Corporate Wellness. (Date and Instructor)

Corporate Wellness (Date and Instructor) 1

Welcome To Corporate Wellness Important Reminders Before We Begin Thank you for coming! Please sign roster now, and fill out all information This is the Corporate Wellness course for two credits You must be present for entire course to earn credit Sales and Internal Company Procedures cannot be used for CE credit Here is the course outline Let s begin! 2

Presented By: <Name> Title: Industry Experience: Education: License or Other Relevant Information: 3

Agenda The Need for Corporate Wellness Wellness Programs: Definition, Legal Implications & Essential Elements Efficacy & Case Studies Business Case & Implementation Incenting Participation & Measuring ROI 4

The Need for Corporate Wellness 5 5

Milestones in Contemporary America Hostess introduces Twinkies, 1953 Ray Kroc franchises the McDonald Brothers, 1955 And then introduces supersizing, 1993 6

Obesity Trends* Among U.S. Adults -- 1993 *BMI 30, or ~ 30 lbs overweight for 5 4 person No Data <10% 10% 14% 15% 19% 7

Obesity Trends* Among U.S. Adults -- 2006 2 (*BMI 30, or ~ 30 lbs. overweight for 5 4 person) No Data <10% 10% 14% 15% 19% 20% 24% 25% 29% 30% 8

A Weighty Toll on Employers Obesity costs U.S. companies $13 billion annually 3 These workers have 36% higher medical costs than fit employees 4 9

The High Cost of Smoking A smoker costs the employer $3856/yr in added healthcare costs and lost productivity 43 The overall prevalence of tobacco use is about 25% of the population, which can be generalized to any workplace population Calculating the cost of smoking: Assume a workplace with 100 employees Assume 25 employees use tobacco Result = $96,400/yr in business borne costs associated with smoking Because of this high cost, it is estimated more than 6,000 companies now refuse to hire smokers Alaska Airlines requires a nicotine test before hiring people Kalamazoo Valley Community College stopped hiring smokers for full-time positions Union Pacific won t hire smokers 10

The Cost of Poor Health Lost productivity related to absence & presenteeism compared to medical & pharmacy costs Presenteeism Lost Productivity 34% Absenteeism Lost Productivity 36% Medical Costs 25% STD/LTD/WC 5% IBI Research Insights, May 2007 - Single employer example 11

The Top 10 Most Costly Health Conditions Chronic disease has $1 TRILLION impact on U.S. lost productivity each year. 12 Goetzl, R; JOEM 45(1) 5-14 2003

Impact of Health Risk Factors on Risk Factors considered in study include: tobacco use, BMI <18.5 or >24.9; poor diet, physical inactivity, lack of emotional fulfillment, high stress, high blood pressure, high cholesterol, alcohol use, overdue preventive visits, and diabetes Mean Lost Productivity 30% 25% 20% 15% 10% Productivity Presenteeism Absenteeism 25.9% 6.3% 5% 0.0% 0% 0 risks 1 risk 2 risks 3 risks 4 risks 5 risks 6 risks 7 risks 8 risks Boles M, Pelletier B, Lynch W. The Relationship Between Health Risks and Work Productivity. JOEM, 2004; 46(7):737-745 13

Imagine If Your Customers Could Shave 25% Off Rising Health Care Costs 25% savings off of Rising Health Care Costs Annual employer health care cost per employee $10,000 $8,000 $6,000 $4,000 $2,000 $0 $7,379 $7,832 $6,348 $6,918 $5,162 $5,758 $1,587 $1,730 $1,845 $1,958 $4,320 $4,604 $1,080 $1,151 $1,291 $1,440 1999 2000 2001 2002 2003 2004 2005 2006 Year 14

Wellness Programs: Definition, Legal Implications & Essential Elements 15 15

Corporate Wellness Programs Defined Assess the health risks of an employee population Include customized and individualized programs and interventions to address the health and wellness needs of workers Track the participation, use and effectiveness of the program to provide quantitative feedback to employers Use quantitative results to evaluate the impact of wellness initiatives 16

Detailed List of Program Components 7 The employer s commitment to improve worker health and manage health plans, sick leave, workers compensation, disability and productivity costs Awareness An annual Health Assessment is the key in driving awareness and beginning participation in the program Education Content is packaged in engaging, easy to understand tools to make learning fun and tailored to adult learning styles Action A variety of activities help members practice and ultimately adopt healthy behaviors and earn points towards incentives Support Ongoing communication and progress tracking are key to long-term employee engagement Telephonic or face-to-face lifestyle coaching for those with risks Incentives to motivate participation and reward improved outcomes 17

