and disorders is preventable. Modifiable health risk
factors are precursors to a large number of diseases and disorders and to
premature death (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
within a 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
health costs (Edington et al., 2001, Goetzel et al., 1999)
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• Worksite health promotion and disease prevention programs save companies
money in health care expenditures and produce a positive ROI (Johnson & Johnson
2002, Citibank 1999-2000, Procter and Gamble 1998, Chevron 1998, California Public
Retirement System 1994, Bank of America 1993, Dupont 1990, Highmark, 2008)
15
POOR HEALTH COSTS MONEY
Drill Down…
• Medical
• Absence/work loss
• Presenteeism
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• Risk factors
16
TOP 10 PHYSICAL HEALTH CONDITIONS
Medical, Drug, Absence, STD Expenditures (1999 annual $ per eligible), by Component
Dis. of ENT or Mastoid Process NEC
Sinusitis
Trauma to Spine & Spinal Cord
Back Disor. Not Specified as Low Back
Chronic Obstructive Pulmonary Dis.
Acute Myocardial Infarction
Mechanical Low Back Disor.
Diabetes Mellitus, Chronic Maintenance
Essential Hypertension, Chronic Maintenaince
Angina Pectoris, Chronic Maintenance
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$0
Medical
$50
Absence
Source: Goetzel, Hawkins, Ozminkowski, Wang, JOEM 45:1, 5–14, January 2003.
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$100
Disability
$150
$200
$250
(in thousands)
THE BIG PICTURE:
OVERALL BURDEN OF ILLNESS BY CONDITION
Using Average Impairment and Prevalence Rates for Presenteeism ($23.15/hour wage estimate)
Allergy
Arthritis
Asthma
Cancer
Depression/Mental illness
Diabetes
Heart Disease
Hypertension
Migraine/Headache
Respiratory infections
©2008 Thomson Reuters
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$0
Inpatient
$50
Outpatient
$100
$200
$150
RX
ER
Source: Goetzel, Hawkins, Ozminkowski, Wang, JOEM 45:46:4, April 2004.
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$250
Absence
$350
$300
STD
$400
(in thousands)
Presenteeism
INCREMENTAL IMPACT OF TEN MODIFIABLE RISK
FACTORS ON MEDICAL EXPENDITURES
Percent Difference in Medical Expenditures: High-Risk versus Lower-Risk Employees
75%
50%
70.2%
46.3%
34.8%
21.4%
25%
19.7%
14.5%
11.7%
10.4%
0%
-0.8%
-3.0%
-9.3%
-25%
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Depression Stress
Glucose
Weight
Tobacco - Tobacco
Blood
Exercise Cholesterol Alcohol
Past
Pressure
Independent effects after adjustment N = 46,026
Source: 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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Eating
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EXAMINING RISK FACTORS AND PRESENTEEISM - NOVARTIS
Outcomes and group of health risks
Predicted Scenario
Predicted Mean
Presenteeism
Impact on
dollars or
days (95%
CI)
Impact as percent
difference from
scenario without the
risk (95% CI)
Annual Unproductive Days
Males
Without Risk(s)
0.50
0.73
146.2%*
With Risk(s)
1.23
(0.65, 0.81)
(129.6%, 162.8%)
Without Risk(s)
0.59
1.33
224.0%*
With Risk(s)
1.93
(1.07, 1.59)
(180.6%, 267.3%)
Without Risk(s)
0.54
0.87
159.7%*
With Risk(s)
1.41
(0.76, 0.97)
(139.8%, 176.9%)
High Biometric Lab Values
Alcohol-Tobacco Use
Emotional Health
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*Indicates a Statistical Significant difference between those with risk and those without risk.
21
PEPSI BOTTLING GROUP - OVERWEIGHT/OBESE ANALYSIS
Adjusted predicted annual cost
Adjusted predicted annual costs for employees by BMI
$10,000
$8,000
*At least one difference significant at the 0.05 level
Diff =
25%,
$987
Diff =
29%,
$613*
$6,000
$4,000
Diff =
58%,
$111*
$2,000
Diff =
26%,
$186*
Diff =
7%,
$49
Diff =
10%,
$28
74% of the
sample is
overweight or
obese
Total
Absences
Presenteeism
WC
STD
Medical
$0
Difference between combined overweight/obese categories
and normal weight is displayed
Normal
Overweight
Class I
Class II
Class III
Source: Henke RM, Carls GS, Short ME, Pei X, Wang S, Moley S, Sullivan M, Goetzel RZ. The Relationship between Health Risks and Health
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and Productivity Costs among Employees at Pepsi Bottling Group. J Occup Environ Med. In Press.
