Originally presented at George Washington University's and ICF International's Research and Evaluation Forum (#GWICF2015), Dr. Ron Goetzel demonstrates why employers should look at value on investment (VOI) rather than return on investment (ROI) of workplace health promotion. Dr. Goetzel goes through: • The severity and cost of obesity • Why the workplace is the optimal environment for health programs • Evidence and examples of how workplace health programs can bring VOI • How employers can get VOI To watch the video of Dr. Goetzel presenting these slides at the GW/ICF Research and Evaluation Forum, visit: http://www.icfi.com/ObesityPreventionRonGoetzel

1. What is the Evidence and Return on Investment
(ROI) of Obesity Prevention and Control in
Worksite Settings?
Ron Z. Goetzel, Ph.D., Johns Hopkins University - Truven Health Analytics
GW-ICF Research and Evaluation Forum -- January 21, 2015 --
Washington, DC
#GWICF2015

2. Q: What problem are we trying to solve?
A: Spending a lot of money on sick care!
• The United States spent $3.056 trillion in
healthcare in 2014, or $9,596 for every man,
woman and child.
• Spending by sector
• Private health insurance - $1.102 billion
• Medicare - $615.9 billion
• Medicaid - $507.2 billion
• Out of pocket -- $338.1 billion
• Health expenditures as percent of GDP:
7.2 % in 1970
17.6% in 2014
19.3% in 2023 (projected)
Source: Sisko et al., Health Affairs, 33:10, September 23, 2014, 1841-1850
#GWICF2015

3. WHY IS HEALTH CARE SO EXPENSIVE?
Source: K.E. Thorpe, "The Rise in Health Care Spending and What to Do About It," Health Affairs 24, no. 6 (2005): 1436-1445; and K.E. Thorpe et al.,
"The Impact of Obesity on Rising Medical Spending," Health Affairs 23, no. 6 (2004): 480-486.
Innovation/advancing technology
(pharmacologic, devices, treatments)
• Newborn delivery costs – five-fold increase
from 1987-2002
– NICU, incubators, ventilators, C-sections
• New/better medicines for treating disease
– Depression (SSRI introduction – 45% treated in
1987 to 80% treated in 1997
– Allergies (Claritan, Allegra, …)
• New treatment thresholds
– Blood pressure
– High blood glucose
– Hyperlipidemia
Rise in spending for treated diseases (37%)
Ken Thorpe
#GWICF2015

4. WHY IS HEALTH CARE SO EXPENSIVE?
(THORPE - PART 2)
• About ¾ of all health care
spending in the U.S. is
focused on patients who
have one or more chronic
health conditions
• Chronically ill patients only
receive 56% of clinically
recommended preventive
health services
And 27% of the rise in
healthcare costs is
associated with increases
in obesity rates…
Rise in the prevalence of disease (63%)
#GWICF2015

5. DISEASES CAUSED (AT LEAST PARTIALLY) BY LIFESTYLE
• Obesity: Cholesystitis/Cholelithiasis, Coronary Artery Disease, Diabetes,
Hypertension, Lipid Metabolism Disorders, Osteoarthritis, Sleep Apnea, Venous
Embolism/Thrombosis, Cancers (Breast, Cervix, Colorectal, Gallbladder, Biliary Tract,
Ovary, Prostate)
• Tobacco Use: Cerebrovascular Disease, Coronary Artery Disease, Osteoporosis,
Peripheral Vascular Disease, Asthma, Acute Bronchitis, COPD, Pneumonia, Cancers
(Bladder, Kidney, Urinary, Larynx, Lip, Oral Cavity, Pharynx, Pancreas, Trachea,
Bronchus, Lung)
• Lack of Exercise: Coronary Artery Disease, Diabetes, Hypertension, Obesity,
Osteoporosis
• Poor Nutrition: Cerebrovascular Disease, Coronary Artery Disease, Diabetes,
Diverticular Disease, Hypertension, Oral Disease, Osteoporosis, Cancers (Breast,
Colorectal, Prostate)
• Alcohol Use: Liver Damage, Alcohol Psychosis, Pancreatitis, Hypertension,
Cerebrovascular Disease, Cancers (Breast, Esophagus, Larynx, Liver)
• Stress, Anxiety, Depression: Coronary Artery Disease, Hypertension
• Uncontrolled Hypertension: Coronary Artery Disease, Cerebrovascular Disease,
Peripheral Vascular Disease
• Uncontrolled Lipids: Coronary Artery Disease, Lipid Metabolism Disorders,
Pancreatitis, Peripheral Vascular Disease
#GWICF2015

