THE C ASE FOR
HEALTH PROMOTION PROGRAMS
AN E M P L O Y E R W H I T E P AP E R
780 Township Line Road
Yardley, PA 19067
Health promotion is an investment in human Link between health risks and medical
capital and productivity. Employees in care costs: Being at high risk for any single
optimal physical and psychological health health condition is associated with higher
are more likely to be on the job and medical costs. Those with multiple risk
performing well. They also are more likely factors cost even more.
to be attracted to, remain with and value a Changes in risk result in changes in costs:
company that obviously values them. The cost increases associated with increased
Health and productivity management is risk are greater than the declines associated
based on the concept that an “at risk” with decreased risk.
workforce is a business liability with direct
Which employees should be targeted?
and hidden costs impacting productivity.
Many health promotion programs focus on
Thus, an essential component of
high-risk individuals, while others focus on
productivity management is managing
both high- and lower-risk employees. Some
research indicates an effective strategy is to
focus on keeping healthy people healthy by
preventing those in low-risk categories from
Health promotion programs are a proven moving to medium- or high-risk status.
method for employers to help employees
Impact on health care costs: A
manage their health. Multiple peer-reviewed
comprehensive review of 72 studies last
studies have concluded that businesses can
year concluded that overall, health
realize from $3 to $8 for every dollar spent
promotion programs result in lower health
on health promotion. These savings
care costs and are considered a viable and
represent both direct costs — reductions in
effective method for helping employers
medical costs and claims — and indirect
reduce employee-related expenses.
savings in reduced absenteeism and
disability and increased productivity. Many Impacts on productivity: In addition to
researchers believe the indirect, higher health care costs, negative impacts
productivity-related savings are double the on productivity are a major, costly product
more easily measured direct health care of poor health. Some researchers believe
costs. productivity losses exceed actual health care
Beyond ROI considerations, health costs.
promotion programs also are ideal for
raising health awareness and getting Worksite health promotion programs can
employees to be active partners in their own improve productivity by attracting
health. superlative workers, reducing absenteeism
and lost time, improving time utilization and
Research Conclusions Regarding employee morale, building goodwill toward
Health Promotion Programs management and reducing employee
Impact on health risks: Numerous turnover.
studies have demonstrated that well- Absenteeism: A common yardstick to
conceived health promotion programs measure productivity and absenteeism
can help workers reduce their health includes missing time from work, such as
risks. personal illness days, as well as short- and
long-term disability and worker's
compensation days. Health risks bear the
HEALTH INK & VITALITY COMMUNICATIONS 2
same relationship to days absent as they Match health promotion initiatives with
do to health care costs: the greater the health indicator issues.
health risks, the higher the absenteeism Utilize periodic health-risk assessment and
rates. Conversely, health promotion screening programs.
programs have been shown to
Systematically funnel workers identified as
significantly reduce absenteeism.
being at higher risk into appropriate follow-
Presenteeism: This relatively new up programs.
concept considers the impact of workers
Measure and evaluate.
who are present but not fully
productive. On-the-job workers with
Depending on how comprehensive the plan,
higher health risks have more
there is a wide cost range associated with health
productivity loss, and presenteeism is
promotion programs. Some companies begin
the major contributor to these
with relatively simple and inexpensive
productivity losses. Researchers who
initiatives, such as distributing a wellness
studied one firm's call center operators
newsletter, which can be an effective way for a
were startled by the type of conditions
company to reach all of its employees and their
that contributed most to presenteeism.
dependents with proactive health messages.
Lower cost, chronic conditions such as
More comprehensive health promotion
allergies, asthma, digestive disorders,
programs can range from less than $50 to over
back pain and mental health problems
$400 per employee — a fraction of the $4,000
were found to have a greater negative
to $5,000 per year the average employer spends
impact on productivity than did high
to ensure productivity through health benefits,
health care cost conditions, such as
which continue to experience annual double-
cardiovascular disease, diabetes and
digit increases. Factoring in productivity losses
due to health, these expenses could amount to
Instituting a Health Promotion $10,000 or more per employee per year.