ESTIMATED ANNUAL COSTS OF HEALTHCARE
UTILIZATION, ABSENTEEISM, AND
PRESENTEEISM BY BMI CATEGORY
Normal
Overweight
$178
$182
$229 *
Doctor Visits
Obese
$149
$155
$219*
Emergency Room
Visits
$1,535
$1,544
Hospital Admissions
$2,034
$872
$918
Absenteeism Days
$1,180 *
$1,200
$1,402 *
$1,416 *
Presenteeism
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$0
$500
$1,000
$1,500
$2,000
$2,500
* P < .05
Source: Goetzel RZ, Gibson TB, Short ME, Chu BC, Waddell J, Bowen J, Lemon SC, Fernandez ID, Ozminkowski RJ, Wilson
MG, DeJoy DM. A Multi-Worksite Analysis of the Relationships among Body Mass Index, Medical Utilization and Worker
Productivity. Journal of Occupational and Environmental Medicine. In press.
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Quiz: How many Americans lead healthy
lifestyles?
1. Non-smokers
2. Healthy weight (BMI of 18.5-25.0)
3. Consume 5+ fruits/vegetable per day
4. Exercise regularly (30 min – 5 days/week)
©2008 Thomson Reuters
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Bottom Line: practice healthy lifestyle across all four
categories
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Results:
1. Non smokers: 76%
2. Healthy weight (BMI of 18.5-25.0): 40%
3. Consume 5+ fruits/vegetable per day: 23%
4. Exercise regularly (30 min – 5 days/week): 22%
All of the above: 3%
©2008 Thomson Reuters
©2009
Source: Reeves & Rafferty, Healthy lifestyle characteristics among adults
in the U.S., 2000, Archives of Internal Medicine, 2005;165:854-857.
BRFSS 2000 data, N=153,000.
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OUTCOMES OF MULTI-COMPONENT WORKSITE HEALTH
PROMOTION PROGRAM
• Purpose: Critically review evaluation
studies of multi-component worksite
health promotion programs.
Literature Review
• Methods: Comprehensive review of 47
CDC and author generated studies
covering the period of 1978-1996.
©2008 Thomson Reuters
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• 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
26
EVALUATION OF WORKSITE HEALTH PROMOTION
PROGRAMS — FEBRUARY 2007 ANALYSIS
Worksite Health Promotion Team
Robin Soler, PhD
David Hopkins, MD, MPH
Sima Razi, MPH
Kimberly Leeks, PhD, MPH
Matt Griffith, MPH
©2008 Thomson Reuters
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CDC COMMUNITY GUIDE TO PREVENTIVE
SERVICES REVIEW – FEBRUARY 2010
28
SUMMARY RESULTS AND TEAM CONSENSUS
Body of
Evidence
Consistent
Results
Alcohol Use
7
Yes
Variable
Sufficient
Fruits & Vegetables
7
11
No
0.16 serving
Insufficient
Yes
+8%
Yes
+12.7%
Outcome
% Fat Intake
% Change in Those
Physically Active
17
Magnitude of
Effect
Tobacco Use
Prevalence
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Cessation
Seat Belt Non-Use
Finding
Strong
Sufficient
Strong
22
23 (9)
Yes
–2.2 pct pt
Yes
3.5 pct pt
10
Yes
–35.4%
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Sufficient
SUMMARY RESULTS AND TEAM CONSENSUS
Outcome
Diastolic blood pressure
Systolic blood pressure
Body of
Evidence
Consistent
Results
Magnitude of Effect
16
18
11
Yes
Diastolic:–1.9 mm Hq
Yes
Systolic:–3.0 mm Hg
Yes
–3.4 pct pt
Yes
–0.5 pt BMI
No
–0.56 pounds
Yes
–2.2% body fat
No
–2.2% at risk
Yes
–5.0 mg/dL (total)
No
+1.1 mg/dL
Yes
–6.6 pct pt
Yes
Small
Risk prevalence
BMI
Weight
% body fat
6
12
4
5
Risk prevalence
Total Cholesterol
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HDL Cholesterol
18
7
11
Risk prevalence
Fitness
5
30
Finding
Strong
Insufficient
Strong
Insufficient
SUMMARY RESULTS AND TEAM CONSENSUS
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Body of
Outcome Evidence
Consistent
Results
Magnitude 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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PROGRAM EVALUATION:
CRITICAL STEPS TO SUCCESS
Financial ROI
Reduced Utilization
Risk Reduction
Behavior Change
Improved Attitudes
Increased Knowledge
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Participation
Awareness
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CASE STUDIES
CITIBANK, N.A.
