Posted by Health Handouts | Posted in Health Handouts, Health Tips | Posted on 20-07-2009
Many employers, as part of their efforts to contain rising healthcare costs, are launching worksite programs variously described as Workplace Wellness Programs, lifestyle programs, health and productivity management, population health management and, simply, wellness programs.
The purpose of this article is to consider whether such programs better health. If so, do they in turn cut utilization of healthcare services and cut healthcare expenditures?
The popular media have done much to promote the concept of employer wellness. Last year, In Business: Madison magazine printed a story accompanied by a table reporting an impressive range of returns on investment (ROI):
Return on Investment (Per dollar ROI for lifestyle programs)
• Coors $6.15
• Kennecott $5.78
• Equitable Life $5.52
• Citibank $4.56
• General Mills $3.90
• Travelers $3.40
• Motorola $3.15
• PepsiCo $3.00
• Unum Life $1.81
Source: 2004 T.E. Brennan Company, as published
Would these ROIs stand up to thorough empirical analysis of the data? What factors produce such disparate returns among these programs? And does the published literature, subject to peer review of scientific methods, support the ROIs reported here?
Health and Productivity Leadership
Illness and injury associated with an unhealthy lifestyle or modifiable risk factors is reported to account for at least 25 percent of employee medical care expenditures. The most significant of these risk factors are stress, tobacco use, overweight or obesity, physical inactivity, excessive alcohol use, and poor nutritional habits. Over the past two decades, a variety of groups at the local, state, and national echelons have promoted the concept that health risk reduction and care management programs can better employee health, and that workplace health education, health risk management, and benefit counseling should complement standard health care insurance benefits.
The intensity of Company Wellness Programs range from bulletin board, pamphlet or newsletter information to onsite fitness facilities, health risk reduction classes, and personal lifestyle change coaching.3 Company Wellness Programs today often include a health risk assessment (HRA) to evaluate each employee’s potentially-modifiable risk factors of disease. Program coordinators then target interventions to those that are at increased risk through personal talks and individual follow-up.
Comprehensive Worksite Health Promotion Programs may include classes on health risk reduction and job safety, fitness and exercise activities, health club memberships, and reductions in co-payments or premiums for workers who adhere to recommended healthcare screening ground rules.
Along with this, some employers are restructuring health benefits and encouraging employees’ cost-sensitivity when accessing health care.5 These changes are intended to decrease employees’ need for and utilization of health care, yielding reduced group health care expenditures. Demonstrated reductions in health care expenditures should then support employers with a powerful bargaining chip in negotiating reduced health care insurance premiums during future terms.
Evidence basis: A range of return on investment estimates
The empirical research has produced results as varied as the popular media on ROI. Nonetheless, evidence continues to grow that well-designed and well-resourced Employee Wellness Program and disease prevention programs offer multi-faceted payback on expenditure. Peer-reviewed evaluations and meta analyses show that ROI is achieved through improved worker health, reduced benefit expense, and enhanced productiveness.
• Goetzel and colleagues, in their meta-analysis of two dozen articles summarizing economic evaluations of health and work rate management programs, found an average return of $3.14 per $1 invested in traditional Corporate Health Promotion Programs. The ROI estimates for the individual programs ranged from $1.49 to $13.7,8
• Aldana reviewed 72 articles and concluded that Company Wellness Programs achieve an average ROI of $3.48 when considering health care expenditures alone, $5.82 per $1 when examining absenteeism, and $4.30 when both outcomes are considered.
• Ozminkowski and collagues conducted a 38 month case study of 23,000 participants in Citibank, N.A.’s health management program and reported that within a 2 year period, Citibank realized a return on investment between $4.56 and $4.73.10 Follow-up studies saw improvements in the risk profiles of participants, with the elevated-risk group improving more than the “usual care” group11 as a result of more intensive programming.
• Chapman’s 2004 meta-assessment of 42 research studies, ranking overriding validity of the research studies, reports cost-benefit ratios from $2.05-$4.64.
In addition to immediately quantifiable expense reductions, researchers have reported a variety of spin-off benefits: greater productiveness, intellectual capacity, and reductions in disability12 and absenteeism.9,13,14,15 Such programs may also have positive effects on employee perceptions of the company14 and worker morale, even among nonparticipants. 13 These outcomes go beyond savings in direct healthcare expenditures to offer non-health related return on investment.
Tailoring program to maximize ROI Worksite Health Promotion Programs aim to cut the health risks of workers at elevated risk while maintaining the health status of those at low risk. A variety of disease management interventions are available to fit the specific risk profiles of various worksites. Insurers and companies now seek to calibrate their interventions in order to achieve optimal risk reduction and costeffectiveness.
In 2001, University of Michigan researchers published on stable trends in healthcare costs for over 2 million current and former workers in an 18 year data set. The mean cost increase per risk factor gained ($350) was found to be more than double the mean cost decrease per eliminated risk factor ($150). In other words, increases in costs when groups of workers moved from low risk to high risk were much greater than the decreases in costs when groups moved from high risk to low risk. Their conclusion: Programs designed to keep healthy people healthy will likely provide the greatest return on investment.
On the other hand, Pelletier’s meta-analysis16 and other program evaluations18 suggest that individualized risks reduction for high-risk workers within the context of inclusive programming is the essential element in achieving beneficial clinical and expense outcomes in worksite interventions.
Dose-Response?
Several factors might affect the impact of various programs and the ultimate ROI, including cultural and environmental factors, workforce demographics, level of participation and longevity of the program.
Most cost-benefit studies have been conducted in large companies with more than fifty staff members. But researchers have shown that similar results can be obtained by small companies with as few as five staff members actively involved in a well-managed program.
Various research studies also suggest that even relatively modest levels of participation have the potential to achieve substantial program effect. Contrary to reports by the popular media that such programs require more than 70 percent participation, published reports of at least one case showed beneficial ROI with 51 percent participation.
Length of intervention appears to be a more salient variable: an impact on medical expenditures generally requires three-to five years of programming.
Future developments
Despite the abundance of beneficial program evaluations, several caveats remain. Negative results are less likely to be reported or published, thus biasing the return on investment upward.
Uncertainty persists regarding the specific impact of the various program components. But as these programs take hold, further research and assessment will enable fine-tuning of program investments.
Meanwhile, the preponderance of data and the strength of the published research stand in favor of a positive return on investment for Workplace Health Promotion Programs. Indeed, the business case for such programs is now well enough defined that some insurance brokers offer discounted rates to employers that institute or subscribe to wellness programs.
Future questions will focus on how best to combine inclusive and focused interventions, the intensity of components, and how to calibrate the dose-response model to achieve a target return on investment. Here, employers, employees, and researchers will need to collaborate to define mutual goals/objectives in terms of both clinical and cost outcomes.