Experts suggest certain elements are
As a means to reduce employees’ health risks,
necessary for a successful health
promotion program. These include: curb health care costs and improve employee
well-being, morale and productivity, health
Determine your company's chief promotion programs are a significant, viable and
organizational health indicator issues. cost-effective tool in employers' health care
HEALTH INK & VITALITY COMMUNICATIONS 3
From a business perspective, health medical shows like ER for years, there is no TV
promotion is an investment in human show about public health.
capital. “It’s not as exciting, not as sexy as the
“Employees are more likely to be on the immediate attention you get for saving a
job and performing well when they are in person’s life, finding a cure or treating a serious
optimal physical and psychological health,” disease,” says Ron Z. Goetzel, Ph.D., vice
the Partnership for Prevention, a nonprofit president of consulting and applied research for
association of corporations, nonprofits and the MEDSTAT Group in Washington, D.C.
state health departments, contends in “But the reality is that the mundane, boring,
Healthy Workforce 2010: An Essential common-sense things your mother told you to
Health Promotion Sourcebook for do 50 years ago — exercise, eat properly, don’t
Employers, Large and Small. “They are also smoke, and balance your work, family and
more likely to be attracted to, remain with social life — actually make a big difference in
and value a company that obviously values your health and well-being.” All of which, in
them. In short, a company’s productivity one way or another, health promotion programs
depends on its employees’ health.”1 address.
Top Reasons for Programs What About Results?
According to the 1999 National Worksite Intuitively this all makes sense. But it has
Health Promotion Survey, the top reasons long been thought difficult, if not impossible, to
employers launch health promotion quantify the financial benefits of health
programs are to improve employee morale, promotion programs. What is the return on
retain good workers, attract good employees investment, the ROI, of health promotion?
and improve productivity — all of which While that may once have been hard to quantify,
worksite health promotion programs target.2 and to quantify in dollars and cents, a growing
Such programs can be particularly body of peer-reviewed studies has concluded
effective because, with a captive work force, there is an ROI, often dramatic, for employer-
companies are dealing with employees who based health and wellness promotion programs.
experience a consistent environment and Multiple studies have shown that businesses can
social and organizational support. Worksite realize from $3 to $8 in savings for every dollar
health programs also have one other spent on health promotion. These savings
powerful feature workers find attractive: represent both direct costs — reductions in
Employers, not the employees, pay for them. medical costs and claims — and indirect savings
As the Partnership for Prevention notes, in reduced absenteeism and disability and
the field has even spawned new business increased productivity. In fact, some researchers
management concepts. Health and believe the indirect, productivity-related savings
productivity management is based on the are double the more easily measured direct
concept that an “at risk” workforce is a health care costs.3
business liability with direct and hidden “The data supporting the claim that health
costs impacting productivity. Thus, an promotion programs can reduce medical care
essential component of productivity costs and reduce absenteeism is of higher
management is managing employee health. quality than the data most businesses have to
Nonetheless, health promotion and support other investments of similar cost,”
disease prevention have an image problem. writes Michael O’Donnell, editor in chief and
While America has watched highly rated president of the American Journal of Health
HEALTH INK & VITALITY COMMUNICATIONS 4
Joseph A. Leutzinger, Ph.D., director of most software or databases don’t have it. We
health promotion at Union Pacific Railroad, also don’t look for ROI for medical and surgical
agrees. “Most business leaders make a lot procedures.”
more important decisions related to But beyond the measurable ROI financial
monetary expenditures based on less data numbers, health promotion programs are an
than they do for spending of health ideal vehicle to enable and encourage
promotion programs,” he says. While he is employees to be active partners in their own
an advocate of health promotion program health — a goal of all employers.
evaluation and has conducted some Workplace health promotion, Leutzinger
impressive evaluations himself, Leutzinger concludes, is simply common sense. “If you
is somewhat mystified by constant demands look at what’s happening in business trends, in
to justify health promotion expenditures. the coming years it’s going to be important for
“Most companies spend on health employees to have a certain core set of skills to
promotion what they spend on carpets and make a company profitable. It becomes pretty
one-day company events,” he says. “Do we intuitive that if the bar is going to be raised on
cost-justify all training programs, business what’s required, if employees are not healthy or
equipment and all other discretionary are dealing with health issues, obviously they
spending at the same intensity and rigor that are not going to be able to perform at this
is required for health promotion? Typically, expected and projected higher level.”
companies say everything has an ROI, but
HEALTH INK & VITALITY COMMUNICATIONS 5
The Most Influential Studies on the
Financial Impact of Health Promotion
As we have said, a growing body of peer- costs. They were followed by high blood
reviewed studies has demonstrated the glucose levels (35 percent more), obesity
financial impact of health promotion. Here (21 percent more), tobacco use (former
are the dozen adjudged the most influential smokers 20 percent more, current smokers
by an expert panel and summarized in a 15 percent more), high blood pressure (12
May/June 2001 American Journal of Health percent more) and poor exercise habits (10
Promotion paper by Thomas Golaszewski, percent more).5 “We thought obesity or
Ed.D., of the State University of New York– smoking would be the most costly,” says
Brockport: Bill Witmer, the HERO president. “The
HERO Studies: In 1996 the Health study’s conclusion, though, was that the
Enhancement Research Organization depression
psychosocial diseases such as Impact on Individual Health Care Costs:
(HERO) was created after organizers
and stress are by far the most costly of the Lower-Risk Employees
realized data existed to create a large, typical controllable risk factors. That’s
Individuals at high risk for
75% 70.2% depression have 70.2%
retrospective, multi-employer health important because, in some cases, those at
higher costs than
employers don’t even provide coverage for
promotion research database. HERO 50% 46.3%
brought together the StayWell a lot
mental health. It got 34.8% of employers
Company, which had a large database of thinking that they should start paying more
25% 21.4% 19.7%
health-risk assessments (HRAs), and the attention to depression and stress.”