HEALTH MANAGEMENT PROGRAM EVALUATION
TITLE
INDUSTRY
TARGET
POPULATION
Citibank Health Management Program (HMP)
Banking/Finance
47,838 active employees eligible for medical benefits
• A comprehensive multi-component health management program
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DESCRIPTION
CITATIONS
• 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.
•
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
HIGH-RISK PROGRAM
80% Low Risk
Timeline
(months)
Questionnaire 1 (Program
Entry and Channeling
beginning January 1994
20% High Cost Risk
High-Risk
Letter/Report 1
35
3 MONTHS
Books,
Audiotapes,
Videotapes
6 MONTHS
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Self-Care Materials
High-Risk
Questionnaire
Letter/Report 2
High-Risk
Questionnaire
Letter/Report 3
Books,
Audiotapes,
Videotapes
9 MONTHS
Letter/Report 1
Books,
Audiotapes,
Videotapes
High-Risk
Questionnaire
Letter/Report 4
Books,
Audiotapes,
Videotapes
PROGRAM PARTICIPATION
47,838
54.3%
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All 47,838 active employees were
eligible to participate.
The participation rate was 54.3
percent.
$10
3,000
Participants received a $10 credit
for 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.
36
CITIBANK RESULTS
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)
100%
95%
93%
75%
50%
33%
31%
32%
26%
25%
21%
18% 19%
15%
12% 12%
4% 2%
2% 2%
3% 2%
1% 1%
0% 0%
Fat
Cholesterol
Salt
Diastolic
Blood
Pressure
Alcohol
0%
©2008 Thomson Reuters
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Fiber
Stress
Exercise Seatbelt
BMI
Tobacco
First HRA
Last HRA
Source: Ozminkowski, R.J., Goetzel, R.Z., et al., Journal of Occupational and Environmental Medicine 42: 5, May, 2000, 502–511.
37
CITIBANK RESULTS
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Impact of improvement in risk categories
on medical expenditures per month
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 ‡
*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
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CITIBANK: MEDICAL SAVINGS-ADJUSTED MEAN NET
PAYMENTS
$350
$300
$257
$250
$212
$200
$150
$180
$170
All Participants
n=11,219
$100
NonParticipants
n=11,714
$50
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$0
Pre-HRA
Time Period
39
Post-HRA
CITIBANK HEALTH MANAGEMENT PROGRAM ROI
PROGRAM COSTS
PROGRAM BENEFITS
PROGRAM SAVINGS
$1.9 million*
$8.9 million*
$7.0 million*
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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.
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JOHNSON & JOHNSON
HEALTH AND WELLNESS PROGRAM EVALUATION
TITLE
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INDUSTRY
J & J Health and Wellness Program (H & W)
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.
41
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 followup health improvement program lose the $500
discount
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• Result: 94% Participation Rate
42
HEALTH & WELLNESS PROGRAM
IMPACT ON EMPLOYEE HEALTH RISKS (N=4,586)
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.
70%
66.2%
Percent Identified at Risk
60%
49.6%
50%
45.8%
43.2%
41.0%
40%
35.1%
32.7%
30%
23.9%
20%
9.7%
10%
4.5%
1.3%
2.7%
3.5%
2.9%
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0%
High
Cholesterol
Low Fiber
Intake
Poor Exercise
Habits
Cigarette
Smoking
Time 1 Health Profile
High Blood
Pressure
Time 2 Health Profile
High Risk Group
43
Seat Belt Use
Drinking &
Driving
JOHNSON & JOHNSON HEALTH & WELLNESS PROGRAM
IMPACT ON MEDICAL COSTS
$225 Annual Medical Savings/ Employee/Year since 1995
$250.00
$224.66
$200.00
$150.00
$118.67
$100.00
$70.89
$45.17
$50.00
-$10.87
$0.00
-$50.00
©2008 Thomson Reuters
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ER Visits
Outpatient/Doctor
Office Visits
Mental Health Visits
Source: Ozminkowski et al, 2002 — N=18,331
44
Inpatient Days
OVERALL SAVINGS
INFLATION-ADJUSTED, DISCOUNTED HEALTH AND
WELLNESS PROGRAM CUMULATIVE SAVINGS
Per Employee Per Year, 1995 – 1999 -- Weighted by sample sizes that
range from N = 8,927 – 18,331, depending upon years analyzed
$500.00
$400.00
$300.00
IP days
MH visits
OP visits
ER visits
$200.00
$100.00
$-
Years Post Implementation
©2008 Thomson Reuters
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$(100.00)
IP days
MH visits
OP visits
ER visits
1
2
3
4
$60.76
$78.42
$1.54
$(12.15)
$94.25
$55.05
$23.57
$(14.43)
$164.72
$51.49
$186.03
$(7.27)
$195.80
$103.43
$181.27
$(8.06)
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PROCTER & GAMBLE
Total Annual Medical Costs For Participants and Non-Participants In Health Check (1990 - 1992)
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
2000
1731
1500
1386
1339
1196
1080
1098
1000
500
0
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Year 1
Year 2
Participants
Year 3
Non-Participants
Source: Goetzel, R.Z., Jacobson, B.H., Aldana, S.G., Vardell, K., and Yee, L. Journal of Occupational and Environmental Medicine, 40:4, April, 1998.
