Can we achieve greater savings if we target our low-risk employees?
Can we achieve greater savings if we target our low-risk employees?
Without proper attention, healthy employees susceptible to increasing risks
It runs counter to conventional wisdom and is certainly not reflected in most current wellness programs, but a growing number of health promotion professionals are coming to believe that the greatest dollar-for-dollar returns may lie not in targeting high-risk employees, but low-risk individuals.
"We have observed that those low-risk individuals are susceptible to increasing their risks without proper attention to help them maintain low-risk status. Our premise is that reducing the flow of low- or medium-risk individuals to high-risk results in a successful reduction of the total number of high-risk individuals within a few years." Thus writes Dee W. Edington, PhD, director of the University of Michigan Health Management Research Center (HMRC) in Ann Arbor, in his "Research Update" overview that serves as a preface to The Ultimate 20th Century Cost Benefit Analysis and Report 1979 to 2000. The comprehensive report documents significant developments, studies, articles, and comments on work site wellness over the past 20 years, including:
• a chronology of work site wellness studies by focus topics;
• perspective on learning and future trends in work site wellness by HMRC’s Corporate Consortium partners;
• summaries of more than 500 articles and studies;
• a review of published studies about the cost-effectiveness of health promotion programs.
It is "mainly our own work" that Edington says led to his conclusion. "Take a certain point in time and look at the data point; you don’t know how or if it’s changing at that point in time," he notes. "The CDC may tell us 20% of the adults in the country are smokers. If last year it was 20% and next year they tell us it’s 20%, the natural conclusion might be that the situation is not changing. But if you look at our transition model, there’s a lot of churn in the population from high-risk to low-risk to medium-risk, with people going every which way. If you try to solve those equations, the only way you’re going to be successful is to stop this supply of high-risk people."
A longitudinal’ look
HMRC takes a "longitudinal" look at individuals over time to see how they change, Edington explains. "It’s almost like a business model; is it easier to get new customers, or to keep old ones? Do you keep fishing people out of the water, or do you try to find out who’s pushing them in?"
Edington’s Corporate Consortium partners agree. "We see time and time again with our own data that if a low-risk person goes to high-risk, those costs are going to go up," says Laura Adams, manager of wellness and fitness programs at Progressive Corp., a Cleveland-based auto insurance firm. "It’s important and it’s easier to target low-risk employees. Not that I want to forget about the high-risk people, but they have to be willing to work on it. So what we do is use the stages of change to narrow down that population."
"I agree with him," says Wayne Burton, MD, senior vice president and corporate medical director of Bank One in Chicago. "There needs to be a balance between low-risk strategies and high-risk strategies. The Pareto Rule’ commonly states that 20% of the population accounts for 80% of the health care costs, or 10% accounts for 90%. It’s been shown, however, that the rule probably is not true except for a given year. Of those people who are high-cost in year one, only a small number continue to be high-cost in year two. If you continue to focus only on high-cost people, you’re aiming at a moving target."
"We [health promotional professionals] never thought much about people gaining risk, but rather about getting rid of risk," adds Edington. "But we’ve not been successful in weight loss programs. As for smoking cessation, raising taxes may be a more successful deterrent than our work site programs. Every time we go into risk-reduction programs, we lose, self-esteem goes down, and so on. So even from a self-esteem position, we need to keep low-risk people low-risk."
Where the money is
This suggested shift aims at the same goals the profession has had from its earliest days: containing costs by addressing issues of employee health. "Certainly 20 years ago when we began, we focused on high-risk strategies because everyone thought that’s where the money was," Burton recalls.
Now, that assertion should be challenged, says Edington. "The science of epidemiology is right on; we can predict global trends," he says. "But the real advance is coming down to the individual level. Look at a 25-year-old smoker. If the outcome is heart disease or cancer 25 years from now, it’s a good investment to help him stop smoking. But what organization wants to wait 25 years for a return? So, then we said, Let’s change the outcome measure.’ Fifteen years ago, we thought we were in the health business, and we still all basically are concerned with health status. But medical economics drove us to different outcome measures — health care costs, outcomes, utilization.
"So now, if you’re going to make a serious business case — and I think you should — outcome measures should have a two- to three-year horizon. How much money should we invest in a smoker to a get return in two to three years? The answer is zero. Not many of us can accept that."
If you have an unlimited budget, says Edington, then of course you should address all levels of risk. "But if you have a limited budget, I propose you need to be strategic. Send a message to the doctor of that 25-year-old smoker to tell them to stop smoking — if that. Then, I would say, go to a 50-year-old smoker, where there’s a chance of them saving a great deal of money over the next two or three years. If you look at investing the right money in the right person at the right time, now you’re getting a return on investment."
