# Presentation: 545186

## Steps to a Healthier US:

**Putting Prevention First**
**April 15-16, 2003 -- Baltimore, MD**
**Why Invest in Prevention:****Economic Perspective**
**Ron Z. Goetzel, Ph.D.**
**Institute for Health and Productivity Studies ****Cornell University and Medstat**
**ron.goetzel@medstat.com **

**Notes:**
Thanks to Nancy Stanisic
Lots of material – short amount of time – apologies

## Questions to ponder:

**  **Do health promotion/disease prevention programs work?
-   Is there a “business case” to support increased    	investment in health promotion/disease prevention?
-   What is the evidence - is it good enough?
-   Are there lessons to be learned from the private sector –      	that can be applied to public sector initiatives?

**Notes:**
Questions asked by “non-believers”

## The Logical Argument:

**If an employer/health plan/government invests in health by offering comprehensive and effective health promotion and disease prevention programs, then people will...**
**... ****have fewer health problems and improve their quality of life,**
**        ... ****consume fewer health care resources,**
**               ****	****... ****be absent from work less frequently,**
**  ****	****                    ... ****be more productive, and**
**                              ****	****              ... ****contribute more effectively to their **
**                                                ****	****   ****employers and society.**
**    **
**	****                 ****______________________________________________   **

## Grappling with some tough issues:

**  ****What do we mean when we say investing in health – understanding the ****	****differences between primary, secondary and tertiary prevention.**
**  ****Is health promotion the same as disease prevention?**
**  ****Distinguishing between clinical preventive services, screening and early ****	****detection, and lifestyle modification programs.**
**  ****Where does health promotion fit in the priority issues facing our nation?**
**                             **
**                 **

**  ****Health care cost inflation**
**  ****Patient safety**
**  ****Quality of care **
**  ****Consumerism **

**  ****Prescription drug coverage**
**  ****The uninsured**
**  ****Patient Bill of Rights**
**  ****HIPAA**

**Notes:**
Fighting for airtime – trying to get our message across over many other loud voices with important and varied agendas

## The Sound Bite:

**Healthy people consume fewer resources in the form of benefit payments for medical**
**care, short and long-term disability, and workers’ compensation.  Further, they are**
**more productive since they are absent less often, and more focused on their tasks**
**while at work.  Their quality of life is improved.  An employer/health plan/government **
**that invests in the health and well-being of people and their communities is socially**
**responsible, which, in the long run, will benefit that employer/health plan/government **
**in both monetary and non-monetary ways.**

**Notes:**
You’re on an elevator (or being interviewed by CNN) and you have 30 seconds to get your point across...

## 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 within**
**    ****a relatively short time window;**
**  ****Modifiable health risks can be improved through effective health promotion and disease**
**    ****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).**

## 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).**

**  ****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).**

**  ****Worksite health promotion and disease prevention programs can 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).**

**Notes:**
First bullet is supported by over 10,000 epidemiological studies in the medical literature
The second bullet and beyond is where I will focus my comments in this presentation

## Understand the sequence of critical success factors:

**Program Evaluation**

## Poor Health Costs Money

- Medical
- Absence / work loss
- Presenteeism
- Risk Factors

**Drill Down...**

## Top 10 High-Cost Physical Health Conditions Affecting American Business

- 1.	Coronary artery disease
- 2.	GI disorders
- 3.	Hypertension
- 4.	Vaginal deliveries
- 5.	Osteoarthritis

**Ref: Goetzel RZ, Ozminkowski RJ, Meneades L, Stewart M, Schutt DC. *****Journal of Occupational and Environmental Medicine***** 42(4) (2000): 338–351.**
**Source: 1996 MEDSTAT MarketScan Fee-for-Service Database, N=4,106,124 lives**

- 6.	Back disorders
- 7.	ENT disorders
- 8.	Diabetes
- 9.	Cerebrovascular disease
- 10.	Gall bladder disease

**Top 10 Physical Health Conditions Affecting Employers – **
**Medical, Rx, Absence, STD Expenditures (1999 annual $ per eligible)**

- Ref: Goetzel, R.Z., Hawkins, K, Ozminkowski, R.J., Wang, S. *Journal of Occupational and Environmental Medicine*, 45:1, 5-14.January, 2003.

**Notes:**
From the Top-20 physical disorder list, the following broad disease categories were identified:
Cardiovascular disorders:  3 conditions, $465.14 total HPM dollars 
Physical – 70%, MH 55%

## Example of a Presenteeism Analysis:  Hours Unproductive During a Typical 8-Hour Day – By Condition*

**** On days when affected by the condition***

## The Relationship Between Modifiable Health Risksand Health Care Expenditures:  An Analysis of the Multi-Employer HEROHealth Risk and Cost Database

- 	Ref: Goetzel RZ, Anderson DR, Whitmer RW, Ozminkowski RJ, Dunn RL, Wasserman J and the HERO Research Committee. *Journal of Occupational and Environmental Medicine* 40 (10) (1998): 843–854.