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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
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– 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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CHARACTERISTICS USED IN MATCHING SUBJECTS –
AIM IS TO SHOW PARTICIPANTS AND NON-PARTICIPANTS
ARE SIMILAR
Overall Comparison
Calendar Year 2001
All Participants
Non-Participants
N = 1890
N = 1890
P-value
484 (25.6)
484 (25.6)
0.98
41.7
41.6
0.94
$1,414
$1,318
0.94
183 (9.7)
184 (9.7)
13 (0.7)
13 (0.7)
0.99
CCI Group 1 comorbidity, n(%)
849 (44.9)
849 (44.9)
0.98
CCI Group 2 comorbidity, n(%)
528 (27.9)
528 (27.9)
0.98
1.75 (0-17)
1.75 (0-18)
0.97
Male, n (%)
Age, 2001 mean years
Net payments for healthcare
expenditures in 2001, mean
Comborbidity Prevalence, %
Heart disease, n(%)
Diabetes, n(%)
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CCI, median (range)
CCI = Charlson comorbidity index; Group 1 comorbidity includes presence of any of these: chronic
obstructive pulmonary disease, rheumatologic disease stomach ulcer or dementia, all as coded by
using the Charlson index; Group 2 comorbidity includes presence of any of these: cancer, renal
failure, liver disease or cirrhosis, autoimmune disease.
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ANNUAL GROWTH IN NET PAYMENTS
Annual growth in costs, Highmark, Inc.
For matched-participants and non-participants over four years – resulting in crude savings
of ~$200/employee/year
3500
3000
2500
2000
Start of Program
1500
1000
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500
0
2001
2003
2002
Participants
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Controls
2004
2005
ESTIMATED ANNUAL SAVINGS AFTER FOUR YEARS OF
FOLLOW-UP — PARTICIPANTS VERSUS NONPARTICIPANTS — ADJUSTED FOR CONFOUNDERS
Participants versus Non-participants
Net
Payments
β Estimate
Intercept
-964.51
All participants, (n=1892)
-176.47
Male gender
497.09
Age, per year
46.05
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Heart disease at baseline
576.59
Diabetes at baseline
1704.01
Group 1 comorbidity
1133.20
Group 2 comorbidity
397.80
4-year savings estimate from participation (β*n)
Per person estimate
$333,881
176.47
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Cost-Benefit (ROI) Analysis
HRA & Incentive
Online
Group
Nutrition Coaching
10,000 Steps
Fitness Center
Highmark Challenge
Maintain Don't Gain Newsletter
Wellness Program Costs
Cost per participant
Estimated Annual Savings from Model $176.47/person
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Net Savings (Estimated Savings - Wellness Program Costs)
2002
2003
2004
2005
# Used Total # Used Total # Used Total # Used
Total
GD Total
1892 $243,731 1303 $143,111 1308 $140,785 1355 $142,605
201
$1,142
247
$1,372
248
$1,300
512
$2,575
34
$1,544
56
$3,077
56
$3,010
0
$0
2
$66
23
$740
51
$1,585
111
$3,420
244
$2,441
413
$3,851
223
$2,061
407 $25,603
495 $29,939
879
$50,958
112
$348
910
$2,766
85
$182
93
$192
$246,483
$176,343
$181,000
$204,577
$130.28
$135.34
$138.38
$150.98 $808,403
$333,881
$87,398
$333,881
$157,538
$333,881
$152,881
Total Savings Estimated 4 Years
Total Costs 4 Years
Return on Investment
Wellness Program Costs, Highmark, inflation-adjusted to 2005 dollars
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$333,881 $1,335,524
$129,304 $527,121
$1,335,524
$808,403
$1.65
LITERATURE REVIEWS
Health Promotion Program Studies
 ROI estimates in these nine
studies ranged from $1.40 $4.90 in savings per dollar
spent on these programs.
