Optimizing Health Readiness of the Relevant, and Modern ...files.constantcontact.com/bf8839eb401/d3291459-bc3...Optimizing Health Readiness of the Force Requires an Effective, Relevant,

Optimizing Health Readiness of the Force Requires an Effective,

Relevant, and Modern Strategy

by

Lieutenant Colonel Victor A. Suarez United States Army

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Under the Direction of: Dr. Peter LaPuma and Mr. Jeffrey Wilson

While a Fellow at: George Washington University

United States Army War College Class of 2017

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Optimizing Health Readiness of the Force Requires an Effective, Relevant, and Modern Strategy

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Lieutenant Colonel Victor A. Suarez United States Army

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Word Count: 8647

14. ABSTRACT

The Department of Defense (DoD) is currently experiencing a health and well-being problem in

the U.S. military whereby the services regularly fall short of reaching or maintaining a desired 90%

or better medical readiness threshold which affects overall military readiness. To boost military

readiness, the DoD could better integrate service unique health and well-being programs and

modernize its institutional health system to be more prevention rather than treatment focused.

Also, by improving service member and beneficiary health, the DoD could also reduce the

demands of health-related costs on the defense budget which in 2016 accounted for

approximately 9% ($48 billion) of the $523.9 billion DoD budget and is projected to reach 11% by

2028 according to the Congressional Budget Office (CBO). By considering advances among the

most successful civilian employee health and well-being programs (Koop Award Winners), the

DoD should embrace an integrated strategy for health optimization, institutionalize best health and

well-being practices using “smart, creative and meaningful” incentives, and ignite an aspirational

culture for health at all stages of service.

15. SUBJECT TERMS

Health and Well-being, Health Optimization, Individual Medical Readiness, Health Readiness

16. SECURITY CLASSIFICATION OF: 17. LIMITATION OF ABSTRACT

SAR

18. NUMBER OF PAGES

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UU c. THIS PAGE

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(8647 words)

Abstract

The Department of Defense (DoD) is currently experiencing a health and well-being

problem in the U.S. military whereby the services regularly fall short of reaching or

maintaining a desired 90% or better medical readiness threshold which affects overall

military readiness. To boost military readiness, the DoD could better integrate service

unique health and well-being programs and modernize its institutional health system to

be more prevention rather than treatment focused. Also, by improving service member

and beneficiary health, the DoD could also reduce the demands of health-related costs

on the defense budget which in 2016 accounted for approximately 9% ($48 billion) of

the $523.9 billion DoD budget and is projected to reach 11% by 2028 according to the

Congressional Budget Office (CBO). By considering advances among the most

successful civilian employee health and well-being programs (Koop Award Winners),

the DoD should embrace an integrated strategy for health optimization, institutionalize

best health and well-being practices using “smart, creative and meaningful” incentives,

and ignite an aspirational culture for health at all stages of service.


“The preservation of a Soldier’s health should be the commander’s first and

greatest care...”

--Baron Von Steuben, “Regulation for the Order and Discipline of the Troops.” 17791

The Department of Defense (DoD) is currently experiencing a health and well-

being problem in the U.S. military whereby the services regularly fall short of reaching or

maintaining a desired 90% or better medical readiness threshold which affects overall

military readiness.2 To boost military readiness, the DoD could better integrate service

unique health and well-being programs and modernize its institutional health system to

be more prevention rather than treatment focused. Also, by improving service member

and beneficiary health, the DoD could also reduce the demands of health-related costs

on the defense budget which in 2016 accounted for approximately 9% ($48 billion) of

the $523.9 billion DoD budget and is projected to reach 11% by 2028 according to the

Congressional Budget Office (CBO).3

In 2015, 70% of active-duty Soldiers were clinically overweight or had obesity4

and 32% reported tobacco use5. In the Navy, approximately 64% of Sailors are

overweight or have obesity6 and since 2002, there has been a 62% rise in obesity

among all active duty forces.7 The DoD spends approximately $3 billion per year

treating both obesity and smoking related medical conditions which are also the top two

behavioral leading causes of premature death in America.8 9 In an analysis of four years

of service-connected disability claim data among new recipients from fiscal 2011 to

2

2015—a proxy measure for strategic health ends--there has been a 153% increase in

musculoskeletal, 79% increase in cardiovascular and 71% increase in mental health

related claims.10 Total annual disability claim expenditures by the Veterans Benefits

Administration now exceed $60 billion for almost 4.2 million total living veterans.11

Despite these alarming health, disability, cost outcomes and their effects on readiness,

the DoD personnel and medical system and policies continue to rely on the status quo

for measuring medical readiness which favors “finding and fixing” disease and injury

over “assessing health risks” and “predicting, personalizing and integrating” ways and

means to prevent them.

This paper presents a compelling case that; current ways of measuring medical

readiness are ineffective and make it very difficult for the DoD to optimize health; that

DoD’s healthcare and personnel system have lost relevancy in helping to produce

healthy service members; and the current “transactional” approach for ensuring service

members adhere to strict medical and fitness standards will likely yield short-term

readiness as now measured, but with severe long-term consequences. In order to

reverse this health readiness problem, the DoD should consider the myriad, complex

and powerful social, political and environmental determinants of health and boldly

create a new vision with a “transformational” approach. The DoD should embrace an

integrated strategy for health optimization, institutionalize best health and well-being

practices using “smart, creative and meaningful” incentives, and ignite an aspirational

culture for health at all stages of service.12

3

Integrated Strategy for Health Optimization

In order to assess whether the DoD’s current personnel and medical system is

either effective or relevant in creating healthy service members, the DoD should

consider better ways to organize, allocate and apply resources in order to achieve

improved health outcomes and well-being without sacrificing the primary mission of

combat readiness. Given the demands and rigors of military training, life, and

operational tempo, it may not be feasible for each service member to experience the

same health and well-being opportunities as many large and modern civilian employers

have provided their employees. However, the DoD has an obligation to the American

public do its best to sustain and improve the health of its service members using

effective, relevant, and modern workplace health and well-being practices. Although

this research paper will explore and highlight best practices found in the civilian world, it

does not suggest that because a program was found to be successful in a non-military

context, that it will be so in a military one. Military service in the 21st century is

burdened with unique and dynamic social complexities, financial and psychological

hardships, and unpredictable dangers rarely ever found in civilian institutions. However,

the military can still learn how some of these large, complex and multi-national

companies, including government entities like the National Aeronautics and Space

Administration (NASA), have embraced an integrated and modern strategy to influence

healthy behavior, optimize health, and apply these practices in the 21st century force.13

Our most pressing and resolvable problem in this regard is DoD having separate

and non-integrated health and well-being programs across four services; all of which

are embedded within three distinct service healthcare systems. Unlike physical fitness

4

standards, which has been successfully researched and argued as service and military

occupational specialty unique14, the health and well-being of our service members is not

exclusively a service-unique matter. It should be applied uniformly across the services

with only very rare exceptions; this appeared to be a major consideration in the 114th

Congress when passing the Fiscal 2017 National Defense Authorization Act (NDAA).

There was concern among congressional members that the lack of integration among

various service healthcare systems led to increased redundancies, inefficiencies, costs,

and worsening health outcomes.15 As a result of the Fiscal 2017 NDAA, all previously

service controlled medical treatment facilities (MTF) will now organize under the

auspices of the Defense Health Agency (DHA). This sweeping legislation also included

language which for the first time opened the door for including financial incentives

among TRICARE beneficiaries for participating in or completing disease management

and prevention programs, much like what has been done for years in the private

sector.16

Although these sweeping changes will take the next few years to implement; now

is the time to embrace an integrated, effective and modern strategy to align programs

with the goal of empowering individuals to optimize their health by mastering new

healthy behaviors and reinforcing them using “smart, creative and meaningful”

incentives. Coupled with further investments among installation level health promoting

facilities and designs (i.e. sidewalks, trails, healthy dining options, fitness and wellness

centers) identified in the Healthy Base Initiative (HBI) report17, and the support from

commanders at all levels, the DoD has a golden opportunity to reduce its increasing

disability rate, lower healthcare costs and boost medical readiness levels to meet

5

service level goals. Although Congress’ intent was to introduce these new incentives

based disease management and prevention programs to non-uniformed TRICARE

beneficiaries to improve health and reduce costs, there is nothing preventing the DoD

from taking the initiative to explore and pilot how these programs could improve health,

readiness, and reduce disabilities of uniformed service members.

