Employers have become increasingly aware that overweight and obesity, lack of physical activity, and smoking have a major impact not only on the health and productivity of their employees, but also on the financial "health" of their businesses. Since the 1970s, many employers have provided a variety of health promotion and disease prevention programs to their employees. These efforts often have focused on overweight and obesity, physical activity, and smoking, as well as other behaviors and conditions (such as depression and stress) linked to the health and well-being of their employees. The motivation behind these programs is to improve the health status of employees, increase the productivity and morale of employees and reduce absenteeism, and reduce business costs that are associated with chronic diseases and disorders among employees. Throughout this report, a small number of noteworthy businesses' health promotion and disease prevention programs along with their key features have been highlighted.(145) These particular companies have won national awards for their health programs, and are presented in this report because they illustrate some of the promising approaches to promoting wellness among employees that many companies across the country are operating.(146)
The proportion of employers who provide such programs has increased over the years, and it is reported that health improvement programs of some kind now are being offered by over 80 percent of worksites with 50 or more employees and almost all large employers with more than 750 employees.(147) The focus and scope of these efforts vary substantially across companies. Some worksite programs may focus on a single risk factor, such as smoking, or a particular disease, such as CVD, while others may focus on a much wider set of risk factors and diseases.(148) Employers offer a wide variety of resources that differ considerably in comprehensiveness, intensity, and duration, and the extent to which they tie together health promotion and disease prevention activities with employee health benefits, occupational health, employee assistance programs, disease management, workers' compensation, disability benefits, and other benefit programs.(149) Clearly, small businesses face a much greater challenge in implementing practical, affordable efforts to improve their employees' health. Future research and public policies will need to address the special needs of small employers.
One survey of more than 1,000 U.S. employers (most of which had more than 1,000 employees) found that 72 percent provided education or training on lifestyle behaviors to their employees, and 40 percent offered financial incentives for participation in health appraisals or screenings.(150) Department of Labor data show that in 2000, 18 percent of all employees (including part-time) were eligible for wellness programs, and 9 percent were eligible for fitness center programs.(151)
Given the large number of companies that have implemented health promotion and disease prevention programs, many for several decades now, it is not surprising that a large amount of information has been reported on the effects of these programs on employee health and productivity, and on the costs and benefits of these programs to the companies that sponsor them. Moreover, many companies and studies have reported that these kinds of programs have had positive effects on employee health and job performance, and have resulted in cost savings for the companies that provide them. The nature and quality of this information vary a great deal, since these programs generally were not designed to be research studies. Many of the available reports are case studies. When more systematic studies are undertaken, they often must address limitations that include selection bias, skewed data, confounding variables, small sample sizes, and lack of control or comparison groups.(152) These limitations in turn make it difficult for studies of worksite programs to attribute a causal relationship between the program and the measured effects and to generalize the findings to other locations, businesses, or workforces.(153)
Figure 9.Source of data: Ref. 150.
A number of comprehensive reviews, or meta-analyses, have analyzed findings across large numbers of individual studies of worksite health promotion and disease prevention programs in the recent years.(154),(155),(156),(157),(158) These and other reviews categorize and examine a broad array of worksite programs, and provide in-depth information and conclusions about many aspects of health promotion and disease prevention activities and their effects on employees and businesses. While these reviews provide information that is too extensive and detailed to be adequately summarized in this brief discussion, they provide a strong indication that many health promotion and disease prevention programs do work and do result in significant cost savings.
Many studies have focused specifically on the return on investment (ROI) from worksite health promotion and disease prevention programs. One recent review identified well-conducted, rigorous evaluation studies of ROI, then documented the range of ROI estimates in these studies, and examined the factors that influenced program outcomes and ROI estimates.(159) Findings on the return on investment for health promotion and disease management programs were reported for nine employers: Canada & North America Life; Chevron; City of Mesa, AZ; General Mills; General Motors; Johnson & Johnson; Pacific Bell; Procter & Gamble; and Tenneco. These programs provide health education to their employees to promote behaviors that will improve health or prevent disease, and typically include exercise programs, health-risk appraisal, weight control, nutrition information, stress management, disease screening, and smoking cessation.(160) The review found significant return on investment for the programs provided by these nine employers, with the range of benefit-to-cost ratios, ranging from $1.49 to $4.91 in benefits per dollar spent on the program, and a median of $3.14. For instance, at the high end, General Motors realized at one of their sites an annual savings of $105.50 in total health care costs per enrollee for an annual program cost of $27 per enrollee-a ratio of 4.91 of benefits-to-cost.
