HRAs and ROI

1
HRAs and ROI

• YANN A. MEUNIER, MD
• Health Promotion Manager
• Stanford Health Improvement Program
• Stanford School of Medicine

Stanford Prevention Research Center Stanford
University School of Medicine
2
EVOLUTION OF HRAs

• Developed by Dr. Lewis Robbins and first used in
  the Framingham study (mortality statistics)
• Geller tables (risk factors)
• Lalonde report (lifestyle/risk factors)
• CDC HRA (health score)
• Nowadays (health education/behavior change tool)
  
• Stanford

3
STANFORD HEALTH AND LIFESTYLE ASSESSMENT

• The SHALA Summary Evaluation Report on the
  following pages is designed to help you get a
• sense of the health of your organization.
• Specifically, it lists the various lifestyle
  behaviors, risk factors, and other constructs
  assessed on
• SHALA. For each variable, the following values
  are provided
• You These numbers represent the responses of
  your group.
• U.S. Baseline These numbers come from Healthy
  People 2010s data on national baseline values
  (where applicable)
• HP 2010 Target These numbers come from Healthy
  People 2010s target objectives for the American
  public (where applicable)
• Comparison with HP 2010
• There are values in this column only when
  the data are available from Healthy People 2010.
• Red signifies that your group falls
  short of U.S. baseline data.
• Yellow signifies that your group falls
  short of Healthy People 2010 targets but meets or
  exceeds U.S. baseline data.
• Green signifies that your group meets
  or exceeds Healthy People 2010 targets.

4
PRESENTATION OUTLINE

• Update on HRAs
• ROI from HRAs
• Corporate level
• Medical condition level
• - Current examples
• - Future possibilities
• Conclusion

5
RENEWED INTEREST IN WELLNESS PROGRAMS

• Employers
• 2006 19 gave incentives for HRAs compared to 7
  in 20041
• 2007 91 believed they could reduce health costs
  by
• influencing healthier
  lifestyles2
• Insurers
• 2007 66 of insurers said they were somewhat or
  very likely to provide incentives for
  health-enhancing behaviors1
• (1) National survey of employer-sponsored health
  plans 2006 survey report. New York Mercer Human
• Consulting, 2007
• (2) Strategic health perspectives data sheet
  questionnaires 2007, New York Harris
  Interactive, 2007

6
THREE KEY BUSINESS BELIEFS

• Individuals can establish and maintain low risk
  health status even as they age
• Employers can help employees maintain low risk
  health status and productive vitality
• ROI at the corporate and individual level will
  come from both short term and long term
  strategies

7
OTHER STUBBORN FACTS

• The vast majority of the economic literature
  concludes
• that health care costs will continue to rise
  despite
• preventive medicine initiatives because they
  are driven
• by technology (macro-economic analysis)1
• Many employers still consider wellness programs
  as
• benefits. Even so, why would medical care be
  
• considered a legitimate benefit but not
  prevention?
• Prevention only produces long-term results
• (1) Brown D. In the balance, The Washington Post,
  April 8, 2008

8
WHY FOCUS ON HEALTH IMPROVEMENT?
9
HEALTH POTENTIAL AS AN ADULT
According to the MacArthur Foundation Select
Panel on Healthy Aging, once you become an adult,
80 of your health is determined by your
lifestyle.
10
HOW ARE HRAs CURRENTLY USED IN WELLNESS
PROGRAMS?

• In isolation
• Followed up with different interventions
• - Interpretation sessions
• - Group coaching
• - One on one coaching
• - Wellness programs
• - Health education plans
• - Preventive medicine actions
• Given with or without incentives

11
HRA PARTICIPATION

• Conditions for high participation
• Good program
• Good communication plan starting from the top
• Easy navigation and understandability
• Easy accessibility
• Easy completion
• Financial incentives and prizes
• Privacy
• Quality of output
• Quality of customer service

12
PARTICIPATION RESULTS

• Much lower without financial incentives
• For 100 incentive 66 average participation
• Stanford example
• Main issues legal matters1 (in particular,
  privacy and HIPAA2)
• (1) Michele M. Mello and Meredith B. Rosenthal.
  Wellness programs and lifestyle discrimination-
  The
• legal limits. N Engl J Med, 3592, July 10,
  2008
• (2) Health Insurance Portability and
  Accountability Act

13
MOTIVATION ASSESSMENTSTANFORD EXAMPLE

• Assess your current behaviors
• Assess readiness for change/Motivational assets
• Build a support network
• Set your long term goal
• Anticipate barriers and design strategies
• Maintain motivation
• Set your first short-term goal
• Assess motivation

14
HRA UPDATE POINTS

• HRAs are more commonly used in 2008
• Their quality varies greatly
• Best results are achieved when HRAs are followed
  by health promotion/wellness programs
• Participation to HRAs and these programs is much
  higher with financial incentives
• HRAs Wellness Programs ROI
• There is (a) Cumulative effect and (b) Dose
  response