Evidence for DoD’s lack of integration among health and well-being programs

was documented in the HBI program evaluation report which found, “many of DoD’s

health related efforts are siloed even though they have similar objectives. Examples

include the Joint Chief’s Total Force Fitness initiative and several Service-led initiatives,

such as the Army’s Performance Triad, the Navy’s Sailor and Marine Initiative, and the

Air Force’s Comprehensive Airmen Fitness initiative.”18 This non-integration has the

tendency of confusing service members19 and runs counter to the approach identified

among best employer health practices by the National Academy of Sciences,

Engineering and Medicine (formerly Institute of Medicine), the National Business Group

on Health, and a project titled, Promoting Healthy Workplaces.20 21

The first and foremost steps needed to implement an effective strategy to

improve health readiness are for all services to: 1) collectively recognize underlying root

causes of poor health and well-being; 2) be transparent about their effects on readiness;

3) integrate disparate health programs which are most likely to improve overall force

readiness; and 4) promptly discard health programs which cannot effectively

demonstrate improved and sustainable health outcomes or improve medical readiness

and adopt use of those which do. Integration of the best performing programs seeks to

ensure a common vision for health with interoperable ways and means for measuring

6

program outcomes and success. The common vision should align with over-arching

organizational values and shared use of evidence based health and well-being

practices.22

One practical way to implement this in the DoD is to stand-up a chartered Joint

Program Office (JPO) for Health and Well-being which would serve as the DoD’s single

point of accountability for cost, schedule and performance for all of the DoD’s health

and well-being programs. This is already done for other Joint service requirements

such as for developing nuclear, biological, chemical agent medical countermeasures,

the electronic health record and other bio-surveillance related detection products and

services. Our military services would still execute service appropriate programs for their

troops, however, they would be held accountable for adherence to shared and

evidenced based implementation strategies, program evaluation metrics and cost

controls to meet Joint requirements administered by this JPO. The JPO would be held

accountable to senior stakeholders through the Joint Requirements Oversight Council

(JROC) and overseen by senior leaders such as the Vice Chairman, Joint Chiefs of

Staff, Military Vice Service Chiefs, Combatant Commanders, the Deputy Assistant

Secretary of Defense for Health Affairs, Deputy Assistant Secretary of Defense for

Reserve Affairs and the Deputy Assistant Secretary of Defense for Research and

Engineering. This high level of oversight, although burdensome, would signal the

importance health and well-being is to military readiness, but also ensure that programs

are integrated force wide and executed using effective ways and means.

7

A Modern and Relevant View of Health

In order to successfully integrate, modernize and make relevant DoD’s health

strategy and programs to improve health readiness and optimize health, the DoD should

consider how economists understand the concepts of “health” and “health production”

as driving forces. Many economists recognize that health is an imprecise concept,

however, view health as a “type of capital, that provides services to an individual. The

services flowing from the stock of health “capital” are consumed continuously over an

individual’s lifetime.23 24 Each person is assumed to be endowed with a given stock of

health at the beginning of a period, such as a year. Over a period, the stock of health

may depreciate, particularly as a person ages, but the loss of health capital may be

augmented through investments in medical services. Death occurs when an individual’s

stock of health falls below a critical minimum level.”25 Economists also believe in the

concept of the “production of good health,” which is, “the creation and maintenance of

health involves a production process.”26 To illustrate this concept, think of the “health

production function as the maximum amount of health that an individual can generate

from a specific set of health-related input in a given period of time.” For example:

Health = H (Profile, Technology, Environment, Social Economic Status, Lifestyle, Medical Care)27

Given this different way of viewing health, as opposed to an “absence of

disease,” and focused primarily on medical care as a primary driver of health, we are

obliged to consider that there are several significant determinants of health and the

single largest driver is our lifestyle behaviors.28 The former fixation on disease focused

medical care being a primary driver of health has poorly served us as a nation.29 Among

all of Western medicine’s great scientific and technological accomplishments in the

fields of biotechnology, advanced drugs, vaccines and therapeutics, surgery and trauma

8

care, its modern day “Achilles’ heel” has been its “commoditization” of health30 which

has contributed to Americans being more “consumers” of health products and services,

rather than “producers” of their own health through a lifestyle of proper diet, exercise,

and rest.

As cited in the National Prevention Strategy, Dr. Steven A. Schroeder, in his high

profile 2007 article published in the New England Journal of Medicine titled, “We Can

Do Better-Improving the Health of the American People,” states, “The single greatest

opportunity to improve health and reduce premature deaths lies in personal behavior. In

fact, behavioral causes account for nearly 40% of all deaths in the United

States. Although there has been disagreement over the actual number of deaths that

can be attributed to obesity and physical inactivity combined, it is clear that this pair of

factors and smoking are the top two behavioral causes of premature death.”31

Unfortunately, the DoD, like our nation’s health system distributes and markets health

services as a massive commodity and spends the greatest predominance of its annual

$48 billion Unified Medical Program budget on healthcare related activities, with only a

fraction of this budget spent on influencing healthy behavior through various health and

well-being initiatives and public health and preventive medicine programs.32

This is not surprising as the commoditization of health works symbiotically within

a capitalist based economy, regardless of health outcomes; there will be unlimited

demand for high-tech health products and services as long as our system continues to

under-emphasize people’s role in their own health.33 For all the great technological

benefits we receive from a commoditized health system, this system primarily relies on

unhealthy people to perpetuate its existence. However, this system has become highly

9

ineffective and irrelevant when it attempts to combat the late 20th and early 21st century

exponential growth in lifestyle induced and environmentally reinforced chronic diseases,

obesity and preventable injuries.

In reviewing figure 1 below, adapted from Dr. Michael McGinnis’ 2002 article in

Health Affairs covering the U.S. population, healthcare only contributes to about 10%

towards influencing premature death, however, behavioral patterns, lifestyle and other

social determinants contribute about 55% of what decides our health status. From a

financial allocation standpoint, are we placing our limited resources (means) in the right

places to affect health and are the most effective health strategies (ways) being shared

effectively across the force? Figure 2, which captures U.S. deaths from behavioral

causes in 2000, illustrates that smoking, obesity, and inactivity are the most effective

killers among the behavioral factors contributing to premature death among the U.S.

population and the U.S. military is not immune to this reality.34

Adapted from McGinnis et al, 2002.35

Proportional Contribution to Premature Death

Social

Genetic circumstances

predisposition 15% 30%

Environmental

5%

10%

40%

10

Adapted from Mokdad et al, 2004.36

If we can fully appreciate and combine the economists view of health as

something which can be produced, primarily by individuals and their lifestyle

behaviors—augmented with medical services when needed--along with a contemporary

view of health as defined by the World Health Organization (WHO) as a “state of

complete physical, mental, and social well-being, and not merely the absence of

disease,”37 we can begin to see the possibilities for effective, relevant and modern policy

making. If we add the concept of “well-being,” to the policy making framework, as

defined in Healthy People 2020 and its Health-Related Quality of Life (HRQOL)

initiative, as “including the presence of positive emotions and moods (e.g., contentment,

happiness), the absence of negative emotions (e.g., depression, anxiety), satisfaction

with life, fulfillment and positive functioning,”38 39 40 41 we can see that our current

medical and personnel readiness policies and strategies which primarily focus on

“finding and fixing” disease and injury are truly ineffective, irrelevant for the 21st century,

and rooted in maintaining the status quo. Therefore, the DoD should seek out and

450 435

400 365

350

300

250

200

150

100 85

43

50 20 29 17

0 Sexual Alcohol Motor Guns Drug Obesity Smoking

Behavior Vehicle Induced and

Figure 2. Numbers of U.S. Deaths from Behavioral Causes, 2000.