## Health Enhancement Research Organization (HERO) Database - Contributors

- Chevron Corporation
- HCA/Health Trust
- Hoffmann-La Roche Inc.
- Marriott Corporation
- State of Michigan
- State of Tennessee

## HERO Database - Data Sources

- Data collected for six-year period:  1/1/90 - 12/31/95
- Medical Claims (transaction level)
- Health Plan Enrollment/Eligibility
- Health Risk Assessment:  self-report & biometric measures
- N = 46,026 employees, 113,963 person-years

## Description of Database: Population at High Risk

_**High Risk Category**__**	**__**	**__**Percentage**_
- Poor exercise habits		       32%
- Former tobacco user		       31%
- Extreme high/low weight		       20%
- Poor nutritional habits		       20%
- High stress    			       19%
- Current tobacco user		       19%
- High cholesterol			       19%
- High blood glucose		         5%
- High alcohol use			         4%
- High blood pressure		         4%
- Depression			         2%

## Difference in Medical Expenditures

*Independent effects after adjustment*

## Population Risk and Cost Impact

- Ref: Anderson, D.R., Whitmer, R.W., Goetzel, R.Z., et. al, *American Journal of Health Promotion*, 15:1, 45-52, September/October, 2000. Health care expenditures - 1996 dollars. Independent effects after adjustment

**High stress generates annual per capita cost of $136 (1996 dollars)**
**$428 per capita for assessed areas**
**24.9% of health care costs**

**Population Risk and Cost Impact**

## Health and Productivity Outcomes of Multi-Component Worksite Health Promotion Programs – Literature Review		

*	**	*
**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.  Well conducted, randomized trial studies suggest that 		           providing opportunities for individualized risk reduction counseling 		           for high risk employees, within the context of comprehensive 		           health promotion programming, may be the critical component of    			  effective programs.

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

## But...Can You Change Risks?  Can You Affect Costs? Citibank Results: Number and Percent of Program Participants at High Risk at First and Last HRA by Risk Category

**Percentages represent the proportion of total participants for whom data are available, **
**by category.  * Statistically significant at the p<0.05 level (McNemar Chi-square). **

**19**

**15**

**169**

**125**

**195**

**1009**

**1732**

**1326**

**2565**

**8325**

**25**

**238**

**114**

**316**

**1058**

**1654**

**1906**

**2506**

**2775**

**8575**

**2023**

**12**

**0**

**1000**

**2000**

**3000**

**4000**

**5000**

**6000**

**7000**

**8000**

**9000**

**Alcohol**

**Diastolic BP***

**Salt***

**Cholesterol**

**Fat***

**Cigarettes***

**BMI***

**Seatbelt***

**Exercise***

**Stress***

**Fiber***

**First HRA**

**Last HRA**

**Ozminkowski, R.J., Goetzel, R.Z., et al., **_**Journal of Occupational and Environmental Medicine**_**, 42:5, May, 2000, 502-511. **

## Impact of Improvement in Risk Categories on Medical Expenditures per Month

- 			   		Unadjusted		Adjusted
- 					_Impact**__	__	__	__Impact**__	_
- Net Improvement* of at least 1 category	                 -$  1.86†                                    - $1.91
- versus Others (N = 1,706)
- Net Improvement* of at least 2 categories               - $  5.34                                      - $3.06
- versus Others (N = 391)
- Net Improvement* of at least 3 categories              -$146.87†                                 - $145.77‡
- versus Others (N = 62)
- 	Total Sample Size = 5,143 employees for whom claims data were available
- __________________________________________________________________________________
- *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.
-  † p < 0.05                ‡ p < 0.01

## A Return-on-Investment Evaluation of the Citibank, N.A. Health Management Program

- Ref: Ozminkowski RJ, Dunn RL, Goetzel RZ, Cantor RI, Murnane J, Harrison M.
*American Journal of Health Promotion* 14(1) (1999): 31–43.

## Program Participation  

- All 47,838 active employees were eligible to participate
- 54.3% participation rate
- 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

## Medical—Adjusted Mean Net Payments

- Total savings associated with program participation for 11,219 participants over an average of 23 months post-HRA is $8,901,413*
- * Based on $34.03 savings and 23.31054 months post-HRA for 11,219 participants

**Citibank Medical Population**
**Adjusted Mean Net Payments for the Pre- and Post-HRA periods**

## Program Return on Investment

- 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***
- *	1996 dollars @ 0 percent discount

## An Evaluation of the First Long-Term Health and 

- Goetzel, R.Z., Ozminkowski, R.J., Bruno, J.A., Rutter, K.R., Isaac, F., and Wang, S.  The Long Term Impact of Johnson & Johnson’s Heath & Wellness Program on Employee Health Risks.  _Journal of Occupational and Environmental Medicine_, 44:5, May 2002.