6. ENVIRONMENTAL CORRELATES OF OBESITY
More driving
• Rise in car ownership
• Increase in driving shorter distances
• Less walking and bicycling
At home, more convenience
• Increase use of “labor saving” devices
• Increase in ready-made foods
• Increase in television viewing, computers, and video games
At work
• Sedentary occupational fields (“knowledge workers”)
In public
• More elevators, escalators, automatic doors and moving
sidewalks
#GWICF2015

7. Opportunities for Health Promotion: Workplace
-- 156 Million Americans at Work Each Day
Certain policies,
procedures and practices
can be introduced and
organizational norms can
be established
Workplaces contain a
concentrated group of
people who share
common purpose and
culture
Financial or other types of
incentives can be offered
to gain participation in
programs
Workplace programs can
reach large segments of
the population not
exposed to and engaged
in organized health
improvement efforts
Social and
organizational
supports are available
Communication with
workers is
straightforward
US Bureau of Labor Statistics, December 2014
#GWICF2015

8. Convince me…
Why should I invest in the health
and well-being of my workers?
#GWICF2015

9. IT SEEMS SO LOGICAL…
If you improve the health and well being of your
employees…
…quality of life improves
…health care utilization is reduced
…disability is controlled
…productivity is enhanced
#GWICF2015

10. What Is The Evidence Base?
• A large proportion of diseases and disorders is preventable. Modifiable health risk
factors are precursors to a large number of diseases and disorders and to
premature death (Healthy People 2000, 2010, Amler & Dull, 1987, Breslow, 1993,
McGinnis & Foege, 1993, Mokdad et al., 2004)
• Many modifiable health risks are associated with increased health care costs
within a relatively short time window (Milliman & Robinson, 1987, Yen et al., 1992,
Goetzel, et al., 1998, Anderson et al., 2000, Bertera, 1991, Pronk, 1999)
• Modifiable health risks can be improved through workplace sponsored health
promotion and disease prevention programs (Wilson et al., 1996, Heaney &
Goetzel, 1997, Pelletier, 1991, 1993, 1996, 1999, 2001, 2005, 2009, 2011)
• Improvements in the health risk profile of a population can lead to reductions in
health costs (Edington et al., 2001, Goetzel et al., 1999, Carls et al., 2011))
• Worksite health promotion and disease prevention programs save companies
money in health care expenditures and produce a positive ROI (Johnson &
Johnson 2002, Citibank 1999-2000, Procter and Gamble 1998, Chevron 1998,
California Public Retirement System 1994, Bank of America 1993, Dupont 1990,
Highmark, 2008, Johnson & Johnson, 2011)
#GWICF2015