MEDSTAT Group, which had a large
database of medical claims. The two
companies were able to merge the
health-risk assessments and medical -50%
claims data of 47,500 employees of six
large employers: Chevron Corporation,
Health Trust, Hoffman La Roche,
Marriott and the states of Michigan and
Tennessee. All of the employees were
enrolled in their employers’ fee-for-
service, self-insured health plans
between 1990 and 1996 and had
completed one or more health-risk Source: Goetzel et al. (1998)
Witmer notes that only 2.2 percent of the
The first HERO study evaluated 10 workers assessed admitted to the costliest
risk factors, six self-reported and four risk factor, depression, even though research
biometric measurements (cholesterol, indicates about 10 percent of the U.S.
blood pressure, blood glucose and population at any given time is clinically
weight). Participants were followed for depressed.
up to three years after completing their
first HRA, following which data showed Another HERO study used the same data
that those with self-reported, persistent and subject group to explore the relationship
depression had adjusted annual health between modifiable health risk and health
care expenditures that were 70 percent care expenditures. Employees with
greater than those who didn’t report modifiable health risks were responsible for
being depressed. Highly stressed 25 percent of total expenditures. Those
individuals incurred 46 percent greater employees who reported being under
HEALTH INK & VITALITY COMMUNICATIONS 6
constant stress with no methods for to go from high to low risk cost an average
coping were responsible for 7.9 percent of $129 less per year; those that moved from
of total health care costs; former low risk to high risk cost $734 more per
smokers, 5.6 percent; overweight, 3.3 year. Since then, ongoing studies by the
percent; current smokers, 2.5 percent; university’s Health Management Research
high blood glucose, 1.7 percent; Center have continued to show positive
persistent depression, 1.5 percent; and results.
high blood pressure, 0.5 percent. Johnson & Johnson Study: Between 1979
and 1983 Johnson & Johnson divided more
“That 7.9 percent is enormous,” says than 11,000 employees at different work
Witmer. “It resulted in the Harvard locations in 18 states into three groups to
Business Review doing a series of judge the value of interventions such as
studies that concluded today’s health screenings, introductory lifestyle
workplace is the most chaotic in history. seminars, lifestyle improvement programs
Mergers, acquisitions, downsizing and such as smoking cessation and stress
the taking away of retirement plans management, and work environment
almost overnight has created changes, such as healthier cafeteria foods
unprecedented chaos, and there’s no and exercise facilities. One group was
question that’s going to generate stress exposed to such interventions early, another
and anxiety and take away from work group received delayed intervention and the
performance.” third group received none. Analysis of
HealthPartners Study: This HMO medical care and utilization data indicate
based in Minneapolis studied 5,689 of the groups that received interventions
its members who were over 40 and had experienced lower rates of increases for
one or more chronic conditions to health care costs, hospital admissions and
determine the relationship between hospital days. J&J saved $980,316 (in 1979
modifiable health risks and health care dollars), or $116 per subject over the four
costs. Over an 18-month period: health years.
care costs decreased from the median by DuPont Study: DuPont gauged the
4.7 percent for every day of the week effectiveness of comprehensive worksite
subjects exercised; costs increased 1.9 health promotion on days lost to disability
percent above the median for every during the 1980s. Comparing more than
increment in Body Mass Index; and for 29,000 hourly workers from 41 intervention
current and former smokers, there were sites to more than 14,000 from
increases of 18 percent and 25 percent, nonintervention control sites, DuPont
respectively, over nonsmokers. concluded the interventions significantly cut
Steelcase Study: University of disability days by .4 days per employee over
Michigan researchers followed 796 two years. That saved 11,726 disability days
employees at this office furniture maker and resulted in a savings of $1.42 for every
who completed health-risk assessments dollar invested.
