ROI from worksite wellness programs is difficult to measure, is generally positive, and varies widely by type of program. Most authorities quote a range of saving $3.50 - $5.00 for each dollar spent. A great buy, but employers tend to follow the lead of the C-suite - investing in wellness if leadership “Believes” in wellness, not investing if leadership are "Non-Believers".
But what about physician wellness visits? Are those a good buy?
Back in 2007, I attended a conference exploring the return on investment (ROI) of corporate health promotion programs. Margaret Sabin, who was CEO of the San Francisco area HMO Sutter Health, introduced her talk by asking:
“What is the right amount to spend on prevention”?
Ms. Sabin quickly admitted that nobody has the slightest idea. She discussed trying to get her HMO’s clients up to 2-4% of total spend, noting that most of them fell well below 0.5-1%.
So…what is the optimum amount for a health plan to spend on prevention, as a percent of total health care costs? Ever since Ms. Sabin’s talk, I’ve kept an eye out for answers.
Shortly after that conference, I became involved in a local project to create a new health plan - the Cornell Program for Healthy Living (CPHL). The concept was most unusual and very leading edge - a community collaboration between a self-insured employer, their third party administrator and the local community primary care physicians.
Insurance companies have historically kept a firewall between employers (the buyers) and physicians (the spenders). Anti-trust laws prohibit collusion between stakeholders, which generally serves the financial interests of insurance companies - they gain bargaining power by negotiating separately, seeking higher rates from employers and payment concessions from small isolated medical practices. CPHL broke from that mold.
Glossing over a great deal of work by many people from Cornell, Aetna and local health care providers, CPHL essentially became Aetna’s basic preferred provider (PPO) plan with the addition of the following benefits:
• Completion of a health risk assessment (our Sustainable Health Questionnaire, or SHQ),
• An Annual Wellness Visit with a primary care physician,
• In this visit, the physician should provide the employee-patient an interpretation of the SHQ,
• The visit can include a physical exam (e.g., women’s health exams)
• Up to 3 follow-up wellness visits during the year,
• An unlimited number of no-copay visits with a nutritionist, and
• A $15-a-month subsidy for membership in 3 local gyms (one being on-Campus).
Cornell has encouraged enrollment by making it their least expensive health plan in employee contributions, with no out-of-pocket expenses for any of these wellness benefits. Additional wellness benefits are covered, but not without a co-pay. CPHL was, for all practical purposes, compliant with the Affordable Care Act more than 2 years before that law was passed. There are no “sticks” to incent employees and beneficiaries. CPHL is a very kind-hearted and collaborative program that is all about offering “carrots” - to both employees/beneficiaries and to primary care doctors.
CPHL somewhat addresses Margaret Sabin’s question, because Cornell ‘grandfathered’ the standard PPO plan without the wellness benefits. While CPHL is not a randomized controlled trial of CPHL vs PPO, it is intriguing to compare aggregated de-identified data from a quality improvement perspective (an activity exempt from oversight of a Human Subjects Committee).
In the first few years, both claims and SHQ data left little doubt that early adopters were mostly “Believers” in wellness. But over time, this skewing (of healthier people in CPHL) diminished and the two plans have increasingly similar demographics.
In the PPO, costs for prevention activities supported by the US Preventive Services Task Force such as vaccinations, skin exams, mammograms, pap smears, etc., averages about 6% of total spend. CPHL adds to this by spending more on screening blood tests (for cholesterol and diabetes) used in the SHQ and wellness visits. How much more? About 5% more, raising CPHL’s spend on prevention to about 11% of the total dollars!
Despite almost doubling the spend on prevention, CPHL does not cost more per member per year (PMPY). It actually costs a few hundred dollars less. If CPHL were randomized controlled research, one would expect to resolve a statistically significant difference in costs of about $70 [my power estimate here assumes 2500 members in each plan, the control group would have $3500 in claims with a $1000 standard deviation, 80% power and a 5% probability of type 1 error]. So depending on the effect of skewing, the PMPY savings in CPHL may just be for real.
Cost growth in CPHL has essentially been nil (there has been some change in how Cornell calculates costs, but PMPY has not changed between 2010 and 2013). These data haven’t been statistically analyzed, but I’ve attended many health plan discussions (for CPHL and others), yet never heard anyone ask if cost differences are statistically significant. When it comes to money, higher is higher! By the way, have your health care costs grown recently?
