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Accolade, Inc.
Affinia Group
American Council of Engineering Companies Life/Health Trust 
American Council on Exercise
American Heart Association
American Psychological Association
American Specialty Health
Aon Hewitt Consulting
BAE Systems Inc.
Barry-Wehmiller Companies, Inc.
Best Doctors
Blue Cross & Blue Shield of MA
Blue Cross & Blue Shield of MN
Boeing Company
Bravo Wellness, LLC
Central Michigan University
Corning Incorporated
Corporate Health Partners 
DTE Energy
Dow Chemical Company
Eastman Chemical Company
Engaged Health Solutions
Ergotron, Inc.
Findley Davies
Gardant Global Inc.
Goldman Sachs
Health to You
HealthSTAT, Inc.
Healthyroads, Inc.
Hennepin County HealthWorks
Hooper Holmes
Howard County Public School System
HUB International
Humana Vitality
INTEGRIS Health, Inc.
Intermountain Healthcare/Selecthealth
Interactive Health
Johnson & Johnson
Kaiser Permanente
Kimberly-Clark Corporation
Life Time Fitness
Lincoln Industries
LL Bean
Lockheed Martin
Lockton Companies
Marsh & McLennan Agency
MasterBrand Cabinets
Mayo Clinic
Medical Mutual of Ohio
MediFit Corporate Services
The MetroHealth System
MHN/Health Net
Michigan State University
National Academy of Sports Medicine
National Security Agency
NextEra Energy
Norton Healthcare
Ohio State University
Oklahoma State University
Onlife Health
Oregon Center for Applied Science
Performance pH
Preventure Inc.
Prudential Financial
Quest Diagnostics
RedBrick Health
Sanofi, US
Schwan Food Company
Shape Up
SeeChange Health Solutions
Spafinder Wellness, Inc.
St. Jospeh Health
State of Nebraska
StayWell Health Management
Target Corporation
Towers Watson
Truven Health Analytics
Tufts Health Plan
Universities Wellness Alliance of Kentucky
University of Alabama
University of Arizona
University of Iowa
University of Michigan
University of Minnesota
US Preventive Medicine
UPMC Health Plan
VAL Health
Vanderbilt University
Virgin Pulse
WebMD Health Services
Wells Fargo
Yale University

HERO Studies

The following information and abstracts provide information about published HERO EHM research.

Research Project Index: Click on any article to view an abstract
A Review of the Knowledge Base on Health Worksite Culture New Findings and Realistic Solutions to Employee Presenteeism
A Wake Up Call for Corporate America
Outcomes-Based Incentives: Joint Consensus Statement
Association Between Health Risks and Medical Expenditures
Phase II: Developing the Business Case - World Cafe Results: Role of Corporate America in Community Health and Wellness
Biometric Health Screening for Employers Presenteeism According to Health Behaviors, Physical Health, and Work Environment
Cardiovascular Risk Reductions Associated with Aggressive Lifestyle Modifications and Cardiac Rehabilitation The Predictive Validity of the HERO Scorecard in Determining Future Health Care Cost and Risk Trends
Creation of the HERO Database
Program Measurement and Evaluation Guide: Core Metrics for Employee Health Management
Effect of Lifestyle Modification and Cardiac Rehabilitation on Psychological Cardiovascular Disease Risk Factors and the Quality of Life Projecting Future Medical Care Costs Using Four Scenarios of Lifestyle Risk Rates
Environmental Scan: Measuring a Culture of Health The Relationship Between Modifiable Health Risks and Group-Level Health Care Expenditures
Environmental Scan: Role of Corporate America in Community Health & Wellness Self-Related Job Performance and Absenteeism According to Employee Engagement, Health Behaviors, and Physical Health
Evaluation of a Best-Practice Worksite Wellness Program in a Small-Employer Setting Using Selected Well-being Indicies

Ten Modifiable Health Risk Factors are Linked to More than One-fifth of Employer-Employee Health Care Spending

The Gender-Specific Effects of Modifiable Health Risk Factors on Coronary Heart Disease and Related Expenditures Toward an Employee Health Management Research Agenda:  What Are The Research Priorities?
The Impact of Worksite Wellness in a Small Business Setting  

Below is a chronological listing of articles (most recent first).  For an alphabetical listing see the table above.