Detailed List of Program Components Range of resources to help individuals change behaviors to improve health Structured opportunities to practice new behaviors and habits Integration of wellness throughout organization Organizational support for wellness; address environmental and cultural barriers Annual evaluation to refine program and improve it s effectiveness 18

Health Assessment Serves as a core measurement and intervention tool when combined with appropriate follow-up and referral Motivational messages reinforce positive behaviors and encourage modification of negative behaviors Health fairs: an ideal venue for health assessments Scores explained in detail in a fully personalized report that includes corrective actions Prioritizes individual s top 3 health risks 19

Research Says: Assessments Help Moderate Health Care Costs Multiple studies link health assessments with cost moderation8, 9, 10 University of Michigan research: As assessment scores increase, health care costs decrease 11 GM wellness program: Assessments linked with reduction of more than 185,000 specific health risks among GM workers 12 20

Making Sure Your Client s Program is Compliant What rules regulate wellness programs? HIPAA Nondiscrimination Rule HIPAA Privacy and Security Rules Americans With Disabilities Act (ADA) Age Discrimination in Employment Act (ADEA) COBRA Federal and State tax laws State lifestyle and nondiscrimination laws 21

HIPAA Nondiscrimination Rules Prohibit an employer from charging different premiums or contributions based on an employee s health factors (health status, medical condition, claims, disability) Prohibit different coinsurance, deductibles and copayments based on an employee s health factors unless done pursuant to a wellness program that meets the requirements set forth in the Rule However, a wellness program based on participation rather than satisfaction of a standard, result or outcome, does not violate HIPAA and is not subject to the requirements in the Rule For example, a blood screening program that is not based on outcomes: waiving copays for well-baby visits or prenatal care 22

An Outcome Based Wellness Plan is not considered Program discriminatory if all 5 requirements are met: 5 Requirements of the HIPAA Nondiscrimination Rule that must be met 1 The value of the reward must not exceed 20% of the total premium for an individual employee s health coverage (may be available to dependents 2 The program must be reasonably designed to promote good health or prevent disease 3 The program must allow employees to qualify at least once per year 4 The reward must be available to all similarly situated individuals and a reasonable alternative standard must be offered if the general standard cannot be met due to a medical condition 5 Plan materials must offer and clearly disclose the alternative standards 5 examples of compliance The total annual premium (employer and employee) for a single coverage under an employer s plan is $2,500 per year A wellness program offers a reward that waives the annual $250 deductible for the next plan year for participants who have a BMI of between 20 and 27 The BMI is determined shortly before the beginning of the calendar year and tested at the end of each plan year If a member cannot follow the walking schedule, he or she will be given the same discount if he or she implements a dietary regimen Materials state that participants who have medical conditions and for whom it would be unreasonable to attain the BMI standard will be given the same discount if the participants each walk for 20 minutes three days a week 23

Americans with Disabilities Act (ADA) ADA prohibits employment discrimination against individuals with a disability or those perceived as having a disability and limits the circumstances in which an employer may require physical exams or medical inquiries Wellness program participation should be voluntary Any medical information gathered in connection with the wellness program should be kept confidential and separate from the employee s personnel records and not used to discriminate against the employee 24

Efficacy & Case Studies 25 25

Numerous Studies Document Strong ROI A multitude of studies show ROI averages of $3 for every $1 invested 14 One recent study had the return as high as 10 to 1 15 Companies must be patient. Worksites typically don t realize returns until about three years into the program. If an organization is willing to wait two or three years, it will be capable of achieving this magnitude (3 to 1) of ROI. 16 A review of 32 studies found claims costs were reduced by 27.8%, physician visits by 16.5%, hospital admissions by 62.5%, disability costs by 34.4% and incidence of injury by 24.7% 17 26

Wellness Works, According to ROI Studies From a review of 73 published studies of worksite wellness programs 18 Average $3.50-to-$1 savings-to-cost ratio in reduced absenteeism and health care costs From a meta-review of 42 published studies of worksite wellness programs 19 Average 28% reduction in sick leave absenteeism Average 26% reduction in health care costs Average 30% reduction in workers compensation and disability management claims costs Average $5.93-to-$1 savings-to-cost ratio A comprehensive health management program at Citibank 20 $4.56-$4.73-to-$1 savings-to-cost ration in reduced total health care costs 27

