September/October 2007

Emerging Trends in Health andProductivity Management

Ron Z. Goetzel, PhD, Ronald J. Ozminkowski, PhD, Kenneth R. Pelletier, PhD, MD,R. Douglas Metz, DC, and Larry S. Chapman, MPH

Setting the Stage

Health care costs in the United States continue to escalate,with no immediate attenuation in sight.1 At the same time,the prevalence of illnesses that are at least in part caused bymodifiable health risk factors and poor lifestyle habitscontinues to rise.2–5 Employers and insurance carriers thatmanage worker health benefits have struggled for decadesto find solutions to spiraling health care costs. Amongsolutions introduced in the past two decades are those thatinvolve certain policing or oversight activities, knowncollectively as managing health care (e.g., utilization review,precertification of services, case management, dischargeplanning); negotiating lower fees with providers of healthcare services; directing or channeling patients topreferred hospitals and doctors; designing benefit plans thatencourage use of certain services while discouraging use ofothers; and offering an array of carve-out benefits such asdisease management, self care, nurse lines, behavioralhealth care, and prescription drug benefit management.Although some of these strategies have been successful, tosome or to a large extent, none individually has producedsustained cost stabilization.6 For most payers, health carecosts continue to increase at alarming rates, and these costsare not aligned with growth patterns in other organizationalspending and general inflation.7

This paper reviews some of the trends in health care thathave been recently observed and our collective thinkingabout what may be in store for employers and payers overthe next 5 to 10 years. Our perspective is from theemployer or payer point of view, with particular emphasison employer efforts directed at worker health promotion

and disease prevention, otherwise referred to as wellness,health management, and health and productivitymanagement (HPM). In recent years, there has beenresurgence of interest in these programs, although in ourview employers are offered little guidance on how to bestdesign, implement, and evaluate such programs so that theycan deliver the greatest cost stabilization effects. Forexample, fewer than 7% of all employers offer programsthat embody all of the key criteria for successful riskmanagement.8 In addition, we observe some employers whostill believe that administering a health risk appraisal (HRA)by itself will produce significant health improvements andcost savings, in spite of the lack of evidence supporting thatview. Additionally, we are troubled by employer healthimprovement initiatives that are inadequately funded,leading to results that are both disappointing andprejudicial of any future investment.

In This IssueEmerging Trends in Health and Productivity Managementby Ron Z. Goetzel, PhD, Ronald J. Ozminkowski, PhD,Kenneth R. Pelletier, PhD, MD, R. Douglas Metz, DC, LarryS. Chapman, MPH . . . . . . . . . . . . . . . . . . . . . . . . . . . 1References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7Selected Abstracts . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8Closing Thoughts, by Larry S. Chapman . . . . . . . . . . 10

Editorial TeamEditor . . . . . . . . . . . . . . . . . . Larry S. Chapman, MPHPublisher . . . . . . . . . . . . . . . . . . . Michael P. O’Donnell,

PhD, MBA, MPH

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In this paper, we highlight some of the major trends thatwe have observed, comment on how these are likely toaffect HPM initiatives in the future, and present some ofthe implications of each trend for health promotionpractitioners.

Ten Emerging Trends in HPM

Trend #1: Current health care growth is unsustainablefor payers; employers are searching for new solutions.Experts estimate that, in 10 years, health care costs willdouble and will consume 20% of the U.S. gross domesticproduct.1 As we know, U.S. spending on health care is muchhigher than in any other industrialized nations, almost all ofwhich provide universal health coverage for their citizens.9

In the United States, major forces that drive large increasesin spending include an aging baby-boom population; therapid introduction of revolutionary, but often expensive,medical treatments; and worsening health habits of people,most notably large increases in the rates of populationweight gain and obesity over the past several decades.7

In the United States, about 160 million people go to workeach day.10 Most receive their health insurance from theiremployer, but the cost of providing these benefits isincreasing at rates two to four times greater than generalinflation.11 Consequently, employers are searching for newsolutions to health care cost inflation. A related concern isthe erosion of employer-sponsored health care benefits asmore employers, especially smaller ones, terminate healthcare coverage for their workers, thus shifting more of thecost burden to government.12

One solution being investigated extensively by employersis working collaboratively with insurers and nationalvendors to provide evidence-based HPM programs, a nextgeneration of worksite health promotion programming.13

This approach is especially attractive to small businessesthat generally lack the scale and resources to providecomprehensive, multi-component, locally based,customized programs at an affordable price.14

In addition, there has been more discussion in recentmonths about the possibility of introducing some sort ofuniversal or national health care system. This is likely to be

a major issue for the upcoming presidential election in2008. Whether some form of nationalized or universalhealth care will actually come to the fore in the next decaderemains doubtful, but these discussions may substantiallyinfluence whether or how employer-sponsored healthinsurance remains the linchpin for insurance coverage inthe United States.

The most significant implication for this trend on healthpromotion practitioners is that worksite and health planefforts for health promotion must more aggressively addressthe health status, health risk, and health care utilization–related factors associated with their target populations.Growth rates in per capita health care costs will likely beone of the most significant metrics expected to showresults by program sponsors. A second, related implicationof this unsustainable growth in health costs is that healthpromotion practitioners will need to stay aware of andhopefully influence health care reform activities to makesure that health promotion and disease prevention areadequately addressed in significant reform proposals.

