Employee Health Promotion

Many employers, as part of their efforts to contain rising health care costs,
are launching worksite programs variously described as Employee Health Promotion
, lifestyle programs, health and work rate management, population health management
and, simply, wellness programs.

The purpose of this article is to consider whether such programs improve health.
If so, do they in turn reduce utilization of health care services and reduce
health care expenditures?

The popular media have done much to reward the concept of organization 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 Employer, as published

Would these ROIs stand up to thorough empirical analysis of the data? What
factors lead to such disparate returns among these programs? And does the published
literature, subject to peer review of scientific methods, support the ROIs published
here?

Health and Productivity Leadership

Illness and injury associated with an unhealthy lifestyle or potentially-modifiable
risk factors is published to account for at least 25% of employee health 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 improve employee health, and that
worksite health education, health risk management, and benefit counseling must
complement standard health care insurance benefits.

The intensity of Employee Health Promotion range from bulletin board, pamphlet
or newsletter information to onsite fitness facilities, health risk reduction
classes, and personal lifestyle change coaching.3 Employee Health Promotion
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 discussions
and individual follow-up.

All-Inclusive Employee Health Promotion 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 employees who adhere to recommended
healthcare evaluation guidelines.

Along with this, some employers are restructuring health benefits and encouraging
employees’ cost-sensitivity when accessing health care.5 These changes
are intended to reduce employees’ need for and utilization of health care,
yielding reduced group health care costs. Demonstrated reductions in health
care expenditures must then offer employers with a powerful bargaining chip
in negotiating decreased health care insurance premiums during future terms.

Evidence basis: A range of ROI 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 Health Promotion and disease prevention programs offer multi-faceted
payback on cost. Peer-reviewed evaluations and meta analyses show that ROI is
achieved through improved worker health, reduced benefit expense, and enhanced
work rate.

• Goetzel and colleagues, in their meta-analysis of two dozen articles summarizing
  economic evaluations of health and work rate management programs, saw an average
  return of $3.14 per $1 invested in traditional Employee Health Promotion .
  The ROI estimates for the individual programs ranged from $1.49 to $13.7,8
• Aldana reviewed 72 articles and concluded that Employee Health Promotion
  achieve an average ROI of $3.48 when thinking of health care costs 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 published that within
  a 2 year period, Citibank realized a ROI between $4.56 and $4.73.10 Follow-up
  studies saw improvements in the risk profiles of participants, with the high-risk
  group improving more than the “usual care” group11 as a result
  of more intensive programming.
• Chapman’s 2004 meta-assessment of 42 different studies, ranking central
  validity of the different studies, reports cost-benefit ratios from $2.05-$4.64.

In addition to immediately quantifiable cost reductions, researchers have published
a variety of spin-off benefits: greater work rate, 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 health
care costs to offer non-health related ROI.

Tailoring program to maximize ROI Employee Health Promotion aim to reduce the
health risks of employees at high 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 organizations
now seek to calibrate their interventions in order to achieve good risk reduction
and costeffectiveness.

In 2001, University of Michigan researchers published on stable trends in health
care costs for over 2 million current and former employees 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 employees 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 offer 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 employees within the
context of accross the board programming is the essential element in achieving
positive clinical and cost outcomes in worksite interventions.

Dose-Response?

Several factors might affect the influence 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 organizations with more
than fifty employees. But researchers have demonstrated that similar results
can be obtained by small organizations with as few as five employees actively
involved in a well-managed program.

Various studies also suggest that even relatively modest levels of participation
can achieve substantial program influence. Contrary to reports by the popular
media that such programs require more than 70% participation, published reports
of at least one case showed positive ROI with 51% participation.

Length of intervention appears to be a more salient variable: an influence
on healthcare costs generally requires three-to five years of programming.

Future developments

Despite the abundance of positive program evaluations, several caveats remain.
Negative results are less likely to be reported or published, thus biasing the
ROI upward.

Uncertainty persists regarding the specific influence 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 ROI for Employee Health Promotion . Indeed, the
organization case for such programs is now well enough defined that some insurance
brokers offer discounted rates to organizations that institute or subscribe
to wellness programs.