before and after the 1985–1990 study Birmingham, Ala. Study: The city
period. Based on 10 lifestyle and implemented a comprehensive health
biomedical risk factors, such as blood intervention program in 1985. Its elements
pressure and cholesterol levels, the included health promotion, such as
workers were classified as either high or mandatory HRAs, referrals for high-risk
low risk (two or fewer risk factors) individuals, a shift to managed care and
during each of two periods: 1985–1987 other medical plan redesigns. Between 1985
and 1988–1990. High-risk workers had and 1990 the average employee medical
high health costs. Those that managed expenses were virtually unchanged (while
HEALTH INK & VITALITY COMMUNICATIONS 7
Alabama state employees’ health care Travelers Study: In 1986 the insurer
costs mushroomed 82 percent). During introduced a health promotion program that
that same period, both hospital focused on both lifestyle and medical self-
admissions (-55 percent) and hospital care interventions to all 36,000 of its
days (-38 percent) declined employees and retirees. The program
significantly. featured multiple communications vehicles,
Citibank Study: In 1994 the financial including newsletters, brochures, videos and
corporation launched a mass a self-care reference book, committees and
communication health promotion social events such as health fairs and
intervention to all of its employees. It contests, and a large fitness facility at the
included a health-risk assessment; corporate headquarters in Hartford, Conn. A
targeted educational programming, total cost-to-benefit analysis was completed
including print material, telephone for 1986 to 1990 and projected to the year
counseling and telephone-accessed 2000. Researchers estimated the cost-benefit
audio material, for those identified as ratio at $3.4 for every dollar spent, a
high risk. There also were follow-up cumulative gain of $146 million by 2000.6
letters and telephone information access
for lower-risk employees, and follow-up
HRAs, reports and self-care books for
everyone. Comparing more than 11,000
participants with more than 11,000 non-
participants, researchers concluded that
health care expenditures ultimately
increased just 25 percent for
participants but 43 percent for non-
participants, a difference of $34.03 per
person per month. Overall total savings
were estimated at between $6.6 million
and $7 million, with a return of between
$4.56 and $4.73 for every dollar spent.
CalPERS Study: The California Public
Employees’ Retirement System during
the early 1990s gauged the effect of a
health-risk assessment and health
promotion program on PERS employees
and retirees both on and not on
Medicare. Interventions included HRAs
every six months, individualized reports
and recommendation letters, as well as
books and materials. The results:
Claims for the combined employee and
retiree intervention group were $361
lower than the controls; in just the
retiree group, the difference was $758
per member. The cost savings over the
entire population was estimated at
between $3.2 million and $8 million.
HEALTH INK & VITALITY COMMUNICATIONS 8
HEALTH INK & VITALITY COMMUNICATIONS 9
What Researchers Have Concluded
About Health Promotion Programs
Researchers have looked at the impact of Just three months after launching a 20-
health promotion in a variety of ways, minute stretching program before its
including what effect they have on health employees began repetitive work, Steelcase
risks, health care costs and productivity. enjoyed significant declines in on-the-job
injuries. Such injuries were even halved in
Impact of Health Promotion one department, and workers reported their
Programs on Health Risks muscles ached less, they felt better
Numerous studies have demonstrated that physically and were sleeping better.8
well-conceived health promotion programs
can help workers reduce their health risks. Link Between Health Risks and
For example, a three-year study of nearly Medical Care Costs
10,000 employees at four auto High risk for any single health-risk factor is
manufacturing plants compared four associated with higher medical costs. For
different approaches at the sites: periodic example, a collaborative 1995 study between
screening and referral only; such screenings what was then the Chrysler Corporation and the
and awareness materials and classes; those United Auto Workers Union concluded that
services plus individual follow-up smokers generate 31 percent higher claim costs
counseling for at-risk employees and a menu than non-smokers, and those with unhealthy
of interventions; and additional social weights had 14.3 percent higher hospitalization
organization at the plant. Participation in the utilization than those with healthy weights. 9
more comprehensive third and fourth Likewise, a study published in 2002
approaches was five times greater, and concluded that a worker with diabetes generates,
substantially greater improvements were on average, more than twice the medical,
achieved in blood pressure results, weight prescription and disability costs as a worker
loss and smoking cessation. Persistent without the disease. The tab at a Fortune 100
outreach and multiple contacts by manufacturing firm: $7,780 per year for workers
counselors were linked closely to risk with diabetes, $3,370 for those without it.
reductions. 7 Nearly a third of the additional costs were
attributed to productivity losses.10
Other examples: Health promotion researchers such as Dee
Coors’ eight-week “Lifecheck” program W. Edington, Ph.D., with the Health
significantly reduced its employees’ risk Management Research Center, Division of
of heart disease. Spending $32 each for Kinesiology at the University of Michigan, have
692 participants resulted in declines in also classified employees according to multiple
blood pressure, blood cholesterol and risks. Those with five or more risk factors — the
weight. high-risk group — and those with medium risk
(three or four risk factors) cost employers more.
Two years after the Minneapolis/St.