Trend #2: Health improvement programs need todemonstrate that they improve health. As a start, HPMprograms need to document participation by, and healthimprovements for, their targeted populations. To measurehealth improvements, employers will need to assess healthrisks in the population periodically and to track improve-ments in employee health behaviors, biometric measures,and utilization of health care services. In order for HPMprograms to work, they need to actively engage a largesegment of the population. Recent research highlights theimportance of incentives, most often financial in nature, asnecessary to achieve meaningful program participation.15

Implications of this emerging trend for health promotionpractitioners include the increasing need for the establish-ment of measurement methods and for cost-efficient waysof creating ongoing valid measures of health status,health risk prevalence, readiness, self-efficacy, healthcare utilization patterns, care avoidance, and methods formeasuring work loss due to health conditions, oftenreferred to as presenteeism. Another important implicationis that the program interventions and strategies must beselected based on their actual effectiveness, requiringincreased skill levels for those who design and implementprograms.

Trend #3: Cost-effectiveness and cost-benefit analy-sis will assume larger roles in evaluating alternativehealthcare interventions and purchasing decisions.When employers and health plan executives consider theutility of HPM programs, improving health alone clearly isnot sufficient grounds for maintaining their investments.More generally, investors are seeking solutions thatsignificantly improve the efficiency of health care deliveryor produce improvements in productivity that enhancetheir financial bottom line. They are dissatisfied withaccounting solutions that simply move money aroundinstead of addressing the underlying causes of increasing

The Art of Health Promotion is published bi-monthly as partof the American Journal of Health Promotion, by the Amer-ican Journal of Health Promotion, Inc., 1120 Chester Ave-nue, Ste. 470, Cleveland, OH 44114. Annual subscriptions

to the combined publication are $99.95 for individuals, $119.95 forinstitutions in the United States, and $19 higher for Canada and Mexicoand $29 higher for Europe and other countries. Copyright 2005 byAmerican Journal of Health Promotion; all rights reserved. To ordera subscription, make address changes, or inquire about editorial content,contact the American Journal of Health Promotion, P.O. Box 15265,North Hollywood, CA 91615, Phone: 800-783-9913.

For information on submission of articles for The Art of Health Promotion,please contact the editor at 206-364-3448.

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costs. They want their employees to have better access tohigh quality care and to do so without breaking the bank.16

Today, employers are demanding better tools to assessthe cost-effectiveness of medical and health interventions.17

For example, when considering interventions to preventcardiovascular disease and diabetes, employers want toweigh the costs and potential benefit of alternativeapproaches, such as reducing copayments for heart attackprevention medications, building a state-of-the-art fitnesscenter, encouraging physical activity through walking clubs,providing one-on-one counseling for smoking cessation, orpaying for over-the-counter nicotine replacement therapy.Although these interventions are quite diverse and imposesignificantly different costs on employers, their relativeefficacy, cost-effectiveness, and cost-benefit are virtuallyunknown; employers need such information to makeinformed decisions about their spending.

The notion of delivering health improvement at areasonable cost is the crux of cost-effectiveness. Very fewnewly approved pharmaceuticals actually save money, butthey can improve health at a reasonable expense.18 In thepharmacy literature, net increases in spending up to$50,000 may be deemed acceptable (i.e., cost-effective) ifthese dollars will save at least one quality-adjusted year oflife.19 But this notion has rarely been used whenconsidering the value of health improvement programs.20

Rather, the more difficult-to-achieve objective of realizingnet savings has generally been required in evaluations ofHPM programs. As employers and payers realize thatinvestments in HPM are long-term in nature and thatthere may be a significant lag between improvementsin health and savings in medical expenditures orimprovements in productivity, the significance ofdocumenting cost-effectiveness may become more popular.This is more likely to occur if investments that yieldcost-effectiveness in the short run will lead to net costsavings in the intermediate and long run.

Especially noteworthy is the C. Everett Koop HealthProject, which has recognized and conferred honors forover a decade on companies that have been able todocument health improvements and cost savings fromtheir health improvement programs. Other notablerecognition awards are those offered by the Secretary ofHealth and Human Services (Innovation in Prevention), thePartnership for Prevention (Leading by Example), theWellness Councils of American (WELCOA Well Company),the American College of Occupational and EnvironmentalMedicine, the National Business Group on Health, and theInstitute for Health and Productivity Management.

The implications of this trend for health promotionpractitioners are numerous. First, program managers willcontinue to face substantial pressure to document their costsavings and to determine their program’s Return onInvestment (ROI). This will require increasing levels ofsophistication in program evaluation and collection of validand credible econometric measures. Second, differential or

incremental attribution of various interventions may bedemanded by decision-makers, leading to the need formore extensive data collection efforts and the use ofregression statistical techniques to attribute relative con-tributions among various interventions. A third implicationis that health promotion practitioners will need to becomemuch more comfortable addressing economic return issuesand understanding what factors influence health careutilization.