15
REFERENCES

• - The relationship between health promotion
  program participation and medical
• costs a dose response. Sexner SA, Gold DB,
  Grossmeir JJ, Anderson DR. J Occup
• Environ Med, 2003 Nov45(11)1196-2000
• - A health promotion program for your workplace?
  Is it important and how will you
• know which one to choose? Scanes L and Coulson
  K., Queensland Mining Industry Health
• Safety Conference 2002, 4-7 August 2002,
  Townsville, Australia, Conference Proceedings,
• pages 61-68
• - Health risk appraisals address employees
  individual problems Programs aim to
• instill healthy habits. Goliath Business
  Knowledge on Demand. Online, 2008
• - Vital Studies in Health Promotion. Health
  Enhancement Systems. Online, 2008
• - Purdue Health Improvement Initiative.
  Literature Review. Online, 2008

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RISK FACTORS GREATER MEDICAL COSTS

• Avg yearly medical costs for risk-free
  employees 1,166
• Avg yearly medical costs for heart disease risk
  profile 3,803

Goetzel et al (1998) Journal of Occupational
Environmental Medicine
17
HIGH RISK EMPLOYEES COST MORE

• Study
• Relationship between modifiable risk factors and
  health care costs
• Findings
• BMI Each unit increase1.9 increase in health
  costs
• Physical Activity Each day per week4.7 less
  health costs
• Smokers 18 higher than nonsmokers
• N. Pronk et al (2000), Journal of the American
  Medical Association

18
REVIEW OF 72 ARTICLES

• For each dollar invested, about
• 4.00 saved in health costs
• 5.00 saved by reducing absenteeism
• Aldana, S.G. (2001). Financial impact of health
  promotion programs
• A comprehensive review of the literature.
  American Journal of Health
• Promotion, 15(5) 296-320.

19
10-YEAR STUDY OF EMPLOYEES IN HEALTH CARE
SETTING

• For each dollar invested
• 6.52 saved in health costs and sick leaves
• Intervention HRA, newsletter, self-care book,
  self-directed
• change materials,
  workshops, financial incentive
  
• Chapman, L., Burt, R., Fry. J., Washburn, J.,
  Haack, T., Rand, J., Plankenhorn, R.,
• Brachet, S. (in publication). Ten-Year Economic
  Evaluation of an Incentive-
• based Worksite Health Promotion Program, American
  Journal of Health Promotion.

20
1-YEAR STUDY OF EMPLOYEES AND RETIREES WORKING AT
BLUE SHIELD OF CALIFORNIA

• For each dollar invested
• 6.00 saved in health costs
• Intervention HRA, newsletter, self-care book,
  self-
• directed change
  materials, nurse line, serial
  feedback
• Fries, J. F. McShane, D., (1998). Reducing need
  and demand for
• medical services in high-risk persons, Western
  Journal of Medicine,
• 169(4) 201-207.

21
2-YEAR STUDY OF RETIREES AND SPOUSES OF BANK OF
AMERICA IN CALIFORNIA

• For each dollar invested
• 5.96 saved in health costs
• Intervention HRA, self-directed change
  materials, serial
• feedback
• Fries, J. F., Bloch, D., Harrington, H.,
  Richardson, N., Beck, R. (1993).
• Two-year results of a randomized controlled trial
  of a health promotion
• program in a retiree population The Bank of
  America study, American
• Journal of Medicine, 94 455-462.

22
3-YEAR STUDY OF EMPLOYEESAT PROCTER AND GAMBLE
IN CINCINNATI

• For each dollar invested
• 6.75 saved in health costs
• Intervention HRA, newsletter, self-care book,
  telephone
• coaching, workshops,
  nurse line
• Goetzel, R. Z., Jacobson, B. H., Aldana, S. G.,
  Vardell, K., Yee, L.
• (1998). Health care costs of worksite health
  promotion participants and
• non-participants, J Occup Environ Med., 40(4)
  341-346.

23
2.5-YEAR STUDY OF EMPLOYEES AND RETIREES OF
CHEVRON IN SAN FRANCISCO

• For each dollar invested
• 6.42 saved in health costs
• Intervention HRA, newsletter, telephone
  coaching,
• workshops
• Goetzel, R. Z., Dunn, R. L., Ozminkowski, R.J.,
  Satin, K., Whitehead, D.,
• Cahill, K. (1998). Differences between
  descriptive and multivariate estimates
• of the impact of Chevron corporations health
  quest program on medical
• expenditures, J Occup Environ Med., 40(6)
  538-545.

24
3-YEAR STUDY OF EMPLOYEES AT CITIBANK, N. A.