Researchers have calculated that the excess
Paul Metropolitan area began a weight
amounts these groups cost employers above the
control/smoking cessation program,
cost of the low-risk group (two or less risk
program participants had lost an average
factors) have a mean of about 25 percent of total
of nearly five pounds and 24 employees
corporate medical costs.
had quit smoking. That represented only
Wellness scores, which most commercially
a 2 percent quit rate, but at a cost of just
available HRAs calculate, also show a strong
$62.50 per successful quitter.
HEALTH INK & VITALITY COMMUNICATIONS 10
correlation between wellness and health Most health promotion programs, perhaps
care costs. understandably, focus on high-risk individuals:
trying to get smokers to quit, for instance, or
Changes in Risk = Changes in Costs obese workers and/or heart patients to lose
As risks increase or decrease, so do costs, weight. “The whole health promotion field,
according to the University of Michigan’s which was begun initially to address
findings, first with Steelcase and then with cardiovascular disease, has been brought up
other members of its corporate consortium. thinking about risk reduction as more of a
Interestingly enough, the cost increases medical rather than a health promotion model,
associated with increased risk are greater trying to reduce medical problems rather than
than the declines associated with decreased promoting health,” says Edington.
risk.11 But Edington’s research suggests the most
effective strategy to increase the proportion of
Lifestyle Accounts for 50% of Deaths low-risk people in a workforce is to prevent
those already in low-risk categories from
10% moving into medium- or high-risk categories. In
other words, he says we should focus on
keeping the healthy people healthy.
“Naturally, you want to prevent heart
Biology disease, lung cancer and diabetes, and most
Health Services corporations who sponsor these worksite
programs of course are interested in that,” says
Edington. But the only way to measure the
success of such efforts is over the long-term, 10
Source: CDC (1980)
Source: CDC (1980) to 15 years from now. But generally employers,
especially companies with high turnover rates
How Soon Does ROI Appear? — two to three years in some cases — are more
“When can we expect to see the benefits of interested in outcomes over the next two or
these programs?” Edington hears that three years, in such measures as short-term
question all the time. The benefits of low- medical costs or impact on productivity.
cost programs often become apparent more Using such a yardstick, Edington’s
quickly than those of high-cost programs. preliminary results suggest that investing in the
Both Steelcase and Progressive realized a low- and medium-risk groups maximizes the
savings-to-cost ratio of greater than 3.5:1 health promotion ROI. Only when programs are
within the third year of some of their low- able to spend more than $300 per year per
cost programs. One company in the individual, he says, should health promotion
University of Michigan consortium that programs target high-risk individuals.13
spent less than $30 per participant Based on multiple risk factors, low-risk
experienced a 3:1 savings-to-cost ratio after employees represent at least 60 percent of the
three years. While the return also was population, with 25 percent more in the
positive for its more intense programs that medium-risk category, according to Edington.
cost up to $200 per employee, it wasn’t as “These are your champions,” he says. “These
high after three years. But Edington’s are your low-cost people who have low
experience indicates savings will triple absenteeism rates.”
expenses within five years.12 In reality, most companies that launch health
promotion programs try to address both groups.
Which Employees Should We Target? Says MEDSTAT’s Ron Goetzel: “You need to
expend funds on primary prevention programs
to keep people healthy at the same time you
HEALTH INK & VITALITY COMMUNICATIONS 11
spend money on high-risk people in order to
change their risk profile.
HEALTH INK & VITALITY COMMUNICATIONS 12
Impact of Health Promotion
Programs on Health Care Costs
A comprehensive review of 72 studies by difference in medical expenditures for
Brigham Young University’s Steven G. employees who had taken part in the
Aldana, Ph.D., last year concluded, “The program and those who hadn’t.
implementation of health promotion Duncan Aviation in Battle Creek, Mich.,
programs seems to result in lower levels of over several years saw health insurance
absenteeism and health care costs.” While costs for its 450 workers rise only 7 percent
conceding there may be some questions to 14 percent while neighboring companies
about the actual causal relationship between suffered 18 percent to 40 percent increases.