Trend #4: Many employers who provide healthimprovement programs continue to do so because theybelieve good healthcare positively affects employeeproductivity. Many employers, especially large ones,provide HPM services to their employees because theybelieve that health improvement programs and good,quality health care can increase worker productivity andorganizational effectiveness.21 Their view is that paying forquality health care and HPM programs is not just the cost ofdoing business, but rather an investment in human capital.

These forward-thinking employers are leveraging theirHPM programs to address productivity drains in theirorganization related to health (e.g., absenteeism, disability,on-the-job injuries, and presenteeism). As evaluations ofHPM programs become more sophisticated, programimpact estimates will expand to include productivitymeasures and their effects on ROI. This will require theability to link multiple sources of data to fully investigatethe impact of HPM programs.

The major implication of this trend for health promotionpractitioners is that it provides increased pressure forinterventions and measurements of the various productivityfactors. This is likely to require skill enhancements forpractitioners, particularly in the measurement of workproductivity. Ongoing data collection that enables theintegration of disparate data and the development of HPMdashboards is likely to be a second demand placed onprogram managers. A third implication is that practitionersare likely to be increasingly drawn into the discussions andactivities that surround group health care purchasingdecisions and how those issues play out with variousbeneficiary groups. This likely will have the effect ofplacing more emphasis on the level of familiarity of thehealth promotion practitioner with health care provision.

Trend #5: There is a move toward consumerism andgreater cost sharing, which holds consumers moreaccountable for health care decisions they make and thefinancial impact of those decisions. To hold down healthcare costs and to better involve patients in their health carepurchasing decisions, employers and health plans haveintroduced a wide variety of consumer-driven healthplan products.7 To take advantage of and effectively usethese products, consumers need simple, yet sophisticated,information systems so that they can make informeddecisions about their health care.

Consumer-driven programs are being introduced at thesame time that health illiteracy is emerging as a major

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concern for health providers, insurers, and employers. Thelack of easily accessible and readily understood healthinformation will limit the extent to which consumers canmake wise use of actionable information.22 New approachesto communication and dissemination are being developedthat may help improve health literacy and informeddecision-making. They include phone-based, virtual,self-help groups; Web-based groups; interactive videoprogramming; and phone interactions with trainedcoaches.23 Given the mammoth amount of information nowavailable about health care decision-making, the challengefor the industry is to make available salient information topatients and providers so that that information can beeffectively applied. Overcoming the information gap will becritical to the success of consumer-directed approaches, sothat these approaches do not result in penny-wise savings atthe expense of pound-foolish lapses in the use ofappropriate health services.

One implication of this trend for health promotionpractitioners is that they likely will be asked to help educateemployees and their family members in becoming wiserhealth care consumers with higher levels of self-efficacyabout health and health care decision-making. A secondimplication is that health promotion practitioners will alsoneed to become more skilled at dealing with health careutilization and consumerism in health care. A thirdimplication is that this change will also providepractitioners with more levers to use in affecting health careutilization, thereby potentially contributing to an increasedeconomic return and ROI from their efforts.

Trend #6: Pay-for-performance approaches arebecoming more common, as experts and providersreach agreement about what are the desired outcomesof care. There is a truism that what gets measured getsmanaged. As employers and health plans carefully definea set of key performance metrics for providers and rewardproviders for achieving certain benchmarks of care, qualityshould improve.7 In addition, as patients obtain betterquality care, efficiency of service delivery will improve andwaste should be reduced. For this to work, the rightoutcomes need to be defined (those that are evidence-basedand not just process measures), achievement of thoseoutcomes needs to be supported by health care deliverysystems, reporting of outcomes needs to be credible andtransparent, and the rewards for performance need to beattractive enough to get the attention of providers. On theother hand, insurance plans may decide to reducepayments, or stop payments altogether, for services that areinconsistent with best practices.

No major or significant implications for health promotionpractitioners appear associated with this observed trend.

Trend #7: Employers are looking more broadly attheir population-based health improvement efforts andare balancing the importance of interventions directedat individuals and those directed at their organizations.Employers are becoming increasingly aware that, to

improve the health and well-being of their employees, theyalso need to address organizational health issues. Inessence, they need to think about the organization asa patient also at risk. An organization is supportive ofindividual health improvement efforts when it providesenvironmental and ecological supports for a healthylifestyle.24 For example, a supportive work environmentis one that provides healthy food choices in cafeterias,stocks vending machines with nutritious snacks, requirescompany-sponsored meals to be healthy, providesopportunities for physical activity, has a campus-wideno-smoking policy, makes staircases attractive, and providesbenefit coverage for recommended preventive screenings.

An organizational culture of health or wellness needs topervade all levels of health improvement initiatives withinthe organization. Without a change in culture, individualhealth improvement programs may well be limited in theiroverall effectiveness.25

An implication for practitioners from this trend is thatgreater weight likely will be placed on interventions thataffect the entire organization and that are instrumental increating a healthy organizational culture. A relatedimplication is that an appropriate balance of attention andstaff time must be focused on making cultural ororganizational interventions along with individual, focusedinterventions. If 90% of employees complete an individualintervention such as an HRA, the concomitant effect isa cultural effect because of the large number of peopleaffected and the proclivity for people to share theirexperiences and scores.