Among the deaths from smoking, the horizontal bar indicates the approx.-mately 200,000 people who had mental illness or a problem with substanceabuse.

No

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develop a more effective, relevant, and modern strategy for health promotion and

readiness which enables strategic leaders, health providers and commanders to inspire

their troops to achieve their health potential. To do this may require a fundamental

change to the DoD’s annual Periodic Health Assessment.

Modernizing the Annual Periodic Health Assessment (PHA)

In order to optimize human health and well-being in the DoD, we can dive into an

unlimited number of pursuits, however, one pressing capability gap preventing the DoD

from migrating to a 21st century health optimization model is the lack of an

institutionalized and comprehensive health risk assessment (HRA). The advantage of

implementing a comprehensive health risk assessment is that it can measure health

risks in various areas and integrate predictive analysis tools which may help guide

prevention and treatment strategies. It also enables personalization and tailoring of

health needs to the individual and most importantly provides meaningful dialogue and

feedback to the individual with their provider on their current health and how they can

improve it. The DoD instead uses an annual PHA which is an assessment tool used by

the U.S. military to classify the individual medical readiness status of its troops. The

annual PHA however, currently lacks the ability to incorporate predictive analysis and

modeling capabilities to measure probability of mission success—a more appropriate

measure of individual medical readiness. A comprehensive HRA capability does not

have to be a separate tool, but could be an adjunctive feature to the current annual

PHA. This additive feature would enable providers to establish baseline health status for

their patients using a risk based scoring system, adjusted for age, gender, and other

predispositions. This expands the utility of the annual PHA to support a new health

12

framework which seeks to empower and incentivize service members to reach their

health and well-being potential. This expansion in capability helps the DoD migrate the

annual PHA from being primarily a monodirectional and qualitative health screening tool

for past, present and deployment limiting conditions to a multidirectional,

comprehensive, and quantitative health risk assessment which enables an on-going

dialogue with the service member to always improve health.

The Army has invested a great deal in this type of capability with their Medical

Readiness Assessment Tool (MRAT) and the Global Assessment Tool (GAT),42

however, the lack of integration across the services has limited its broader use across

the DoD. This capabilities expansion in the PHA’s purpose and design would capture

past and present health data and would perform sophisticated “predictive modeling”

using a validated multifactorial approach43 to determine if “risk clusters” exist.44 This

modern approach could incorporate greater emphasis on physically examining our

service members or exploring available technologies to assess mobility and function to

better predict and prevent future injury. 45 This was a major gap identified by General

Robert B. Abrams, Commanding General, U.S. Army Forces Command when the

military transitioned from a more-in depth physical exam every few years to one which

placed less emphasis on physically examining service members unless prompted by

self-reporting.46 A new and more modern health risk assessment, could then incorporate

a validated and reliable “gradient scoring system” or “health index score” which could

enable service members to know their current health status and risks and understand

how far they may be from reaching their health potential.

13

This concept is not new nor original in the civilian employer sector and health risk

assessments using this methodology are commonly administered voluntarily rather than

mandated for all service members in the Pentagon’s Fit-to-Win Clinic and approximately

30 plus Army Wellness Centers. The DoD therefore lacks the ability to systematically

provide service members and their commanders a "health risk assessment" and it

instead provides them a "screening" tool (PHA) with a "pass/fail" methodology where

the four assessment categories rate service members as either "fully ready, partially

ready, not medically ready or medically indeterminate" with no means to communicate

degree of health risk for key areas (i.e. cardiovascular, musculoskeletal, nutrition,

mental health, sleep) as inputs into individual medical readiness (IMR)

reporting. Furthermore, the results of the current annual PHA cannot easily be used as

a feedback report to educate the service member on his own health status, let alone

help him understand where his health lies in relation to an optimal state of health given

his own health potential.

This feature is a critical and necessary capability to enable the DoD to migrate to

a health optimization paradigm where the DoD can better “predict” health risks and

implement “personalized” prevention strategies. This capability becomes even more

important when available contact time between patient and provider is diminished and

sometimes rushed during periods of large unit pre-deployment and post-deployment

assessments. Figure 3 below breaks down the input and output elements of the IMR

process inclusive of the annual PHA and other medical and dental inputs. Strategic

leaders and commanders ought to be asking the medical community how would one

determine true health readiness status or risk given the four IMR categories? And how

14

would a commander assess the probability that some of his troops would not likely

complete their mission without a comprehensive risk based health assessment?

Figure 3 Adapted from “Draft Medical Fitness White Paper,” F. Mollah, Jan 2017

By not incorporating predictive modeling in the DoD’s PHA and IMR processes,

the DoD is exposing unit commanders and their troops to great uncertainties prior to

deployment and this serves as a major barrier to improving health for three main

reasons. First, it perpetuates a system focused on meeting minimum health standards

rather than one interested in continually optimizing health. Second, it relies heavily on

inputs from self-reported information and a review by a single health professional,

sometimes not necessarily trained in preventative health and well-being matters, who

cannot alone incorporate real time, epidemiological or predictive modeling analysis.

Third, it is problematic because it lacks the ability to convey the degree or probability

that a service member is medically ready or at risk for accomplishing their mission as

one could theoretically achieve a “minimal passing score” in several key areas, yet still

be classified as “fully medically ready.” This can be extremely misleading to

commanders and their troops and exposes them to more risk in carrying out their

missions.

15

This is further troublesome because use of predictive modeling has been a best

practice to prevent poor health outcomes as discussed widely in scientific literature and

recommended by the National Academy of Sciences(NAS)/Institute of Medicine (IOM).47

48 For example, a 2005 NAS/IOM report on improving employer health says, “Recently,

data-driven analytical techniques have been developed to identify clusters of risks that

could lead to disease or loss of productivity (personally as well as on the job).”49

To further provide evidence of this concern, members of the Joint Chairman’s

Total Force Fitness Capabilities Based Assessment medical domain working group led

by the Office of the Secretary of Defense, Personnel Risk and Resiliency (OSD P&R),

determined that the DoD does not have an institutional process across the services to

measure, assess risk or perform any analytical “predictive modeling” for medical non-

deployable risks. The DoD’s capability to incorporate predictive modeling capability to

assess health risks is not only a modern best practice as noted by the National

Academy of Sciences, Engineering and Medicine50, but a 2015 prospective prognostic

study published in Clinical Orthopaedics and Related Research demonstrated the

critical importance of physically examining Soldiers for multiple factors leading to

musculoskeletal injury risks. The study sought to “determine whether a combination of

predictors would enhance the accuracy for determining future musculoskeletal injury

risk in U.S. Army Rangers.”51

This study, led by a senior Army physical therapist and research scientist,

“yielded a prediction model consisting of a combination of modifiable and nonmodifiable

risk factors (smoking status, history of surgery, history of recurrent injury, limited duty in

the prior year, pain on one of the Functional Movement Screen clearing tests,

16

asymmetry dorsiflexion range of motion, run time, and sit-up performance).”52 The

results of the study determined “that a common set of self-report, physical performance,

and movement based factors can predict comprehensive and overuse injuries in an

U.S. Army Ranger cohort.” This health risk information—if institutionalized and

integrated across the force--could enable commanders, health and fitness providers and

first-line supervisors to appropriately personalize service member physical and

nutritional fitness plans and other interventions to better prevent injury or adjust physical

stress loads during training and operations.

