1. St. John’s, Newfoundland, Canada June 28-29, 2005 CIA Annual Meeting Session 3203 Value of Wellness Improving Health, Addressing Costs Nico Pronk, Ph.D., MA, FACSM, FAWHP HealthPartners Health Behavior Group HealthPartners Center for Health Promotion HealthPartners Research Foundation Minneapolis, Minnesota

2. LOOKING BACK…focused on the future Outline Disease costs, prevention saves Medical care expenditures and Disease status Modifiable health factors Productivity and health risks Changing health risks and associated costs Using health assessments to identify opportunities for cost management Incentives and participation Conclusions

3. LOOKING BACK…focused on the future Disease cost, prevention saves Why invest in prevention?

4. LOOKING BACK…focused on the future Healthy/low Risk At-Risk High Risk Early Symptoms Active Disease 20% of people generate 80% of costs That means, 80% of people generate only 20% of the costs Disease costs, prevention saves. Claims Cost Distribution

5. LOOKING BACK…focused on the future …improve the health and well being of members (employees, patients)… …so that, function is improved… … and quality of life improves… …and health care cost and utilization reduces …and disability is controlled …and productivity is enhanced The approach is to…

6. LOOKING BACK…focused on the future If you maintain the health and well being of currently healthy members (employees, patients)… …quality of life stays high …health care cost and utilization stays low …disability is prevented …productivity stays high …excess costs are avoided. Furthermore…

7. LOOKING BACK…focused on the future So, why is it so hard to prove the value of prevention?

8. LOOKING BACK…focused on the future  Disease is preventable;  Modifiable health risk factors occur prior to disease onset;  Many modifiable health risks are associated with increased health care costs;  Modifiable health risks can be improved;  Improvements in health risks can lead to reductions in health costs;  Improvements in health risks can lead to improvements in productivity;  Well-designed and well-implemented programs can save more money than they cost (positive ROI) The Logic Flow

9. LOOKING BACK…focused on the future 1.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). 2.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). 3.Modifiable health risks can be improved through workplace sponsored health promotion and disease prevention programs (Wilson et al., 1996, Heaney & Goetzel, 1997, Pelletier, 1999). 4.Improvements in the health risk profile of a population can lead to reductions in health costs (Martinson, et al., 2003, Edington et al., 2001, Goetzel et al., 1999). 5.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). The Evidence

10. LOOKING BACK…focused on the future Medical Care Expenditures

11. LOOKING BACK…focused on the future MEAN CUMULATIVE 3-YEAR MEDICAL CHARGES FOR DIABETES PATIENTS BY CO-MORBIDITIES AND GLYCEMIC CONTROL $ DM = Diabetes HTN = Hypertension HD = Heart Disease Source: Gilmer, et al. Diab. Care, 1997; 20:1847-1853

12. LOOKING BACK…focused on the future Mean annual health care charges for low-risk and high-risk individuals by gender and race (adjusted for chronic disease) Low-risk: BMI=25 kg/m2 Never smoker Physical activity at 3 d/wk High-risk: BMI=27.5 kg/m2 Current smoker Sedentary (0 d/wk) Overall mean charges = $4,201 Absolute difference in charges ranges between $1,500 and $2,500 Relative risk difference equals 49% $ Source: Pronk, et al. JAMA 1999;282:2235-2239 Lifestyle-related, Modifiable Risk Factors and Costs

13. LOOKING BACK…focused on the future Percent Difference in Medical Expenditures: High-Risk versus Lower-Risk Employees Independent effects after adjustment 70.2 46.3 34.8 21.4 19.7 14.5 11.7 10.4 -9.3-3.0 -0.8 -50 -25 0 25 50 75 100 Percent Depression Stress Glucose Weight Tobacco-Past Tobacco Blood pressure Exercise Cholesterol Alcohol Eating Source: Goetzel RZ, et al, Journal of Occupational and Environmental Medicine 40 (10) (1998): 843–854. Incremental Impact of 10 Modifiable Risk Factors on Medical Expenditures

14. LOOKING BACK…focused on the future Source: Anderson, D.R., 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 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 Per Capita Cost of High-Risk Status $136 $97 $70 $56 $44 $29 $26 $8 -$33 -$3 -$2 $(75) $(50) $(25) $- $25 $50 $75 $100 $125 $150 $175 Stress Tobacco- Past Weight Exercise Tobacco Glucose Depression Blood Pressure Alcohol Cholesterol Eating Dollars Per Employee

15. LOOKING BACK…focused on the future Productivity and Work Performance

16. LOOKING BACK…focused on the future Source: Pronk, NP. ACSM’s Health & Fitness Journal 2003;7(3):31-33 100 75 50 25 0 -25 -50 -75 -100 Optimal, best possible performance, fully present Fully absent, no work or duties performed Worst possible performance, fully present Performance Quality Units (%) 100 75 50 25 0 -25 -50 -75 -100 Hours-on-Task (%) Work Performance Scale