Case Study: Citibank, N.A. 21, 22 Title Citibank Health Management Program Industry Banking/Finance Target Population 47.838 active employees eligible for medical benefits Description A comprehensive multi-component program that aims to help employees improve health behaviors, better manage chronic conditions and reduce demand for unnecessary and inappropriate health services, and in turn, reduce prevalence of preventable diseases and show significant cost savings and positive ROI. 28

Case Study: Citibank, N.A. Program Participation All 47,838 active employees were eligible to participate The participation rate was 54.3% Participants received a $10 credit toward Citibank s Choices benefit plan enrollment for the following year Approximately 3,000 employees participated in the high-risk program each year it was offered Program ROI Costs = $1.9 million Benefits = $8.9 million Savings = $7.0 million ROI = $4.7 in benefits for every $1 in costs 29

Additional Case Studies 23 Reynolds Electrical & Engineering Co. in Las Vegas 80% participation 21% lower lifestyle-related claims costs among participants Savings: $127.89 per participant Cost-benefit ratio: 1:1.68 Union Pacific Railroad Net savings of $1.26 million Voluntary program component: 1:1.57 cost-benefit ratio 45% in treatment lowered risk of high blood pressure, 34% reduced high cholesterol, 30% moved out of at-risk for weight, 21% stopped smoking Wisconsin School Districts Savings of as much as $4.75 for every $1 spent Even higher savings from group with nurse-line, self-care book and health ed materials 30

Business Case and Implementation 31 31

Defining Health Risks & Risk Levels 24 Health Risk Measure Alcohol High Risk Criteria > 14 drinks per week Blood Pressure Systolic >139 mmhg/diastolic >89 mmhg Body Weight BMI =/>27.5 Cholesterol Existing Medical Problem HDL Illness Days Life Satisfaction Perception of Health Physical Activity Safety Belt Usage Smoking Stress Overall Risk Levels Low Risk >239 mg/dl Heart, Cancer, Diabetes, Stroke <335 mg/dl >5 days last yr Partly or not satisfied Fair or Poor <1 time per week Using safety belts <100% of time Current smoker High 0 to 2 high risks Medium Risk High Risk 3 to 4 high risks 5 or more high risks 32

Linking higher Costs With Higher Health Risk 25 ($) $8,000 $7,000 $6,000 $5,000 $4,000 $3,000 $2,000 $1,000 $0 $4,530 $5,813 $7,123 $2,667 $3,364 $4,718 $2,110 $2,912 $3,894 $1,523 $2,081 $2,941 35-44 High Risk 45-54 55-64 35-44 Medium Risk 45-54 55-64 35-44 Non-Participant 45-54 55-64 35-44 Low Risk 45-54 55-64 Age Group 33

Average Annual Medical Costs Average Annual Disability Costs $6,000 $5,000 $4,000 $3,000 $2,000 $1,000 $0 $1,500 $1,000 $500 $0 As Health Risks Increase, So do Excess Costs Excess Costs Base Cost Low Risk (0-2 Risks) Excess Costs Base Cost Low Risk (0-2 Risks) N=685 $840 HRA Non- Participant $175 HRA Non- Participant N=4,649 $1,261 Medium Risk (3-4 Risks) $292 Medium Risk (3-4 Risks) N=520 $3,321 High Risk (5+ Risks) $757 High Risk (5+ Risks) N=366 Chart Sources: Medical: Edington. AJHP. 15(5):341-349, 2001; Disability: Wright, Beard, Edington. JOEM. 44(12):1126-1134, 2002 These represent the maximum savings opportunity if you moved people from High (6+ risks) to Low (0-2 risks) 34

Company Specifics Can Bolster Business Case Sample XYZ Company Summary Report Percentage of employees who: Have at least 1 coronary risk factor 75% Were rated poor for nutrition practices 70% Have high blood pressure 60% Smoke 57% Are 20% over their ideal body weight 40% Exercise Regularly 20% -There were 3 complicated pregnancies last year that cost the company $300,000 -The interest survey indicated that the majority of employees would like to participate in programs with their families, would like aerobics classes during the day and would like a weight control class at work. A few employees indicated they wish to quit smoking. -An additional survey showed that almost all managers were supportive of the proposed wellness program. It further indicated that managers would participate and encourage others to as well. 35

