I N F O R M A T I O N
S O L U T I O N S
Why is There a Need for Risk Reduction?
The Financial Burden of Cardiovascular Disease
Council of State Governments
Health Policy Forum on Cardiovascular Health and Wellness
Phoenix, Arizona
September, 2006
Ronald J. Ozminkowski, Ph.D.
Associate Director, Cornell University Institute for Health and Productivity Research and
Director, Health and Productivity Research, Thomson Medstat
Ron.Ozminkowski@Thomson.com
I N F O R M A T I O N
S O L U T I O N S
Agenda
• The cost burden of cardiovascular disease, relative to other conditions
– In the private sector
– In Medicaid
• The relationships between health risks and expenditures for
cardiovascular disease treatment
– The HERO – NASA study
• The cost savings of reducing health risks
• Lifestyle issues
– Tobacco use
– Obesity / heart disease / hypertension / diabetes
– Other health risks
• What can legislators do?
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I N F O R M A T I O N
S O L U T I O N S
The Burden of Heart Disease -- Top 10 High-Cost Physical Health
Conditions for Private Sector Employers in the U.S.
No other condition has a greater impact on the health of the workforce than cardiovascular
disorders.
1.
Coronary artery disease
6.
Back disorders
2.
GI disorders
7.
ENT disorders
3.
Hypertension
8.
Diabetes
4.
Vaginal deliveries
9.
Cerebrovascular disease
5.
Osteoarthritis
10. Gall bladder disease
What would this list look like for companies in your state?
What does it look like for your State Medicaid program?
-- Provide incentives to find out.
Ref: Goetzel RZ, Ozminkowski RJ, Meneades L, Stewart M, Schutt DC. Pharmaceuticals: Cost or Investment, Journal
of Occupational and Environmental Medicine, 2000;42(4): 338–351. See also Matson Koffman et al., Hearth Healthy
and Stroke Free, American Journal of Preventive Medicine, 2005;29(5S1): 113—121.
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I N F O R M A T I O N
S O L U T I O N S
How Much of the Cost Burden is Due to Each Cost Component?
Knowing this can help you figure out where to intervene.
$450
$400
$350
Presenteeism
STD
Absence
RX
ER
Outpatient
Inpatient
$250
$200
$150
$100
$50
M
ig
ra
in
e/
H
ea
da
R
ch
es
e
pi
ra
to
ry
In
fe
ct
io
ns
yp
er
te
ns
io
n
H
H
ea
rt
D
is
ea
se
D
ia
be
te
s
lln
es
s
s/
M
en
ta
lI
C
an
ce
r
A
ny
hm
a
D
ep
re
ss
io
n/
S
ad
ne
s
A
st
A
rth
rit
is
$-
A
lle
rg
y*
Annual Costs
$300
Source: Goetzel, Long, Ozminkowski, et al. JOEM, 2004; 46(4):398-412)
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I N F O R M A T I O N
S O L U T I O N S
Incremental Impact of Ten Modifiable Risk Factors on Medical Expenditures
(Need Your State’s Version of This)
Percent Difference in Medical Expenditures: High-Risk versus Lower-Risk Employees
100
Independent effects after adjustment
N = 46,026
70.2
46.3
50
34.8
21.4 19.7
25
14.5 11.7 10.4
-0.8 -3.0 -9.3
Eating
Alcohol
Cholesterol
Exercise
Blood pressure
Tobacco
Weight
Tobacco-Past
-50
Glucose
-25
Stress
0
Depression
Percent
75
Goetzel RZ, Anderson DR, Whitmer RW, Ozminkowski RJ, et al., The Relationship Between
Modifiable Health Risks and Health Care Expenditures. Journal of Occupational and
Environmental Medicine, 1998;40(10):843–854.
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I N F O R M A T I O N
S O L U T I O N S
The Gender-Specific Effects of Modifiable Health
Risk Factors on Coronary Artery Disease and
Related Expenditures
The HERO – NASA Study
Wasserman J, Whitmer RW, Bazzarre K, Kennedy S, Merrick N, Goetzel RZ, Dunn RL, and
Ozminkowski RJ, Journal of Occupational and Environmental Medicine, 2000; 43: 1060-1069..
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I N F O R M A T I O N
S O L U T I O N S
Purpose
• To determine the gender-specific association between coronary heart
disease (CHD) and:
–
–
the prevalence of modifiable health risks and
medical expenditures.