Environmental Scan: Measuring a Culture of Health

The Robert Wood Johnson Foundation (RWJF) in the 2014 President's Message shared a vision "that striving toward a culture of health will help us realize our mission to improve the health and health care for all Americans." HERO has been sponsoring a "Culture of Health" Study Committee charged with providing guidance to members related to building cultures of health in their organizations. With support from RWJF, HERO has embarked on an initiative to enlist members and others with expertise in culture to produce and test definitions and measures of a culture of health with a focus on process metrics that will enable and incentivize employers to support communities in advancing health. This report represents the first phase of the initiative to better understand measures currently being used to assess the concept of a culture of health. (Contributors:  Cathy Baase, MD, Jennifer Flynn, MS, Ron Goetzel, PhD, Nico Pronk PhD, Paul Terry, PhD, John M. White, PhD) read this study

Program Measurement and Evaluation Guide: Core Metrics for Employee Health Management

A core set of metrics for the evaluation of employee health management programs. HERO and PHA are responding to employers who seek a greater level of clarity regarding the value of their wellness efforts. Thus, we recommend an initial set of measures to assess the impact of the health management programs offered to employees. The results are better informed business decisions and boardroom discussions.  HERO and PHA collaborated with more than 40 other organizations in developing the Program Measurement and Evaluation Guide. Virtually all industry segments were represented, including employers, health plans, program providers, academic research centers, and certification agencies.

(Contributors: Matt Damsker, Mercer; Michael Connor, DrPH, Alere Health; Edward Marc Framer, PhD, Health Fitness; Beth Umland, Mercer; David Anderson PhD, StayWell; Geoff Alexander, Onlife Health; Michael Brennan, MS, MBA, The Boeing Company; Jennifer Flynn, MS, Mayo Clinic; Jessica Grossmeier, PhD, MPH, StayWell; Ben Hamlin, NCQA; Iver A. Juster, MD, AcitveHealth Management; Gordon D. Kaplan, PhD, Alere Health; Adam Long, PhD, Health to You, LLC; Craig F. Nelson, DC, MS, American Specialty Health; LaVaughn Palma-Davis, MA, University of Michigan; Robert Palmer, PhD, MSN, RN, Alere Health; Prashant Srivastava, eVive Health; David Veroff, MPP, Health Dialog; Jerry Noyce Health Enhancement Research Organization; Karen Moseley, Population Health Alliance. Read the executive summary   Read the guide overview

Phase II: Developing the Business Case - World Cafe Results: Role of Corporate America in Community Health and Wellness

This report is the result of a one-day meeting of over 50 thought leaders representing Corporate America, Federal Government, Foundations, and Non-profit Organizations who all have a stake in the health of the nation. The meeting was sponsored by the Robert Wood Johnson Foundation. The convener of this project was the Health Enhancement Research Organization (HERO), a national leader in employee health management, research, education, policy, strategy, leadership and infrastructure (www.the-hero.org). Denise E. Stevens, Ph.D. of MATRIX Public Health Solutions, Inc. (www.matrixphs.com), an independent consultancy, summarized the results of this meeting and turned it into this report.  Read this article

Environmental Scan: Role of Corporate America in Community Health & Wellness

Although the U.S. spends more on health care than any other nation, 17.7% of its GDP (gross domestic product), the U.S. continues to lag behind other countries in terms of life expectancy (ranking 27th), and other health indicators (OECD, 2013). The inequities within the U.S. health care system are even more startling than those between nations, as the social determinants of health--neighborhood and built-environment, economic stability, education, and cultural community context-- are directly affecting health access and outcomes.

HERO has established the HERO Employer-Community Collaboration Committee (HECC Committee composed of 25 members representing a variety of business and foundation stakeholders).  The purpose of this committee is to develop a framework and report that presents a rationale for businesses to be involved in addressing population health at the community level and the role that business community plays or can play in this arena.

This report focused on establishing a baseline of current knowledge regarding the role and extent of involvement that corporate America has in population health efforts. The environmental scan includes the following: major stakeholders among businesses, coalitions/association, and foundations; review of key documents and resources; summary of the current state of affairs; and initial statement of the business case for corporate investment in community health improvement.

The phase one report, sponsored by the Roundtable on Population Health Improvement at the Institute of Medicine (IOM), is the first systematic attempt to document these efforts. Future phases will build on the knowledge gained from this study and include a dialogue session with key stakeholders and development of a Web resource for employers. (Author: Denise Stevens, PhD, contributors: Cathy Baase, MD, Nico Pronk, PhD, Jerry Noyce) Read this article

The Predictive Validity of the HERO Scorecard in Determining Future Health Care Cost and Risk Trends

Objective: To determine the ability of the Health Enhancement Research Organization (HERO) Scorecard to predict changes in health care expenditures.