No such capability exists in the DoD’s mandatory institutional processes to

prevent such injuries and with musculoskeletal injuries being the number one reason for

being non-medically ready to deploy in the Army53, this should be a top DoD priority to

resolve immediately. Therefore, the DoD should provide the appropriate ways (policy

support, predictive modeling) and means (effective health programs and funds) to

enable the next version of the annual PHA to capture predictive modeling risk

information as well as provide feedback to service members using a “gradient score” or

“health index score” so they can determine where their health lies in relation to what it

could be. This would also enable commanders to determine whether their troops or

formations are barely healthy enough to pass IMR thresholds or are functioning at the

upper end of their health potential. Right now, commanders and their troops are blind to

this powerful knowledge.

17

Institutionalizing Best Health and Well-being Practices

In order to establish context and rationale for institutionalizing best health and

well-being practices from the private sector into the DoD, we should first explore some

underlying concepts and theories rooted in social and health science. When the DoD

heavily emphasizes compliance using “transactional” forms of leadership to enforce

health and fitness standards—an overwhelmingly powerful use of extrinsic motivation--it

does so at the peril of eroding, instead of building intrinsic motivation. These

motivational concepts have been widely studied in the psychology and public health

fields and are embedded in the “self-determination theory” or SDT, which “is a general

theory of human motivation that emphasizes the extent to which behaviors are relatively

autonomous (i.e., the extent to which behaviors originate from the self) versus relatively

controlled.”54 Intrinsic motivation, however, is generally defined as performing an

action due to enjoyment of the activity itself55, whereas extrinsic motivation is normally

associated with “performing a behavior for some separable outcome, whether this

comes in the form of tangible rewards, social acceptance, proving something to oneself,

or maintaining consistency between one's values and one's behaviors.”56

The DoD’s penchant for taking a “big stick approach” for service members to

meet threshold medical and fitness benchmarks has been touted by some as to why

the DoD has a generally healthier and more fit population than its civilian counterparts.

However, this approach has likely created a “compliance culture” with low expectations

among many who serve who have lost intrinsic motivation to sustain healthy behaviors

after years of exposure to overly powerful extrinsic motivators such as threats to one’s

career. This heavy-handed and often punitive approach, along with the stigma

18

associated with how some leaders implement command directed reconditioning

programs for weight control and physical fitness test failures has likely made it more

difficult for less healthy and fit service members to correct their deficiencies or modify

their behaviors as determined by the Defense Health Board in 2013.57 It is also

possible that DoD’s current strategy of strictly enforcing standards in a punitive context

erodes any residual intrinsic motivation among the less fit and makes achieving self-

efficacy—that is the confidence and mastery of skills to perform tasks found in the

social cognitive theory (SCT)58--nearly impossible for those at most risk.

An alternative approach for DoD to strongly consider using (for its uniformed

service members) in order to influence health seeking behavior, especially with the

passage of the FY17 NDAA, are “carrots” in the form of well-designed and targeted

incentives. In order to effectively implement these incentives, they must be perceived

as “smart, creative, and meaningful” and should be complemented with effective

programs that build self-efficacy for healthy behavior and cultivate intrinsic motivation

overtime. Strategies for policy incentives include allowing service-members limited duty

time to pursue lifestyle sports and activities which they find appealing and can reinforce

a lifestyle of physical fitness and sport as an adjunct to formal military physical training

requirements if they meet certain health and fitness benchmarks. Creative approaches

in developing a health culture in the military was emphasized between World War I and

World War II as chronicled in a 2000 study on physical fitness in the military, “other

skills such as self-reliance and confidence were emphasized and stressed through

swimming, climbing, boxing, wrestling, and gymnastic exercises.” 59

19

In today’s military, service members ought to be encouraged to pursue these

lifestyle sports and other activities they may be passionate about including martial arts,

snowboard/skiing, cross-country skiing, cross-fit, cycling, mountain biking, running,

hiking, orienteering, adventure races, Pilates, yoga, and commercial obstacle and

challenge course events. This is currently lacking as a strategic approach to incentivize

and cultivate an active lifestyle at the department level and should be strongly

considered as part of a modern health and well-being strategy fully integrated with

Morale, Welfare, and Recreation resources. A very popular “self-efficacy” focused effort

found to be highly popular during the Healthy Base Initiative was Cooking Matters,

where service members and their families got hands on learning opportunities with

healthy cooking. This program, although widely attended, struggled to receive adequate

funding across the services and therefore could not be institutionalized across the

DoD.60

The lack of institutionalization of widely popular programs which focus on building

confidence in cooking healthy foods is an example which makes DoD’s episodic and

non-integrated strategy to optimize health readiness handicapped and ineffective when

compared to private sector approaches.61 The DoD’s struggle to balance intrinsic and

extrinsic motivation and build self-efficacy for health and fitness seeking behavior is

what likely leads the force towards a “disability culture” when service members

approach transition or retirement. This disability culture is “marked by an attitude or

belief that if one is in the service, that eventually one will succumb to disability and it’s

only a matter of time which is reinforced by so many who have multiple disability claims

for ailments which may have questionable service connectivity.”62 This is not only

20

evident in the major recent increase of disability claims for non-combat related

disabilities63, but also in the 2013 Defense Health Board findings on the increase of

obesity in the military which state, “Weight gain is greatest from the time of discharge

from service and in the three years before discharge. Many factors contribute to this

phenomenon, including lower levels of energy expenditure without a compensatory

decrease in food intake, lack of incentives to manage and control weight, the change in

the food environments, and stress or disability related to Service experiences.”64 As

discussed in a previous strategy paper on health readiness, this “disability culture is

highly incentivized by the potential for lifetime monetary payments within the disability

system. This powerful financial incentive creates a quandary for many service members

near transition or retirement who desire to be healthier, however, realize that any

improvements in their health could potentially invalidate certain disability claims.”65

Further compounding this health readiness problem and its underlying disability

culture are the social, economic, political and health challenges of 21st century

American society for which our service members and their families are not immune.

There is a tremendous asymmetry of health and well-being knowledge and behaviors

among health providers, commanders and service members. The very powerful

financial incentive of future disability payments likely contributes to many capitulating

towards life-long disability, mainly for preventable chronic diseases and musculoskeletal

injuries.66 67 Although these observations and costs make DoD’s health problems seem

overwhelming and may lead some to believe they can only be managed by delivering

better and more-efficient healthcare or creating stricter compliance standards; these

problems are reversible. They are so because there is overwhelming empirical

21

evidence and examples where other very large and complex organizations have

dramatically improved the health and well-being of their workers and families by

creating healthy environments, building self-efficacy and incentivizing healthy behavior

and choices.68

Incentives

As discussed earlier, the Fiscal 2017 National Defense Authorization Act,

specifically Section 729, titled, “Improvement of Health Outcomes and Control of Health

Care under TRICARE Program Through Programs to Involve Covered Beneficiaries,

Medical Intervention Incentive Program,” states, “The Secretary of Defense shall

establish a program to incentivize covered beneficiaries to participate in medical

intervention programs established by the Secretary, such as comprehensive disease

management, that may include lowering fees for enrollment in the TRICARE program by

a certain percentage or lowering copayment and cost share amounts for healthcare

services during a particular year for covered beneficiaries with chronic diseases or

conditions in paragraph (2) who met participation milestones, as determined by the

Secretary, in previous year in such medical intervention programs.”69 Additionally, this

ground-breaking legislation describes other incentive programs allowed including, a

“Lifestyle Intervention Incentive Program and a Healthy Lifestyle Maintenance Incentive

Program,” which the Secretary of Defense must report back implementation status to

the Senate and House Armed Services Committees by no later than January 1, 2020. 70

This legislation is ground-breaking because the Congress is enabling the DoD to

implement practices widely used in the private sector for decades. However, before the

22

DoD proceeds to develop these types of programs, it should consider reviewing the best

performing large civilian employer health and well-being programs.