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I N F O R M A T I O N
S O L U T I O N S
Methods
•
ICD-9-CM/CPT-4 codes used to identify 2,452 employees with CHD
(Study Group) – 61 cases per 1,000
•
Study Group demographics: 66% male; 34% female; average age
of 43 years
•
Health risk data obtained from voluntary participation in employersponsored health risk appraisal (HRA) surveys and biometric
evaluations provided by clinicians
•
Descriptive and multivariate statistical techniques used to analyze
HERO database
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I N F O R M A T I O N
S O L U T I O N S
Results (1)
Table 1. Descriptive Analysis of Health Risk Status by CHD Status
CHD %
Non-CHD %
Sex*
Male
66.3
63.8
Female
33.7
36.2
Former Tobacco Use
41.3*
31.8
Sedentary Lifestyle
33.7*
26.3
High Cholesterol
29.1*
18.7
Obesity
28.8*
18.2
High Stress
24.2*
19.1
23.5*
19.4
High Blood Glucose
9.6*
4.6
High Blood Pressure
5.3*
3.7
Excessive Alcohol Use
4.5
4.1
Depression
2.7
2.3
Risk Factors
Current Tobacco Use
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I N F O R M A T I O N
S O L U T I O N S
Results (2)
Table 2. Health Risk Status by Gender
Males (n = 25,583)
Females (n = 14,416)
Former Tobacco Use*
(36.4%)
Sedentary Lifestyle
(32.9%)
Sedentary Lifestyle*
(23.2%)
High Stress
(25.2%)
High Cholesterol*
(21.1%)
Former Tobacco Use
(25.1%)
Current Tobacco Use
(19.9%)
Obesity
(21.3%)
Obesity*
(17.5%)
Current Tobacco Use
(19.1%)
High Stress*
(16.1%)
High Cholesterol
(16.1%)
High Blood Glucose*
(5.7%)
Depression
(3.4%)
Excess Alcohol Use*
(5.7%)
High Blood Glucose
(3.3%)
High Blood Pressure*
(4.5%)
High Blood Pressure
(2.6%)
Depression*
(1.7%)
Excessive Alcohol Use
(1.4%)
* Significantly different between genders - p < .05, 2
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I N F O R M A T I O N
S O L U T I O N S
Results (3)
Table 4: Predicted Annual Healthcare Expenditures (1996 dollars) for Persons
with CHD with Multiple Behavioral Risk Factors
Risk Category
Pooled
Males
Females
No Risk Factors
4,398
4,398
4,270
Tobacco + No Exercise + Stress + Obesity
10,057
11,242
7,819
All Above + Glucose + Depression
19,697
28,870
12,421
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I N F O R M A T I O N
S O L U T I O N S
Conclusions of HERO - NASA Study
•
People with CHD cost twice as much as people without.
•
Smoking, stress, poor exercise habits and obesity can double
the costs again.
•
Adding high blood sugar and depression quadruples the cost!
•
Obesity was most consistent predictor of CHD for males and
females
•
For those with CHD:
– Self-reported depression associated with the highest expenses
in males but not females
– High blood glucose was most costly risk factor among females
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I N F O R M A T I O N
S O L U T I O N S
Heart Disease Leads to Cost / Productivity / Quality of
Life Challenges
• Many of these problems begin with problematic health.
• Cost controls would therefore be more successful if problematic health
could be avoided.
– Need to measure and better understand risks for heart disease.
• Efforts to control costs have a better chance to succeed if considered
within a broader context of health promotion
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I N F O R M A T I O N
S O L U T I O N S
Let’s Talk About Health Promotion
• In our society, fewer than 2% of health care dollars are spent on
preventive services or health promotion.
• But if “an ounce of prevention is worth a pound of cure,” why don’t we
spend 16 times as much on prevention?
• Something is wrong with this picture!
– Legislators can help.
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I N F O R M A T I O N
S O L U T I O N S
What Can State Legislators Do?
• Promote health:
– Look for win-win scenarios to make employers, employees, beneficiaries,
and government better off
– Provide incentives to implement interventions that the private sector
would not normally undertake.
• These should be tailored for large, medium, and small employers
– Provide incentives for Medicaid beneficiaries to manage their heart
health.