Methods: Individual employee health care insurance claims data for 33 organizations completing the HERO Scorecard from 2009 to 2011 were linked to employer responses to the Scorecard. Organizations were dichotomized into "high" versus "low" scoring groups and health care cost trends were compared. A secondary analysis examined the tool's ability to predict health risk trends.

Results: "High" scorers experienced significant reductions in inflation-adjusted health care costs (averaging an annual trend of -1.6% over 3 years) compared with "low" scorers whose cost trend remained stable. The risk analysis was inconclusive because of the small number of employers scoring "low."

Conclusions: The HERO Scorecard predicts health care cost trends among employers. More research is needed to determine how well it predicts health risk trends for employees.

This research project is complete, peer-reviewed and is published in the February 2014, JOURNAL of OCCUPATIONAL and ENVIRONMENTAL MEDICINE (Goetzel, Ron Z. PhD; Henke, Rachel Mosher PhD; Benevent, Richele MS; Tabrizi, Maryam J. PhD, MS; Kent, Karen B. MPH; Smith, Kristyn J. BA; Roemer, Enid Chung PhD; Grossmeier, Jessica PhD, MPH; Mason, Shawn T. PhD; Gold, Daniel B. PhD; Noeldner, Steven P. PhD; Anderson, David R. PhD, LP)  Purchase this article

Biometric Health Screening for Employers

Employer wellness programs have grown rapidly in recent years with the interest in making an impact on employees’ health. Successful programs are delivered through comprehensive solutions that are linked to an organization’s business strategy and championed by senior leadership. Successful employee health management programs vary in the services, yet typically include the core components of health risk identification tools, behavior modification programs, educational programs, as well as changes to the workplace environment and culture. This article focuses on biometric screenings and was intended to provide employers and other stakeholders with information and guidance to help implement a successful screening program as part of an overall employee health management approach. The article is organized into four sections: goals and key success factors; methods and oversight; operations and delivery; and engagement and evaluation.

This research project is complete, peer-reviewed and published in the January 2013 issue of the JOURNAL of OCCUPATIONAL and ENVIRONMENTAL MEDICINE Chris Behling, AXA Equitable, HERO-CCA; Rebecca Kelly, University of Alabama, HERO; Jane Ruppert, Interactive Health, HERO; Laurie Whitsel, American Heart Association, HERO; Marissa Hudson, Viridian Health Management, HERO; Paul Terry, Staywell Health Management, HERO; Fred Goldstein, CCA; T. Warner Hudson, UCLA Health System-ACOEM; Pamela Hymel, Disney-ACOEM; Ron Loeppke, US Preventive Medicine-ACOEMHERO. The authors thank the following other contributors: Pamela Allweiss (ACOEM/CDC/ONDIEH/NCCDPHP); Dave Campbell, Bravo Wellness-HERO; Janice Gasaway, University of Michigan- HERO; Wendi Mader, Quest Diagnostics-HERO; Myrtho Montes, Prudential Financial-HERO; Jim Narum, Health Solutions-HERO; and Burt Wolder, Hooper Holmes-HERO  Read this article

Self-Rated Job Performance and Absenteeism According to Employee Engagement, Health Behaviors, and Physical Health

Objective: To better understand the combined influence of employee engagement, health behavior, and physical health on job performance and absenteeism. Methods: Analyses were based on 20,114 employees who completed the Healthways Well-Being Assessment from 2008 to 2010. Employees represented three geographically dispersed companies in the United States. Results: Employee engagement, health behavior, and physical health indices were simultaneously significantly associated with job performance and also with absenteeism. Employee engagement had a greater association with job performance than did the health behavior or physical health indices, whereas the physical health index was more strongly associated with absenteeism. Specific elements of the indices were evaluated for association with self-rated job performance and absenteeism. Conclusion: Efforts to improve worker productivity should take a holistic approach encompassing employee health improvement and engagement strategies.

This research project is complete, peer-reviewed and published in the January 2013 issue of the JOURNAL of OCCUPATIONAL and ENVIRONMENTAL MEDICINE (Merrill, Ray M. PhD, MPH; Aldana, Steven G. PhD; Pope, James E. MD; Anderson, David R. PhD, LP; Coberley, Carter R. PhD; Grossmeier, Jessica J. PhD; Whitmer, R. William MBA; HERO Research Study Subcommittee) Purchase this article

Ten Modifiable Health Risk Factors are Linked to More than One-fifth of Employer-Employee Health Care Spending