Trend #8: Large-scale, federally funded studies likelywill exert a major influence on how the market viewshealth improvement within the context of health caredelivery. There are several large studies underway to testalternative HPM models. Examples include the Centers forMedicare and Medicaid Services’ Senior Risk ReductionDemonstration ,26 the National Heart Lung and BloodInstitute’s Obesity Management in the Workplace studies, 27

and the Centers for Disease Control and Prevention’s HealthProtection Research Initiative.28 HPM programs likely willbe favorably influenced by these ongoing and newly fundedresearch studies. Further, these studies will increase ourknowledge about the relative effectiveness of behavioralchange interventions and the manner in which theseprograms can be delivered most efficiently, for example bycomputer-based interactive programs, health coaching,specialized referrals, and financial incentives. The sciencesupporting behavior changes in such areas as improvingpharmacological compliance, weight loss, and smokingcessation is still evolving. Large-scale governmentresearch likely will inform future program design andimplementation.29

Armed with better and more practical data on whatworks, federal, state, and local governments can play a largerrole in disseminating information about evidence-basedprograms, with the expectation that such dissemination will

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prompt more employers to adopt them. Through legislativeor other initiatives, government agencies may also supportfinancial incentives (e.g., tax credits) to encourageemployers to implement effective programs.30

One implication for practitioners is the need to beaware of these studies, their interim and final results,and the effects of the results themselves on the design,implementation, and evaluation of their own programefforts. Another implication is the need for practitioners tounderstand the interplay of public policy on the adoptionand continuance of health improvement efforts, particularlyin worksite settings.

Trend #9: Information technology in the form ofpersonal health records (PHR), electronic medicalrecords (EMR), interconnectivity, Web-based healthimprovement programs, and information portals, willstrongly influence the efficiency of health care deliveryand health improvement efforts and will move themboth from a cottage industry to an interconnectedsystem with appropriate checks, reminders, oversight,reporting, and communication components. To promotestandardization, government will likely step in and proposePHR and EMR design consistency, implementation, anddissemination. The current proprietary models do notsupport system-wide interconnectivity. Standardized in-formation systems will enable the sharing of the most basichealth information (e.g., medical history, diagnostic testresults, and vital signs) to the most sophisticated (e.g.,nanotechnology-based, remote, biometric screening infor-mation).31

Similarly, health and disease-management vendors willstandardize and merge their offerings so that there is a truecontinuum of care that provides health promotion services tothe well population to keep them well and provides disease,demand, and case management services to individuals whoare at high risk for illness or are already ill to preventexacerbation of their illness. Seamless health managementis required for a sustainable healthcare system. Asignificant component of that system is integration of themulti-dimensional interventions that support the population,including disease management, utilization management,primary care delivery, and health improvement programs.Some HPM vendors have invested in new delivery modelsthat attempt to integrate wellness and disease-managementservices, and this is likely to continue.7

Nnanotechnology will permit ongoing, noninvasivemonitoring and telemetry of an array of vital signs,including heart rate and regularity, aerobic capacity,glucose/insulin levels, blood pressure, sleep patterns, stresslevels at the neurophysiological and hormonal levels, andother indicators of ongoing health status.32 Thus, theprocess of biometric screening, as applied by many HPMvendors or programs, may evolve substantially in thecoming years to take advantage of this new technology.Ongoing, in vivo information for self-care and for remotemonitoring of ongoing health or illness status may then

serve as the basis for developing, maintaining, or enhancingpersonalized risk-management interventions.

Superordinate to individual imaging technologies,biomonitors, nanotechnology, and more effectivebehavioral change will be a telemedicine delivery model.7

Computers, e-mail, cellular phones, and other evolvingwireless devices will create a convenience of access and usethat is known to be a major determinant of sustainedhealthy behavior. Such a telemedicine model may be morecost-effective than our current infrastructure (although thisis yet to be determined) and has the potential fordisseminating relevant, timely, and targeted healthinformation to patients and their health care providers.

Health improvement decisions will be influencedby advances in noninvasive imaging technologiesas well. Further development of functional MRIs, CTangiograms, virtual colonoscopy, and other noninvasiveimaging technologies will influence the targeting ofhealth-improvement interventions at the participant level.32

These provide clear and early evidence of major organ,circulatory, and central nervous system problems.

Today’s internet is a 1.0 version, and the introductionof Web 2.0 will transform the internet into an entirelynew, more interactive, highly personalized, self-careenvironment of major magnitude.33 This has positive andnegative features. For example, e-mail users are inundatedevery day with electronic junk mail and internet links toinformation about purported remedies for obesity or othermaladies or about easy ways to obtain low-cost prescriptiondrugs. Much of this information is unfiltered, misleading,and even dangerous. The ability to communicate moreefficiently has led to this downside of the informationage. Therefore, it will be a major challenge to the HPMindustry to address this problem by using evidence-based,yet highly individualized, interactive products andservices.