• For each dollar invested
• 4.64 saved in health costs
• Intervention HRA, newsletter, self-care book,
  telephone coaching,
  workshops, nurse line, serial
  feedback
• Ozminkowski, R.J., Dunn, R., Goetzel, R., Cantor,
  R., Murnane, J., Harrison,
• M. (1999). A return on investment evaluation of
  the Citibank, N.A. health
• management program, American Journal of Health
  Promotion, 14(1) 31-43.

25
SUMMARY

• Source
  Health Costs ROI (for 1.00)
• Review 72 Articles
  4.00
• Health Care Setting
  6.52
• Blue Shield, CA
  6.00
• Bank of America, CA
  5.96
• Procter Gamble, OH
  6.75
• Chevron, CA
  6.42
• Citibank
  4.64

26
DISEASE PREVENTION

• Could save America more than 16 billion in five
  years
• Focusing only increasing physical activity,
  improving nutrition and preventing smoking would
  produce a ROI gt 5/1
• Released by the Trust for Americas Health
  (TFAH). Prevention for a
• Healthier America Investments in Disease
  Prevention Yield Significant
• Savings, Stronger Communities, July 17, 2008
  Washington, D.C.

27
FURTHER EVIDENCE OF ROI

• From 2000 to 2004, the vast majority of more than
  122
• research studies indicated positive clinical and
• cost outcomes.
• Pelletier KR. A review and analysis of the
  clinical and cost-effectiveness
• studies of comprehensive health promotion and
  disease management at
• the worksite Update VI 2000-2004. J Occup
  Environ Med. 2005471051-
• 1058

28
WELLNESS PROGRAMS SHORT TERM RESULTS

• Smoking annual cost for lost productivity
• Non-smokers 0
• Former smokers 623
• Current smokers 1,807
• Bunn, William B., Stave, Gregg M. et al. (2006).
  Effect of smoking status on
• productivity loss. J Occup Environ Med., 481-10

29
QALY SAVINGS
Intervention A- Screening people over 50 for
colo-rectal cancer B- Screening men 65-75 who
smoked for aortic aneurysm (U.S.) C- ASA
prevention for adults at increased risk for CAD
Savings A- 10,000 to 30,000 B- 14,000 to
20,000 C- 11,000
30
REFERENCES

• A- Pignone M, Saha S, Heorger TJ, Mandelblatt J.
  Cost-effectiveness analyses of colo-rectal cancer
  screening a systematic review. Ann Intern Med
  200213713796-104
• B- Meenan RT, Fleming C, Whitloc EP, Beil TL,
  Smith P. Cost-effectiveness analyses of
  population-based screening for abdominal
• aortic aneurysm Evidence synthesis. AHRQ
  Electronic Newsletter Issue No 159. Rockville,
  MD Agency for Healthcare Policy and
• Research. Quarterly February 4, 2005.
• C- Pignone M, Earnshaw S, Tice JA, Pletcher MJ.
  Aspirin, statins or both drugs for the primary
  prevention of coronary heart diseases in men a
  cost-utility analysis. Ann Intern Med 2006 Mar
  7144(5)326-36

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32
FUTURE? BRIDGING THE HEALTH CARE GAP

• Combining HRA information with health data
  stemming from health
• plans, pharmacy drug use and medical parameters
  stored in
• electronic data bases will enable to
• Improve care management by creating real time
  care gap alerts
• Determine a population health profile more
  accurately and thoroughly
• Establish health priority needs and design
  tailor-made health promotion interventions

33
AUTOMATED CARE MANAGEMENT AND REAL-TIME CARE GAP
ALERTS
Physician E-mail, Fax, Call
BP DRUG NON-COMPLIANCE
Care Manager
Care Gap Rules Engine
Care Gap Rules Engine
Member
Systolic BP 172
Wt 192
Dx CHF BP 130Wt 1862 wks ago
Care Gap Rules Engine
Smithson
Healthcare Consulting, LLC
34
AUTOMATED HEALTH PROMOTION MANAGEMENT
ALERT
Wellness Coach
Fitness Center
Care Gap Rules Engine
Care Gap Rules Engine
Member
Wellness Gap Rules Engine
Wt 1726 mths ago
Wt 192
adapted from
Smithson Healthcare Consulting
35
FUTURE? BRIDGING THE HEALTH CARE GAPS

• HRA as a consultation tool
• For physicians
• Data gathering source
• For patients
• Basis of the doctor-patient relationship
  (wellness appointment)
• Instrument to become a better consumer

36
MOVING TOWARDS PREVENTION?
37
CONCLUSION

• For better results, HRAs should be science-based
  and the port of entry to wellness programs
• When well-conceived, selected and implemented,
  HRAs and wellness
• programs produce good ROI
• The behavior change readiness assessment step is
  often missing before
• wellness plans, but it is crucial for
  success
• Wellness programs should include outcome
  measurements to ensure sustainability
• Beside financial rewards, wellness programs yield
  many other benefits
• The overall goal is to build a new and healthier
  corporate/community culture