Future questions will focus on how best to combine accross the board and focused
interventions, the intensity of components, and how to calibrate the dose-response
model to achieve a target ROI. Here, employers, employees, and researchers will
need to collaborate to define mutual goals/objectives in terms of both clinical
and cost outcomes.

As organizations today continue to compete in the global economy, cost containment
strategies will be increasingly important. Controlling the rising cost of employee
sickness is becoming a priority for corporate leaders. The emerging corporate
culture in the U.S. is one which has an employee population centered in health,
safety and wellness.

Creating a corporate plan for Employee Health Promotion and disability management
makes great organization sense. The following eight-step process ensures a strategic,
integrated, needs-driven and outcome-oriented approach.

The following process works best in organizations with strong leadership
and a long-term responsibility to employee health.

1. Identify Your Employee Health Promotion Champion

This person must be a leader in your organization and a strong advocate of
health. Most often this is an individual who actively pursues his or her own
personal quest for good health.

The program champion must have the resources and authority to propel the program
forward. The program champion’s key role is to be sure the strategic plan
for health is aligned with the organization’s objectives, strategic focus and
organization values. By way of example if the organization promotes that “our
strength is our people” the wellness program must show how initiatives
will nurture and protect that important resource.

2. Form Your Employee Health Promotion Strategy Team

The Employee Health Promotion Strategy Team must include decision makers and
stakeholders from parts of the organization that can influence health and the
company’s bottom line. These areas may include; finance, human resources,
training and development, health services, compensation and benefits, employee
assistance services (EAP), marketing, facilities, health and safety, rehabilitation,
cafeteria or meal services and the union. A team of six to eight representatives
is recommended.

The role of the Strategy Team is to foster and enable the strategic plan, look
for opportunities to reward health, be sure the program is integrated into key
areas of the organization, streamline efforts, maximize organization resources
and program assessment.

3. Complete an Employer Health Audit

The purpose of an Employer Health Audit is to evaluate your existing programs
and services, physical environment and policies & procedures that support
health. It is also important to look at your organization culture or “how
things are done” around the organization.

Members of the Strategy Team complete the Audit independently and then meet
to discuss their assessment. During the assessment process, health problems
and opportunities are discussed in preparation for the development of the strategic
plan.

4. Analyze Your Organization’s Cost Pressures

Cost pressures are identified by analyzing a number of areas including; benefit
costs, Workplace Safety Insurance Board (WSIB) claims, prescription usage, type
of paramedic claims, absenteeism data and EAP utilization. This process helps
to target areas that can be positively impacted by a Employee Health Promotion
and to offer a baseline for evaluating change.

5. Conduct a Health Risk Appraisal or Employee Needs & Interest
Survey

The next step is to determine your employee’s health risks, interests
and readiness to change. A confidential health risk appraisal can accomplish
many goals/objectives. It supplies a baseline from which to measure personal
lifestyle changes, supplies employees with relevant health information, motivates
employees to take charge of their health and assists in program planning. Most
health risk appraisals offer individual reports and a corporate report identifying
high-risk areas in the organization.

Many organizations choose to administer customized needs and interest survey
to evaluate employee needs. The benefit of this approach is that the organization
is able to gather information on the employees’ perceived wellness needs
and program interests. This information can be incorporated into the strategic
plan. Administering a survey also has the added benefit of fostering a sense
of employee ownership to the program.

6. Design Your Strategic Plan for Wellness

The strategic plan must incorporate information collected from the Employer
Health Audit, your organization’s cost pressures, and health risk appraisal
data or employee survey results. The strategic plan must include your program
mission, three or four objectives and several initiatives under each goal. The
strategic plan supplies a framework to encourage, support and evaluate “best
health practices.”

It is also important that the plan align itself with the vision, goals/objectives
of the organization.

The sample strategic plan that follows was developed for blue jeans maker Levi
Strauss & Co. (Canada) Inc. Levi Strauss & Co.’s mission statement
and aspirations (how employees interact with each other in a organization environment)
guided the development of the plan.

Levi Strauss & Co.’s aspirations include the following statement:
Above all, we want satisfaction from accomplishments and friendships, balanced
personal and professional lives, and to have fun in our endeavors. The wellness
program plan included a number of components to see that it embraced this statement
including the following:

A vision statement, which tied in with the company’s aspirations.

