Delivering the Science and the Art of Health Promotion

Robert F. Allen
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Introduction

Ron Z. Goetzel

The Financial Impact of Health Promotion and Disease Prevention Programs—Why Is It So Hard To Prove Value?

Ron Goetzel, editor of this special issue, reviews the contents and context.

Methodology

David R. Anderson

Seth A. Serxner

Daniel B. Gold

Conceptual Framework, Critical Questions, and Practical Challenges in Conducting Research on the Financial Impact of Worksite Health Promotion

A conceptual framework to guide research on the financial impact of health promotion programs is described.  Important questions that must be answered within this framework are discussed and brief summaries of the research addressing these questions are summarized.  Key issues and challenges that are encountered in designing and implementing financial outcome research are reviewed.  

Ronald J. Ozminkowski

Ron Z. Goetzel

Getting Closer to the Truth:  Overcoming Research Challenges When Estimating The Financial Impact of Worksite Health Promotion Programs

The authors describe the most important methodological challenges often encountered in conducting research and evaluation on the financial impact of health promotion.  These include selection bias, skewed data, small sample size, metrics.  They discuss when these problems can and cannot be overcome and suggest how some of these problems can be overcome through a creating an appropriate framework for the study, and using state of the art statistical methods.

Reviews

Steven G. Aldana

Financial Impact of Health Promotion Programs:  A Comprehensive Review of the Literature

A comprehensive review of the literature on the relationship between lifestyle behaviors, health promotion programs and financial outcomes of absenteeism and medical care costs was conducted to determine the methodological quality of the literature, determine if costs are higher for those with unhealthy lifestyles and if health promotion programs save money.  The search produced 196 studies, 74 of which meet the inclusion criteria.  Of the 34  correlational studies 9 had multivariate controls of confounding variables.  Of the 50 intervention studies, 4 had experimental designs, 24 had quasi-experimental designs and 22 had non-experimental designs.  There are good correlational data to suggest that high levels of stress, excessive body weight, and multiple risk factors are associated with increased health care costs and illness-related absenteeism.  The associations between seat belt use, cholesterol, diet, hypertension, and alcohol abuse and absenteeism and health care expenditures are either mixed or unknown.  Eighteen of 18  intervention studies found that absenteeism dropped after the introduction of the health promotion program and the six studies which reported cost benefit ratios averaged savings of $5.07 for every dollar invested.  Twenty eight of the 32  intervention studies found that medical care costs dropped after the introduction of a health promotion program and the 10 studies which reported cost benefit ratios averaged savings of $3.93 for every dollar invested.  The overall quality of the literature is rated "indicative" meaning that even though the relationship is probably causal,  a statement of causality is premature until larger scale studies with randomized control designs are completed.

Wendy Max

The Financial Impact of Smoking on Health Related Costs:  A Review of the Literature

A literature search was conducted to determine the financial impact of smoking on health related outcomes.  The literature cited in three recent prominent literature searches was supplemented with searches of three literature databases to identify the most recent literature and literature focusing on specific subgroups.  Forty-nine studies were reviewed.  Studies on the annual costs concluded that 6% to 14% of all direct medical costs are attributed to smoking.  Studies on lifetime costs of smoking were less definitive and contradictory, finding that smokers die early and have high annual medical costs while they are alive.  However, because smokers die early, they use medical services for fewer years, draw fewer dollars from pensions and Social Security; but also contribute income taxes for fewer years.  For employers, greater annual health care use is well documented for specific employers or groups and seems to account for approximately 6% of medical care costs, but no national studies exist.  The financial impact of second hand smoke is not included in these estimates of direct costs and the indirect costs are probably two to three greater than the direct costs.

Thomas Golaszewski

Shining Lights:  Studies That Have Most Influenced The Understanding of Health Promotion's Financial Impact

A panel of experts was assembled to identify and then rank the five to 10 highest quality studies which have been published on the relationship between health risks, health promotion programs and financial outcomes.  Twenty-three studies were identified.  Twelve studies were selected for review based on the both the quality of research methodology and the authors efforts to present results from a broad range of intervention areas and program settings.  The methodology, results and limitations of the 12 highest rated are reported here. 

