1. INFORMATION SOLUTIONS Why is There a Need for Risk Reduction? The Financial Burden of Cardiovascular Disease Council of State Governments Health Policy Forum on Cardiovascular Health and Wellness Phoenix, Arizona September, 2006 Ronald J. Ozminkowski, Ph.D. Associate Director, Cornell University Institute for Health and Productivity Research and Director, Health and Productivity Research, Thomson Medstat Ron.Ozminkowski@Thomson.com

2. Copyright 2005 Thomson Medstat 2 INFORMATION SOLUTIONS Agenda The cost burden of cardiovascular disease, relative to other conditions –In the private sector –In Medicaid The relationships between health risks and expenditures for cardiovascular disease treatment –The HERO – NASA study The cost savings of reducing health risks Lifestyle issues –Tobacco use –Obesity / heart disease / hypertension / diabetes –Other health risks What can legislators do?

3. Copyright 2005 Thomson Medstat 3 INFORMATION SOLUTIONS The Burden of Heart Disease -- Top 10 High-Cost Physical Health Conditions for Private Sector Employers in the U.S. No other condition has a greater impact on the health of the workforce than cardiovascular disorders. 1.Coronary artery disease 2.GI disorders 3.Hypertension 4.Vaginal deliveries 5.Osteoarthritis What would this list look like for companies in your state? What does it look like for your State Medicaid program? -- Provide incentives to find out. Ref: Goetzel RZ, Ozminkowski RJ, Meneades L, Stewart M, Schutt DC. Pharmaceuticals: Cost or Investment, Journal of Occupational and Environmental Medicine, 2000;42(4): 338–351. See also Matson Koffman et al., Hearth Healthy and Stroke Free, American Journal of Preventive Medicine, 2005;29(5S1): 113—121. 6.Back disorders 7.ENT disorders 8.Diabetes 9.Cerebrovascular disease 10.Gall bladder disease

4. Copyright 2005 Thomson Medstat 4 INFORMATION SOLUTIONS How Much of the Cost Burden is Due to Each Cost Component? Knowing this can help you figure out where to intervene. Source: Goetzel, Long, Ozminkowski, et al. JOEM, 2004; 46(4):398-412)

5. Copyright 2005 Thomson Medstat 5 INFORMATION SOLUTIONS Percent Difference in Medical Expenditures: High-Risk versus Lower-Risk Employees Independent effects after adjustment N = 46,026 70.2 46.3 34.8 21.4 19.7 14.5 11.7 10.4 -9.3-3.0 -0.8 -50 -25 0 25 50 75 100 Percent Depression Stress Glucose Weight Tobacco-Past Tobacco Blood pressure Exercise Cholesterol Alcohol Eating Incremental Impact of Ten Modifiable Risk Factors on Medical Expenditures (Need Your State’s Version of This) Goetzel RZ, Anderson DR, Whitmer RW, Ozminkowski RJ, et al., The Relationship Between Modifiable Health Risks and Health Care Expenditures. Journal of Occupational and Environmental Medicine, 1998;40(10):843–854.

6. Copyright 2005 Thomson Medstat 6 INFORMATION SOLUTIONS The Gender-Specific Effects of Modifiable Health Risk Factors on Coronary Artery Disease and Related Expenditures The HERO – NASA Study Wasserman J, Whitmer RW, Bazzarre K, Kennedy S, Merrick N, Goetzel RZ, Dunn RL, and Ozminkowski RJ, Journal of Occupational and Environmental Medicine, 2000; 43: 1060-1069..

7. Copyright 2005 Thomson Medstat 7 INFORMATION SOLUTIONS Purpose To determine the gender-specific association between coronary heart disease (CHD) and: –the prevalence of modifiable health risks and –medical expenditures.

8. Copyright 2005 Thomson Medstat 8 INFORMATION SOLUTIONS Methods ICD-9-CM/CPT-4 codes used to identify 2,452 employees with CHD (Study Group) – 61 cases per 1,000 Study Group demographics: 66% male; 34% female; average age of 43 years Health risk data obtained from voluntary participation in employer- sponsored health risk appraisal (HRA) surveys and biometric evaluations provided by clinicians Descriptive and multivariate statistical techniques used to analyze HERO database

9. Copyright 2005 Thomson Medstat 9 INFORMATION SOLUTIONS Results (1) Table 1. Descriptive Analysis of Health Risk Status by CHD Status CHD %Non-CHD % Sex* Male Female 66.3 33.7 63.8 36.2 Risk Factors Former Tobacco Use41.3*31.8 Sedentary Lifestyle33.7*26.3 High Cholesterol29.1*18.7 Obesity28.8*18.2 High Stress24.2*19.1 Current Tobacco Use 23.5*19.4 High Blood Glucose 9.6* 4.6 High Blood Pressure 5.3* 3.7 Excessive Alcohol Use4.5 4.1 Depression2.7 2.3

10. Copyright 2005 Thomson Medstat 10 INFORMATION SOLUTIONS Results (2) * Significantly different between genders - p <.05,  2

11. Copyright 2005 Thomson Medstat 11 INFORMATION SOLUTIONS Results (3) Table 4: Predicted Annual Healthcare Expenditures (1996 dollars) for Persons with CHD with Multiple Behavioral Risk Factors

12. Copyright 2005 Thomson Medstat 12 INFORMATION SOLUTIONS Conclusions of HERO - NASA Study People with CHD cost twice as much as people without. Smoking, stress, poor exercise habits and obesity can double the costs again. Adding high blood sugar and depression quadruples the cost! Obesity was most consistent predictor of CHD for males and females For those with CHD: –Self-reported depression associated with the highest expenses in males but not females –High blood glucose was most costly risk factor among females