• But support interventions that can start even before Medicaid
enrollment
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I N F O R M A T I O N
S O L U T I O N S
The State Government’s Role in Promoting Health
• Adapted from Gov. Mike Huckabee’s vision, and the National Governors
Association’s vision for a Healthy America
• Key elements:
– Coordinate activities across state agencies
• Generate a strategic plan to promote health and safety
• Make sure all agencies have their incentives aligned toward this plan.
– Partner with public health policy and research experts
• Learn from the literature and follow best practices
– Provide “senior management support” and be role models
– Promote wellness at work, and in the community
Source: Huckabee M. A vision for a healthier America: What the states can do. Health Affairs
25(4): 1005 – 1007, 2006
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I N F O R M A T I O N
S O L U T I O N S
Q: Where Should Incentives Be Applied?
A: At Every Phase
Phase IV
Measurement
Phase I
Diagnosis
Phase II
Strategic and
Tactical
Planning
Phase III
Intervention
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I N F O R M A T I O N
S O L U T I O N S
What Really Works?
• Tax undesirable behaviors
– Smoking
– Drinking
– Others …
• Provide incentives for “social marketing:”
– Ban smoking in public places
– Create limited smoking areas at work
– These may annoy some people ….
– But being annoyed to death is better than being cancered to death.
• In the latter case, we really die.
Source: Simon PA, Fielding JE, Pubic health and business: A partnership that makes cents. Health
Affairs 25(4):1029 – 1039, 2006.
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I N F O R M A T I O N
S O L U T I O N S
What Else Might Work?
• Consider additional tax incentives
– Should there be a “fat tax”?
• A study by Thomson Medstat in 2006 shows that most people do not
understand the consequences of poor nutritional habits and poor exercise
habits
– Consider reducing taxes or offering subsidies to employers who invest in hearthealthy employees
• Make worksites safe, walkable
– Provide price incentives to vendors to offer higher quality food at work and in
schools
– Reduce taxes or provide subsidies for employers and insurance companies who
offer plans that engage in substantially more preventive care that is designed to
reduce health risks and increase heart-health:
• Measure BP, cholesterol for at-risk people
• Treat more of them with high-quality medications
• Provide incentives for patient self-management
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I N F O R M A T I O N
S O L U T I O N S
What Will Work? Formative Research is Key to Find Out
• For another project funded by the NIH, Medstat and The Dow Chemical
Company are teaming with Cornell University and the University of Georgia to
design, implement, and evaluate environmentally-based interventions to
combat obesity.
• It was not clear which interventions would work best
• So formative research was conducted
– Surveys of key stakeholders to assess senior management commitment to healthy
lifestyles among employees
– Focus groups of employees (production staff, managers)
– Individual interviews
– Outside (UGA / Cornell’s) assessment of plant structure, cafeteria offerings, etc.,
that promote healthy activities
– Examinations of historical medical claims data, HRA, and absenteeism data
• Results can help decide which interventions are more likely to succeed, and
where.
• Companies may need government incentives to do this.
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I N F O R M A T I O N
S O L U T I O N S
Which Interventions Will Work in Your State?
• Most likely, a combination of individually-based and environmentally
based interventions would be useful.
• Provide incentive for companies to look at their data and conduct
formative research to find out
• Learn from best practices at other companies or in other State
Medicaid programs ….
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I N F O R M A T I O N
S O L U T I O N S
In Summary
• Set up incentives internally and externally (within and across state
government agencies) to promote health
• Use money and the power of the pulpit to influence behavior
– Increase taxes on undesirable behaviors
– Reduce taxes or provide subsidies to employers and individuals who
engage in healthier behavior
• Look for ways to collaborate with the private sector to generate good
ideas and test those ideas
– Evaluate, refocus, reload, and try again
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I N F O R M A T I O N
S O L U T I O N S
Conclusions
• Why is there a need to reduce the risks of heart disease?
– To improve health, quality of life, and save money
• Will risk reduction really work?
– “… when corporations, health plans, governments, and employees collectively
embrace comprehensive health and disease-prevention programs and services:
• “companies will have healthier employees, and
• save on the costs associated with health care, absenteeism, disability, and
lost productivity.”
Quoted from Matson Koffman, et al., Heart Healthy and Stroke Free, American Journal of Preventive Medicine,
2005;29(5S1): p. 121
• A health-focused state government will motivate a health-focused state
economy.
• Better health and monetary savings will follow.
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