The gold standard among corporate health and well-being programs is the C.

Everett Koop National Health Award. The award is named after the late Surgeon

General of the United States from 1982-89 who made a significant impact in tobacco

cessation in the United States during his tenure and is awarded by a program titled, The

Health Project.71 The Koop Award “recognizes outstanding worksite health promotion

and improvement programs.”72 It also has advanced the body of knowledge for

implementing, managing and evaluating work place health and well-being programs,

and “one of the unique and important requirements of the Koop Awards is that winners

are able to document results, both in terms of health improvement and economic

impact.”73 Dr. Ron Goetzel, a nationally recognized expert in workplace health and well-

being programs and program evaluator of the DoD’s Healthy Base Initiative

demonstration project, led a study team in 2015 which sought to determine what

consistent factors allowed these companies to not only improve health outcomes and

reduce healthcare costs for their workers, but also achieve exceptional business

success.74 His study observed five consistent behaviors among the nine visited Koop

Award winners over a two year period. They are:

1) Each program gained leadership commitment and support from the CEO

down to middle-managers.

2) The companies measured value on investment in addition to return on

investment for health programs; measuring the right things was essential to

effectively managing their programs and getting results.

23

3) The winners all established a Culture of Health which was intentionally built

into every aspect a worker experienced, and aligned through their corporate

visions, values, beliefs and integrated throughout their policies in a holistic

manner.

4) They all talked to their employees regularly and received feedback on all their

programs so as to tailor them for effectiveness.

5) They all offered “Smart Incentives.” That is, they ensured they balanced

intrinsic and extrinsic motivation and aligned salient rewards and recognitions

to things that mattered to their workers. They also focused on cultivating

intrinsic motivation as well as building self-efficacy for healthy behavior skill

mastery.75

A remarkable characteristic that many Koop Award winners shared in common

was their business success. Dr. Goetzel led another study which reviewed 26 Koop

Award winning companies whose stock performance was measured over a 14-year

period against the Standard and Poor’s (S&P) 500 Index; these winning companies

cumulative stock outperformed the S&P 500 Index 325% to 105% from 2000 to 2014.76

24

Figure 6: Do’s and Don’ts of Workplace Health and Wellbeing Programs Virgin Pulse, 201677

The rationale for highlighting financial success among Koop Award winners in

figure 6 (above), within the context of implementing best practices for using “smart,

creative, and meaningful” incentives in DoD, is that successful health and well-being

programs have created value for companies in terms of worker productivity, morale and

motivation to be the best and this is reflected in stock valuation. For DoD, readiness and

trust, not stock value are the ways the U.S. citizenry measures success for the military

outside of war and tangibles like decreasing absenteeism, improving presenteeism,

training proficiency, productivity and raw troop strength and intangibles such as

perceived military strength, morale, well-being and being socially and emotionally

connected may be the decisive attributes which are needed to propel a health, rather

than disability seeking culture. By reviewing four select Koop Award winners, we may

glean lessons to inform the DoD how to best proceed when developing a health

incentive program as cited in the Fiscal 2017 NDAA. These companies (USAA,

Johnson & Johnson, Dell, and Citi) were selected for their broad and escalating

25

approaches in applying incentives within their corporate health and well-being

programs. These approaches could be applied singularly or in combination within the

DoD and tailored to address service and unit cultures and individual service member

preferences. The following companies and incentive design highlights are listed below

in figure 7:

Koop Award Winners: Incentive Design Highlights

1) United Services Automobile Association (USAA): “Incentive Design: Use a Healthy Points Program in “which employees earn credits by participating in health promotion activities and may redeem points for a medical plan premium reduction. All rewards are tiered, which allows workers to set realistic goals.”

2) Johnson & Johnson (J&J): “Incentive Design: “Incentives offered, but they are somewhat de-emphasized; the program tries to tap into employees’ intrinsic motivations to improve their health. Employees can earn up to a $500 credit in their health insurance premiums.” Use a Health Risk Assessment and “strive to make their programs meet employees’ different needs and interests, and makes these programs convenient, which is one of the largest factors driving engagement—even more than financial incentives.”

3) Dell: “Incentive Design: In recent years, Dell has moved away from an incentive that was based solely on participation-based, to one that rewards employees for participation, progress, and outcomes. Up to $975 discount on premiums ($910 for spouses). Incentives given to employees who: complete health risk assessment, complete screenings, meet five goals, participate in a physical activity challenge, enroll and complete a health coaching program and show improvement, or obtain a waiver or modification options from a doctor. Outcomes-based incentives for employees who do not use tobacco and those who meet goals related to weight, physical activity, and blood pressure.”

4) Citi: “Incentive Design: Citi uses both participation and outcomes based incentives. Employees/spouses who complete the health risk assessment each receive $150. There is a penalty of $600 annually (insurance premium differential) for employees/spouses who use tobacco. If the employee completes either an online program or a health coaching program, the tobacco penalty is eliminated and all penalty payments for that year are refunded. $50 reward for each healthy lifestyle program completed (up to $300 per person). $300 reward for completing a chronic condition management program (invite only).”

Figure 7. Four Koop Award Winners Demonstrating Broad Range of Incentive Designs78 79 80 81

As the DoD and the military health system explore ways and means to implement

health and well-being incentive programs, it ought to be mindful of a few key principles

which are supported in the literature as well as by prominent groups such as the

National Academy of Sciences, Engineering and Medicine, the National Business Group

26

on Health, the Institute for Health and Productivity Studies, Johns Hopkins University

and the Health Project funded by the Robert Wood Johnson Foundation. Some

pertinent considerations (Figure 8) for DoD to consider with regard to using incentives

include, but are not limited to:

Considerations for DoD Use of Incentives for Health and Well-being Programs

1) Focus on getting participation first, migrate to building self-efficacy/intrinsic motivation and then migrate to incentives for specific outcomes. Use of incentives may help accelerate some people (precontemplaters and contemplaters) to move to the planning and action stages of the trans theoretical model (TTM) for change behavior (see figure 9 below).

2) Allow the service-member to choose from a range of incentives which are meaningful to them (may include mix of financial, personal recognition, reduce costs for health insurance or other perks such as free leave or permissive temporary duty, promotion points).

3) Avoid punitive measures if possible, but reward those with healthy behaviors; use incentives as carrots not sticks to reward and reinforce healthy behavior and choices.

4) Augment incentives with comprehensive, evidenced based, and integrated health and well-being programs and environmental support resources (fitness facilities, trainers, healthy dining options, active movement design facilities and installations etc.).

5) Make the incentive part of the total and integrated employee benefit system--that is linked to their healthcare coverage, pay, fringe benefits--a holistic means to integrate the health and human resource enterprises.

6) Must have very strong leadership commitment, participation and buy-in from very top down to middle managers and line leaders. Leaders need to role model healthy behaviors in actions and words.

7) Recruit and designate “health and well-being” champions who are unit level representatives of the program to inspire and motivate others; recognize them, hold them in high regard and have them share their stories.

8) Consider using a fully integrated and DoD-wide healthy reward points system for healthy behavior and activity that can be used with families. Ideas include points for MWR health activities, purchasing healthy foods at the dining facility and the commissaries (fruits and vegetables) and ability to redeem points at other point of sale locations (i.e. discounts for gas at Army and Air Force and Navy and Marine Exchange.)

