What is the Evidence and Return on Investment (ROI) of Obesity Prevention and Control in Worksite Settings?

Ron Z. Goetzel, Ph.D., Johns Hopkins University - Truven Health Analytics

GW-ICF Research and Evaluation Forum -- January 21, 2015 --Washington, DC

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Q: What problem are we trying to solve? A: Spending a lot of money on sick care!

• The United States spent $3.056 trillion in

healthcare in 2014, or $9,596 for every man,

woman and child.

• Spending by sector

• Private health insurance - $1.102 billion

• Medicare - $615.9 billion

• Medicaid - $507.2 billion

• Out of pocket -- $338.1 billion

• Health expenditures as percent of GDP:

7.2 % in 1970

17.6% in 2014

19.3% in 2023 (projected)

Source: Sisko et al., Health Affairs, 33:10, September 23, 2014, 1841-1850

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WHY IS HEALTH CARE SO EXPENSIVE?

Source: K.E. Thorpe, "The Rise in Health Care Spending and What to Do About It," Health Affairs 24, no. 6 (2005): 1436-1445; and K.E. Thorpe et al., "The Impact of Obesity on Rising Medical Spending," Health Affairs 23, no. 6 (2004): 480-486.

Innovation/advancing technology

(pharmacologic, devices, treatments)

• Newborn delivery costs – five-fold increase from 1987-2002

– NICU, incubators, ventilators, C-sections

• New/better medicines for treating disease

– Depression (SSRI introduction – 45% treated in 1987 to 80% treated in 1997

– Allergies (Claritan, Allegra, …)

• New treatment thresholds

– Blood pressure

– High blood glucose

– Hyperlipidemia

Rise in spending for treated diseases (37%)

Ken Thorpe

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WHY IS HEALTH CARE SO EXPENSIVE? (THORPE - PART 2)

• About ¾ of all health care

spending in the U.S. is

focused on patients who

have one or more chronic

health conditions

• Chronically ill patients only

receive 56% of clinically

recommended preventive

health services

And 27% of the rise in

healthcare costs is

associated with increases

in obesity rates…

Rise in the prevalence of disease (63%)

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DISEASES CAUSED (AT LEAST PARTIALLY) BY LIFESTYLE

• Obesity: Cholesystitis/Cholelithiasis, Coronary Artery Disease, Diabetes, Hypertension, Lipid Metabolism Disorders, Osteoarthritis, Sleep Apnea, Venous Embolism/Thrombosis, Cancers (Breast, Cervix, Colorectal, Gallbladder, Biliary Tract, Ovary, Prostate)

• Tobacco Use: Cerebrovascular Disease, Coronary Artery Disease, Osteoporosis, Peripheral Vascular Disease, Asthma, Acute Bronchitis, COPD, Pneumonia, Cancers (Bladder, Kidney, Urinary, Larynx, Lip, Oral Cavity, Pharynx, Pancreas, Trachea, Bronchus, Lung)

• Lack of Exercise: Coronary Artery Disease, Diabetes, Hypertension, Obesity, Osteoporosis

• Poor Nutrition: Cerebrovascular Disease, Coronary Artery Disease, Diabetes, Diverticular Disease, Hypertension, Oral Disease, Osteoporosis, Cancers (Breast, Colorectal, Prostate)

• Alcohol Use: Liver Damage, Alcohol Psychosis, Pancreatitis, Hypertension, Cerebrovascular Disease, Cancers (Breast, Esophagus, Larynx, Liver)

• Stress, Anxiety, Depression: Coronary Artery Disease, Hypertension

• Uncontrolled Hypertension: Coronary Artery Disease, Cerebrovascular Disease, Peripheral Vascular Disease

• Uncontrolled Lipids: Coronary Artery Disease, Lipid Metabolism Disorders, Pancreatitis, Peripheral Vascular Disease

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ENVIRONMENTAL CORRELATES OF OBESITY

More driving• Rise in car ownership

• Increase in driving shorter distances

• Less walking and bicycling

At home, more convenience• Increase use of “labor saving” devices

• Increase in ready-made foods

• Increase in television viewing, computers, and video games

At work• Sedentary occupational fields (“knowledge workers”)

In public• More elevators, escalators, automatic doors and moving

sidewalks

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Opportunities for Health Promotion: Workplace -- 156 Million Americans at Work Each Day

Certain policies, procedures and practices

can be introduced and organizational norms can

be established

Workplaces contain a concentrated group of

people who share common purpose and

culture

Financial or other types of incentives can be offered

to gain participation in programs

Workplace programs can reach large segments of

the population not exposed to and engaged

in organized health improvement efforts

Social and organizational

supports are available

Communication with workers is

straightforward

US Bureau of Labor Statistics, December 2014

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Convince me…

Why should I invest in the health

and well-being of my workers?