And that’s not all. Quality-of-care is somewhat better in CPHL, as estimated by the percentage of patients who meet benchmarks for delivery-of-care (I don’t know of any CPHL metrics on health outcomes).
Admittedly, there are a lot of questions - CPHL is a real world health plan, not a randomized controlled trial; Ithaca, NY, is a college town, not a major metropolitan area and very unlike most rural communities. It is by no means clear that CPHL is a superior program. Still, in my opinion, through 6 years of experience it is most definitely not inferior.
The two biggest questions are:
• The amount of residual skewing of the plan populations, and
• Only modest effort has been spent on monitoring the nature of the wellness visits.
The program’s participating physicians derived a commonly-approved set of general guidelines for lifestyle recommendations, which we imbedded in the SHQ, but each PCP is free to counsel in his or her own way. In a controlled study, one would need to spend more energy on monitoring the interventions.
Nonetheless, 2 extremely provocative and important hypotheses emerge from CPHL:
1) Spending ~11% of total dollars on preventive services appears to not increase total costs, suggesting that the “right amount of spend” on prevention may be at least 10% (wow!), and
2) Spending an extra ~5% on wellness visits caused no obvious increase in PMPY costs, suggesting that savings elsewhere may offset these expenses in the very same year.
CPHL challenges general assumption that the cost of a wellness program must be recouped through averted health expenses in the future (in discounted dollars). An ROI calculation may be moot if the costs of Annual Wellness Visits are offset in the very same year by savings not spent on other claims. Such a program is, for all practical purposes, FREE (cost-neutral is probably how an accountant would express it). Any down-the-road savings on averted health costs would be the proverbial "icing on the cake".
The Choose Wisely campaign from the American Board of Internal Medicine says health maintenance visits are not a good buy, but that recommendation is based on studies designed to institute medical treatment in patients at increased risk. Projects like CPHL that included a wellness / lifestyle intervention were excluded from the meta-analysis in the Cochrane review that is the basis for the Choose Wisely recommendation.
CPHL is sufficiently innovative that there are not good data on embedding community-based primary care physicians as a collaboration central to an employee wellness benefit. Certainly, a PCP is a far more neutral advisor than is a health insurance company, an employer’s Human Resources office or an employer's company doctor. The innovation here is to break down the silos and collaborate with each giving their strengths.
The CPHL model needs to be examined in more rigorous research. But in a monetary analysis where higher is higher, shouldn’t everyone in the C-suite, Believer in wellness or Non-Believer, at least be interested in trying Annual Wellness Visits?
CPHL really does appear to serve up carrot cake, with icing, and everyone gets to enjoy his or her own piece. What are you waiting for, America? Have a piece of cake!
REFERENCES:
Baxter S, Sanderson K, Venn AJ, Blizzard CL, Palmer AJ. The relationship between return on investment and quality of study methodology in workplace health promotion programs. Am J Health Promot. 2014; 28:347–363.
Krogsbøll LT, Jørgensen KJ, Grønhøj Larsen C, Gøtzsche PC. General health checks in adults for reducing mor- bidity and mortality from disease. Cochrane Database of Systematic Reviews 2012, Issue 10. Art. No.: CD009009. DOI: 10.1002/14651858.CD009009.pub2
O’Donnell MP. What Is the ROI of Workplace Health Promotion? The Answer Just Got Simpler By Making the Question More Complicated. American Journal of Health Promotion: July/August 2014; 28(6), iv-v.
doi: http://dx.doi.org/10.4278/ajhp.28.6.iv
Personal communications: Paul Bursic and Veronica Banks, of Cornell; Ellen Rosa and Jean Falter, of Aetna.
Reid TR. The Healing of America: A Global Quest for Better, Cheaper, and Fairer Health Care. Penguin Press, London, 2010.
ISBN 978-0-14-311821-3
Sabin M. Put Me in (Charge) Coach!: Incentivized lifestyle, disease and medical management to improve employee health programs. Proceedings in Achieving Return on Investment for Wellness: Measuring and Quantifying the Value of Health Promotion and Worksite Wellness. World Research Group, October 23-25, 2006, San Diego, CA.
USPSTF A and B Recommendations. U.S. Preventive Services Task Force. October 2014.
http://www.uspreventiveservicestaskforce.org/Page/Name/uspstf-a-and-b-re...
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