health promotion programs and reduced Duncan got the better rates, even though its
health care costs, he concluded that “health health plans are more comprehensive,
promotion programs should be considered a because over a 13-year period its health
viable and effective method for helping awareness program had eliminated 60
employers reduce employee-related percent of its employees’ identified health
Aldana’s review of 13 studies that
As the Partnership for Prevention notes, even
reported benefit/cost ratios indicated the
narrowly focused health promotion programs
mean benefit was $3.72 in reduced health
can generate significant financial savings:
care costs and $5.06 in reduced absenteeism
costs per dollar invested.15 Another review Sunbeam-Oster Co., a manufacturer of small
of studies by Goetzel reported a median electrical appliances with a largely female
benefit of health promotion programs of workforce, made it mandatory for its
$3.14 per dollar invested, a median benefit pregnant employees to attend prenatal
of programs that addressed demand for classes. They made it easy by offering the
medical services of $4.50 and a median classes on site during work hours, and paid
benefit for disease management of $8.88.16 the women their full salaries while they
were in class. The result: In the eight years
Consider these examples: after the program was launched, just four
premature births occurred, compared with
When Citibank spent $2 million to
five in the two years before the program
provide a health-risk appraisal and
began. Even including the cost of the pre-
appropriate follow-up interventions for
natal classes, the company’s costs for
chronic conditions to 40 percent of its
maternal and newborn care declined by 86
42,000 employees, over a 38-month
percent in just two years. Average costs fell
period it realized $12.6 million in
from $27,243 to $3,792 per program
program benefits — mostly from the
Short-Term Long-Term The Hanford Nuclear Reservation cut lost
workdays nearly in half among workers who
took advantage of flu vaccinations offered at
various worksites. Estimated savings per
Demand $2-$5 person vaccinated were nearly $84,
including productivity gains and medical
care and prescription drug reductions.18
HEALTH INK & VITALITY COMMUNICATIONS 13
Impacts on Productivity Control Data estimates its StayWell
program saved the company at least $1.8
Besides health care costs, negative impacts million over six years as a result of reduced
on productivity are considered a major, and absenteeism among employees who had
costly, product of poor health. Some lowered their health-risk scores.
researchers even believe productivity losses In the year after a health promotion program
exceed actual health care costs. was launched at multiple sites involving a
According to the Partnership for police force, a chemical company and a
Prevention, worksite health promotion banking firm, weekly participation in
programs can improve productivity by: supervised exercise cut sick leave by an
Attracting superlative workers. average of 4.8 days per person.20
Reducing absenteeism and lost time.
Improving on-the-job decision making
and time utilization. Recently, researchers also have been focusing
Improving employee morale and on the impact of presenteeism: workers being
fostering stronger organizational present at work, but not fully productive.
commitments. Measuring on-the-job productivity is difficult,
Reducing organizational conflict by and necessarily has to be job-specific. In a study
building a reservoir of goodwill toward of Bank One call center operators, University of
management. Michigan researchers found that workers with
Reducing employee turnover.19 higher health risks have more productivity loss,
and presenteeism was the major contributor to
Absenteeism those productivity losses.
One of the most startling results of the Bank
One common yardstick to measure One study was the type of conditions that
productivity losses is absenteeism. That contributed most to the presenteeism.
includes days missed from work, including Researchers compared the impact of expensive,
personal illness days. It also encompasses high health care cost conditions, such as
short- and long-term disability and worker’s cardiovascular disease, diabetes and cancer —
compensation days. At Steelcase, for conditions that many health promotion programs
example, researchers early on discovered target — and lower-cost but chronic conditions
that the health risks bore the same such as allergies, asthma, digestive disorders,
relationship to days absent as they did to back pain and mental health problems. The
health care costs. results: The lower-cost conditions heavily
Results of health promotion programs on impact productivity. While a heart attack results
reduced absenteeism can be dramatic. in high medical costs, after four weeks or so
Consider these examples gathered by the most workers can return fully productive. 21
Partnership for Prevention: “But if you have a condition that affects you
on a daily basis, minute to minute, like
A 1998 analysis of five absenteeism
headaches or back pain or irritable bowel
studies concluded the programs
syndrome,” explains Edington, “you’re not
averaged savings of almost $5 for every
going to be productive since your mind is trying
dollar spent. A health promotion
to get through the pain before actually
program at DuPont was credited with
concentrating on your work.”
cutting days lost to illness or disability
Goetzel agrees: “If I’m at my desk eight
by 14 percent. A rehab program Coors
hours a day and suffering from allergies,
sponsored for 180 post-coronary
migraines or headaches, back pain or a host of
patients cut lost days by 68 percent.
other issues, what proportion of my day is
HEALTH INK & VITALITY COMMUNICATIONS 14
essentially unproductive because I’m not these conditions without being effectively
performing at optimal levels? Some research treated.”
indicates that may be as much as a quarter Presenteeism, Edington concludes,
or half a day lost if you are suffering from contributes more to productivity losses than
HEALTH INK & VITALITY COMMUNICATIONS 15
Instituting a Good Health
Depending on how comprehensive the plan, optimal levels — indicate the business and
there is a wide cost range associated with program objectives are aligned.”
health promotion programs. Some Determine your company’s chief
companies begin with relatively simple and organizational health indicator issues:
inexpensive initiatives, such as distributing Some organizations, says Leutzinger,
a wellness newsletter. On the more determine these issues through an analysis
comprehensive side, multi-faceted health of health claims data that might, for
promotion programs usually begin with a instance, identify heart disease risk, high
health-risk assessment to benchmark the cholesterol and/or obesity. Other companies
starting point and to guide future steps. The might be more interested in productivity
costs for programs pale when you consider issues, such as absenteeism, employee
what most employers already are spending relations, or recruitment and containment.
to ensure health and productivity.