Implementing a Successful Wellness Program 36 36

What Doesn t Work Health Assessments alone Low budget, low intensity, low participation rates Programs that focus on what s in it for the organization, not the individual participant Under the radar initiatives NIH (not invented here) philosophy Huge incentives that would be better used for programming HERO Panel: EHM What Really Works? HERO Forum for Employee Health Management Solutions New Orleans, Louisiana -- October 2007 Ron Z. Goetzel, Ph.D. Cornell University and Thomson Medstat 37

Best Practice Criteria for Wellness Programs Employ features and incentives that are consistent with the organization s core mission, goals, operations, and administrative structures; Operate at multiple levels, simultaneously addressing individual, environmental, policy, and cultural factors in the organization; Target the most important health care issues among the employee population; Engage and tailor diverse components to the unique needs and concerns of individuals; Achieve high rates of engagement and participation, both in the short and long term; Achieve successful health outcomes, cost savings, and additional organizational objectives; and Are evaluated based upon clear definitions of success, as reflected in scorecards and metrics agreed upon by all relevant constituencies. 38

Best Practices - Implementation Key activities woven into the fabric of healthy behavior targets Healthy Behavior Targets Tobacco Cessation Weight management Physical Activity Nutrition Stress management Preventive Health Back Care Substance Abuse Activities Phone Coaching Internet Interactivity Print Communications Integration of all Touchpoints HRA with biometric assessment Discounts/Incentives Monthly Theme with Resources Physical Activity Program 39

Understand What Motivates Stimulate Interest and Make It Fun! Appeal to the majority of the population and the individual Implement a variety of communication formats Web, Phone, Paper, Onsite Periodically energize your program (walking challenges, onsite sessions, etc.) Customize incentive offering Obesity is Contagious so is losing weight and quitting smoking Leverage teamwork and accountability 40

Implementation: Indicators of Success Driven from the top CEO on down. Wellness champions in home office and field locations. Driven by participation in health assessments, company resources to help people maintain or improve health and an incentive program Concrete, measurable metrics e.g.: Achieve a 1:3 cost-benefit ROI, due to reduced claim costs Increase percentage of low-risk employees to at least 70% Hit 80% participation in program over any three-year period 41

Client Should Team With Provider Operating Plan Components to Craft Plan Overall goal of wellness program Clear, concise, measurable objectives, preferably based on assessment results Plan for evaluating progress against goals and objectives Implementation plan and timeline Itemized budget sufficient to implement program Technology now allows employers of all sizes an effective, wellness program at a low cost 42

Examples of Measurable Objectives Objective #1 To contain health care costs, we will decrease the number of employees with high blood pressure by 8 percent by the end of next fiscal year. Evaluation This objective will be evaluated by having participants complete a follow-up health assessment after the program to assess if risk levels have declined. The post-program data will be compared with previously collected baseline data. Objective #2 To contain health care costs, our company will reduce the number of ER visits by employees 10 percent using self-care materials by next mid-fiscal year. Evaluation A utilization review will be completed two years after concluding the program. 43

A Timeline for Member Communications WHEN CAMPAIGN COMMUNICATION 4 weeks prior to launch 2 weeks prior to launch Launch week 1 Week 3 Months 2-3 Receive employer CD, employee brochure, fliers and posters from Account Manager. Plan Administrator sends teaser e-mail. Account Manager presents wellness presentation to employees at enrollment meeting. Plan Administrator distributes wellness program fliers at enrollment meeting. Plan Administrator sends Health Assessment e-mail and hangs posters. Account Manager provides Health Assessment participation report. Plan Administrator sends Reminder Health Assessment e-mail, distributes fliers/stuffers and hangs posters. Qualified participants receive outreach from Health Coach to enroll in coaching program. Quarterly Month 6 2x during program year Periodically during year 2 weeks prior to each quarterly challenge, Plan Administrator sends pertinent Challenge e-mail, distributes fliers/stuffers and hangs posters. Participants receive e-mail reminder to take second Health Assessment. Plan Administrator sends Healthy Living Program/Online Seminar e-mail, hangs posters. Enrolled participants receive online behavior change program e-mails. 44

Health Assessment Signals Start of Program Questions about smoking, drinking and use of seatbelts, for example, give an indication as to what lifestyle risks an individual is taking all factors which affect their score and provide insight into developing health behavior change programs 45

