united states healthcare costs continue to escalate with no immediate relief in sight . in 2005 , healthcare spending totaled us$2.0 trillion16% of the gross domestic product ( gdp ) ( poisal et al 2007 ) . further , healthcare spending is projected to account for 18.4% of gdp by 2013 , when more than one out of every four dollars of personal consumption will be spent on healthcare ( heffler et al 2004 ) . the aging of americans is a central component fueling cost increases . in the year 2000 , 12.4% of americans were over age 65 , but this will increase to 19.6% in 2030 ( goulding et al 2003 ) . chronic diseases , especially prevalent in the senior population , generate a large proportion of medicare spending . in 19951999 ( the most recent data ) , only 5% of medicare beneficiaries , presumably many with chronic diseases , accounted for almost half ( 47% ) of total spending . a much larger segment of the population ( 40% ) , those in relatively good health , accounted for only 1% of the total ( liberman et al 2003 ) . preventing or postponing the onset of chronic disease among seniors has become a crucial public health issue , as has the potential to compress the period of morbidity prior to death ( vita et al 1998 ) . it has been estimated that approximately 70% of the total burden of disease ( as measured in terms of premature deaths and potential years of life lost ) can be traced back to illnesses that are preventable ( department of health and human services 1991 ) . particularly noteworthy is research by mcginnis and foege ( 1993 ) and mokdad and colleagues ( 2004 ) who concluded that about half of all deaths in the us are caused by modifiable risk factors . although death is inevitable , it is now becoming clear that successful health promotion programs can improve health , prevent much disability , delay mortality , and thereby substantially improve the quality of seniors lives ( aldana 2001 ; chernoff 2001 ) . the growing awareness of the value of prevention and health promotion is evident at the executive branch of government . the president launched the healthierus initiative , promoting healthier lifestyles and a reduction of risk factors such as inactivity , obesity , and smoking ( healthierus 2003 ) . the rationale for this initiative , especially in relation to health promotion efforts directed at seniors , is described on the white house website : 
  poor health should not be a foregone consequence of aging . improvements in diet and physical activity can greatly improve the quality of life at any age . regular physical activity also helps older americans maintain joint strength and mobility and substantially delays the onset of functional limitations and loss of independence . improvements in diet and physical activity can greatly improve the quality of life at any age . regular physical activity also helps older americans maintain joint strength and mobility and substantially delays the onset of functional limitations and loss of independence . the rapidly rising cost of healthcare , an aging population , and the high prevalence of chronic disease among the elderly generate a sense of urgency for finding innovative solutions to this country s healthcare crisis , including health promotion and disease prevention initiatives . in this paper , we highlight several key studies that underscore the value of introducing health promotion and risk reduction programs directed at seniors . furthermore , we present evidence suggesting that health promotion and risk reduction programs may reduce unnecessary healthcare utilization and related expenditures for the medicare program , yielding a favorable return - on - investment ( roi ) for such interventions . we finish our discussion with a description of an innovative demonstration project that centers for medicare and medicaid services ( cms ) will be introducing in 2007 to test whether health promotion programs can improve the health of seniors and also achieve a positive cost - benefit ratio . a growing literature presents convincing evidence that seniors who reduce their modifiable health risks can forestall disability , reduce their utilization of health services , and ultimately save medicare money ( hickey et al 1997 ; king et al 1998 ; vita et al 1998 ; fries 2002 ; omenn 2003 ) . lubitz and colleagues ( 2003 ) presented evidence that elderly persons in better health at age 70 live about 2.7 years longer than those in poor health , and their cumulative medicare healthcare expenditures are no greater than those who die earlier ; in fact , they may be slightly lower . the macarthur study on aging , consisting of dozens of studies conducted over a decade , helped researchers identify components of successful aging ( seeman et al 2001 ) . for example , quitting smoking and initiating other lifestyle changes even later in life have produced substantial health benefits ( hickey et al 1997 ; hermanson et al 1988 ) . importantly , several studies confirm the value of physical activity for improving health among the elderly ( king 2001 ) . physical activity can extend life , help prevent heart disease and colon cancer , ( christmas and andersen 2001 ; penedo et al 2004 ) mitigate the effects of chronic diseases such as arthritis