These reviewers also examined what they call "demand-management programs," or programs that encourage and help employees increase the use of self-care and decrease their use of medical care, often through self-care books, newsletters, telephone information lines, counseling, and other means. Looking at studies of ROI for demand-management programs (Blue Shield of California, five California counties, Group Health, Rhode Island Group Health Association, and United Health Care), they found greater variation in the return on investment in these kinds of programs, ranging from $2.19 to $13 in benefits per dollar spent. They also examined three studies of ROI for disease-management programs and found a range in benefit-to-cost ratios from $7.33 to $10.38. For multiple category programs that combined elements of these programs, they found a range of $5.47 to $6.47 in benefits per dollar spent.
The goal of CIGNA's Working Well Program is to keep its 34,000 U.S. employees healthy and at work. The Working Well Program's annual budget is $2.5 million. The program is implemented at all 250 domestic offices. Working Well has a broad range of programs for all employees with special emphasis on issues of concern to women who make up 76% of CIGNA's employees.
The Working Well Moms Program encourages and supports breast-feeding. Over three-quarters of CIGNA women are of childbearing age. Breast feeding duration rates for participants are 72% at 6 months and 36% at 12 months, significantly higher than control groups and U.S. data. This has decreased pharmacy costs - 62% fewer prescriptions for breast-fed children. The program has also contributed to decreased medical costs - a savings of $240,000 in healthcare expenses. In addition, program participants have 74 fewer absences per 100 mothers, a savings of $60,000 in lost time annually.
The Working Well Triumph Program provides skill training and support for disabled employees to improve their health, adopt healthy lifestyles, and reduce the likelihood of future disability leave. This program has resulted in healthcare costs savings of more than $900 per program participant.
The Working Well Flu Shots Program provides free immunization inoculations at all significant employee locations. The program is aimed at reducing workplace absenteeism. Program participants has 29% less absenteeism as compared to employees not getting a shot. This produced a savings of $33 per employee participant. The overall return on investment for the program was 3 to 1.
CIGNA's smoking cessation program, which combines behavioral counseling and pharmacologic treatment, is offered to all CIGNA employees and their benefits-eligible family members who want to quit smoking. The program helped 67 percent of its participants quit smoking after 12 months, a quit rate up to three times higher than comparable smoking cessation programs. CIGNA estimates saving $949 in health care costs for each successful participant, a return on investment of 9.5 to 1.
To contact CIGNA for more detailed information, see: www.Cigna.com.
For these employers, disease management programs resulted in the highest returns on investment, and the educational health promotion and disease prevention programs the lowest returns. Moreover, the more expensive programs resulted in lower returns on investment than some of the less expensive ones. The reviewers suggest the possibility that the higher costs may stem from the larger capital investments that go into on-site fitness centers or classroom-based education programs. They also point out that the typical health promotion and disease prevention program provides health education to most or all employees but usually shows savings for only a small portion of the neediest employees, whereas disease management programs are targeted on a smaller selected group of employees. They conclude that, in designing effective programs that will improve employee health and productivity and produce good returns on investment, employers should consider an array of health and productivity programs (rather than focus on the "pure" wellness program) and integrate them with health and demand-management or disease-management activities.(161)
Most of the information on the costs, effects, and benefits of corporate health promotion and disease prevention programs has come from studies of relatively short time periods, e.g., two years or less. Relatively little information is available on the long-term effects of such programs on the health status of employees and their utilization of health care services, and the return on investment over these longer periods. One recent study examined the long-term impact of the Johnson & Johnson Health & Wellness Program on medical care and expenditures.(162) Johnson & Johnson has offered a health promotion program since 1979 and has spent several million dollars on evaluations of the program. According to this study, the Johnson & Johnson program integrates employee health, wellness, disability management, employee assistance, and occupational medicine programs, and places considerable emphasis on health promotion and disease prevention. The study looked at up to five years of data and found that, while there was a slight increase in emergency department expenditures per employee per year ($10.87), there also were significant decreases in expenditures for outpatient and office visits ($45.17), mental health visits ($70.69), and inpatient hospital days ($119.67). Across all of these categories, total savings were $224.66 per employee per year. Moreover, the study found a substantial increase in savings in years 3 and 4 for outpatient and physician visits and inpatient days. While these researchers caution that a variety of methodological limitations make it difficult to definitively establish causality for the observed effects and savings, and to be certain about the exactness of the savings for each of the health outcome categories, they suggest that a more in-depth and comprehensive analysis would likely show that the total program savings were even greater, and they conclude:
This study demonstrates that a well-conceived health and wellness program that focuses on prevention, self-care, risk factor reduction, and disease management can produce substantial benefits for employers and their employees. Utilization and expenditures may be reduced by better coordination of existing health and productivity management programs, with many of these benefits occurring in later years.(163)