17. LOOKING BACK…focused on the future Obesity impact on work limitations NHANES III and NHANES 1999-2000 data Obese workers, regardless of gender, are more likely than normal weight workers to report being limited in the amount or type of work they can do because of physical, mental or emotional problems (6.9% vs. 3.0%, respectively) Source: Hertz, et al. JOEM 2004; 46:1196-1203. Impact of obesity on work limitations is akin to 20 years of aging Productivity and Health Risks Obesity and Work Limitations

18. LOOKING BACK…focused on the future Annual excess absenteeism, presenteeism, and critical incidents studied in: Reservation agents Customer service representatives Executives Railroad engineers Assessment tool: WHO Health and Work Performance Questionnaire (WHO HPQ) (www.hpq.org) Source: Wang, et al., JOEM, 2003; 45(12):1303-1311. Chronic Conditions and Work Performance

19. LOOKING BACK…focused on the future PA moderateQuality0.05740.0017Improvement Work rate0.05170.0047Improvement PA vigorousWork rate0.05380.0039Improvement CardiorespiratoryQuantity0.01180.0454Improvement FitnessExtra effort0.20980.0299Improvement BMI obeseGetting along-0.2390.0156Decrement BMI morbidWork loss days1.01550.032Decrement Dep. Var. β pEffect on PROD Source: Pronk, et al., JOEM, 2004; 46(1): 19-25. Work Performance and Physical Activity, Cardiorespiratory Fitness, and Obesity

20. LOOKING BACK…focused on the future Does a Change in Health Risk Result in a Change in Cost?

21. LOOKING BACK…focused on the future Improving health risks contains escalating medical costs and improves productivity (esp. STD costs) Largest reduction in costs experienced in those moving from high-risk to low-risk Total 2-year costs for groups was follows: H-H = $6,942 H-L = $3,919 L-H = $3,897 L-L = $2,477 Those who remain at low risk maintain the best cost and productivity profile Note: Risk assessed by HRA; linked to medical and STD costs for the years 1998-1999 compared to 2000-2001 Source: Edington and Musich. HPM 2004;3(1):12-15. $ Change in Health Risk and Change in Cost

22. LOOKING BACK…focused on the future Prospective cohort study (N=2,393 adults, age 50 and older) Predicting changes in health care charges between two 1-year periods (Sept ’94 to Aug ’95 and Sept ’96 to Aug ’97) due to increased physical activity Statistical adjustment for age, gender, co-morbidity, smoking, BMI Source: Martinson, et al. Preventive Medicine 2003;37:319-326. Change in Physical Activity, Change in Costs Considering a more rigorous study design using an actual underlying cause of mortality, i.e., physical activity

23. LOOKING BACK…focused on the future Increased PA among older adults is associated with lower annual health care charges within 2 years (1994-1995 to 1996-1997) as compared to continuously inactive controls Among those who increase PA from 0-1 to 3+ days per week, decline in costs is as much as ~$2,200 Such cost savings easily justify investments in PA programs Source: Martinson, et al. Preventive Medicine 2003;37:319-326. Change in PA, Change in Costs

24. LOOKING BACK…focused on the future Focus: Peer reviewed journals (English Language) – 196 studies pared down to 72 studies meeting inclusion criteria for review Scoring Criteria: 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) 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 ROI: 3.48 to 1.00 (7 studies) Steven G. Aldana, Ph.D. American Journal of Health Promotion, May/June, 2001, 15:5. Literature Review on Financial Impact

25. LOOKING BACK…focused on the future Using Health Assessments to identify health behavior change opportunities in order to better manage costs

26. LOOKING BACK…focused on the future 9,981 employees were invited to complete the HA in early 2004 5,113 (51.2%) completed the HA Selected risk-related variables were associated with paid medical care expenditures Analyses were limited to employees who were members for 9-12 months of enrollment in 2003 (n=3,937) Gender ratio of HA responders: 83% female, 17% male Non-responders were, on average, 7 years older than responders Compared to a multi-employer comparison group, HP HA responders have significantly higher rates of asthma, depression, diabetes, periodontal disease, back pain, and gestational diabetes (based on self-report) RespondersNon Responders n3,9373,827 Average age42.2 years49.3 years Average paid claims$3,685$4,280 Prevalence of CHF*0.25%1.52% Prevalence of CAD*1.87%6.54% Prevalence of Diabetes*1.41%4.7% * Based on HealthPartners diagnosed disease registry, 2004 data. All values significant at p<0.05. Background

27. LOOKING BACK…focused on the future Total Health Potential Score is out of a possible 1,000 points n = 3,937 Paid expenditures tend to decrease as the Total Health Potential Score increases Averages for the lowest Total Health Potential Score categories are significantly higher than the means for the highest Total Health Potential Score categories (p<0.05) $% HA Total Health Potential Score and Paid Medical Care Costs