27

9) Consider implementing a DoD wide healthy reward point system which accumulates points for consecutive months of being fully medically ready to deploy; have feature to pause point collection if service member is on temporary profile/duty limitation as-long-as they are in- compliance with their rehabilitation plan. Explore option of cashing in points if service member deploys to a combat zone or takes a hardship tour. Points may accrue at a higher rate during deployment as an incentive to complete deployment. Cash out could be tax-free. Healthy reward points could accumulate over one’s career (deferred) and could later be converted to a “health savings account” (HRA) akin to what is being commonly offered in the private sector. This feature could make accumulated points transferable if one transitions from service, not unlike one’s Thrift Savings Plan (TSP) could be transferred into a 401k.

10) Survey service members for feedback on what incentives would work best for them; what may be important to a 19-year-old private will likely be different for a 39-year-old Lieutenant Colonel or senior enlisted advisor or a 55-year-old flag level officer. Feedback may vary also by service and type of service (combat arms, service support, active, reserve or guard etc.). Continually incorporate feedback for program evolution and improvement.

11) Pilot any incentive program across multiple sites and services to assess and refine design before rolling out full program.

12) Make any incentive program a default for all service members with an opt-out design feature using well-designed behavioral economic principles. Participants may opt-out anytime, preserving choice, but they must do so deliberately. This type of design is being used in the new blended retirement system beginning in January 2018 for all new recruits.

13) Ensure incentives encourage maximum use of under-utilized health and well-being programs such as service wellness centers, the Pentagon Fit-to-Win Clinic and MWR programs. Develop a way to enable service members to accumulate healthy rewards points for using these facilities and programs and ensure these points are transferable across the services in an integrated system.

Figure 8. Considerations for DoD Use of Incentives for Health and Well-Being Programs 82 83 84 85 86

28

Figure 9 Transtheoretical Model of Change Behavior87

Igniting an Aspirational Cultural for Health

The DoD should ignite and promote an aspirational culture for health whereby

service members always seek to improve and optimize their health and fitness during all

phases of their service. It must do so in order to counter the growing chronic disease

and injury disability culture previously discussed. Evidence of this growing disability

culture is reflected in a 104% increase in disability claims for new recipients from

FY2011 to FY2015 in which payments exceed $60 billion annually.88 Further

exacerbating the disability culture is the common practice of being “advised” by many

recent retirees, senior leaders near retirement and veteran service organizations

serving as VA certified disability claim advocates to document everything, even potential

chronic ailments with questionable service connectivity, in order to maximize potential

29

disability compensation.89 There is a growing concern among select senior leaders in

the Army that some initial term enlistees may be joining the military ranks with no intent

of finishing their enlistment and are seeking full disability benefits before ever

completing their initial entry training.90

The DoD should break free of this disability culture and migrate to a culture which

is aspirational, health optimizing and health producing through all phases of a service

member’s career. In order to build an aspirational culture, the DoD will first need to

implement a fully integrated personnel and health system which incentivizes healthy

behavior using a combination of financial and non-financial rewards and recognition. It

must do so on the front end of service so as to counter balance the very powerful

financial incentive of disability pay on the back end. If properly designed, framed,

communicated, and implemented, these incentives and associated intervention

programs and environmental changes which focus on building self-efficacy, should

result in improved health outcomes and readiness. The DoD would then realize any

incentive payment for health readiness and/or intervention programs would be less

expensive than what our tax payers now spend on life-long disability payments and long

term healthcare costs.91 A second way to build an aspirational culture is to ensure our

senior leaders set the example in terms of health, fitness, well-being and address our

disability culture in a candid manner. They should convey that many will still have

legitimate disability claims, yet inspire their troops to always seek to improve and

sustain their health during all phases of their service, guided by the principles of the

Public Trust and the Profession of Arms.92

30

And finally, in order to embrace a new aspirational culture for health, the DoD,

using the previous two recommendations, should shift the conversation with service

members and their families to approach their health with an “owners” versus “renters”

mentality. The cultural norm would be a shared understanding and partnership that the

DoD cares about service member and family health and well-being, even beyond

service, and service members would commonly discuss and explore ways and means

to become as able bodied, healthy and fit as they can be even when approaching

retirement eligibility. This behavior would replace the current norm of many service

members nearing transition or retirement openly discussing how they plan to maximize

their disability claim without regard for simultaneously optimizing their health. This new

aspirational culture for health would be reflected in more service members taking

personal ownership of their health earlier in their careers and be willing to invest their

time and effort into building health capital. This health capital would help troops endure

the associated rigors and set-backs of military life and provide them a higher quality of

life after service.93 The DoD cannot treat its way out of its current medical readiness

shortcomings, but it can take on a leadership role for the Nation by implementing

creative and proven ways and means to disrupt preventable chronic disease, obesity,

injury, and disability which have plagued thousands of service members and their

families.

Conclusion

One of the underlying issues senior leaders are grappling with inside and outside

of the DoD is on the direction and role of the military health system. It is tempting

simply to go with momentum and simply maintain the traditional healthcare delivery

31

model, but there is an ever-growing need to advocate for change. As the

DoD transitions from a healthcare delivery system to a system for health--more focused

on prevention and health optimization and well-being—the DoD will continue to support

both treatment and prevention since troops and their families will still suffer from

disease and injury. One challenge is to determine at what rate will this transition occur

and be reflected in new policy and programs going forward. Another challenge is to

recognize that creating and maintaining a healthy, ready and well force is a

commander’s first responsibility and the health system is just one of several important

means to help commanders and troops realize their health and readiness objectives

prior to deployment or combat operations.

This is especially pertinent for preventable chronic health and injury policies and

programs often related to lifestyle and not pertaining to combat operational care. The

DoD must not misapply a "transactional" form of policy making for trauma and

operational medicine which has its purpose in enforcing strict protocols and treatment

guidelines during crisis with a needed "transformational" policy shift towards a health

optimization model to prevent chronic conditions and improve health and well-

being. The latter will continue to challenge and perplex those brought up strictly in a

treatment focused model.

However, by establishing the context outlined previously in this paper may help

those advocating for the status quo to understand that health and well-being initiatives

are not threats to the healthcare system, but the necessary evolution in thinking and

action to appropriately address the underlying public health and readiness problems at

hand. It is important for bold and visionary leaders to take decisive action to embrace

32

and modernize an integrated strategy for health optimization, institutionalize best health

and well-being practices using “smart, creative, and meaningful” incentives, and ignite

an aspirational culture for health at all stages of one’s service.

Top Five Recommendations

The following is a top five list of immediate recommendations for optimizing

health readiness in the DoD. It serves as a starting point for any strategic working

group or task force assigned to explore how to optimize health readiness using a more

effective, relevant and modern strategy:

1) Charter a Joint Task Force under the auspices of Office of the Secretary of

Defense, Personnel Risk and Resiliency comprised of broad mix of hand

selected leaders at multiple ranks from all services to explore how to best

integrate a comprehensive DoD health and well-being program. Ensure program

parameters include all services, components (active, guard, reserve), civilians,

and beneficiary categories and the task force is adequately funded to carry out

chartered objectives.

2) Ensure the Joint Task Force utilizes best practices and experts in the field

including sources such as Improving Health: An Employer Handbook from the

National Academy of Sciences and others cited in this research paper.

3) Immediately update the annual Periodic Health Assessment as outlined in this

paper with a health risk assessment component and use this platform to begin

building an integrated and comprehensive system to help service members

optimize their health. Once the PHA is updated with a risk component and

33

predictive modeling capability, ensure appropriate IMR updates are made to

improve granularity for commanders and troops within IMR reporting categories.

4) Pilot well-designed incentive programs for service members within the next 2

years and ensure multiple designs are tested. Incentive programs are iterative,

so make them adjustable, scalable, and testable among all the services and

components.