Match health promotion programs with
“The average employer today is spending
health indicator issues: “If you’re most
between $4,000 and $5,000 per year on
interested in reducing claims from one year
health benefits. With annual double-digit
to the next, you probably want to install a
increases, in some cases over 20 percent,
self-care education program that can show
spending is going up dramatically on the
an immediate return. If that was your goal,
health care side,” says Goetzel. “If you
you wouldn’t want to open an 80,000-
factor in productivity losses due to health —
square-foot fitness center in the first year,”
absences, disability, workers compensation
says Leutzinger. “But if a company like
and items such as turnover costs — that
Microsoft was interested in recruiting and
figure can double to $10,000 or more per
retaining promising younger-generation
employee per year.
employees, being able to show off a large
“When viewed that way, the cost of a
fitness center at the end of the interview
prevention program doesn’t look all that
may help persuade the candidate to take the
Experts such as Goetzel and Union
Pacific’s Joseph Leutzinger suggest certain Senior management must champion the
elements are necessary for a successful program.
health promotion program. These include: Champions at the worker level also must
Align the program with the be passionate and enthusiastic: Their
company’s purpose and mission: advocacy must be a meaningful part of their
“You can’t have programs sitting off in work.
the backwoods in a trailer somewhere Periodic health-risk assessment and
where it’s very easy to get rid of them screening program: Regular assessments
when times get tough,” says Goetzel. get as many employees as possible involved.
“Companies whose mission statements Incentives might be necessary. According to
focus on human capital — such as being Goetzel, Citibank offered employees a $10
dedicated to attracting and motivating credit on their benefit plan and generated a
the best employees, being an employer 50 percent participation rate in their
of choice, making sure employers work assessment program; a Johnson & Johnson
in safe and protected environments and program that offered employees a $500
making sure the employees are incentive generated a 90 percent
physically and mentally performing at participation rate. According to the
HEALTH INK & VITALITY COMMUNICATIONS 16
University of Michigan’s Dee W. employee involvement stimulates interest
Edington, annual health-risk assessment and ownership of the program; it’s
participation rates of 20 percent to 30 contagious. Encourage advisory committee
percent are common. Among long-term members to talk up the program informally,
employees at Progressive, over 10 years even before a program starts. Word of
80 percent of the employees participated mouth often is the best marketing device.
at least once; 60 percent did so at least Ask people what they want and give it to
twice and 40 percent at least three them: A needs-assessment survey builds a
times. So, given the chance, most sense of anticipation and excitement that
employees eventually will participate. can help increase participation. Failure to
Systematically triage and funnel understand the needs and interests of
workers identified as being at higher potential program participants will almost
risk into appropriate follow-up assure low program participation.
programs. Make the program fun: People enjoy
Encourage individuals to participate doing what’s fun. Use balloons, flowers and
in multiple programs: This is a key music to create a festive atmosphere for
success indicator. At Progressive, health fairs or health-screening activities.
individuals who took part in programs Provide incentives: Well-conceived
multiple times over a nine-year period incentives can be expected to increase
had lower health care costs. For those program participation rates by 12 percent to
who participated in zero to three 35 percent. Incentives also can encourage
programs during that period, health care the completion of or attendance at multiple
costs rose 7.8 percent annually. Those program sessions and help participants
who participated in four or more adhere to long-term behavior change.
programs saw health care costs decrease
Publicize the program in different ways:
1 percent annually — a total savings of
Use multiple upbeat methods to promote the
nearly $4 million over the nine years.
program to potential participants, including
Measure and evaluate: “You can have bulletin boards, pamphlets, payroll inserts,
the finest program with the best science voice-mail messages, electronic billboards,
and motivated program managers, but if etc. A creative program name and logo will
you don’t have measures to document help to create a positive image that can help
the program impacts, in many ways increase utilization.
you’re wasting your money,” says Wow, the boss is doing it! Small business
Goetzel. “Eventually someone is going owners or top managers who participate in a
to ask ‘Does this work?’ Unless you program encourage others by their example.
have the data to support that it is The general manager for a large refinery in
working, both in terms of improving Joliet, Ill., frequently told employees that
health and potentially saving money, anyone could talk with him while he is on
you’re going to have a hard time the treadmill where he works out virtually
justifying the program.” every morning. Cultivate support from all
levels of management.