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IT SEEMS SO LOGICAL…

If you improve the health and well being of your

employees…

…quality of life improves

…health care utilization is reduced

…disability is controlled

…productivity is enhanced

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What Is The Evidence Base?

• A large proportion of diseases and disorders is preventable. Modifiable health risk

factors are precursors to a large number of diseases and disorders and to

premature death (Healthy People 2000, 2010, Amler & Dull, 1987, Breslow, 1993,

McGinnis & Foege, 1993, Mokdad et al., 2004)

• Many modifiable health risks are associated with increased health care costs

within a relatively short time window (Milliman & Robinson, 1987, Yen et al., 1992,

Goetzel, et al., 1998, Anderson et al., 2000, Bertera, 1991, Pronk, 1999)

• Modifiable health risks can be improved through workplace sponsored health

promotion and disease prevention programs (Wilson et al., 1996, Heaney &

Goetzel, 1997, Pelletier, 1991, 1993, 1996, 1999, 2001, 2005, 2009, 2011)

• Improvements in the health risk profile of a population can lead to reductions in

health costs (Edington et al., 2001, Goetzel et al., 1999, Carls et al., 2011))

• Worksite health promotion and disease prevention programs save companies

money in health care expenditures and produce a positive ROI (Johnson &

Johnson 2002, Citibank 1999-2000, Procter and Gamble 1998, Chevron 1998,

California Public Retirement System 1994, Bank of America 1993, Dupont 1990,

Highmark, 2008, Johnson & Johnson, 2011)

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POOR HEALTH COSTS MONEY

Drill Down…

• Medical

• Absence/work loss

• Presenteeism

• Risk factors

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THE COST OF CHRONIC DISEASETOP 10 MOST COSTLY PHYSICAL HEALTH CONDITIONS

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©2008 T

hom

son R

eute

rs

$-

$50

$100

$150

$200

$250

$300

$350

$400

$450

Allerg

y*

Arthrit

is

Asthm

a

Any Cance

r

Depress

ion/S

adness/M

ental I

llness

Diabete

s

Heart Dise

ase

Hyperte

nsion

Mig

rain

e/Headach

e

Respira

tory

Infe

ctio

ns

An

nu

al C

ost

s

Presenteeism

STD

Absence

RX

ER

Outpatient

Inpatient

THE BIG PICTURE: OVERALL BURDEN OF ILLNESS BY CONDITION

Using Average Impairment and Prevalence Rates for Presenteeism

($23.15/hour wage estimate)

Source: Goetzel, Long, Ozminkowski, et al. JOEM 46:4, April, 2004)

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HERO II STUDY – PUBLISHED NOV. 2012

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RISK-COST IMPACTS – HERO II EXHIBIT 1 Average Unadjusted And Adjusted Medical Expenditures, In 2009 Dollars, By Risk

Levels

Risk measure

Risk

level

Unadjusted

means ($)

Adjusted

means ($)

Unadjusted

difference

(%)

Adjusted difference

(% )

Depression High 6,207 6,738 59.1 48.0

Lower 3,902 4,553

Blood glucose High 6,532 6,849 70.0 31.8

Lower 3,842 5,196

Blood pressure High 5,264 5,734 27.4 31.6

Lower 4,132 4,356

Body weight High 4,956 5,078 41.7 27.4

Lower 3,498 3,988

Tobacco use High 4,192 4,184 10.8 16.3

Lower 3,784 3,597

Physical inactivity High 4,477 4,582 26.6 15.3

Lower 3,537 3,976

Stress High 5,024 5,249 13.0 8.6

Lower 4,444 4,836

Cholesterol High 4,780 4,913 2.0 -2.5

Lower 4,688 5,037

Nutrition and eating

habits High 3,245 3,261

-23.2 -5.2

Lower 4,226 3,440

Alcohol consumption High 3,857 3,843 -3.94 -9.48

Lower 4,015 4,246

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Individual vs. Population-Based Costs

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Cost Per Capita of Risk Factors

