Barton Margoshes, MD Chief Medical Officer CIGNA Group Insurance 1 Health, Absence, & Productivity Trends and New Perspectives Atlanta Association of Health Underwriters May 13, 2005

2 Demographic Tsunami Aging Workforce + Chronic Diseases Increasing Medical + Disability Costs

3 Aging Workforce ● In 2010, 51% of labor force will be over 40  US Census Bureau ● In 2003, Americans aged 55 and older made up approximately 12% of the workforce - the highest percentage ever recorded  Bureau of Labor Statistics ● Aging labor force is expected to cause 37% increase in incidence of disability  JHA Factbook 2001

4 Chronic Conditions ● The five illnesses where costs increased the most were heart disease, asthma, mental disorders, cancer and hypertension  Health Affairs 8/04 ● “The highest rate of increase in medical and disability claims costs is among 30 to 39 year olds, and both are due to obesity.”  Helen Darling, president of the National Group on Health, a Washington, D.C. consortium of 208 large employers ● 26% of STD episodes involve a chronic illness and represents 52% of employee medical costs  CIGNA Study, 2004

5 Rising Medical Costs ● Factors fueling rising costs include:  Rapidly rising hospital unit costs  Prescription drug cost increases  Increasing consumer demand  Aging population Health care as a % of GDPEmployee contributions Source: John Hopkins Bloomberg School of Public Health Total cost = unit cost x utilization

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7 Disability Costs ● 33% of employers reported in a National survey that short-term disability incidence rates increased while only 10% reported a decrease in incidence rates ● Employers responding to the survey also cited certain disability conditions as increasing in cost or frequency (ranked from high to low):  stress or depression (70%);  cancer (60%);  low back pain (57%);  upper extremity repetitive trauma, such as carpal tunnel syndrome (55%);  other musculoskeletal issues (52%); and  respiratory conditions (37%) Survey of Employers' Time-Off and Disability Programs by Mercer Human Resource Consulting and Marsh Inc.

8 Source: Department of Labor Individuals Receiving LTD Increased 62% from

9 The Aging Workforce & Lifestyle Health Risks Correlate with Short Term Disability ● Risk factors studied:  Age  High blood pressure  High cholesterol  Diabetes  Family history of heart disease  Obesity  Tobacco use  Lack of exercise Source: Wayne Burton, M.D., IHPM North American Summit Meeting 2000

10 Employer Costs of Lost (% of Payroll) DirectIndirectTotal AON4-6%8-12%12-18% Towers Perrin8-12%4-6%12-18% Watson Wyatt6.1%2-4x direct costs12-30% Mercer4.4%.5-4x direct costs 7-22% The Impact of Lost Productivity ● Average $6,000 Per Employee Per Year ● Averages 15% Of Payroll Direct Premium Costs – Only 1-2% of payroll

11 Presenteeism According to studies at Cornell University 60% of the total cost of worker illness stems from”on-the-job productivity losses” also known as “presenteeism” exceeding what companies spend on medical and disability benefits and sick days. The biggest productivity drains are headaches, allergies, and arthritis. Research shows the average U.S. employee loses 115 productive hours each year to health conditions, costing employers an estimated $2,000 per worker per year.

12 Integrated Health & Productivity Management Model ● Holistic approach to optimize a company’s human capital – investment in an employer’s people ● Addresses presenteeism, lost time, and employee health to lower costs and increase productivity ● Health related systems involved include :  Healthcare  Incidental absence & FMLA  Short and long term disability  Behavioral health  Pharmacy  Wellness and disease management  Workers’ compensation

13 Non Health Related Systems involved in a HPM Model  Corporate Culture  Policies and Procedures  Benefit plan designs  Alignment of incentives  Training and human resources  Employee communication  Data Integration

14 Integration Rationale ● The ultimate health outcome is return to work and productivity BUT return to work is not a traditional healthcare outcome ● There is inherent fragmentation within the healthcare and disability system  Healthcare controls cost and quality through appropriate medical utilization and medical necessity  Disability management controls cost and quality through matching functional ability and functional demands of the job ● Integration helps employers measure and manage the total cost of benefits

15 Integration is not just for large employers Interest in Linking Benefits by Employer Size The Workplace Path to Productivity and Health, Integrated Benefits Institute 2004

16 Goals of HPM Strategy The Workplace Path to Productivity and Health, Integrated Benefits Institute 2004

17 CIGNA’s Disability & Healthcare Connect ● A comprehensive and integrated approach for controlling quality and cost outcomes of a disability event ● Key components include:  Proactive pre-disability outreach  Coordinated disability and medical case management  Referral to disease management services  EAP assessment and referral ● Common philosophy, linked processes and technology

18 Key Study Findings ● Short term disability (STD) durations and return to work percentages are consistently better for claimants having both CIGNA Disability and CIGNA HealthCare ● 20% of employees were responsible for 91% of employee medical costs ● Employees on short term disability represented only 5% of employees, but were responsible for 35% of employee medical costs ● Behavioral health conditions associated with a medically related disability result in poorer outcomes (durations 28% longer; incidence rate 7% greater)

19 Key Study Findings (continued) ● Most of the top cost drivers are the same for both disability and medical ● Disability claimants with chronic conditions experience longer durations whether or not the disability was primarily due to the chronic condition ● Employees engaged in WellAware’s (disease management) Cardiovascular Disease and Low Back Pain programs experience shorter disability durations & lower incidence of short term disability

20 12% Shorter STD Durations 6% Higher Return to Work Rates 0% 5% 10% 15% 20% Solutions that Address Both Medical and Disability Cost Drivers Have a Greater Impact Proven Results Claimants with both a CIGNA STD and a CIGNA HealthCare claim have:

21 Average Medical & Disability Costs for Employees

22 Disease Management Reduces Both Medical and Disability Costs Condition Admission Rate Reduction Medical Cost Savings Disability Incidence Rate Reduction Disability Duration Reduction Cardiac4.0%13.0%3.0%7.7% Low Back2.2%12.0%1.0%18.0% Disease Management

23 Disease Management Reduces Costs Average Medical & Disability Costs for Employees

24 Summary ● Healthcare and disability costs will continue to escalate due to demographic trends ● Aging, chronic diseases, and mental health are inter-related and will have an adverse effect on employers profitability and competitive advantage ● Employers need to consider the total cost of care (healthcare + disability + lost productivity) ● Investing in an employer’s human capital through wellness, disease management, quality healthcare, and integrated disability makes business sense

25 Questions