An underlying premise of the Affordable Care Act provisions that encourage employers to adopt health promotion programs is an association between workers’ modifiable health risks and increased health care costs. Employers, consultants, and vendors have cited risk-cost estimates developed in the 1990s and wondered whether they still hold true. Examining ten of these common health risk factors in a working population, we found that similar relationships between such risks and total medical costs documented in a widely cited study published in 1998 still hold. Based on our sample of 92,486 employees at seven organizations over an average of three years, $82,072,456, or 22.4 percent, of the $366,373,301 spent annually by the seven employers and their employees in the study was attributed to the ten risk factors studied. This amount was similar to almost a quarter of spending linked to risk factors (24.9 percent) in the 1998 study. High risk for depression remained most strongly  associated with increased per capita annual medical spending (48 percent, or $2,184, higher). High blood glucose, high blood pressure, and obesity were strongly related to increased health care costs (31.8 percent, 31.6 percent, and 27.4 percent higher,respectively), as were tobacco use, physical inactivity, and high stress. These findings indicate ongoing opportunities for well-designed and properly targeted employer-sponsored health promotion programs to produce substantial savings.

This research is copyrighted and published by HOPE/Health Affairs (Millwood):(2012) 31. NO.11 , Nov. 2012
Ron Z. Goetzel, PhD, Xiaofei Pei, Maryam J. Tabrizi, Rachel M. Henke, Niranjana Kowlessar, Craig F. Nelson, R. Douglas Metz

Purchase this article

New Findings and Realistic Solutions to Employee Presenteeism

Corporate financial statements and annual reports highlight the effects of the rising cost of employee health care. It has become a substantial budget item that must be carefully monitored and controlled. Because it is a tangible cost, benefits managers and chief financial officers tend to focus these efforts on controlling health care costs. Yet a much larger employee expense and management opportunity lurks in the shadows - on-the-job productivity losses resulting from employee health problems, also called presenteeism. This paper is complete and available here.

Presenteeism According to Health Behaviors, Physical Health, and Work Environment

The objective of this study is to identify the contribution that selected demographic characteristics, health behaviors, physical health outcomes, and workplace environmental factors have on presenteeism (on-the-job productivity loss attributed to poor health and other personal issues). Analyses are based on a cross-sectional survey administered to 3 geographically diverse US companies in 2010. Work-related factors had the greatest influence on presenteeism (eg, too much to do but not enough time to do it, insufficient technological support/resources). Personal problems and financial stress/concerns also contributed substantially to presenteeism. Factors with less contribution to presenteeism included physical limitations, depression or anxiety, inadequate job training, and problems with supervisors and coworkers. Presenteeism was greatest for those ages 30–49, women, separated/divorced/widowed employees, and those with a high school degree or some college. Clerical/office workers and service workers had higher presenteeism. Managers and professionals had the highest level of presenteeism related to having too much to do but too little time to do it, and transportation workers had the greatest presenteeism because of physical health limitations. Lowering presenteeism will require that employers have realistic expectations of workers, help workers prioritize, and provide sufficient technological support. Financial stress and concerns may warrant financial planning services. Health promotion interventions aimed at improving nutrition and physical and mental health also may contribute to reducing presenteeism.

This research is complete an published in Population Health Management Purchase this article
Ray M. Merrill, Steven G. Aldana, James E. Pope, David R. Anderson, Carter R. Coberley, and R. William Whitmer, and HERO Research Study Subcommittee

Toward an Employee Health Management Research Agenda:  What Are The Research Priorities?

As employee health management (EHM) programs continue to grow and mature, employers are increasingly interested in gaining a deeper understanding of contributing factors to EHM program success.  To lead in this effort, HERO has evaluated the current research, established new research priorities and created a strategic road map to guide our direction. This article will give you insight into the process HERO employed to determine what research priorities are most important to our members and the industry, consistent with the HERO mission.

This research is complete and published in AJHP The Art of Health Promotion Section: July/August 2012
David Anderson, PhD; Melondie Carter, DSN, RN; Kristi Rahrig Jenkins, PhD; Terry Karjalainen,PhD, R. William Whitmer, MBA purchase this article

Outcomes-Based Incentives: Joint Consensus Statement

This joint consensus statement is the combined effort of the members of HERO and the American Cancer Society, American Cancer Network, American Diabetes Association and American College of Occupational and Environmental Medicine.  HERO wishes to thank these associations for their thoughtful work and dedication to fulfilling our joint mission to provide guidance to employers on the design and implementation of outcomes-based incentives in their wellness programs. This should not be considered an endorsement of this approach, but rather as guidance for those who choose to implement such an approach. Find out more

 A Review of the Knowledge Base on Health Worksite Culture

Objective: To identify the need for worksite cultures of health, the organizational factors that support worksite cultures of health, the tools that have been used to measure worksite cultures of health, and the research needs related to healthy worksite culture.