-100

-50

0

50

100

150

200

250

300

350

347

178.6

128.2106.2 104.1

80.8

38.3-6.4 -14 -75.4

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RESEARCH ON RISK-COST RELATIONSHIPS - NOVARTIS

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RISK FACTORS AND PRESENTEEISM (N = 5,875)

RISK-COST RELATIONSHIPS AT PEPSICO

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10%

16%

4%

15% 15%

5%

23%

77%

18%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Perc

enta

ge S

am

ple

with H

igh R

isk

HEALTH RISK PREVALENCE

Biometric Risks Health Behavior RisksPsychosocial Risks

BMI BREAKDOWN BY CATEGORY

25%

44%

22%

7%

3%

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

NormalBMI < 25

OverweightBMI 25-30

Class IBMI 30-35

Class IIBMI 35-40

Class IIIBMI 40+

Perc

enta

ge S

am

ple

In E

ach B

MI

Cate

go

ry

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PEPSICO – OVERWEIGHT / OBESE ANALYSIS (N=11,217)

*At least one difference significant at the 0.05 level

Source: Henke RM, Carls GS, Short ME, Pei X, Wang S, Moley S, Sullivan M, Goetzel RZ. The Relationship between Health Risks and Health and Productivity Costs

among Employees at Pepsi Bottling Group. J Occup Environ Med. 52, 5, May 2010.

Difference between combined overweight/obese categories and normal weight is displayed

Diff =

29%,

$613*

Diff =

58%,

$111*

Diff =

25%,

$987

Diff =

10%,

$28

Diff =

7%,

$49

Diff =

26%,

$186*

• 74% of the

sample is

overweight

or obese

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NHLBI MULTI-CENTER STUDY: ESTIMATED ANNUAL COSTS OF HEALTHCARE UTILIZATION, ABSENTEEISM, AND PRESENTEEISM BY BMI CATEGORY

$1,416

$1,180

$2,034

$229

$1,402

$918

$1,544

$155

$182

$1,200

$872

$1,535

$149

$178

$219

$0 $500 $1,000 $1,500 $2,000 $2,500

Presenteeism

Absenteeism Days

Hospital Admissions

Emergency Room

Visits

Doctor Visits

Normal

Overweight

Obese

*

*

*

*

*

* P < .05

Source: Goetzel RZ, Gibson TB, Short ME, Chu BC, Waddell J, Bowen J, Lemon SC, Fernandez ID, Ozminkowski RJ, Wilson

MG, DeJoy DM. A multi-worksite analysis of the relationships among body mass index, medical utilization, and worker

productivity. J Occup Environ Med. 2010 Jan;52 Suppl 1:S52-8.

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Worksite Health Promotion Works!

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CDC Community Guide to Preventive Services Review – AJPM, February 201086 Studies Reviewed

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SUMMARY RESULTS AND TEAM CONSENSUS

Outcome

Body of

Evidence

Consistent

Results

Magnitude of

Effect Finding

Alcohol Use 9 Yes Variable Sufficient

Fruits & Vegetables

% Fat Intake

9

13

No

Yes

0.09 serving

-5.4%

Insufficient

Strong

% Change in Those

Physically Active

18 Yes +15.3 pct pt Sufficient

Tobacco Use

Prevalence

Cessation

23

11

Yes

Yes

–2.3 pct pt

+3.8 pct pt

Strong

Seat Belt Non-Use 10 Yes –27.6 pct pt Sufficient

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Outcome

Body of

Evidence

Consistent

Results Magnitude of Effect Finding

Diastolic blood pressure

Systolic blood pressure

Risk prevalence

17

19

12

Yes

Yes

Yes

Diastolic:–1.8 mm Hq

Systolic:–2.6 mm Hg

–4.5 pct pt

Strong

BMI

Weight

% body fat

Risk prevalence

6

12

5

5

Yes

No

Yes

No

–0.5 pt BMI

–0.56 pounds

–2.2% body fat

–2.2% at risk

Insufficient

Total Cholesterol

HDL Cholesterol

Risk prevalence

19

8

11

Yes

No

Yes

–4.8 mg/dL (total)

+.94 mg/dL

–6.6 pct pt

Strong

Fitness 5 Yes Small Insufficient

SUMMARY RESULTS AND TEAM CONSENSUS

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CDC Community Guide Obesity Review

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SUMMARY RESULTS AND TEAM CONSENSUS

Outcome

Body of

Evidence

Consistent

Results

Magnitude of

Effect Finding

Estimated Risk 15 Yes Moderate Sufficient

Healthcare Use 6 Yes Moderate Sufficient

Worker Productivity 10 Yes Moderate Strong

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WHAT ABOUT ROI?CRITICAL STEPS TO SUCCESS

Reduced Utilization

Risk Reduction

Behavior Change

Improved Attitudes

Increased Knowledge

Participation

Awareness

Financial ROI

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HEALTH AFFAIRS ROI LITERATURE REVIEWBaicker K, Cutler D, Song Z. Workplace Wellness Programs Can Generate Savings. Health Aff (Millwood). 2010; 29(2). Published online 14 January 2010.