Advances in technology will also help integrate diseasemanagement with what actually happens in the usualtreatment process. Web 2.0 can help merge the delivery ofwellness and medical care, allowing users to engage inhighly individualized and personalized treatments thatfoster wellness-focused lifestyles.

The major implication of this emerging trend forhealth promotion practitioners is that it will require a muchmore robust set of skills surrounding integration ofinterventions and use of advanced technologies. Increasedpersonalization of interventions will require more extensiveknowledge of available resources and a more systematic riskstratification process that uses more highly integratedprogram infrastructures. Another implication is theneed to arrive at the right programming balance betweenthe high-tech and the high-touch facets of programming.

Trend #10: Health improvement programs willintegrate evidence-based integrative medicine into thestandard offerings. Employers are already beginning toincorporate evidence-based complementary and alter-

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native medicine (CAM) into an integrative medicineapproach to HPM.34 The integration of conventional andCAM interventions to promote optimal health will form thefoundation of comprehensive HPM programming.35

It is also likely that part of the increasing consumerism inhealth care will need to address how to make consumersmore knowledgeable about CAM services as well astraditional allopathic medical remedies. These skills mayhave many elements in common with the application ofconsumerism to health care decision-making and the use ofconventional health services.

One implication of this emerging trend is that healthpromotion practitioners will also need to become morefamiliar with CAM interventions and integrative medicine.This may include skills at being a wise and discerningconsumer of all forms of health care. Financial incentivesand disincentives are likely to influence use of theseservices over time. If there is true substitutability or perhapseven increased therapeutic or preventive value associatedwith a specific alternative care modality, then it becomesa clear set of decisions that can guide its inclusion in plandesign. Unfortunately, those situations are likely to be rare;therefore, the issues of what alternative services are coveredunder the health plan and how much cost-sharing isappropriate come into play.

Implications for HPM Vendors

We believe that the ten trends listed above will drive keyelements of employer-based HPM programs over the next 5to 10 years. Employers that aim to design and implementsuccessful HPM programs should seriously considerthese trends as they develop interventions for near-termimplementation. In addition to the implications for healthpromotion practitioners mentioned with the above tenemerging trends, the following implications in the form ofrecommendations targeted on HPM vendors are offered forconsideration.

1. Provide a solid evidence base for program services:This may require rigorous, randomized trials; well-conducted, quasi-experimental studies with matchedcomparison groups; or the use of sophisticatedstatistical approaches to demonstrate program effec-tiveness. Program providers may have to increase theirinvestment in evaluation technology to meet thisobjective.

2. Establish the appropriate program investment level:Determine in a rigorous, quantitative, and replicablefashion what the optimal level of investment is likely tobe for those who will pay for HPM programs. Provideanswers to questions about what is an appropriate cost-minimizing and health-maximizing level of investment.Help employers and health plans figure out intelli-gently how much to invest.

3. Focus on short term economic return strategies:Demonstrate that cost-effectiveness in the short run is

achievable and that cost-effectiveness may yieldpositive, net savings of dollars expended in the longrun. This may require that some contracts for servicesbe extended beyond the typical one to three year timehorizon. Offer incentives for beta-testing new ap-proaches to employers willing to engage in such pilots,so that rigorous studies of long-term impact can beconducted.

4. Support data integration: Offer consulting or dataintegration services that make it easier for employers tomerge disparate types of data from health riskappraisals, medical claims, productivity files (e.g.,absenteeism, disability, and workers’ compensationprogram files), employee-assistance programs, andquality-of-life surveys. This will allow more completeevaluations of program impacts to be conducted.

5. Rigorously evaluate consumer-directed health careprogram offerings: Use the results to refine programs,if necessary, to assure that programs save money in theshort run without sacrificing appropriate health serviceutilization in the long run. Utilize fully covered healthplan preventive services, and consider using incentivesfor individuals to stay current in their screeningactivities.

6. Provide tools for improved health care decision-making by consumers: Generate methods to helpconsumers better educate themselves about appropri-ate health care use and to allow them to fairly comparemultiple program offerings during open enrollmentseason.

7. Support innovative pay-for-performance strategies:Facilitate pay-for-performance approaches by offeringways to integrate HPM programs with traditionalcurative medical services.

8. Develop methods to help employers improve the workenvironment: For example, develop or enhancedistribution networks to help vendors offer healthiersnacks for vending machines or better cafeteria food.Offer consultation on where to set up walking trails andhow to monitor their use. Offer incentives to useexercise facilities in areas of the community nearworksites.

9. Be aware of the results of federally funded HPMstudies: Use results from the federally funded studies toincrease the evidence-base of HPM services.

10. Integrate your health improvement efforts with prima-ry care physicians: Offer services that office-basedmedical care providers (e.g., doctors, nurse practi-tioners) can use to motivate patients or to enhancepatient use of appropriate preventive services and toeducate patients about how to manage their diseases.

11. Promote integrative medicine approaches: Incorporaterigorously evaluated and evidence-based CAM ap-proaches into standard benefit-plan offerings.

12. Continuously examine the evidence for best practiceapproaches in HPM: Operate from the perspective that

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continual improvement is central to the long-termcontribution of what the field can provide. Constantlyexamine the best-practice aspects of current pro-gramming strategies, and work for improvements.