Methods: A cross-sectional survey involving a sample of 500 companies representing a broad spectrum of industries and business sectors. A literature review was conducted.

Results: Similar to a culture of safety that encourages safer behaviors and enables a safer workplace, a culture of health provides a supportive work leadership with a favorable work environment and health-related policies that promote employee health and result in substantial decrease in employee health risks and medical costs.

Conclusion: Worksite policies and environments supporting a culture of health are important to helping employees adopt and maintain healthy behaviors.

This research project is complete, peer-reviewed and published in the April, 2012 issue of the JOURNAL of OCCUPATIONAL and ENVIRONMENTAL MEDICINE JOEM. volume 54, issue 4, p 414 - 419, Aldana, Steven G.; Anderson, David R.; Adams, Troy B.; Whitmer, R. William; Merrill, Ray M.; George, Victoria; Noyce, Jerry purchase this article

Evaluation of a Best-Practice Worksite Wellness Program in a Small-Employer Setting Using Selected Well-being Indices

Objective: To measure the effectiveness of a wellness program in a small company using four well-being indicators designed to measure dimensions of physical health, emotional health, healthy behavior, and basic access to health-related conditions and services.

Methods: Indicator scores were obtained and compared between Lincoln Industries employees and workers in the neighboring Lincoln/Omaha community during 2009.

Results: Nearly all Lincoln Industries employees participated in the wellness program. Physical health, mental health, and healthy behavior were significantly greater for Lincoln Industries employees. Self-perceived access to basic needs was not significantly greater among Lincoln Industries employees.

Conclusion: Well-being index scores provide evidence for the effectiveness of the wellness program in this small company setting with respect to better dimensions of physical health, emotional health, and healthy behavior than geographically similar work

This research project is complete, peer-reviewed and published in the April, 2011 issue of the JOURNAL of OCCUPATIONAL and ENVIRONMENTAL MEDICINE, volume 53 issue 4 (Merrill, Ray M. PhD, MPH; Aldana, Steven G. PhD; Pope, James E. MD; Anderson, David R. PhD, LP; Coberley, Carter R. PhD; Vyhlidal, Tonya P. MEd; Howe, Greg MS; Whitmer, R. William MBA) Purchase this article

The Impact of Worksite Wellness in a Small Business Setting

Objective: This study evaluates the level of participation and effectiveness of a worksite wellness program in a small business setting.

Methods: Three years of wellness participation and risk data from Lincoln Industries was analyzed.

Results: All Lincoln Industry employees participated in at least some level of wellness programming. Significant improvements in body fat, blood pressure, and flexibility were observed across time. The largest improvements in risk were seen among older employees and those with the highest baseline values.

Conclusions: This small business was able to improve the health of the entire workforce population by integrating wellness deeply into their culture and operations. Replication of this program in other small business settings could have a large impact on public health since 60 million adults in the United States work in small business.

This research project is complete, peer-reviewed and published in the Feb, 2011 issue of the JOURNAL of OCCUPATIONAL and ENVIRONMENTAL MEDICINE, volume 53, Issue 2 (Ray, M. Merrill, PhD, MPH; Steven G. Aldana, PhD; Tonya P. Vyhlidal, MEd; Howe, Greg, MS; David R. Anderson, PhD, LP; R. William Whitmer, MBA) Purchase this article

Effect of Lifestyle Modification and Cardiac Rehabilitation on Psychological Cardiovascular Disease Risk Factors and Quality of Life

A prospective and randomized research project to compare the effectiveness of the Ornish Program with traditional cardiac rehabilitation in reducing carotid artery media and intima thickness and a variety of other health parameters. A prospective, controlled and randomized evaluation of heart disease patients who agree to be randomized into either the Ornish or traditional cardiac rehabilitation programs. In addition to all the outcomes evaluated in the above research project, these study subjects also have carotid artery ultrafast-sonography to determine media and intima thickness (a direct measure of vascular disease.) This test will provide hard copy pictures of atherosclerotic (plaque) build up in the carotid artery. There is good evidence that the amount of plaque in the carotid artery corresponds to the plaque in coronary (heart) arteries. In addition, there will be blood analysis for homosystene (HCY), C-reactive protein, ferritin, and fibrinogen. The hypothesis states that those who are randomized and remain in the Ornish program will have less thickening or actual reduction in carotid artery thickness (reversal of cardiovascular disease) over time compared to the traditional rehabilitation group. 