5) Stand up a Joint Program Office (JPO) for Health and Well-being to execute a

DoD-wide and integrated health and well-being program, chartered with full

program funding and authority to oversee cost, schedule and performance to

address the eight domains of the Joint Chairman’s Total Force Fitness

Framework. Charge this JPO with over-arching DoD responsibilities to integrate

health improvement and well-being programs across all services and to ensure

measured focus on improving health outcomes, medical readiness, and reducing

leading causes of service connected disabilities for preventable chronic

conditions, diseases and injuries.

“We will not be able to successfully treat our way out of the obesity epidemic in the United States - the medical infrastructure is simply inadequate for the task. Based on 2008 data we estimated that the medical costs of obesity were $147 billion annually -- primarily borne by Medicare, Medicaid and private insurance. Treatment is critical, yet the successful control of obesity will turn on the continued development of strategic interventions -- delivered at key points in the lifecycle -- to prevent obesity and the subsequent disease, injury and disability that often follow. The military is uniquely positioned to lead innovation in obesity prevention and well-being initiatives that can be replicated in the civilian population. I see this as an incredible leadership opportunity in service to our nation.”94 William H. Dietz, MD, PhD Chair, Sumner M. Redstone Global Center for Prevention and Wellness Milken Institute School of Public Health The George Washington University

34

Endnotes

1 Baron Von Steuben, “Regulation for the Order and Discipline of the Troops.” 1779, quoted in Health Readiness and System for Health Playbook, (U.S. Army Medical Command and Office of the Surgeon General, G-3/5/7, Falls Church, VA), 41.

2 Heidi Warrington, “The Total Force Fitness (TFF) Capabilities Based Assessment (CBA) Working Group: Medical Fitness Domain, Pentagon Conference Center, Washington DC, March 2, 2016

3 Congressional Budget Office, “Approaches to Reducing Spending on Military Healthcare,” January 2014, http://www.cbo.gov/sites/default/files/113th-congress-2013-2014/reports/44993-MilitaryHealthcare.pdf (accessed May 5, 2017).

4 Evaluation of the TRICARE Program: Access, Cost, and Quality Fiscal Year 2015 Report to Congress.

5 US Army Public Health Center (Provisional) Staff, Health of the Force 2015 (Edgewood, MD, 2015).

6 Assistant Secretary of Defense, Health Affairs, Evaluation of the TRICARE Program: Access, Cost and Quality & NBSP; Fiscal Year 2016 Report to Congress (Assistant Secretary of Defense, Health Affairs, 2016).

7 William Christeson; Kara Clifford; Amy D. Taggart, “Retreat is Not an Option,” 12 March 2015, http://missionreadiness.s3.amazonaws.com/wp-content/uploads/MR-NAT-Retreat-Not-an-Option.pdf (accessed February 18, 2017)

8 Timothy M. Dall, "Cost Associated with being Overweight and with Obesity, High Alcohol Consumption, and Tobacco use within the Military Health System's TRICARE Prime-Enrolled Population." American Journal of Health Promotion 22, no. 2 (11): 139; 139.

9 Schroeder, S. A. "Shattuck Lecture - We Can Do Better - Improving the Health of the American People." The New England Journal of Medicine 357, no. 12 (0, 9): 1221; 1221.

10 Veterans Benefits Administration, US Department of Veterans Affairs, “VBA Annual Benefits Report Fiscal Year 2015,” May 9, 2015, http://www.benefits.va.gov/REPORTS/abr/index.asp (accessed October 22, 2016).

11 Ibid.

12 Victor A. Suarez, Health Readiness: A New Way of Thinking, Strategy Paper (Carlisle Barracks, PA; U.S. Army War College, November 4, 2016).

13 Institute of Medicine, Integrating Employee Health: A Model Program for NASA. (Washington DC: The National Academy Press, 2005).

http://www.cbo.gov/sites/default/files/113th-congress-2013-2014/reports/44993-MilitaryHealthcare.pdf

http://www.cbo.gov/sites/default/files/113th-congress-2013-2014/reports/44993-MilitaryHealthcare.pdf

http://missionreadiness.s3.amazonaws.com/wp-content/uploads/MR-NAT-Retreat-Not-an-Option.pdf

http://missionreadiness.s3.amazonaws.com/wp-content/uploads/MR-NAT-Retreat-Not-an-Option.pdf

http://www.benefits.va.gov/REPORTS/abr/index.asp

14 Constable, Stefan and Barbara Palmer. The Process of Physical Fitness Standards

Development2000, http://www.dtic.mil.proxygw.wrlc.org/docs/citations/ADA495349. (accessed February 25, 2017).

15 National Defense Authorization Act for Fiscal Year 2017. 114th Congress Report, House of Representatives.” 2d Session, S2943.

16 Ibid.

17 Department of Defense, Office of the Secretary of Defense, Personnel & Readiness, “The Healthy Base Initiative.” http://www.militaryonesource.mil/footer?content_id=295237. (accessed February 10, 2017).

18 Ibid.

19 Ibid.

20 Institute of Medicine and The National Business Group on Health, Improving Health: An Employer Tool Kit (Washington, DC: National Business Group on Health, 2006).

21 Goetzel, Ron Z. "Do Workplace Health Promotion (Wellness) Programs Work?" Journal of Occupational and Environmental Medicine 56, no. 9 (0, 9): 927; 927.


23 Michael Grossman. The Demand for Health: A Theoretical and Empirical Investigation. New York: National Bureau of Economic Research, 1972a

24 Michael Grossman. “On the Concept of Health Capital and the Demand for Health.” Journal of Political Economy 80 (March-April 1972b), pp 223-55.

25 Santerre, Rexford E. and Stephen P. Neun. Health Economics: Theory, Insights, and Industry Studies Mason, Ohio: South-Western Cengage Learning, c2013; 6th ed, 2013.

26 Ibid.

27 Ibid.


29 Ibid.

30 McKee, J. "Holistic Health and the Critique of Western Medicine." Social Science & Medicine (1982) 26, no. 8 (0, 1): 775; 775.

31 Ibid.

32 Assistant Secretary of Defense, Health Affairs, Evaluation of the TRICARE Program: Access, Cost and Quality & NBSP; Fiscal Year 2016 Report to Congress (Assistant Secretary of Defense, Health Affairs, 2016).

http://www.dtic.mil.proxygw.wrlc.org/docs/citations/ADA495349

http://www.militaryonesource.mil/footer?content_id=295237

33 McKee, J. "Holistic Health and the Critique of Western Medicine." Social Science &

Medicine (1982) 26, no. 8 (0, 1): 775; 775.


35 McGinnis, J. Michael. "The Case for More Active Policy Attention to Health Promotion." Health Affairs (Millwood, Va.) 21, no. 2 (2002): 78.

36 Mokdad, A. H., J. S. Marks, D. F. Stroup, J. L. Gerberding, Ali H. Mokdad, James S. Marks, Donna F. Stroup, and Julie L. Gerberding. "Actual Causes of Death in the United States, 2000." JAMA: Journal of the American Medical Association 291, no. 10 (2004): 1238-45.

37 Preamble to the Constitution of WHO as adopted by the International Health Conference, New York, 19 June - 22 July 1946, http://www.who.int/suggestions/faq/en/ (accessed February 21, 2017).

38 Frey BS, Stutzer A. Happiness and economics. Princeton, N.J.: Princeton University Press; 2002.

39 Andrews FM, Withey SB. Social indicators of well-being. New York: Plenum Press; 1976:63–106.

40 Diener E. Subjective Well Being: The Science of Happiness and a Proposal for a National Index. American Psychologist 2000;55(1):34–43.

41 Ryff CD, Keyes CLM. The structure of psychological well-being revisited. Journal of Personality and Social Psychology 1995;69(4):719–727.