Conclusion

All of these emerging trends and the implications for healthpromotion practitioners inside and outside employersettings can be summarized with the idea that one canenhance the art of health promotion and HPM first byadvancing its science base. Program practitioners andvendors then may be in a position to build and to deliverproducts and services from this science base, leading to anincreased level of integrity and value in their offerings totheir customers and end users.

Ron Z. Goetzel, PhD, is Director, Institute for Health andProductivity Studies, Cornell University and also VicePresident, Consulting and National Practice, ThomsonHealthcare, Ronald J. Ozminkowski, PhD, is AssociateDirector, Institute for Health and Productivity Studies,Cornell University, and also Director, Health and Pro-ductivity Management Research, Thomson Healthcare,Kenneth R. Pelletier, PhD, MD(hc), is Clinical Professor ofMedicine, Department of Medicine, University of CaliforniaSchool of Medicine (UCSF) San Francisco and alsoUniversity of Arizona School of Medicine, R. Douglas Metz,DC, is Chief Health Services Officer, American SpecialtyHealth and Larry S. Chapman MPH, is Senior VicePresident, WebMD Health Services and Editor, The Art ofHealth Promotion.

Acknowledgment

This paper was funded by American Specialty Health. The authors would like to thankMaryam Tabrizi for her help in editing the final manuscript. The opinions expressed inthis paper are the authors’ and do not necessarily represent the opinions of ThomsonHealthcare, Cornell University, American Specialty Health, University of California SanFrancisco, University of Arizona, or WebMD.

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24. Jonas WB, Chez RA, Duffy B, Strand D. Investigating the impact of optimalhealing environments. Altern Ther Health Med. 2003;9(6):36–40.

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35. Astin JA, Pelletier KR, Marie A, Haskell WL. Complementary and alternativemedicine use among elderly persons: one-year analysis of a Blue Shield Medicaresupplement. J Gerontol A Biol Sci Med Sci. 2000;55(1):M4–9.

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Selected Abstracts:

Medical Costs and Productivity Lossesdue to Interpersonal and Self-DirectedViolence in the United States.

Corso PS, Mercy JA, Simon TR, Finkelstein EA, Miller TR.

BACKGROUND: Violence-related injuries, including suicide,adversely affect the health and welfare of all Americans throughpremature death, disability, medical costs, and lost productivity.Estimating the magnitude of the economic burden of violence iscritical for understanding the potential amount of resources thatcan be saved if cost-effective violence prevention efforts can bebroadly applied. From 2003 to 2005, the lifetime medical costsand productivity losses associated with medically treated injuriesdue to interpersonal and self-directed violence occurring in theUnited States in 2000 were assessed. METHODS: Severalnationally representative data sets were combined to estimate theincidence of fatal and nonfatal injuries due to violence. Unitmedical and productivity costs were computed and then multipliedby corresponding incidence estimates to yield total lifetime costs ofviolence-related injuries occurring in 2000. RESULTS: The totalcosts associated with nonfatal injuries and deaths due to violencein 2000 were more than $70 billion. Most of this cost ($64.4billion or 92%) was due to lost productivity. However, anestimated $5.6 billion was spent on medical care for the more than2.5 million injuries due to interpersonal and self-directed violence.CONCLUSIONS: The burden estimates reported here provideevidence of the large health and economic burden of violence-related injuries in the U.S. But the true burden is likely far greaterand the need for more research on violence surveillance andprevention are discussed.

Am J Prev Med. 2007;32:474–482.

Incidence and Lifetime Costs of Injuriesin the United States.

Corso P, Finkelstein E, Miller T, Fiebelkorn I, Zaloshnja E.

BACKGROUND: Standardized methodologies for assessing eco-nomic burden of injury at the national or international level do notexist. OBJECTIVE: To measure national incidence, medical costs,and productivity losses of medically treated injuries using the mostrecent data available in the United States, as a case study forsimilarly developed countries undertaking economic burdenanalyses. METHOD: The authors combined several data sets toestimate the incidence of fatal and non-fatal injuries in 2000. Theycomputed unit medical and productivity costs and multiplied thesecosts by corresponding incidence estimates to yield total lifetimecosts of injuries occurring in 2000. MAIN OUTCOME MEASURES:Incidence, medical costs, productivity losses, and total costs forinjuries stratified by age group, sex, and mechanism. RESULTS:More than 50 million Americans experienced a medically treatedinjury in 2000, resulting in lifetime costs of 406 billion dollars; 80billion dollars for medical treatment and 326 billion dollars forlost productivity. Males had a 20% higher rate of injury thanfemales. Injuries resulting from falls or being struck by/against anobject accounted for more than 44% of injuries. The rate ofmedically treated injuries declined by 15% from 1985 to 2000 inthe US. For those aged 0–44, the incidence rate of injuries

declined by more than 20%; while persons aged 75 and olderexperienced a 20% increase. CONCLUSIONS: These nationalburden estimates provide unequivocal evidence of the large healthand financial burden of injuries. This study can serve as a templatefor other countries or be used in intercountry comparisons.