11. #GWICF2015

12. POOR HEALTH COSTS MONEY
Drill Down…
• Medical
• Absence/work loss
• Presenteeism
• Risk factors
#GWICF2015

13. THE COST OF CHRONIC DISEASE
TOP 10 MOST COSTLY PHYSICAL HEALTH CONDITIONS
#GWICF2015

14. ©2008ThomsonReuters
$-
$50
$100
$150
$200
$250
$300
$350
$400
$450
A
llergy*
A
rthritis
A
sthm
a
A
ny
C
ancer
D
epression/S
adness/M
entalIllness
D
iabetes
H
eartD
isease
H
ypertension
M
igraine/H
eadache
R
espiratory
Infections
AnnualCosts
Presenteeism
STD
Absence
RX
ER
Outpatient
Inpatient
THE BIG PICTURE: OVERALL BURDEN OF ILLNESS BY CONDITION
Using Average Impairment and Prevalence Rates for Presenteeism
($23.15/hour wage estimate)
Source: Goetzel, Long, Ozminkowski, et al. JOEM 46:4, April, 2004)
#GWICF2015

15. HERO II STUDY – PUBLISHED NOV. 2012
#GWICF2015

16. RISK-COST IMPACTS – HERO II
EXHIBIT 1 Average Unadjusted And Adjusted Medical Expenditures, In 2009 Dollars, By Risk
Levels
Risk measure
Risk
level
Unadjusted
means ($)
Adjusted
means ($)
Unadjusted
difference
(%)
Adjusted difference
(% )
Depression High 6,207 6,738 59.1 48.0
Lower 3,902 4,553
Blood glucose High 6,532 6,849 70.0 31.8
Lower 3,842 5,196
Blood pressure High 5,264 5,734 27.4 31.6
Lower 4,132 4,356
Body weight High 4,956 5,078 41.7 27.4
Lower 3,498 3,988
Tobacco use High 4,192 4,184 10.8 16.3
Lower 3,784 3,597
Physical inactivity High 4,477 4,582 26.6 15.3
Lower 3,537 3,976
Stress High 5,024 5,249 13.0 8.6
Lower 4,444 4,836
Cholesterol High 4,780 4,913 2.0 -2.5
Lower 4,688 5,037
Nutrition and eating
habits High 3,245 3,261
-23.2 -5.2
Lower 4,226 3,440
Alcohol consumption High 3,857 3,843 -3.94 -9.48
Lower 4,015 4,246
#GWICF2015

17. Individual vs. Population-Based Costs
#GWICF2015

18. Cost Per Capita of Risk Factors
-100
-50
0
50
100
150
200
250
300
350
347
178.6
128.2
106.2 104.1
80.8
38.3
-6.4 -14 -75.4
#GWICF2015

19. RESEARCH ON RISK-COST RELATIONSHIPS - NOVARTIS
#GWICF2015

20. RISK FACTORS AND PRESENTEEISM (N = 5,875)

21. RISK-COST RELATIONSHIPS AT PEPSICO
#GWICF2015

22. 10%
16%
4%
15% 15%
5%
23%
77%
18%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
PercentageSamplewithHighRisk
HEALTH RISK PREVALENCE
Biometric Risks Health Behavior RisksPsychosocial Risks

23. BMI BREAKDOWN BY CATEGORY
25%
44%
22%
7%
3%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
Normal
BMI < 25
Overweight
BMI 25-30
Class I
BMI 30-35
Class II
BMI 35-40
Class III
BMI 40+
PercentageSampleInEachBMI
Category
#GWICF2015

24. PEPSICO – OVERWEIGHT / OBESE ANALYSIS (N=11,217)
*At least one difference significant at the 0.05 level
Source: Henke RM, Carls GS, Short ME, Pei X, Wang S, Moley S, Sullivan M, Goetzel RZ. The Relationship between Health Risks and Health and Productivity Costs
among Employees at Pepsi Bottling Group. J Occup Environ Med. 52, 5, May 2010.
Difference between combined overweight/obese categories and normal weight is displayed
Diff =
29%,
$613*
Diff =
58%,
$111*
Diff =
25%,
$987
Diff =
10%,
$28
Diff =
7%,
$49
Diff =
26%,
$186*
• 74% of the
sample is
overweight
or obese
#GWICF2015