13. Copyright 2005 Thomson Medstat 13 INFORMATION SOLUTIONS Heart Disease Leads to Cost / Productivity / Quality of Life Challenges Many of these problems begin with problematic health. Cost controls would therefore be more successful if problematic health could be avoided. –Need to measure and better understand risks for heart disease. Efforts to control costs have a better chance to succeed if considered within a broader context of health promotion

14. Copyright 2005 Thomson Medstat 14 INFORMATION SOLUTIONS Let’s Talk About Health Promotion In our society, fewer than 2% of health care dollars are spent on preventive services or health promotion. But if “an ounce of prevention is worth a pound of cure,” why don’t we spend 16 times as much on prevention? Something is wrong with this picture! –Legislators can help.

15. Copyright 2005 Thomson Medstat 15 INFORMATION SOLUTIONS What Can State Legislators Do? Promote health: –Look for win-win scenarios to make employers, employees, beneficiaries, and government better off –Provide incentives to implement interventions that the private sector would not normally undertake. These should be tailored for large, medium, and small employers –Provide incentives for Medicaid beneficiaries to manage their heart health. But support interventions that can start even before Medicaid enrollment

16. Copyright 2005 Thomson Medstat 16 INFORMATION SOLUTIONS The State Government’s Role in Promoting Health Adapted from Gov. Mike Huckabee’s vision, and the National Governors Association’s vision for a Healthy America Key elements: –Coordinate activities across state agencies Generate a strategic plan to promote health and safety Make sure all agencies have their incentives aligned toward this plan. –Partner with public health policy and research experts Learn from the literature and follow best practices –Provide “senior management support” and be role models –Promote wellness at work, and in the community Source: Huckabee M. A vision for a healthier America: What the states can do. Health Affairs 25(4): 1005 – 1007, 2006

17. Copyright 2005 Thomson Medstat 17 INFORMATION SOLUTIONS Q: Where Should Incentives Be Applied? Phase IV Measurement Phase III Intervention Phase II Strategic and Tactical Planning Phase I Diagnosis A: At Every Phase

18. Copyright 2005 Thomson Medstat 18 INFORMATION SOLUTIONS What Really Works? Tax undesirable behaviors –Smoking –Drinking –Others … Provide incentives for “social marketing:” –Ban smoking in public places –Create limited smoking areas at work –These may annoy some people …. –But being annoyed to death is better than being cancered to death. In the latter case, we really die. Source: Simon PA, Fielding JE, Pubic health and business: A partnership that makes cents. Health Affairs 25(4):1029 – 1039, 2006.

19. Copyright 2005 Thomson Medstat 19 INFORMATION SOLUTIONS What Else Might Work? Consider additional tax incentives –Should there be a “fat tax”? A study by Thomson Medstat in 2006 shows that most people do not understand the consequences of poor nutritional habits and poor exercise habits –Consider reducing taxes or offering subsidies to employers who invest in heart- healthy employees Make worksites safe, walkable –Provide price incentives to vendors to offer higher quality food at work and in schools –Reduce taxes or provide subsidies for employers and insurance companies who offer plans that engage in substantially more preventive care that is designed to reduce health risks and increase heart-health: Measure BP, cholesterol for at-risk people Treat more of them with high-quality medications Provide incentives for patient self-management

20. Copyright 2005 Thomson Medstat 20 INFORMATION SOLUTIONS What Will Work? Formative Research is Key to Find Out For another project funded by the NIH, Medstat and The Dow Chemical Company are teaming with Cornell University and the University of Georgia to design, implement, and evaluate environmentally-based interventions to combat obesity. It was not clear which interventions would work best So formative research was conducted –Surveys of key stakeholders to assess senior management commitment to healthy lifestyles among employees –Focus groups of employees (production staff, managers) –Individual interviews –Outside (UGA / Cornell’s) assessment of plant structure, cafeteria offerings, etc., that promote healthy activities –Examinations of historical medical claims data, HRA, and absenteeism data Results can help decide which interventions are more likely to succeed, and where. Companies may need government incentives to do this.

21. Copyright 2005 Thomson Medstat 21 INFORMATION SOLUTIONS Which Interventions Will Work in Your State? Most likely, a combination of individually-based and environmentally based interventions would be useful. Provide incentive for companies to look at their data and conduct formative research to find out Learn from best practices at other companies or in other State Medicaid programs ….

22. Copyright 2005 Thomson Medstat 22 INFORMATION SOLUTIONS In Summary Set up incentives internally and externally (within and across state government agencies) to promote health Use money and the power of the pulpit to influence behavior –Increase taxes on undesirable behaviors –Reduce taxes or provide subsidies to employers and individuals who engage in healthier behavior Look for ways to collaborate with the private sector to generate good ideas and test those ideas –Evaluate, refocus, reload, and try again

23. Copyright 2005 Thomson Medstat 23 INFORMATION SOLUTIONS Conclusions Why is there a need to reduce the risks of heart disease? –To improve health, quality of life, and save money Will risk reduction really work? –“… when corporations, health plans, governments, and employees collectively embrace comprehensive health and disease-prevention programs and services: “companies will have healthier employees, and save on the costs associated with health care, absenteeism, disability, and lost productivity.” Quoted from Matson Koffman, et al., Heart Healthy and Stroke Free, American Journal of Preventive Medicine, 2005;29(5S1): p. 121 A health-focused state government will motivate a health-focused state economy. Better health and monetary savings will follow.