Research Application

Dee W. Edington

Emerging Research:  A View from One Research Center

The Health Management Research Center at the University of Michigan has assembled a database on health risks, medical care costs, an in some cases, productivity measures for over 2,000,000 individuals.  For employees of its corporate consortium members, the database contains seven to eighteen years of data.  Working with this data, the research team has observed a number of emerging trends.   These trends have been stable in this data set for a number of years, but some of them are yet to be subjected to rigorous external peer review.  The trends are summarized below.

1) Annual participation rates of 20% to 30% in Health Risk Appraisal are typical; over 10 years, 80% participate at least once, 60% at least twice and 40% at least three times.  2) Among the employers in the data base, excess risk factors account for 21% to 31% of medical care costs, with a mean of 25%. 3) Medical care costs increase as the number risk factors and age increase.  As risk factors increase, medical costs increase;  as risk factors decrease, medical care costs decrease.  The mean cost increase per risk factor increased ($350) may be more than double the mean cost decrease per risk factor decreased ($150).  4) Cost savings greatest among those who participate in programs multiple times.  5) Absenteeism seems to be higher and other measures of productivity lower for those with health risk factors.  6) Programs designed to keep healthy people healthy in addition to reducing the risks of those with multiple risks will probably provide the greatest return to the employers. 7) Best results may be achieved by focusing efforts on employees who have clusters of risk factors associated with low perceived health status.  8) A corporate wellness score which combines risk factor levels and participation rates may provide a "corporate wellness score" which can be used to compare health status across employer.  9) Increased use of longitudinal data sets, fuzzy cut points for data categories and data mining techniques may allow breakthroughs in future analysis efforts.

Jeffrey R. Harris

Helen H. Schauffler

Arnold Milstein

Patricia Powers

David P. Hopkins

Expanding Health Insurance Coverage for Smoking Cessation Treatments: Experience of the Pacific Business Group on Health  

Despite strong consensus on the behavioral and cost effectiveness of smoking cessation treatments, most employer sponsored health insurance plans do not cover clinical treatments for smoking cessation.  The Pacific Business Group on Health is a consortium of large employers in California and the western United States which negotiates health coverage for these employers.  The business case used to decide to expand its coverage for smoking cessation.

Perspectives

Ron Z. Goetzel

Corporate Perspectives

Managers in 10 corporate settings reflect on what matters to them and their top management in determining if health promotion is a good investment for their organization.

Introduction: A Corporate Perspective: Reflections From the Economic Buyer of Health Promotion Programs

Gregg M. Stave

The Glaxo Wellcome Health Promotion Program: The Contract for Health and Wellness

Vincent E. Kerr

Prevention: Is There Value for Corporate Purchasers [General Electric]

Lawrence G. Shoner
Laura Cioffi

A Corporate Perspective from Lucent Technologies: Reflections From the Economic Buyer of Health Promotion Programs—What Really Matters to Me and My Boss?

Catherine Baase

An Optimistic View From the Corporate Perspective [Dow Chemical]

Firky Isaac

P. Flynn

Johnson & Johnson Live for Life Program: Now and Then

D’Ann Whitehead

A Corporate Perspective on Health Promotion: Reflections and Advice From Chevron

Mary Schmitz

When the Health Promotion Program Does Not Adapt to Changing Business Priorities: The Experience at Southern California Edison

Michael A. Anderson

John A. Stoltzfus

The 3M Corporate Experience: Health As a Business Strategy

Molly J. McCauley

An Overview of Two Worksite Health Promotion Programs—The Quest for Qualitative and Quantitative Results: What Really Matters?

Judy Webster

Strategy, Not Return on Investment, Drives Health Promotion at Applied Materials, Inc.

Federal Government Perspectives

Officials from two government agencies reflect on their agencies policies related to investment in health promotion

Jeffrey R. Harris 

Priscilla B. Holman 

Vilma G. Carande-Kulis

Financial Impact of Health Promotion: We Need To Know Much More, but We Know Enough To Act

Catherine G. Gordon

Pauline J. Lapin

A Government Perspective: If There Is So Much Proof, Why Is Medicare Not Rapidly  Adopting Health Promotion and Disease Prevention Programs?

Policy Perspectives

Policy experts from a foundation setting and an academic setting reflect on the apparent discrepancy between our knowledge of the impact of health promotion and its limited application.

Lester Breslow

Why Health Promotion Lags Knowledge About Healthful Behavior

J. Michael McGinnis

Does Proof Matter? Why Strong Evidence Sometimes Yields Weak Action

American Journal of Health Promotion |  248-682-0707