28. LOOKING BACK…focused on the future Modifiable Health Potential Score is out of a possible 520 points for men or 505 points for women n = 3,937 Paid expenditures tend to decrease as the Modifiable Health Potential Score increases Averages for the lowest Modifiable Health Potential Score categories are significantly higher than the averages for the highest Modifiable Potential Score categories (p<0.05) $ % HA Modifiable Health Potential Score and Paid Medical Care Costs

29. LOOKING BACK…focused on the future Paid Medical Care Costs for Those with HA-based Report of Heart Disease Compared to Those Who are at High-Risk for Heart Disease and Those Who are at Low-Risk for Heart Disease n = 3,937 Average expenditures are significantly different from each other (p<0.0001) $%

30. LOOKING BACK…focused on the future n = 3,937 Members with BMI between 18 and <25 are in the normal BMI range Average expenditures for those with BMI of 30 and over is significantly higher than all other categories (p<0.05) $% Paid Medical Care Costs Comparison by Body Mass Index Category

31. LOOKING BACK…focused on the future n = 3,937 Average expenditures decrease with increasing levels of physical activity Average expenditures for those who are sedentary is significantly higher than all other categories (p<0.05) $% Paid Medical Care Costs Comparison by Level of Physical Activity

32. LOOKING BACK…focused on the future For all graphs, comparison groups are significantly different from each other: Perceived health = p<0.0001 Physical health = p<0.0001 Emotional health = p<0.001 Paid Medical Care Costs comparison by Perceived Health Status (n=3,937)

33. LOOKING BACK…focused on the future For all graphs, comparison groups are significantly different from each other: All = p<0.0001 Paid Medical Care Costs comparison by Medication Use (n=3,937) Use of Non-Prescription Medications 4247 3139 49 51 0 1000 2000 3000 4000 5000 YesNo 0 20 40 60 80 100 Paid Dollars % of Respondents Polypharmacy (7+ Medications) 7662 3469 5 95 0 2000 4000 6000 8000 10000 YesNo 0 20 40 60 80 100 Paid Dollars % of Respondents Use of Prescription Medications 4600 2016 65 35 0 1000 2000 3000 4000 5000 YesNo 0 20 40 60 80 100 Paid Dollars % of Respondents

34. LOOKING BACK…focused on the future Do Incentives Drive Participation?

35. LOOKING BACK…focused on the future Source: Serxner, et al. The Art of Health Promotion Newsletter. 2004; March/April. What Does the Literature Tell Us?

36. LOOKING BACK…focused on the future Harvard Medical School, Department of Health Care Policy HealthPartners, Center for Health Promotion and Research Foundation Group Health Cooperative, Center for Health Studies Kaiser Permanente, Denver American Airlines, Dallas The effect of intensity of recruitment effort on response disposition

37. LOOKING BACK…focused on the future The effect of intensity of recruitment effort on response disposition IVR interview with one or two mailings Telephone interview with no incentive or $20 incentive Overall cumulative response rate was 26.4% % Source: Wang, et al. Medical Care, 2002;40:752-760 Results-HRA Response Disposition

38. LOOKING BACK…focused on the future Data reflects: Incentives/Marketing and communication 78 companies in 3 rd/4th Q 2003 Total of 22,838 HA invitees 77.1% of the variance in HA completion is explained by type of incentive and marketing and communication Incentives Low = e.g., merchandise awards, drawing, small gift, etc. Medium = $25 gift certificate, prize drawings, etc. Strong = e.g., mandatory, premium reduction, co-pay reduction, etc. Marketing and communication Low = e.g., very limited messaging, short timeline Medium = “soft” messaging, no strategic communication plan Strong = e.g., appropriate messaging, communication plan and timeline Impact of Incentives and Marketing/ Communication on HA Completion 92 64.5 61.5 43.3 7.3 15.1 Trend R 2 = 0.771 0 10 20 30 40 50 60 70 80 90 100 Strong/Strong Strong/MediumMedium/Strong Strong/LowLow/Strong Medium/Medium Low/Low Percentage completion

39. LOOKING BACK…focused on the future Modifiable health risk factors are associated with health care expenditures and productivity Health assessments (HA) can be used to measure modifiable health risks HA can be used to project associations between health risks and costs Incentives work Conclusions

40. LOOKING BACK…focused on the future Nico Pronk, PhD Vice President, Center for Health Promotion Executive Leader, Health Behavior Group Research Investigator, HealthPartners Research Foundation HealthPartners, Inc. 8100 34th Ave. S., MS21111H P.O. Box 1309 Minneapolis, MN 55440-1309 Telephone: 952-967-6729 Fax:952-967-6710 Email:nico.p.pronk@healthpartners.com Thank you Contact Information