Inj Prev. 2006 Aug;12:212–8.

Personalized Medicine: Elusive Dreamor Imminent Reality?

Lesko LJ.

The market for molecular diagnostic tests is predicted to grow atextraordinary rates over the next 10 years, fueled by pharmacoge-netics and the elusive dream of personalized medicine. Thechallenge is managing the expectations of the medical communityand the public at large that have already been set by speculation,promises, and the repeated exposure to headlines about geneticdiscoveries. Personalized medicine is a paradigm that exists more inconceptual terms than in reality, with only a few marketed drug-testcompanion products and not very many actual clinical practices setup to personalize medicine in the way that supporters haveintended. Nevertheless, the reality of personalized medicine hasbecome more imminent because of the increased awareness of theshortcomings in the delivery of drugs with adequate benefit/risk topatients, a better molecular understanding of how to optimize drugselection and dosing, and an increased demand for integrating moreclinically relevant genetic information into the drug developmentprocess to improve both innovation and productivity. This paperfocuses on personalized medicine by (1) looking at some convergingchanges taking place in the health-care landscape that are creatinga scientific and social infrastructure to enable personalizedmedicine, (2) considering challenges that need to be addressedwith regard to clinical evidence standards for validatinggenotype-phenotype associations, and (3) considering how clinicalpharmacology can help construct a rational personalized medicineframework. As therapeutic experts, clinical pharmacologists canwork to assure that ‘‘good therapeutics follows good diagnostics’’.They are well equipped to provide timely genetic education toothers and to interpret genetic data so that actionable decisions,especially about drug dosing in individual patients, can beimplemented in clinical practice.

Clin Pharmacol Ther. 2007;81:807–16.

Prevalence and Economic Implicationsof Chronic Pain.

Burgoyne DS.

Chronic pain is a major public health issue that affects the qualityof life and productivity. It is costly and has a significant impact onhealth resource utilization. Management of chronic pain requiresa multidisciplinary approach that focuses on disease managementand takes into account the need for ongoing support by familymembers and other caregivers. Managed care pharmacies can playan important role in pain management to effect positive outcomesand reduce health resource utilization.

Manag Care. 2007;16(Suppl 3):2–4.

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Consensus-based Findings andRecommendations for Estimating theCosts of Health-related ProductivityLoss from a Company’s Perspective.

Uegaki K, de Bruijne MC, Anema JR, van der Beek AJ, vanTulder MW, van Mechelen W.

OBJECTIVES: There were two study objectives: (i) to identify, viaconsensus, a key set of items for estimating the costs ofproductivity loss from a company’s perspective and (ii) to developrecommendations for the costs of estimating productivity loss onthe basis of consensus findings. METHODS: A modified Delphiprocedure was utilized in which a predetermined set of 26 itemsformed the basis for inquiry in the first round. Thirty-six expertsfrom five stakeholder groups in the Netherlands (employers,employees, policy makers and insurers, occupational healthprofessionals, and researchers) participated in the panel. Opinionswere sought regarding the relevance and retrievability of data onitems related to the following three forms of work loss: workpresenteeism (i.e., decreased work performance while at work),short-term absenteeism (,2 weeks), and long-term absenteeism(.2 weeks). The data were analyzed quantitatively and qualita-tively. The consensus for relevance was set at 70%. RESULTS:After two rounds, 4 items were found relevant for estimating thecosts of productivity loss due to work presenteeism, 6 items wererelevant for short-term absenteeism, and 11 items remained forlong-term absenteeism. The retrievability of data varied. Threesets of recommendations were formulated for estimating the costsof productivity loss from a company’s perspective. CONCLUSION:A streamlined set of relevant items has been identified viaconsensus and formulated into recommendations for estimatingthe costs of productivity loss from a company’s perspective.Although not definitive, these recommendations represent animportant step towards standardizing the way these costs areestimated, and, in turn, facilitate the comparability and utility ofeconomic evaluations of occupational health interventions.

Scand J Work Environ Health. 2007;33:122–30.

How Health Affects Small Business inSouth Africa.

Chao LW, Pauly MV.

Preventable and treatable diseases have taken a devastating humanand economic toll on many developing countries. That economic tollis likely to be underestimated because most studies focus onproductivity losses in the formal, or large-firm, sector; yet, a largeportion of the population of developing countries works in theinformal sector in very small businesses, either as an owner-workeror as an employee. It is plausible that ill health might affect smallbusinesses most severely, possibly putting the entire business at risk.This Issue Brief summarizes a three-year study that tracks smallbusinesses in Durban, South Africa, and investigates the connectionbetween the owner’s health and business growth, survival, or closure.The results bolster the economic case for investing resources in theprevention and treatment of disease in developing countries.

LDI Issue Brief. 2007;12:1–4.

Indirect Cost Burden of Migraine in theUnited States.

Hawkins K, Wang S, Rupnow MF.