Support for At-Risk Members Health assessment scores determine at-risk individuals. At-risk people should receive: Automatic notices reminding them to retake the assessment; E-mails containing links to articles and an individualized newsletter; Access to a nurse-line; A special e-mail invitation to join an online behavior change program; At-risk-plus individuals are invited to work with health coach 46

Reports Help Employers Track Progress and Spot Improvement Opportunities Risk Profiles Population-level distribution Risk factor by prevalence Risk level (low, medium, high) Risk Status Distribution Low (0-2 risks) Medium (3-4 risks) High (5+ risks) Risk Factors Distribution Weight Safety Belt Use 30% Stress 21% Blood Pressure 19% Use of Drugs 17% 41% Physical Activity 15% Low 62% Medium 25% High 13% Life Satisfaction Job Satisfaction 15% 11% Cigarette Smoking 10% Medical Problems 9% LOW RISK $2,051 MEDIUM RISK $2,634 HIGH RISK $6,548 Perceived Health 7% HDL Cholesterol 6% Top 3 Risk Factors 1 Body Weight 2 Safety Belt Use 3 Stress Alcohol Use 5% Personal Illness 5% Cholesterol 2% Age Risk 1% 0% 10% 20% 30% 40% 50% 47

Incenting Participation & Measuring ROI 48 48

Use of Wellness Incentives Has Risen Dramatically 28 70% 60% 50% Percent 40% 30% 20% 40% 60% 10% 0% 14% 1995 2004 2007 Year 49

Incentives Should Be Based on Carefully Considered Criteria Behavior and Participation No tobacco use since Jan. 1, or participation in tobacco cessation program during this time period Average 2x/week or more use of fitness facility, or completion of Web-based activity log, since Jan. 1. Biometrics Total cholesterol<200 mg/dl or at least a 10%reduction from previous score BMI<30 or at least an improvement of 3 points since last assessment, or participation in a weight management program or wellness coaching process 50

One Approach: Link Incentives to Plan Design 29 Meet any eight out of 10 wellness criteria and Employee receives $1,000 annual discount off health plan premium contribution, or Employee receives $1,000 of additional benefit credits for use in Section 125 Cafeteria Plan, or Employee receives $1,000 additional contribution in HSA Or, couple wellness incentives with full-replacement CDHP: Higher employer account deposits plus lower employee payroll deductions could make employee s cost for CDHP less than or equal to legacy PPO (Lowering deductibles could disqualify a HDHP for HSA purposes). 51

Cold Cash and Lower Payroll Deductions Are Most Appealing Wellness Incentives 30 60% 50% 40% Percent 30% 20% 51% 44% 10% 0% Reduced health insurance costs Cash 2% 3% A gift valued at $100 Other 52

Minimum Monthly $ to Incent Healthy Behavior 31 53

An ROI Formula 54

Evaluation Questions For a Broader View of ROI 32 Did the program meet its objectives? How much program activity actually reached people? How many people participated in the program? How many people completed the program? How did the users like the program? How did it affect them? What improvements in individual health or risk factors occurred? What effect did the program have on our organization? How much did the program cost? What was the net economic impact (i.e., cost-benefit ratio) of the program? How should the program change next year? 55

Data Sources for Evaluation Health assessments Biometric data (e.g., lab draws, blood pressure) Participation records Annual program evaluation surveys End-of-event evaluations (for specific wellness events such as health fairs) Ad hoc surveys Payroll and HR data Claims data 56

Year-Over-Year Changes in Results of Health Assessments An invaluable but often cost-prohibitive analysis Must be conducted as cohort study Documents statistically significant biometric and other changes in health status: Physical inactivity, including aerobic exercise and strength training Alcohol consumption Fat intake Cholesterol Blood pressure BMI Or, documents reduction in overall health risk to demonstrate value of investment 57

Case Study 58 58

Create a Company Culture of Health The power of social networking and team based health competitions Published in the New England Journal of Medicine, a recent Framingham study concluded that social networks can spread positive health behaviors. The authors wrote that weight loss interventions that provide peer support-that is, that modify the person s social network- are more successful than those that do not. People are connected, and so their health is connected. 1 A recent study conducted by Buck Consultants found that 81% of surveyed U.S. employers plan to offer a health competition program within the next three years. 2 1 The Spread of Obesity in a Large Social Network over 32 Years. Christakis, Nicholas A., etal. The New England Journal of Medicine 2007 2 Working Well: A Global Survey of Health Promotion and Workplace Wellness Studies. Buck Consultants, Oct.2007 59