**An Evaluation of the First Long-Term Health and **
**Wellness Program at Johnson & Johnson**
**1990-1999**

## Health & Wellness Impact on Medical Costs 

**$225 overall Savings/ Employee/Year since 1995**

**Utilization Type**

## Inflation-Adjusted, Discounted Health and Wellness Program Savings Per Employee Per Year, by Year After Program Began -- Weighted by sample sizes that range from N = 8,927 – 18,331, depending upon years analyzed

## Health & Wellness Program Impact on Employee Health Risks 

**% Identified at Risk**

_**High Risk Group**_

- After an average of 23⁄4 years, risks were reduced in eight categories but increased in four related categories: body weight, dietary fat consumption, risk for diabetes, and cigar use.

## Summary of Findings

-    Overall, the Health and Wellness Program resulted in _annual _savings of about $8.55 - $8.77 million for the company.

**Summary of Findings**

## What’s the ROI?

**A Systematic Review of Return on Investment (ROI) Studies of Corporate Health and Productivity Management Initiatives**
**Ron Z. Goetzel, Ph.D.**
**Timothy R. Juday, MPA**
**Ronald J. Ozminkowski, Ph.D.**
***Ref: AWHP’s Worksite Health*****, Summer 1999, pp. 12-21**

## Health Management Program Studies

- ROI studies of health management programs at:
- Canada and North American Life
- Chevron Corporation
- City of Mesa, Arizona
- General Mills
- General Motors
- Johnson & Johnson
- Pacific Bell
- Procter and Gamble
- Tenneco

- ROI estimates in these nine studies ranged from $1.40 - $4.90 in savings per dollar spent on these programs.
- Median ROI was $3 in benefits per dollar spent on program.
- Sample sizes ranged from 500 - 50,000 subjects in these studies.

## 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
- *Participant costs were 29% lower

- 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.

## 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**
_*Content Areas:*_
**Health promotion programs and financial outcomes**
_*Scoring Criteria:*_
- Grade
**A (experimental design)**
**B (quasi-experimental – well controlled)**
**C (pre-experimental, well-designed, cohort, case-controlled)**
**D (trend, correlational, regression designs)**
**E (expert opinion, descriptive studies, case studies)**

## Results:

_**Health promotion program impact on financial outcomes:**_
- 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 ROI: 3.48 to 1.00 (7 studies)
- Absenteeism costs:
- 14 evaluation studies examined – Grades: A (0), B (11), other (3)
- Positive impact: 14 studies
- Average ROI: 5.82 to 1.00 (3 studies)

## Centers for Medicare & Medicaid Services (CMS)

**Healthy Aging Initiative**
**Senior Risk Reduction Program (SRRP)**
**Demonstration Design Project **

**http://cms.hhs.gov/healthyaging/srrp.asp**

**Translating Private Sector Initiatives into Public Policy**

## The Problem

**  ****Of the 35 million seniors enrolled in Medicare, those reporting poor health **
**   ****spend 5 times as much as those reporting excellent health**
**  “****Compression of Morbidity” research suggests people who adopt good health**
**    ****habits forestall disability, improve health and use fewer health services**
**  ****DHHS has an interest in keeping beneficiaries as healthy as possible for as long**
**    ****as possible**
**   ****The potential gains to seniors covered by Medicare and society may be substantial**

## Purpose of the Senior Risk Reduction Program Demonstration

** ****Examine whether private sector risk reduction programs can work with**
**  ****Medicare beneficiaries to improve health and reduce avoidable **
**  ****health care utilization**
**  ****Identify best ways to reduce risk factors in the senior population**
**  ****Identify and test effective tailored intervention materials**
**  ****Facilitate evaluation of program impact on risk factors**
**  ****Test program’s ability to make referrals to community/volunteer programs**
**  ****Determine whether program features are acceptable to beneficiaries**
**  ****Develop a design that examines cost impact and ROI**

## Current Status

**  ****CMS, Medstat and Cornell are designing the Senior Risk**
**    ****Reduction Program demonstration.**
**  ****Design is being coordinated with other Federal agencies**
**  ****Design should be completed and presented to OMB for funding in **
**    ****November 2003**
**  ****Once approved, the demonstration will be implemented and evaluated,**
**    ****which will take between three to five years.**

## Vision

**In the future, health promotion and disease prevention will become a critical factor influencing the health and productivity of Americans**
**Lessons learned from the private sector will be applied, where appropriate, to public sector initiatives**
**The value of health promotion and disease prevention will be supported by excellent research and demonstration projects**
**Increased investment in health promotion/disease prevention will pay off – through improvements in population health and efficient management of health and productivity costs**
**	****	****	****	****	**