42 US Army Public Health Center (Provisional) Staff, Health of the Force 2015 (Edgewood, MD, 2015).

43 Teyhen, Deydre S., Scott W. Shaffer, Robert J. Butler, Stephen L. Goffar, Kyle B. Kiesel, Daniel I. Rhon, Jared N. Williamson, and Phillip J. Plisky. "What Risk Factors are Associated with Musculoskeletal Injury in US Army Rangers? A Prospective Prognostic Study." Clinical Orthopaedics and Related Research 473, no. 9 (2015): 2948-58


45 Improved Performance Strategies Home Page, www.trazer.com (accessed 1 March 2017).

46 GEN Robert B. Abrams, FORSCOM Commanding General, video teleconference interview by author, January 31, 2017.

47 Institute of Medicine, Integrating Employee Health: A Model Program for NASA. (Washington DC: The National Academy Press, 2005).


http://www.who.int/suggestions/faq/en/

http://www.trazer.com/

49 Institute of Medicine, Integrating Employee Health: A Model Program for NASA.

(Washington DC: The National Academy Press, 2005).


51 Teyhen, Deydre S., Scott W. Shaffer, Robert J. Butler, Stephen L. Goffar, Kyle B. Kiesel, Daniel I. Rhon, Jared N. Williamson, and Phillip J. Plisky. "What Risk Factors are Associated with Musculoskeletal Injury in US Army Rangers? A Prospective Prognostic Study." Clinical Orthopaedics and Related Research 473, no. 9 (2015): 2948-58.

52 Ibid.


54 Patrick, Heather and Geoffrey C. Williams. "Self-Determination Theory: Its Application to Health Behavior and Complementarity with Motivational Interviewing." The International Journal of Behavioral Nutrition and Physical Activity 9 (2012).

55 Ibid.

56 Ibid.

57 Dennis S. O’Leary, “Decision Brief, Obesity/Overweight in the Military.” Defense Health Board, November 18, 2013, www.health.mil/ReferenceCenter/Presentations/2013/11/18/Decision_Brief_Obesity (accessed February 20, 2017).

58 McKenzie, James F., Brad L. Neiger, and Rosemary Thackeray. Planning, Implementing, and Evaluating Health Promotion Programs: A Primer New Jersey]: Pearson, 2017]; 7th edition, 2017.

59 Constable, Stefan and Barbara Palmer. The Process of Physical Fitness Standards Development 2000, http://www.dtic.mil.proxygw.wrlc.org/docs/citations/ADA495349. (accessed February 25, 2017).


61 Ibid.

62 William H. Dietz, email message from author, February 9, 2017.


64 Dennis S. O’Leary, “Decision Brief, Obesity/Overweight in the Military.” Defense Health Board, November 18, 2013,

http://www.health.mil/ReferenceCenter/Presentations/2013/11/18/Decision_Brief_Obesity

http://www.dtic.mil.proxygw.wrlc.org/docs/citations/ADA495349



www.health.mil/ReferenceCenter/Presentations/2013/11/18/Decision_Brief_Obesity (accessed February 20, 2017).

65 Victor A. Suarez, Health Readiness: A New Way of Thinking, Strategy Paper (Carlisle Barracks, PA; U.S. Army War College, November 4, 2016).


67 US Army Public Health Center (Provisional) Staff, “Health of the Force 2015,” November 2015, https://www.army.mil/e2/c/downloads/419337.pdf (accessed October 11, 2016).


69 National Defense Authorization Act for Fiscal Year 2017. 114th Congress Report, House of Representatives.” 2d Session, S2943.

70 Ibid.

71 The Health Project Home Page, http://thehealthproject.com/about-us/ (accessed February 26, 2017).

72 Ibid.

73 Ibid.

74 Goetzel, Ron Z. "The Stock Performance of C. Everett Koop Award Winners Compared with the Standard & Poor's 500 Index." Journal of Occupational and Environmental Medicine 58, no. 1 (0, 1): 9; 9.

75 Ron Z. Goetzel. Why Building a Culture of Health and is a True Differentiator: The Do’s and Don’ts of Workplace Health and Wellbeing Programs, Virgin Pulse Paper, 2016.



78 USAA, TD Magazine 69, no. 11 (Nov 1, 2015): 83. http://www.jhsph.edu/research/centers-and-institutes/institute-for-health-and-productivity-studies/projects/current-projects/promoting-healthy-workplaces/, (accessed February 26, 2017).

79Johnson&Johnson, http://www.jhsph.edu/research/centers-and-institutes/institute-for-health-and-productivity-studies/projects/current-projects/promoting-healthy-workplaces/, (accessed February 26, 2017).

http://www.health.mil/ReferenceCenter/Presentations/2013/11/18/Decision_Brief_Obesity


https://www.army.mil/e2/c/downloads/419337.pdf

http://thehealthproject.com/about-us/

http://www.jhsph.edu/research/centers-and-institutes/institute-for-health-and-productivity-studies/projects/current-projects/promoting-healthy-workplaces/





80 Dell, Inc. http://www.jhsph.edu/research/centers-and-institutes/institute-for-health-and-

productivity-studies/projects/current-projects/promoting-healthy-workplaces/, (accessed February 26, 2017).

81 Citi. Asia-Pacific Banking & Finance (AB+F) 6, no. 3 (Apr 1, 2014): 23, http://www.jhsph.edu/research/centers-and-institutes/institute-for-health-and-productivity-studies/projects/current-projects/promoting-healthy-workplaces/, (accessed February 26, 2017).






87 Prochaska, J.O., Redding, C.A., & Evers, K.E. (2008). The transtheoretical model and stages of change. In AMAC Web Page. http://amactraining.co.uk/resources/handy-information/free-learning-material/models-and-theories-of-health-behaviour-change-index/models-and-theories-of-health-behaviour-12/, (accessed January 26, 2017).


89 Tom Philpott, “Attorney urges congress to end sleep apnea claims abuse,” May 30, 2016, http://www.stripes.com/news/veterans/attorney-urges-congress-to-end-sleep-apnea-claims-abuse-1.223588 (accessed October 23, 2016).

90 Eric E. Porter, SES, G-1, U.S. Army Forces Command, and select staff, telephone interview by author, February 24, 2017.

91 Musich, S., McCalister, T., Wang, S., & Hawkins, K. (2015). An evaluation of the well at dell health management program: Health risk change and financial return on investment. American Journal of Health Promotion: AJHP, 29(3), 147, http://www.ncbi.nlm.nih.gov/pubmed/25559251 (accessed August 24, 2016).

92 Robert L. Caslen Jr., “The Army Ethic, Public Trust and the Profession of Arms,” September 30, 2011, http://usacac.army.mil/CAC2/MilitaryReview/Archives/English/MilitaryReview_20110930PofA_art007.pdf (accessed October 23, 2016).






http://amactraining.co.uk/resources/handy-information/free-learning-material/models-and-theories-of-health-behaviour-change-index/models-and-theories-of-health-behaviour-12/




http://www.stripes.com/news/veterans/attorney-urges-congress-to-end-sleep-apnea-claims-abuse-1.223588

http://www.stripes.com/news/veterans/attorney-urges-congress-to-end-sleep-apnea-claims-abuse-1.223588

http://www.ncbi.nlm.nih.gov/pubmed/25559251

http://usacac.army.mil/CAC2/MilitaryReview/Archives/English/MilitaryReview_20110930PofA_art007.pdf

http://usacac.army.mil/CAC2/MilitaryReview/Archives/English/MilitaryReview_20110930PofA_art007.pdf

93 Victor A. Suarez, Health Readiness: A New Way of Thinking, Strategy Paper (Carlisle

Barracks, PA; U.S. Army War College, November 4, 2016).

94 William H. Dietz, email message to author, February 27, 2017.

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