Successful Behavior Change Through an Active Weight Management and Fitness Program Who are the players? A wellness company - offering a suite of turnkey solutions for small to midsize employers A Team Based Fitness Competition The Employer What was the problem? What was the solution? What were the results? Wellness programs can be scaled to benefit any size employer group resulting in reduced health claims, healthier, happier and more productive employees. 60

The Problem: The Client s Health Risks Client Metric 2005 200 6 2007 RTC* Indus try 201 0 Goal Obesity 67% 66% 62% 74% 65% 50% High Cholesterol 36% 34% 27% n/a 38% 25% High Blood Pressure 66% 64% 61% n/a 67% 55% Lack of Exercise 39% 29% 20% 61% 40% 15% Uses Tobacco 22% 20% 19% 31% 20% 15% *2007 Readiness To Change = Preparation and Action Stages 61

The Client s Wellness Plan Implemented Quarter Two Wellness Focus = Movement I. Main Program Team Based Fitness Program ( A 12 week healthy lifestyle program includes a significant weight-loss competition component,,scalable to any size employer group) II. Supporting programs Take the Stairs campaign, Walking Wednesdays Company sponsored races Driving participants back to wellness portal website for additional health and wellness information in the fitness and nutrition areas 62

The Solution: Client s Wellness Calendar Smoking Cessation Lifestyle Coaching Newsletter Weight Mgt Classes Q1 Focus Nutrition Q2 Focus Movement Q3 Focus Stress Management Lunch & Learns Q4 Focus Self-Care 5ADay Challenge Nutrition Scavenger Hunt Team Based Fitness Program My Stress Solution Desktop Yoga Health Assessment & Screening Guide to Self-Care Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec 63

Team Based Fitness Program Actual Goal Book of Business Teams 140 100 n/a Participants 47% (1235) Client s Results 40% 25% Retention 78% 80% 74% A strong marketing campaign, an engaged Wellness Committee and a strong incentive program allowed the client to exceed team based fitness company book of business for first time companies. 64

Client s Performance Cumulative Individual Weight loss 3,805 lbs 7.9 lbs BMI reduction 598 points 1.2 points Steps taken 328,668 mi 8,008 steps / day Exercise 49,613 hrs 44 min / day A 1- point BMI reduction is considered clinically significant and has been associated with a $202.30 annual reduction in medical claims and pharmaceutical costs per employee. 1 1 Association of Healthcare Costs with Per Unit Body Mass Index Increase. Wang et al. JOEM July 2006 65

A Call to Action A Duke University Medical Center analysis found that obese workers filed: 2x workers' compensation claims 7x higher medical costs from those claims 13 more days of work lost from work injury or work illness (than non-obese workers) 66

Questions 67 67

Next Steps Before you leave, please make sure you ve completely filled out and signed the roster- include all information Print legibly and include your full name, work address, work telephone number, name of company Complete the evaluation form You should receive your certificate within three weeks Thank you! 68

Footnotes 1. Behavioral Risk Factor Surveillance System, Centers for Disease Control, www.cdc.gov, 2006. 2. Ibid. 3. Ibid. 4. Grossman, Robert J., Countering a Weight Crisis, HR Magazine, March 2004, Vol. 49, No. 3. 5. Finkelstein et. al., Journal of Health Promotion, September 2005. 6. National Sleep Foundation, Sleep in America Poll, 2005. 7. Zengerle, Jason, Presenteeism, New York Times Magazine, Dec. 12, 2004. 8. Economic Costs of Obesity and Inactivity, Medicine and Science in Sports and Exercise, 1999. 9. American Physiological Association, 2004. 10. Mercer Human Resource Consulting, National Survey of Employer-Sponsored Health Plans, 2005. 11. IFTF, Center for Disease Control and Prevention, 2002 and 2003; Whitmer, R., Pelletier, K., Anderson, D., et. al., A Wake-up Call for Corporate America, Journal of Occupational and Environmental Medicine, September 2003. 12. TripleTree LLC, Health & Wellness: An Introduction to Health & Wellness With a Focus on Health & Productivity Management, Spotlight Report, 2005. 13. Ibid. 14. Edington, D.W., Emerging Research: A View From One Research Center, American Journal of Health Promotion, pp. 541-549, 2001. 15. University of Michigan Health Management Research Center, The Worksite Wellness Benefit Analysis and Report, pp. 7-15, 1979-2004. 16. Serxner, S.A., Gold, D.B., Grossmeier, J.J., Anderson, D.R., The Relationship Between Health Promotion Participation and Medical Costs, A Dose Response, Journal of Occupational and Environmental Medicine, pp. 1196-1200, 2005. 17. Yen, I., McDonald, T., Hirschland, D., Edington, D.W., Association Between Wellness Score From a Health Risk Appraisal and Prospective Medical Claim Costs, Journal of Occupational and Environmental Medicine, pp. 1049-1057, 2003. 18. Partnership for Prevention, Leading by Example, p. 19, 2005. 19. From TripleTree discussions and interview with Ron Goetzel, The Cost of Wellness, Wellness Councils of America, 2004. 20. Aldana, Steven; Merrill, Ray; Price, Kristine; Hardy, Aaron and Hager, Ron, Financial Impact of a Comprehensive Multisite Workplace Health Promotion Program, Preventive Medicine, pp. 131-137, 2005. 69