This study was funded by the Midwest Center for Health and Healing, in Rockford IL. (Aldana, S, Whitmer, R., Greenlaw, R., et al). BEHAVIOR MODIFICATION.  Vol. 30, No 4, July 2006; 506-525)  Purchase this article

Cardiovascular Risk Reductions Associated With Aggressive Lifestyle Modification and Cardiac Rehabilitation

Patients who have been treated for coronary heart disease can enroll in traditional cardiac rehabilitation, the Ornish program, or no rehabilitation. No study has compared the impact of each on cardiovascular disease (CVD) risk factors.

This study compares CVD risk changes in post coronary bypass graft or percutaneous coronary intervention procedure patients who participated in the Ornish Heart Disease Reversing Program, a traditional cardiac rehabilitation program, and a control group that received no formal cardiac risk-reduction program. This was a longitudinal, observational study of 84 patients receiving CVD standard of care who elected to participate in one of the three study groups. Assessments of CVD risk factors and anginal severity were obtained at baseline, 3 months and 6 months.

Those patients participating in the Ornish program had significantly greater reductions in original frequency, body weight, body mass index, systolic blood pressure, total cholesterol, low-density lipoprotein cholesterol, glucose, dietary fat and increases in complex carbohydrates than were experienced in the traditional or control groups.

(Aldana S., Whitmer R., Greenlaw R., et.al) Heart & Lung (32) (6), Nov/Dec 2003; 374-381.) Purchase this article

A Wake Up Call for Corporate America: An Editorial Project

 In 2003, the cost per employee, for family health care coverage, when averaged across all plan designs was $9,068. Of this amount, the employer paid $6,656. If increases average a conservative 10% per year over the next several years, then in 2008, the cost per employee will be $14,601, with the employer paying $10,659 per employee. This assumes the current percent contribution between employer and employee remains constant. For most employers, this is a crisis situation, with little relief in site.

This invited editorial provides a detailed over-view of employer reactions to routine double digit annual increases in health care costs based on numerous published employer surveys. Commentary explores why there is little hope for moderation in health care costs: the baby boomers, the graying of America, escalating hospital charges and the obesity epidemic. The editorial documents that 50% - 70% of all diseases and medical problems are caused by life style choice: smoking, obesity, excess stress, lack of fitness, poor nutrition, lack of compliance in managing diabetes, hypertension, etc. The dichotomy of the health care cost crisis is that of the $1.8 trillion annual budget, less than 6% is devoted to prevention of all kinds, including attempts to influence lifestyle choices.

The editorial concludes, “A Wake-Up Call for Corporate America is that an employee health care cost crisis is here. If the employer assumes the responsibility to pay for the diagnosis and treatment of employee/dependent illness, then serious consideration must be given to the reallocation of existing investment in human capital funds. This redirection of funding should be toward health enhancement programs and services that optimize employee/dependent health, which can reduce health care use, moderate cost increases, reduce illness absence and improve work performance”.

(Whitmer R., Pelletier K., Anderson D., et.al) Journal of Occupational and Environmental Medicine (45) (9), Sept. 2003; 916-925.) Purchase this article

The Gender-Specific Effects of Modifiable Health Risk Factors on Coronary Heart Disease and Related Expenditures

This research project uses the HERO database. Of the 46,026 employees in the database 2,459 were diagnosed as having CAD through CPT and ICD-9-CM codes. This represents the study group.

A variety of risk factors, many of which are controllable through lifestyle changes, contribute to the probability of CAD and health care costs. The risks include: stress, smoking, obesity, hypertension, diabetes, lack of regular exercise, high cholesterol and family history.

While there is minimal data available on the comparative economical impact of risk factors on health care cost, there is even less when investigating this question based on gender. Because of this, the following questions are addressed:

  • Based on gender, what are the absolute and relative costs associated with each risk factor when treating patients with CAD? What are the differences across risk factors? Are there differences in costs when comparing males and females? If so, what are the differences?

  • Based on gender, what is the occurrence of CAD and hospitalization due to CAD? Are there differences when comparing males and females? If so, what are the differences?

  • Based on odds ratios, which risk factors are most prevalent among a group of employees with CAD? What is the rank order?

Among this large, multi-employer group of workers who completed a health risk appraisal (HRA), the difference between the occurrence of CAD between males (6.3%) and females (5.7%) was only 0.6%. Among males, smoking was the number one predictor of heart disease, while with women, profound obesity and uncontrolled stress were the prime predictors. There was no level of consistency between men and women relative to the association between health risks and costs. For example, men reporting to be depressed most of the time had total health care costs 91% more than men who reported not being depressed. Among women, those reporting to be depressed most of the time had health care costs only 5% more than those reporting not being depressed.