OBJECTIVE: The purpose of this study was to determinethe indirect cost burden associated with migraine. METHODS:Data were obtained from Thomson-Medstat’s Health andProductivity Management (HPM) database for the 2002through 2003 calendar years. The migraine cohort wascomposed of patients who had a diagnosis of migraine ormigraine-specific abortive prescription medication, or both. Acontrol cohort of patients without migraine was matched topatients in the migraine cohort. The average annual indirectburden of illness (BOI) of migraine and a national indirect BOIwere estimated. RESULTS: Annual indirect expenditures weresignificantly higher in the migraine group compared with thecontrol group ($4453 vs $1619; P,0.001). The national annualindirect BOI, excluding presenteeism, was estimated to be $12billion (mostly attributed to absenteeism). CONCLUSIONS:Migraine imparts a substantial indirect cost burden. Projected toa national level, this amounts to an annual cost to US employers ofapproximately $12 billion.

J Occup Environ Med. 2007;49:368–74.

A Review of Methods to MeasureHealth-related Productivity Loss.

Mattke S, Balakrishnan A, Bergamo G, Newberry SJ.

BACKGROUND: Annual US health-related productivity losses areestimated to reach some $260 billion, attributable not only toabsenteeism but also to presenteeism (being present at work butworking at a reduced capacity). The search for remedies has beenhampered by the lack of accurate estimates of the loss ofproductivity and its true costs. To date, little effort has been madeto assess the availability of measurement instruments or thevalidity and reliability of those that exist. OBJECTIVES: Tosystematically review the instruments used to measure productivityloss and its costs and to assess limitations in current research.DESIGN: A systematic search was conducted of the published andgray-market research literature from 1995 through 2005 onmethods for estimating productivity loss and monetizing thatloss. RESULTS: Twenty survey instruments were identifiedthat assess the effect of health problems on absenteeism orpresenteeism by attempting to quantify self-perceived orcomparative impairment or by measuring unproductive worktime. Some of the methods have been validated. The challengesof measuring presenteeism far exceed those of measuringabsenteeism primarily because many jobs do not have easilymeasurable output. Methods to estimate the cost of lostproductivity were also identified; however, none have beenvalidated, to our knowledge. CONCLUSIONS: The greatestimpediment to estimating the cost of productivity lost to illness isthe lack of established and validated methods for monetization.The issues raised in this review are intended to stimulate futureresearch to validate and improve such methods.

Am J Manag Care. 2007;13:211–7.

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By Larry S. Chapman, MPH

Is Health and productivity manage-ment (HPM) here to stay? I believeso. However, there are, as usual,several factors that need to becarefully watched in arriving ata certain answer to the question. Iwould like to lay these factors out forthe reader:

1. HPM ultimately must be able tobe efficiently delivered to smallemployers and the self-employed:

Approximately 56% of the U.S. labor force works foremployers with fewer than 100 employees. Largeorganizations have pioneered the HPM approach, but canthese interventions be packaged, priced, and delivered tosmall employers and the self-employed? If we are not ableto accomplish this, then I believe it will significantly slowthe diffusion of HPM here and in other developed anddeveloping nations.

2. The metrics and evaluation of HPM have to beadministratively sustainable: The very strong case made inthis edition of The Art of Health Promotion for rigorous,credible, and efficient methods of data collection andanalysis has to be tempered by the administrativesustainability of such an effort. Can large, medium, andsmall employers utilize data collection techniques that canbe continued in the midst of the significant challengesimposed by the business cycle? Can we design and apply anannual risk stratification process that is non–work-invasive,low-cost, and yet valid? Can we conduct evaluationprocesses that provide meaningful formative feedback tolead to improvements in our future HPM efforts? I believewe can, but it will not be without significant compromises.

3. Organizational decision-makers must be rational intheir approach to HPM: The inherent assumption thatbusiness decision-making is entirely rational is questionable

at best. Decisions get made with rational and irrationalundercurrents. To the degree that human capital strategicdecisions are reached with rationale, HPM will likely grow.Many of the assumptions made by the authors arepredicated on a rational analysis of the information to makedecisions regarding investment in human capital. To thedegree that decision-making in HPM is based on a rationalprocess and confirmed facts, HPM will flourish.

4. HPM needs a sound program infrastructure andcontinuity of process and effort: To the degree thatemployers, health plans, and multiple employer trusts caninvest in a sound program infrastructure that can serve 100%of their beneficiaries and to the degree that an intentionalrisk stratification and intervention process is used each year,HPM will succeed. If HPM is simply a collection ofreductionist projects that serve a small percentage of thepopulation, it will not likely grow and multiply.

5. Employers must have a clear economic incentive toperform HPM: If the economic incentive associated withhealthy employees and family members is not clearlypresent then HPM will likely pass into oblivion. Employersare strongly influenced by economic factors; if there is noeconomic benefit to healthier employees, then why work sohard to improve the health of employees and familymembers? I believe this factor largely explains the ratherdismal pattern of worksite health efforts, or rather the lackof them, in most countries with some form of community-rated national health insurance or national health service.Take away the economic incentive, and we can say goodbyeto HPM.

To the extent that these factors are present andaccounted for, we are likely to see a robust, long-termpattern of growth to our HPM efforts.

Larry Chapman is the Editor of The Art of HealthPromotion.

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