 ROI studies of health
management programs at:
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– Canada and North
American Life
– Chevron Corporation
– City of Mesa, Arizona
– General Mills
– General Motors
– Johnson & Johnson
– Pacific Bell
– Procter and Gamble
– Tenneco
 Median ROI was $3 in
benefits per dollar spent on
program.
 Sample sizes ranged from
500 - 50,000 subjects in
these studies.
Source: Goetzel, Juday, Ozminkowski. AWHP’s
Worksite Health, Summer 1999, pp. 12-21
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Generic Study Limitations – Corporate Research
Self-Selection
High Attrition
Treatment Diffusion
Poor Instrumentation
“Wish Bias”
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Publication Bias
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Financial Impact – Literature Review
Steven G. Aldana, Ph.D., American Journal of Health Promotion, May/June,
2001, 15:5.
• Focus: Peer reviewed journals (English Language) –
196 studies pared down to 72 studies meeting inclusion
criteria for review
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• Scoring Criteria:
– A (experimental design)
– B (quasi-experimental – well controlled)
– C (pre-experimental, well-designed, cohort, casecontrolled)
– D (trend, correlational, regression designs)
– E (expert opinion, descriptive studies, case studies)
• Health promotion program impact on health care costs:
– 32 evaluation studies examined – Grades: A (4), B
(11), other (17)
– Average duration of intervention: 3.25 years
– Positive impact: 28 studies
– No impact: 4 studies (none with randomized
designs)
– Average
55 ROI: 3.48 to 1.00 (7 studies)
Meta Evaluation of Worksite Health Promotion Economic Return
Studies: 2005 Update
Larry Chapman, Art of Health Promotion, July/August, 2005
• Analysis includes a review of 56 peer
reviewed studies
• Study methods are scored using 10 criteria
• Median year of publication – 1994
• Number of combined subjects in all studies –
483,232
• Average study duration- 3.66 years
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• Primary outcomes examined: health care
utilization/cost (28 studies) and absenteeism
(25 studies)
• Results:
– Average reduction in health care costs –
26%
– Average
reduction in absenteeism – 27%
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DO EMPLOYEE HEALTH MANAGEMENT PROGRAMS WORK?
SERXNER, GOLD, MERAZ, GRAY, THE ART OF HEALTH PROMOTION,
MARCH/APRIL 2009, 1-8.
Annual Estimated Program Impacts on Self-Insures Employee Populations
Health Promotion
Average savings (% impact
on medical costs)
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Average return on
investment
Disease
Management
Employee Health
Management
Low
Range
High
Range
Low
Range
High
Range
Low
Range
High
Range
2.20
2.76
1.01
1.27
3.22
4.02
3.0:1.0
2.0:1.0
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2.5:1.0
HEALTH AFFAIRS ROI LITERATURE REVIEW
©2008 Thomson Reuters
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Baicker K, Cutler D, Song Z. Workplace Wellness Programs Can Generate
Savings. Health Aff (Millwood). 2010; 29(2). Published online 14 January 2010.
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©2008 Thomson Reuters
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RESULTS - MEDICAL CARE COST SAVINGS
Description
N
Average ROI
Studies reporting costs and
savings
15
$3.37
Studies reporting savings only
7
Not Available
Studies with randomized or
matched control group
9
$3.36
Studies with non-randomized or
matched control group
6
$2.38
All studies examining medical
care savings
22
$3.27
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©2008 Thomson Reuters
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RESULTS – ABSENTEEISM SAVINGS
Description
N
Average ROI
Studies reporting costs and
savings
12
$3.27
All studies examining
absenteeism savings
22
$2.73
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SO, WHAT IS IMPORTANT WHEN EVALUATING HEALTH AND
DISEASE MANAGEMENT PROGRAM OUTCOMES?
Financial
Outcomes
Cost savings, return on
investment (ROI) and net
present value (NPV).
©2008 Thomson Reuters
©2009
Where to find savings:
• Medical costs
• Absenteeism
• Short term disability
(STD)
• Workers’ compensation
• Presenteeism
Health
Outcomes
Adherence to evidence
based medicine.
Behavior change, risk
reduction, health
improvement.
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QOL and
Productivity
Outcomes
Improvement in quality of life.
Improved “functioning” and
productivity.
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 health
management programs can:
• Improve the health of workers and lower their risk
for disease;
• Save businesses money by reducing healthrelated losses and limiting absence and disability;
• Heighten worker morale and work relations;
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• Improve worker productivity; and
• Improve the financial performance of
organizations instituting these programs.
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