Behavioral change intervention application has usually been the same for men and women. If the intent is to provide interventions based on the potential for maximum reduction in medical costs, occurrence of CAD and hospitalization due to CAD, this study suggests different intervention goals between males and females may be appropriate.

This study was funded through grant number NAG-6218 from the National Aeronautics and Space Administration (NASA).  (Wasserman, J, Whitmer, R, Bazzarre, T, et. al., Jour Occup Env Med, (42)(11), November 2000; 973-985). Purchase this article

Projecting Future Medical Care Costs Using Four Scenarios of Lifestyle Risk Rates

This study uses the HERO database. Union Pacific Railroad (UPRR), like many others, has an aging workforce. Prudent financial planning mandates that future medical expenses be understood.

UPRR has a long history of providing and promoting aggressive health promotion programs. For this reason, they have a rich database of employee health risks and demographics. The objective was to adjust the HERO database to accurately reflect the demographic characteristics of the UPRR employee population. Multivariate statistical techniques were used to create models predicting health risk prevalence and expenditures based on information contained in the HERO database plus demographic characteristics, risk values and cost data provided by the UPRR database. Risk factors examined are: 1) alcohol consumption, 2) blood glucose, 3) blood pressure, 4) cholesterol, 5) nutrition, 6) fitness, 7) mental health, 8) tobacco use, 9) stress and 10) weight. Demographics included are: 1) age, 2) gender, 3) ethnicity and 4) job classification. These models will be used to estimate future health risks and expenditures.

In summary, the study indicates:

This study paper describes the development of an economic forecasting model to predict medical care expenditures assuming four different scenarios of population risk. The variables used to predict medical care expenditures are employee demographics and health risk profiles. Intermediate outcomes include health risk measures related to exercise patterns, body weight, eating habits, smoking, alcohol consumption, total cholesterol, blood glucose, blood pressure, stress and depression. Major outcome measures included projected total annual payments by UPRR for medical care services, for the decade following 1998. The UPRR work force is projected to grow by 500 employees per year over the ten-year study period. The average age is expected to increase form 44 to 48. The study reports that without further health promotion intervention, seven of the 11 risk factors assessed would likely worsen among UPRR’s work force. Medical care cost increases are projected to range from $22.2 million to $99.6 million in constant 1998 dollars over the next decade, depending on the effectiveness of risk factor modification programs. If UPRR is successful in reducing modifiable health risks 1% per year over a ten year period, the aggregate reduction in health care costs are projected to be 77.4 million With an expected health promotion budget averaging $1.9 million annually over ten years, health risks must decline at least 0.09% per year for the program to pay for itself.

This study was funded by and unrestricted grant from the Union Pacific Railroad.  (Leutzinger, J, Ozminkowski, R, Dunn, R, et. al. Am J Health Promot, (15)(1), Sept/Oct 2000; 35-44 Purchase this article

The Relationship Between Modifiable Health Risks and Group-Level Health Care Expenditures

This study uses the HERO database in which 46,026 employees met all inclusion criteria for the analysis. The purpose was to assess the relationship between modifiable health risks and total health care expenditures for a large group of employees. This study is different than Research Project Two which examined individual health care expenditures as the outcome. Here the outcome is the total cost impact of a given health risk.

Risk data were collected through voluntary participation in health risk assessments (HRA) and workplace biometric screening. These data were linked to health care plan enrollment and employee health care expenditures from employer’s fee-for-service health care plans over a six year period.

Several research questions were addressed:

  • What is the association between each of the eleven modifiable health risks and health care expenditures?
  • What percent of total health care expenditures are associated with each of the eleven modifiable risks?

It was found that employees with modifiable health risks were responsible for 25% total expenditures. Those employees who reported being under constant stress with no methods for coping were responsible for 7.9% of total health care costs. Being a former smoker was associated with 5.6% total medical expenditures followed by obesity at 4.1%. The association between risks and expenditures was estimated using a two-part regression model, controlling for demographics and other confounders. Risk prevalence data were used to estimated group-level impact of risks on expenditures.

This study was co-funded through an unrestricted grant from HERO and The StayWell Company.  (Anderson, D, Whitmer, R, Goetzel, R, et. al., Am J Health Promot, (15)(1), Sept/Oct 2000; 45-52). Purchase this article

Association Between Health Risks and Medical Expenditures

A medical economics study using the HERO database, that addresses two questions:

  • Do those at high risk have greater health care costs than those at lower risk? If so, what is the amount over time? What is the most expensive, what is number two, number three, and so on?
  • Do those with specific risk factor combinations have greater medical expenditures than those without these risks? If so, what is the amount over time?

