Many employers, as part of their efforts to contain rising medical care costs, are implementing worksite programs variously described as Workplace Health Promotion Programs, lifestyle programs, health and work rate management, population health management and, simply, wellness programs.

The purpose of this article is to consider whether such programs better health. If so, do they in turn cut utilization of health care services and cut health care expenditures?

The popular media have done much to encourage the concept of company wellness. Last year, In Business: Madison magazine printed a story accompanied by a table reporting an impressive range of returns on investment (ROI):

Return on Investment (Per dollar ROI for lifestyle programs)
• Coors $6.15
• Kennecott $5.78
• Equitable Life $5.52
• Citibank $4.56
• General Mills $3.90
• Travelers $3.40
• Motorola $3.15
• PepsiCo $3.00
• Unum Life $1.81
Source: 2004 T.E. Brennan Organization, as reported

Would these ROIs stand up to thorough empirical analysis of the data? What factors lead to such disparate returns among these programs? And does the published literature, subject to peer review of scientific methods, support the ROIs reported here?

Health and Productivity Leadership

Illness and injury associated with an unhealthy lifestyle or potentially-modifiable risk factors is stated to account for at least 25 percent of employee medical care expenditures. The most significant of these risk factors are stress, tobacco use, overweight or obesity, physical inactivity, excessive alcohol use, and poor nutritional habits. Over the past two decades, a variety of groups at the local, state, and national echelons have promoted the concept that health risk reduction and care management programs have the potential to better employee health, and that workplace health education, health risk management, and benefit counseling must complement standard healthcare insurance benefits.

The intensity of Worksite Health Promotion Programs range from bulletin board, pamphlet or newsletter information to onsite fitness facilities, health risk reduction classes, and personal lifestyle change coaching.3 Worksite Health Promotion Programs today often include a health risk assessment (HRA) to evaluate each employee’s modifiable risk factors of disease. Program coordinators then target interventions to those that are at increased risk through personal communications and individual follow-up.

All-Inclusive Company Health Promotion Programs may include classes on health risk reduction and job safety, fitness and exercise activities, health club memberships, and reductions in co-payments or premiums for staff members who adhere to recommended medical screening instructions.

Along with this, some employers are restructuring health benefits and encouraging employees’ cost-sensitivity when accessing healthcare.5 These changes are intended to cut employees’ need for and utilization of healthcare, provideing reduced group healthcare expenditures. Demonstrated reductions in healthcare expenditures should then provide employers with a powerful bargaining chip in negotiating lower health insurance premiums during future terms.

Evidence basis: A range of ROI estimates

The empirical research has produced results as varied as the popular media on return on investment. Nonetheless, evidence continues to grow that well-designed and well-resourced Employee Health Promotion Program and disease prevention programs support multi-faceted payback on investment. Peer-reviewed evaluations and meta analyses show that return on investment is achieved through improved worker health, reduced benefit expense, and enhanced productivity.

• Goetzel and colleagues, in their meta-analysis of two dozen articles summarizing economic evaluations of health and work rate management programs, reported an average return of $3.14 per $1 invested in traditional Worksite Health Promotion Programs. The ROI estimates for the individual programs ranged from $1.49 to $13.7,8
• Aldana reviewed 72 articles and concluded that Corporate Health Promotion Programs achieve an average ROI of $3.48 when thinking of medical care expenditures alone, $5.82 per $1 when examining absenteeism, and $4.30 when both outcomes are considered.
• Ozminkowski and collagues conducted a 38 month case study of 23,000 participants in Citibank, N.A.’s health management program and stated that within a 2 year period, Citibank realized a return on investment between $4.56 and $4.73.10  Follow-up studies observed improvements in the risk profiles of participants, with the high-risk group improving more than the “usual care” group11 as a result of more intensive programming.
• Chapman’s 2004 meta-assessment of 42 different studies, ranking overriding validity of the different studies, reports cost-benefit ratios from $2.05-$4.64.

In addition to immediately quantifiable cost reductions, researchers have published a variety of spin-off benefits: greater productiveness, intellectual capacity, and reductions in disability12 and absenteeism.9,13,14,15 Such programs may also have positive effects on employee perceptions of the company14 and worker morale, even among nonparticipants. 13 These outcomes go beyond savings in direct health care expenditures to offer non-health related return on investment.

Tailoring program to maximize ROI Company Wellness Programs aim to decrease the health risks of employees at high risk while maintaining the health status of those at low risk. A variety of disease management interventions are available to fit the specific risk profiles of various worksites. Insurers and corporations now seek to calibrate their interventions in order to achieve good risk reduction and costeffectiveness.

In 2001, University of Michigan researchers published on stable trends in medical care costs for over 2 million current and former staff members in an 18 year data set. The mean cost increase per risk factor gained ($350) was found to be more than double the mean cost decrease per eliminated risk factor ($150). In other words, increases in costs when groups of staff members moved from low risk to high risk were much greater than the decreases in costs when groups moved from high risk to low risk. Their conclusion: Programs designed to keep healthy people healthy will likely offer the greatest return on investment.

On the other hand, Pelletier’s meta-analysis16 and other program evaluations18 suggest that individualized risks reduction for high-risk employees within the context of all-inclusive programming is the critical element in achieving beneficial clinical and expense outcomes in worksite interventions.

Dose-Response?

Several factors might affect the impact of various programs and the ultimate ROI, including cultural and environmental factors, workforce demographics, level of participation and longevity of the program.

Most cost-benefit research studies have been conducted in big companies with more than fifty employees. But researchers have determined that similar results can be obtained by small companies with as few as five employees actively involved in a well-managed program.

Various research studies also suggest that even relatively modest levels of participation can achieve substantial program influence. Contrary to reports by the popular media that such programs require more than 70 percent participation, published reports of at least one case showed positive ROI with 51 percent participation.

Length of intervention appears to be a more salient variable: an influence on healthcare costs generally requires three-to five years of programming.

Future developments

Despite the abundance of beneficial program evaluations, several caveats remain. Negative results are less likely to be reported or published, thus biasing the return on investment upward.

Uncertainty persists regarding the specific impact of the various program components. But as these programs take hold, further research and evaluation will enable fine-tuning of program investments.

Meanwhile, the preponderance of data and the strength of the published research stand in favor of a positive ROI for Employee Wellness Programs. Indeed, the corporation case for such programs is now well enough defined that some insurance brokers offer discounted rates to employers that institute or subscribe to wellness programs.

Future questions will focus on how best to combine inclusive and focused interventions, the intensity of components, and how to calibrate the dose-response model to achieve a target ROI. Here, employers, employees, and researchers will need to collaborate to define mutual goals/objectives in terms of both clinical and cost outcomes.