Footnotes 21. Ibid. 22. Aurora Healthcare, www.aurorahealthcare.org, as reported at http://tpm.scgov.net/roi.aspx, 2005. 23. Aldana, S.G., Financial Impact of Health Promotion Programs: A Comprehensive Review of the Literature, American Journal of Health Promotion, pp. 296-320, 2001. 24. Chapman, L.S., Meta-Evaluation of Worksite Health Promotion Economic Return Studies, The Art of Health Promotion, pp. 1-16, 2003. 25. Ozminkowski, R.J., Dunn, R.I., Goetzel, R.Z., Cantor, R.I., Murnane, J., Harrison, M., A Return on Investment Evaluation of CitiBank N.A. Health Management Program, American Journal of Health Promotion, pp. 31-43, 1999. 26. Chapman, L., Meta-Evaluation of Worksite Health Promotion Economic Return Studies, The Art of Health Promotion, American Journal of Health Promotion, July/August 2005. 27. Ozminkowski, R.J., Goetzel, R.Z., Smith, M.W., Cantor, R.I., Shaughnessy, A., Harrison, M., The Impact of the Citibank, N.A., Health Management Program on Changes in Employee Health Risks Over Time, Journal of Occupational and Environmental Medicine, pp. 502-511, 2000. 28. Op. cit., Ozminkowski, Dunn, Goetzel, Cantor, Murnane, Harrison. 29. Goetzel, R.Z., Ozminkowski, R.J., Bruno, J.A., Rutter, K.R., Isaac, F., Wang, S., The Long-Term Impact of Johnson & Johnson s Health and Wellness Program on Employee Health Risks, Journal of Occupational and Environmental Medicine, pp. 417-424, 2002. 30. Ozminkowski, R.J., Ling, D., Goetzel, R.Z., Bruno, J.A., Rutter, K.R., Isaac, F., Wang, S., Long-Term Impact of Johnson & Johnson s Health & Wellness Program on Health Care Utilization and Expenditures, Journal of Occupational and Environmental Medicine, pp. 21-29, 2002. 31. NutriScience Corp., www.nutrisciencecorp.com/health-roi.html, July 7, 2005. 32. Edington, D.W., University of Michigan Health Management Research Center, Lost Productivity, the High Cost of Doing Nothing, updated PowerPoint presentation of findings originally reported in 2001 edition of American Journal of Health Promotion and based on data drawn from nearly two dozen companies, with an eight- to 18-year time horizon, 2006. 33. Ibid. 34. Ibid. 35. Ibid. 36. Great-West Healthcare pricing data for wellness book of business and publicly available competitor pricing data, 2006. 37. Hewitt Associates LLC, Healthcare Expectations Survey, 2004. 38. Stolovitch, D., Clark, R.E., Condly, S.J., Incentives, Motivation and Workplace Performance: Research and Best Practices, 2002. 70

Footnotes 39. Chapman, L.S., Using Wellness Incentives: Carrots or Sticks? PowerPoint presentation, 2006 40. Great-West Healthcare, Consumer Attitudes Toward Health Care Survey, posted to www.greatwesthealthcare.com, 2006. 41. Ibid. 42. Chapman, Larry, Wellness Program Evaluation, PowerPoint presentation, 2006. 43. National Business Group on Health Wellness POWERED BY: 71