This study was funded by a consortium of 22 HERO sustaining partners. Research design involves a retrospective, two-stage, multi-variate analysis, including logistic and linear regression models. This permits the examination of specific risk factors as independent variables, thus eliminating the impact of other risks. In addition to adjusting for specific risk factors, other confounding factors adjusted for were: gender, age, educational level, race, type of job, employer and number of months employees were followed after the first HRA was completed. Ten risk factors were evaluated, six self-reported and four biometric. The self-reported were: physical activity, alcohol consumption, nutrition, tobacco use, stress and depression. The biometric measurements were: cholesterol, blood pressure, blood glucose and weight.

Using the HERO database, research inclusion criteria were: active employees age 18 to 64 at the time of the first HRA and those who could be followed for at least six months after the completion of the first HRA. Based on this, there were 46,026 study subjects, all of whom completed a common HRA and were enrolled in fee-for-service health care plans. They were followed for up to three years after the completion of the first HRA.

It was found that those with self-reported, persistent depression (n=997, 2.2% of the study sample) had adjusted annual health care expenditures 70% greater than those who reported not being depressed. Number two was uncontrolled stress (n=8,641, 18%). These individuals had annual adjusted medical costs 46% greater than those who were not stressed. The third most costly risk was high blood glucose (n=2,271, 5%), with adjusted medical expenses 35% greater than those with normal blood glucose. The other most costly risks in descending adjusted order were: obesity (+21%), tobacco use (former +20%, current +15%), high blood pressure (+12%), and poor exercise habits (+10%). There was a dichotomy between the adjusted and unadjusted data relative to high cholesterol levels (n=8,641, 18%). Based on unadjusted data, health care costs were 17% greater than those with normal cholesterol levels, however, when adjusted, health care costs were 0.8% lower. Those at high risk for health problems due to excessive alcohol consumption (n=1,723, 4%) had adjusted health care expenditures 3% lower than those at lower risk. This is not unexpected, as those with drinking problems often avoid the health care system. In the case of nutrition, those who reported poor nutritional habits (n=9,278, 20%) had adjusted health care expenditures 9% lower than those who reported good nutritional habits. This finding was perplexing, because it is in contrary to the body of published nutrition research. It may be explained by the fact that the impact of all other risks usually associated with poor nutrition (obesity, hypertension, high cholesterol, high blood glucose) have been eliminated through the adjustment process.

The finding that psychosocial risks were the most costly was unexpected and medically newsworthy. This study suggests that sufficient attention should be directed toward worksite depression and stress screening along with the opportunity for adequate diagnosis and treatment.

This research project is complete, peer-reviewed and published in the October 1998 issue of the JOURNAL of OCCUPATIONAL and ENVIRONMENTAL MEDICINE (Goetzel, Anderson, Whitmer, et.al., JOEM, (40) (10). October 1998; 1-12). Purchase this article

Creation of The HERO Database

HERO has facilitated the creation of a large, retrospective, multi-employer health promotion research database. This was accomplished by collaboration among HERO, the StayWell Company, the MEDSTAT Group, and six large employers: Chevron Corporation, Health Trust, Inc., Hoffmann La Roche, Marriott Corporation and the states of Michigan and Tennessee. All employers are clients of The StayWell Company and The MEDSTAT Group. A top priority in the creation of the HERO database was the ability to examine the impact of risk factors, risk factor combinations and risk factor change on individual medical expenditures.

The HERO health promotion research database includes 47,500 employees, all of whom completed a common health risk appraisal (HRA), the StayWell Health Path®, and were enrolled in a fee-for-service, self-insured health care plan for the study period of 1990 to 1996. Approximately 12,000 of the employees completed two or more HRAs during this time. The HERO database was created by connecting the HRA data set with the medical claims data set along with the eligibility data set. Including the eligibility data permitted the inclusion of study subjects that had no medical claims. The confidentiality of individuals was maintained by scrambling personal identifiers across all data sources. The merging of these data sets yielded 113,963 person years experience. The previous largest research database of this kind is the Control Data - Milliman Robertson database which includes about 13,000 study subjects and provides approximately 40,000 person years experience.

Creation of the HERO database could have a major impact on the future of health promotion and disease management research. It is amenable to the design of numerous longitudinal research studies that examine the association or impact of single risk factors, risk factor combinations, risk factor change, selected chronic diseases and demographics on: medical costs, diagnosis, treatments, procedures, outcomes, hospitalization or any other parameter usually recorded in a typical fee-for-service medical claims database.

A consortium of 20 HERO sustaining partners funded the creation of the database. HERO is willing to facilitate research, using the database, for outside clients.

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