Individualization is critical
Looking at each individual case is a key consideration in targeting, notes Edington. "What if our 25-year-old smoker (who we had decided not to target) has an 8-year-old daughter with asthma? Then, it’s a different story," he notes. "That’s why it’s important for a company to address the health care needs of the entire family. You should not only provide HRAs [health risk appraisals] for the employee, you’d but better think about the whole family."
By the same token, he adds, it’s important not just to look at specific risk factors, but at the combination of risk factors that may apply to an individual. "Just being overweight by itself is not necessarily bad," he explains. "You truly can be fat and happy,’ or at least relatively happy. Now, if you are overweight and diabetic and a smoker, then you have a major problem."
Adams agrees. "Family can have a big impact. A high-risk person who has a family that’s into high-risk behavior will be very difficult to change."
"There is absolutely a tie-in between the individual and being able to reach his family," says Burton. "Right now, it’s very expensive to reach family members through printed materials, which is why technology is so exciting. If someone has a chronic disease, he will be able to go on that Internet site and receive information tailored to his needs, with a goal of better controlling that disease. There’s a great deal of research and effort going on to develop this kind of technology."
Identifying, targeting low-risk employees
So how does a wellness professional make the shift to targeting low-risk employees? What would such programming look like? What is the appropriate balance between programming for high-risk and low-risk individuals?
"We don’t think the world can ever be perfect," says Edington, "So when we look at cost analysis, we think that employees with zero, one, or two risk factors are OK. Three to four are medium-risk, and five high. At least those are the measures we used five years ago."
What other considerations would he recommend today? "I’d rank the employees in order," he says. "Which person can give you the best return on investment? Rank everyone, then determine the best intervention for that person. Targeting low-risk individuals may not have any associated costs at all, but you must pay attention to them, because they are your champions."
"The things you do for your high-risk people are definitely more costly," says Adams. "Dee has put together a system called trend management, which looks at risk and claims over a three-year time span. That’s the period of time where you get your 3-1 return, and that’s where I would start. In fact, we’re starting to use it here to determine who to target." (One corporate partner has already incorporated low-risk targeting into her wellness program. See story, p. 75.)
Burton says it’s important to maintain a balance in your program. "It’s premature to recommend a specific percentage, but once we have more data, that kind of analysis will be very important," he says.
"Bank One has fitness centers, and we know that the people who use them for the most part are healthy, and the argument has been that they would exercise anyway," he continues. "That may be true, but they might not exercise to the same degree. By following club members over time they will continue to stay healthy and low-risk."
Significantly better control
However, Bank One also has high-risk programs for asthma, depression, and diabetes. "We know if we offer these programs at the work site we can assist employees in gaining better control of these diseases, and have lower costs and less disability," says Burton. "On depression, we have long-term data that show this to be true. On the other two conditions, we can say that work site programming can result in significantly better control."
Fitness centers should be an integral part of targeting low-risk employees, says Edington. "They’re one of the best low-risk programs available, so let’s get the employees in there and keep them in," he says.
Other low-risk maintenance programs could involve activities around the cafeteria, Edington suggests. "Walk through the lines and remind people of the healthy choices that are available," he says. "Also, place little bulletin boards all around the work site and post ideas that remind people about health. We started out that way; trying to change the whole culture is just too big a job."
Low-risk people may be high risk later
Adams is concerned with a specific segment of her corporate culture. "There is a very, very large group of our people who are low-risk at present," she notes. "We are a very young company, but it’s important for them to understand that they won’t necessarily be healthy forever. Working with them will ensure that a lower percentage of our total population will be high-risk later on."
Adams also cites fitness centers as excellent vehicles for targeting low-risk individuals. "They also work as a retention tool and a recruiting tool," she notes. In addition, Adams uses newsletters to help motivate low-risk employees.
Edington is convinced this is the way to go. "If you’re always taking care of the short-term, your outcome measures in two to three years, the rest will take care of itself," he asserts.
Is Edington aware that what he is suggesting may well turn health promotion on its head? "Oh, yeah," he says. "I get tickled when I hear people ask at meetings, How do you get to the high-risk people?’ When I hear them start asking how to get to the low-risk people, then I’ll know I’ve made it!"
[Editor’s note: Copies of The Ultimate 20th Century Cost Benefit Analysis and Report 1979 to 2000 are available from the University of Michigan for $195. Contact: Dee W. Edington, PhD, Director, The University of Michigan Health Management Research Center, 1027 E. Huron St., Ann Arbor, MI 48104-1688. Telephone: (734) 763-2462. Fax: (734) 763-2206. Web site: www.umich.edu/~hmrc.]
• Laura Adams, Progressive Corp., 6300 Wilson Mills Road, Mayfield Village, OH 44143. Telephone: (440) 446-7612.
• Wayne Burton, Bank One, 1 Bank One Plaza, Chicago, IL 60670-0006. Telephone: (312) 732-6434.
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