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RESULTS - MEDICAL CARE COST SAVINGS

Description N Average ROI

Studies reporting costs and

savings

15 $3.37

Studies reporting savings only 7 Not Available

Studies with randomized or

matched control group

9 $3.36

Studies with non-randomized or

matched control group

6 $2.38

All studies examining medical

care savings

22 $3.27

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RESULTS – ABSENTEEISM SAVINGS

Description N Average ROI

Studies reporting costs and

savings

12 $3.27

All studies examining

absenteeism savings

22 $2.73

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The Dow Chemical Company

An Environmental

Obesity Prevention

Program at The Dow

Chemical Company

NHLBI: 5 R01 HL079546-05

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• Quasi-experimental – treatment vs.

control/pre vs. post (3 data points –

baseline, year 1, year 2)

• 12 Dow Chemical Company worksites

received environmental/ecological

interventions at varying levels of intensity

• Intervention sites*: Texas (8) and

Louisiana (1)

• Control sites: New Jersey (1), West

Virginia (1), and Louisiana (1)

• Other Dow sites in US providing

benchmark/comparison data

The Dow LIGHTENUP Study

©2009 Google – Map Data ©2009 Tele Atlas

*One intense site was part of a business unit that was sold to another company. Data from this site were not included in any

process evaluations but were included in other evaluations.

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The Dow Study - Interventions at All Sites #GWICF2015

The Dow Study - Interventions at High Intensity Sites #GWICF2015

The Dow Study: Health Behaviors (T1–T3): High Risk Category

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The Dow Study: Biometric Values (T1–T3) – Cohort Data

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Consistent Improvement in High-Priority Risk Since 2004 Baseline.

Between 2004 and September 2011 high priority risks:

• the average risk prevalence is improving (see graph).

• a 22 percentage point (28%) reduction in high risk people.

• a 23 percentage point (20%) increase in low risk people in these three categories.

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

2004 2005 2006 2007 2008 2009 2010 2011

Positive Trend in Targeted Health Risks

BMI, Tobacco, Physical Activity

High Risk

Low Risk

Avg

Ris

k P

reve

lan

ce

DOW RESULTS: IMPROVING EMPLOYEE HEALTH#GWICF2015

DOW RESULTS

• 2004 – 2011

– Saved over $120 Million in US healthcare costs

via Health Strategy

• In 2011

– 9% better health risk profile than comparison companies

– 17% fewer chronic health conditions

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Identifying “Best Practices” in Workplace Health Promotion: What Works?

Source: Goetzel RZ, Shechter D, Ozminkowski RJ, Reyes M, Marmet PF, Tabrizi M, Chung

Roemer E. Critical success factors to employer health and productivity management efforts:

Findings from a benchmarking study. Journal of Occupational and Environmental Medicine.

(2007) February; 49:2, 111-130.

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What Is Needed to Achieve Success?

1. Leadership commitment

2. Specific goals and expectations

3. Healthy company culture

4. Employee driven program design

5. Excellent communication

6. Smart incentives

7. Effective screening and triage

8. State-of-the-art interventions

9. Effective implementation

10. Measurement and evaluation

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Creating a…

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Workplace Health Promotion Programs Work –If You Do Them Right!

Financial Outcomes

Health Outcomes

QOL and Productivity Outcomes

Cost savings, return on investment (ROI) and net present value (NPV).

Where to find savings:

Medical costs

Absenteeism

Short term disability (STD)

Safety/Workers’ Comp

Presenteeism

Adherence to evidence based medicine.

Behavior change, risk reduction, health improvement.

Improved “functioning” and productivity

Attraction/retention –employer of choice

Employee engagement

Corporate social responsibility (CSR)

Balanced scorecard

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To watch Dr. Goetzel’s presentation online,

visit: www.icfi.com/ObesityPrevention-

RonGoetzel

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