1. An incentive system to encourage and reward the accomplishment of healthy
   milestones.
2. A recognition system to applaud effectiveness.
3. Friendly competitions between Levi Strauss & Co. locations to ensure
   a fun environment.
4. Opportunities to take part in small group educational programs to foster
   team support.
5. Initiation of support groups for employees completing wellness programs
   (i.e. smoking control support group).
6. Programs dealing with work and family balance.

Other information that was analyzed and used to foster the plan included:

1. Employer demographics
2. Focus groups
3. Cultural audit
4. Top prescription report
5. EAP utilization
6. Employee benefit services report
7. Health and dental claims
8. Operational effectiveness summaries
9. Health risk appraisals
10. Prepare a Employer Case to Support Your Plan

Your organization case for wellness supplies the necessary details for approval
at the senior staff level. The organization case includes:

1. The Strategic Plan for Health
2. A proposed program budget
3. Marketing strategies
4. Program leadership options
5. An implementation plan
6. Evaluation methodology.

In presenting the strategic plan it is important to highlight how the plan
aligns itself with the strategic direction of the organization.

The program budget must include educational resources, marketing costs, rewards
and incentives, leadership costs and supplies.

Marketing strategies must address how the program will be promoted and rolled
out to various groups within the organization i.e. decentralized locations,
high risk employees, older employees.

Program leadership must address how volunteers will be used, internal resources
and whether consultants have been proposed. All play an equally important role
in the implementation of your wellness program.

The program implementation plan must incorporate the following types of programs
that help foster awareness of positive health practices, help employees in making
lifestyle changes and initiatives, which support long-term change.

Awareness programs foster an awareness of the significance of healthy lifestyle
practices and arouse employees to take the next step. Examples of awareness
programs include posting educational posters, newsletter articles and lunch
and learn courses.

Lifestyle change programs are more accross the board and longer in duration.
They are designed to help employees in changing behavior. Examples of lifestyle
change programs are nutrition education programs, stress management programs,
back care classes and smoking control programs.

A supportive corporate environment encompasses everything from corporate policies
& procedures, the physical environment and creating a corporate culture
that supports great health practices. Follow-up sessions and support groups
for employees who have completed 6-10 week wellness programs also offer a supportive
environment for long-term change.

Reviewing the effectiveness of a Employee Health Promotion is ongoing. A formal
assessment must be conducted annually and may include; re-administering steps
three to five, program participation statistics and a year end survey to revisit
“soft” problems such as morale, program satisfaction and future
program direction.

8. Solicit Input and Communicate Your Plan

Employee input is essential to the long-term effectiveness of your program.
An Employee Advisory Committee must be formed to roll out the plan. Another
key responsibility of this team is to solicit feedback from all echelons of
the organization to ensure buy-in. Front line Manager’s Information Sessions
and focus groups are also important. This group needs to buy-in to the notion
that they play a key role in supporting positive health practices. Regular gatherings
are advised with front line managers to receive ongoing input, address problems
and orient new managers.

Conclusions

The World Health Organization’s definition of health is “a state
of complete physical, mental and social wellness and not merely the absence
of disease and infirmity.” In order for us to create healthy workplaces,
wellness initiatives must have a program champion, have employee ownership,
be senior staff supported, outcome driven and strategically aligned with the
central organization objectives of the organization.

Wellness plan that embrace these qualities will have a positive influence on
an organization’s bottom line. Canadian research points to many case studies
where onsite programs have resulted in diminished absenteeism, reduce claims
and increased work rate.

Employers who have embraced wellness as part of “how they do business”
have one thing in common. They show a responsibility to their most important
resource – their people. They be aware of the increased pressures associated
with downsized organizations, a rapidly changing workplace, an aging work force
and the challenge of balancing work and family obligations. And they share a
common belief that healthy employees are happier, absent less and more productive.

References:

Design of Employee Health Promotion by Michael P. O’Donnell. 1995. Published
by the American Journal of Health Promotion.

Pro Fit-ability by Veronica Marsden. Group Healthcare Management. May 1997.

Meeting Expectations by Laura Mensch. Employee Health and Productivity. August
1999

7 Steps to Health Promotion by Daphne Woolf and Veronica Marsden. Group Healthcare
Management. February 1996.

Published in The Journal of Health Promotion for Northern Ireland, Issue 9,
March 2000