or diabetes ( christmas and andersen 2001 ; bean et al 2004 ) , improve coordination and flexibility to help avoid falls ( christmas and andersen 2001 ; bean et al 2004 ) , and alleviate depression among older adults ( christmas and andersen 2001 ) . adults who practice even simple physical activity can improve their health status and use fewer health and social services ( aldana 2001 ) . to emphasize the importance of physical activity , a comprehensive review by himes ( 2002 ) identified these two overriding determinants of health status for seniors : social isolation as a strongly negative influence and regular physical activity as a strongly positive factor . in the private sector , evidence suggests that multicomponent health promotion and risk reduction programs can permanently change lifestyle habits and reduce population health risks for nonseniors ( heaney and goetzel 1997 ) . a report by rand ( 2001 ) concluded that successful risk reduction programs directed at working and senior populations share certain characteristics that make them effective in changing life - long health habits . successful programs are anchored in behavior change theory , employ tailored and personalized interventions , are sufficiently intensive , and are complemented by adequate social supports . such programs appear to work effectively even if they are not delivered face - to - face , but instead provided by telephone , internet , and mail . in addition , health promotion programs that engage participants in self - care activities and increase their involvement in healthcare decision - making can achieve long - term behavior change and risk reductions ( heaney and goetzel 1997 ) . although much of this private sector research has been conducted with those under age 65 , the underlying principles and methods employed by these programs possess sufficient flexibility to be tailored to the unique needs of diverse populations , suggesting that risk reduction programs targeting seniors have a high potential to achieve lasting behavior changes and potentially lower utilization of healthcare services ( rand 2001 ) . other research in the private sector is pointing in the direction that evidence - based health promotion and risk reduction programs can save money . several literature reviews that weighed the evidence from experimental and quasi - experimental research studies suggest that programs grounded in behavior change theory and that utilize tailored communications and individualized counseling for high - risk individuals produce a positive roi ( goetzel et al 1999 ; aldana 2001 ; us department of health and human services 2003 ) . much of the roi research has emerged from employer - sponsored health promotion programs directed at active employees ( goetzel et al 1999 ; pelletier 2001 ) . in a review of 32 health promotion program evaluations , aldana ( 2001 ) found 28 studies that reported medical cost savings . of the seven studies that calculated cost - benefit ratios , financial returns averaged $ 3.48 for every dollar expended . studies often cited with the strongest research designs and large numbers of subjects included those performed at johnson and johnson ( bly et al 1986 ; breslow et al 1994 ) , citibank ( ozminkowski et al 1999 ) , dupont ( bertera 1990 ) , the bank of america ( leigh et al 1992 ; fries et al 1993 ) , tenneco ( baun et al 1986 ) , duke university ( knight et al 1994 ) , the california public employee retirees system ( calpers ) ( fries et al 1994 ) , procter and gamble ( goetzel , jacobsen , et al 1998 ) , and chevron corporation ( goetzel , dunn , et al 1998 ) . even accounting for certain inconsistencies in design and results , most produced positive cost outcomes . the most recent review on this topic conducted by chapman ( 2003 ) , summarizing the results from 42 qualifying financial impact studies conducted over the past two decades , concluded that worksite programs achieve a 25%30% reduction in medical and absenteeism costs in an average period of about 3.6 years ( goetzel , jacobsen , et al 1998 ) . similarly , the rand report ( 2001 ) concluded that health promotion and risk reduction programs using health risk assessments ( hras ) and ongoing tailored interventions have the potential to be cost - beneficial . five financial analyses are especially pertinent to cost - benefit calculations for medicare enrollees engaged in health promotion programs : four ( fries et al 1993 ; fries et al 1994 ; fries and mcshane 1998 ; ozminkowski et al 2006 ) focused on risk reduction programs for seniors ( at the bank of america , calpers , and at general motors corporation ) , and one for working - age individuals at citibank ( ozminkowski et al 1999 ) . employing available medical claims data to estimate changes in medical expenditures , that roi estimate was similar to one obtained in a randomized trial using the same intervention program in a different population ( fries et al 1993 ) . using methods that imputed changes in medical expenditures from changes in utilization , the evaluations of bank of america and calpers programs for seniors reported rois of approximately $ 5.00 to $ 1.00 . the general motors study was not an roi study , because it contained no program cost