25. NHLBI MULTI-CENTER STUDY: ESTIMATED ANNUAL COSTS
OF HEALTHCARE UTILIZATION, ABSENTEEISM, AND
PRESENTEEISM BY BMI CATEGORY
$1,416
$1,180
$2,034
$229
$1,402
$918
$1,544
$155
$182
$1,200
$872
$1,535
$149
$178
$219
$0 $500 $1,000 $1,500 $2,000 $2,500
Presenteeism
Absenteeism Days
Hospital Admissions
Emergency Room
Visits
Doctor Visits
Normal
Overweight
Obese
*
*
*
*
*
* P < .05
Source: Goetzel RZ, Gibson TB, Short ME, Chu BC, Waddell J, Bowen J, Lemon SC, Fernandez ID, Ozminkowski RJ, Wilson
MG, DeJoy DM. A multi-worksite analysis of the relationships among body mass index, medical utilization, and worker
productivity. J Occup Environ Med. 2010 Jan;52 Suppl 1:S52-8.
#GWICF2015

26. Worksite Health Promotion Works!
#GWICF2015

27. CDC Community Guide to Preventive Services
Review – AJPM, February 2010
86 Studies Reviewed
#GWICF2015

28. SUMMARY RESULTS AND TEAM CONSENSUS
Outcome
Body of
Evidence
Consistent
Results
Magnitude of
Effect Finding
Alcohol Use 9 Yes Variable Sufficient
Fruits & Vegetables
% Fat Intake
9
13
No
Yes
0.09 serving
-5.4%
Insufficient
Strong
% Change in Those
Physically Active
18 Yes +15.3 pct pt Sufficient
Tobacco Use
Prevalence
Cessation
23
11
Yes
Yes
–2.3 pct pt
+3.8 pct pt
Strong
Seat Belt Non-Use 10 Yes –27.6 pct pt Sufficient
#GWICF2015

29. Outcome
Body of
Evidence
Consistent
Results Magnitude of Effect Finding
Diastolic blood pressure
Systolic blood pressure
Risk prevalence
17
19
12
Yes
Yes
Yes
Diastolic:–1.8 mm Hq
Systolic:–2.6 mm Hg
–4.5 pct pt
Strong
BMI
Weight
% body fat
Risk prevalence
6
12
5
5
Yes
No
Yes
No
–0.5 pt BMI
–0.56 pounds
–2.2% body fat
–2.2% at risk
Insufficient
Total Cholesterol
HDL Cholesterol
Risk prevalence
19
8
11
Yes
No
Yes
–4.8 mg/dL (total)
+.94 mg/dL
–6.6 pct pt
Strong
Fitness 5 Yes Small Insufficient
SUMMARY RESULTS AND TEAM CONSENSUS
#GWICF2015

30. CDC Community Guide Obesity
Review
#GWICF2015

31. SUMMARY RESULTS AND TEAM CONSENSUS
Outcome
Body of
Evidence
Consistent
Results
Magnitude of
Effect Finding
Estimated Risk 15 Yes Moderate Sufficient
Healthcare Use 6 Yes Moderate Sufficient
Worker Productivity 10 Yes Moderate Strong
#GWICF2015

32. WHAT ABOUT ROI?
CRITICAL STEPS TO SUCCESS
Reduced Utilization
Risk Reduction
Behavior Change
Improved Attitudes
Increased Knowledge
Participation
Awareness
Financial ROI
#GWICF2015

33. HEALTH AFFAIRS ROI LITERATURE REVIEW
Baicker K, Cutler D, Song Z. Workplace Wellness Programs Can Generate
Savings. Health Aff (Millwood). 2010; 29(2). Published online 14 January 2010.
#GWICF2015

34. RESULTS - MEDICAL CARE COST SAVINGS
Description N Average ROI
Studies reporting costs and
savings
15 $3.37
Studies reporting savings only 7 Not Available
Studies with randomized or
matched control group
9 $3.36
Studies with non-randomized or
matched control group
6 $2.38
All studies examining medical
care savings
22 $3.27
#GWICF2015