information . however , it did demonstrate that health promotion programs offered to seniors , particularly those that are based upon administering a health risk appraisal , can save $ 101 to $ 648 per person per year ( at the us dollar value for 2006 ) , depending upon who participates and how many programs they use . admittedly , the methodological rigor of evaluations performed at many corporate health promotion programs has not been consistent . in fact , randomized trials are hard to find in the literature , largely because they are not well accepted in a business environment . however , methodological shortcomings in earlier analyses have diminished significantly over the past two decades . the most recent evaluations using sophisticated econometric methods that control for selection bias do assess impact over several years ( with some extending for three to five years and one , performed at johnson & johnson , lasting nine years ) ( ozminkowski et al 2002 ) . these advances should inform future study designs of similar health promotion interventions directed at seniors . in short , a focus on prevention and health promotion offers a most promising approach to the urgent challenges that the medicare program faces today and into the future . research in the private sector presents compelling evidence to warrant large scale federally funded demonstrations that test the prospect for well - designed health promotion and risk reduction efforts to pay for themselves through lower healthcare expenditures . although some corporate studies have recently begun to focus on productivity impacts from these programs ( eg , reduced absenteeism , shortened disability periods , decreased  presenteeism  ) , much of the private sector research has emphasized healthcare cost savings . this is the same focus of policy makers and legislators with oversight responsibility for medicare . there are still several unanswered questions related to the application of health promotion and risk reduction programs in an elderly population . for example , will living a healthy life truly reduce seniors illnesses and incidence of disability prior to their demise or will they simply live longer and their illnesses and disability be delayed ? thus , will a longer life span cost medicare more because seniors are alive longer and may still experience significant end - of - life illness and costs ? these are testable hypotheses . while successful health promotion interventions could extend the period of healthy life and result in costs being incurred to the medicare program over a longer period of time , the alternatives are not appealing . researchers at rand recently estimated the costs of the future obese elderly , and found that medicare will spend 35% more caring for an obese 70-year - old person over his or her lifetime than for a normal weight person , at a cost of $ 36,000 ( lakdawalla et al 2005 ) . to explore these very complex issues , in 2007 , medicare will initiate a three and a half year research project entitled senior risk reduction demonstration ( srrd ) , to test the health and economic impacts of providing health promotion services , modeled after programs provided to those under age 65 . the srrd will provide insights on how to deliver such programs practically , an important step in advancing the medicare program from one focused on the diseases of older people to one focused on improving their health and quality of life . cms will offer risk reduction services to noninstitutionalized medicare beneficiaries between the ages of 67 and 74 , to be delivered by private sector vendors . five vendors will be given contact information for a random sample of beneficiaries from across the us , as well as from communities that have exemplary information and referral / assistance ( i&r / a ) programs for seniors.voluntary participation . incentives will be offered to induce high participation and retention rates , but participation will be at the discretion of the beneficiary.focus on self - care . the srrd will emphasize health improvement and risk reduction to complement the clinical aspects of medical services that are offered by other healthcare professionals . the program will contain elements of chronic disease self - management that take the form of patient education , advice , and counseling but will be primarily targeted at seniors who are well and do not need disease management services.tailoring to beneficiaries . vendor programs will be tailored to the needs , concerns , and learning styles of seniors . the goal is to develop personalized materials and instruments , followed by interventions tailored to the risks presented by the participants.central coordination . programs will deliver interventions via the mail , internet , and/or telephone counseling and coaching.referral to local community resources . vendors will be required to refer beneficiaries to national or local community resources . for beneficiaries residing in preselected exemplary i&r / a communities , vendors will be required to make referrals to the local i&r / a organizations.multiple behavior change modules . programs will address several modifiable health risk categories simultaneously in the assessment , triage , and follow - up phases of the intervention . risk factors addressed in the srrd include the following : 1 ) physical inactivity / lack of exercise ; 2 ) poor nutrition ; 3 ) smoking / tobacco use ; 4 ) excessive alcohol consumption ; 5 ) high blood pressure ; 6 ) high blood glucose ; 7 ) high total cholesterol ; 8) being overweight / obese ; 9 ) inappropriate use of clinical preventive services ; 10 ) depression ; 11 ) high stress ; 12 ) lack of general well - being ; 13 ) burden of providing care giving ; 14 ) social isolation ; 15 ) lack of motor vehicle / home safety ; 16 ) falls ( preventable accidents ) ; and 17 ) polypharmacy / medication issues . target population . cms will offer risk reduction services to noninstitutionalized medicare beneficiaries between the ages of 67 and 74 , to be delivered by private sector vendors . five vendors will be given contact information for a random sample of beneficiaries from across the us , as well as from communities that have exemplary information and referral / assistance ( i&r / a ) programs for seniors . incentives will be offered to induce high participation and retention rates , but participation will be at the discretion of the beneficiary . focus on self - care . the srrd will emphasize health improvement and risk reduction to complement the clinical aspects of medical services that are offered by other healthcare professionals . the program will contain elements of chronic disease self - management that take the form of patient education , advice , and counseling but will be primarily targeted at seniors who are well and do not need disease management services . tailoring to beneficiaries . vendor programs will be tailored to the needs , concerns , and learning styles of seniors . the goal is to develop personalized materials and instruments , followed by interventions tailored to the risks presented by the participants . programs will deliver interventions via the mail , internet , and/or telephone counseling and coaching . vendors will be required to refer beneficiaries to national or local community resources . for beneficiaries residing in preselected exemplary i&r / a communities , vendors will be required to make referrals to the local i&r / a organizations . programs will address several modifiable health risk categories simultaneously in the assessment , triage , and follow - up phases of the intervention . risk factors addressed in the srrd include the following : 1 ) physical inactivity / lack of exercise ; 2 ) poor nutrition ; 3 ) smoking / tobacco use ; 4 ) excessive alcohol consumption ; 5 ) high blood pressure ; 6 ) high blood glucose ; 7 ) high total cholesterol ; 8) being overweight / obese ; 9 ) inappropriate use of clinical preventive services ; 10 ) depression ; 11 ) high stress ; 12 ) lack of general well - being ; 13 ) burden of providing care giving ; 14 ) social isolation ; 15 ) lack of motor vehicle / home safety ; 16 ) falls ( preventable accidents ) ; and 17 ) polypharmacy / medication issues . the srrd will be judged on its ability to achieve high enrollment , participation , and retention rates ; improve beneficiaries health , health risks , and functionality ; and achieve a positive roi for the medicare program . readers interested in learning more about the srrd are invited to visit cms website ( cms 2006 ) . this administration s interest in prevention , combined with the impending insolvency of the medicare trust fund , make it timely for cms to explore and test evidence - based approaches to risk reduction and health promotion that may not only help beneficiaries to take better care of themselves , but that are likely to generate a positive roi . the srrd will provide insights on how to deliver such programs practically , an important step in advancing the medicare program from one focused on the diseases of older people to one focused on improving their health and quality of life . in short , a focus on prevention and health promotion offers a most promising approach to the urgent challenges that the medicare program faces today and into the future .
the impact of an aging population on escalating us healthcare costs is influenced largely by the prevalence of chronic disease in this population . 
 consequently , preventing or postponing disease onset among the elderly has become a crucial public health issue . 
 fortunately , much of the total burden of disease is attributable to conditions that are preventable . in this paper 
 , we address whether well - designed health promotion programs can prevent illness , reduce disability , and improve the quality of life . 
 furthermore , we assess evidence that these programs have the potential to reduce healthcare utilization and related expenditures for the medicare program . 
 we hypothesize that seniors who reduce their modifiable health risks can forestall disability , reduce healthcare utilization , and save medicare money . 
 we end with a discussion of a new senior risk reduction demonstration , which will be initiated by the centers for medicare and medicaid services in 2007 , to test whether risk reduction programs developed in the private sector can achieve health improvements among seniors and a positive return on investment for the medicare program .