35. RESULTS – ABSENTEEISM SAVINGS
Description N Average ROI
Studies reporting costs and
savings
12 $3.27
All studies examining
absenteeism savings
22 $2.73
#GWICF2015

36. The Dow Chemical Company
An Environmental
Obesity Prevention
Program at The Dow
Chemical Company
NHLBI: 5 R01 HL079546-05
#GWICF2015

37. • Quasi-experimental – treatment vs.
control/pre vs. post (3 data points –
baseline, year 1, year 2)
• 12 Dow Chemical Company worksites
received environmental/ecological
interventions at varying levels of intensity
• Intervention sites*: Texas (8) and
Louisiana (1)
• Control sites: New Jersey (1), West
Virginia (1), and Louisiana (1)
• Other Dow sites in US providing
benchmark/comparison data
The Dow LIGHTENUP Study
©2009 Google – Map Data ©2009 Tele Atlas
*One intense site was part of a business unit that was sold to another company. Data from this site were not included in any
process evaluations but were included in other evaluations.
#GWICF2015

38. The Dow Study - Interventions at All Sites #GWICF2015

39. The Dow Study - Interventions at High Intensity Sites #GWICF2015

40. The Dow Study: Health Behaviors (T1–T3):
High Risk Category
#GWICF2015

41. The Dow Study: Biometric Values (T1–T3) – Cohort Data
#GWICF2015

42. Consistent Improvement in
High-Priority Risk Since 2004
Baseline.
Between 2004 and September 2011
high priority risks:
• the average risk prevalence is
improving (see graph).
• a 22 percentage point (28%)
reduction in high risk people.
• a 23 percentage point (20%)
increase in low risk people in
these three categories.
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
2004 2005 2006 2007 2008 2009 2010 2011
Positive Trend in Targeted
Health Risks
BMI, Tobacco, Physical Activity
High Risk
Low Risk
AvgRiskPrevelance
DOW RESULTS: IMPROVING EMPLOYEE HEALTH
#GWICF2015

43. DOW RESULTS
• 2004 – 2011
– Saved over $120 Million in US healthcare costs
via Health Strategy
• In 2011
– 9% better health risk profile than comparison companies
– 17% fewer chronic health conditions
#GWICF2015

44. Identifying “Best Practices” in Workplace
Health Promotion: What Works?
Source: Goetzel RZ, Shechter D, Ozminkowski RJ, Reyes M, Marmet PF, Tabrizi M, Chung
Roemer E. Critical success factors to employer health and productivity management efforts:
Findings from a benchmarking study. Journal of Occupational and Environmental Medicine.
(2007) February; 49:2, 111-130.
#GWICF2015

45. What Is Needed to Achieve Success?
1. Leadership commitment
2. Specific goals and expectations
3. Healthy company culture
4. Employee driven program design
5. Excellent communication
6. Smart incentives
7. Effective screening and triage
8. State-of-the-art interventions
9. Effective implementation
10. Measurement and evaluation
#GWICF2015

46. Creating a…
#GWICF2015

47. Workplace Health Promotion Programs Work –
If You Do Them Right!
Financial
Outcomes
Health
Outcomes
QOL and
Productivity
Outcomes
Cost savings, return on
investment (ROI) and net
present value (NPV).
Where to find savings:
 Medical costs
 Absenteeism
 Short term disability
(STD)
 Safety/Workers’ Comp
 Presenteeism
 Adherence to evidence
based medicine.
 Behavior change, risk
reduction, health
improvement.
 Improved “functioning” and
productivity
 Attraction/retention –
employer of choice
 Employee engagement
 Corporate social
responsibility (CSR)
 Balanced scorecard
#GWICF2015

48. To watch Dr. Goetzel’s presentation online,
visit: www.icfi.com/ObesityPrevention-
RonGoetzel
#GWICF2015