Tips to Increase Participation Remove barriers: Make health promotion
Here’s some advice from the Partnership and related activities easy to sign up for and
for Prevention on how to increase employee conveniently located.
participation in health promotion programs: Provide program choices: Don’t just offer
Involve people in planning: Ensuring a group smoking cessation program. Also
good participation starts with the offer guided self-help programs such as
program planning process. Broad
HEALTH INK & VITALITY COMMUNICATIONS 17
video or audiotapes and workbooks that participants liked best about the program,
employees can use privately. what they liked least and also solicit
Ask how you are doing: Routinely suggestions for program improvements or
measure program participants’ new topics to address.
satisfaction with the program content, Why not? Ask some of the people who do
instructors, logistical arrangements and not participate, why not? Their answers can
other program components. A simple help formulate strategies to help ensure
evaluation can determine what participation of non-participants.22
HEALTH INK & VITALITY COMMUNICATIONS 18
Basic Components of
Health Promotion Programs
Following are some of the initiatives 6. Offer interactive services such as personal
included in corporate health promotion menus for access to health encyclopedias.
programs: 7. Offer special topic-targeted supplements:
These enable employers to address special
Newsletters and Other Health needs within their organizations, such as
Education Materials self-care cost containment programs,
Newsletters are an affordable first step and chronic conditions, substance abuse issues,
an ongoing foundation for corporate productivity and seniors’ health.
wellness efforts. Newsletters or magazines
can combine news about company programs Health-Risk Assessments (HRAs)
with general interest articles on timely These gauge risks, health history and readiness
health topics. A wealth of print, online and to change. Generally offered to employees on a
video materials also is available, including voluntary basis, HRAs are the key to identifying
self-care guides, self-management advice the health and lifestyle status of your workers.
for persons with chronic conditions and They also provide immediate confidential
instruction sheets on wellness topics. Such feedback that can get people thinking about their
educational tools can heighten awareness, lifestyles and how choices they make affect their
enhance personal performance and reduce health. By building such awareness, health
costly health care utilization. Such assessments are the first step in encouraging
communication materials: employees to maintain their healthy lifestyles
1. Send a positive message: Employees and to take positive steps to improve their health
receiving such materials notice and status.
appreciate their company's concern for Focusing on behaviors that people can
their health and well-being and that of change, assessments cover such areas as activity
their families. and exercise; alcohol use; back care;
2. Educate people to make better health demographics; driving; eating habits; height,
decisions: As we ask people to take weight and body frame; mental health; screening
greater responsibility for their health, exams; screening values; self-care skills;
health and wellness communications smoking/tobacco use; stress management;
help them make better informed health weight control; family history of chronic
decisions, then reinforce such decisions disease; and readiness to change.
regularly. When employees retake these assessments in
subsequent years, they receive comparative data
3. Enable companies to reach each
that illustrate how much or how little progress
employee’s unique health interests:
they are making toward healthier lifestyles and
To ensure that there's something for
reduced risk. Whether it’s the first or umpteenth
everyone in each issue, most newsletters
time an employee has taken an HRA, the
address a variety of important wellness
assessments reinforce positive scores; compare
topics in each issue.
the individual to others of the same age and
4. Offer visual appeal: Bold formats are gender; highlight each individual’s main health
attractive and inviting to readers, both risks; outline the benefits of changing risky
employees and insured dependents. habits; and suggest positive steps to take
5. Reach readers at home: This is where immediately. Employees also are alerted to any
health issues and health decisions occur.
HEALTH INK & VITALITY COMMUNICATIONS 19
health conditions that warrant a doctor’s Focused interventions: Phone-based and
prompt follow-up. on-site wellness coaching and mail-based
Meanwhile, employers receive an educational programs on lifestyle and chronic
aggregate data report on their workforce. disease management issues targeted to risk level
The StayWell Company’s management and tailored to individual needs. Intervention
reports, for example, highlight: programs with health educators can include:
Risk factors: Reports identify five Weight management
primary risks in the total workforce and Nutrition
among high-risk individuals, who — as Exercise
we have seen — usually cost more to Stress management
cover. The reports also outline the Self-care
degree of readiness to change at each Smoking cessation
risk level, which is key information for Blood pressure management
targeting behavior-change programs. Cholesterol management
Avoidable costs: Based on the Adult asthma
company’s risk profile, the report Type 2 diabetes
estimates the direct health care costs, Coronary artery disease
indirect costs (such as absenteeism and
low productivity), total costs associated
Chronic heart failure
with behaviors that people can change,
and the potential savings from reducing Back care/occupation ergonomics
risk. Chronic disease self-management
Online services: Intranet or Internet-based
Recommendations: By identifying the
health improvement tools include HRAs,
most costly health issues and the degree
health and self-care information,
of readiness to change, recommenda-
personalized health news and customer-
tions are geared toward creating the
greatest benefit for employees and the
company. To control health costs and Onsite services: Health screenings, health
improve well-being, recommendations fairs and events, campaigns and fitness
might include behavior-change center management.
programs for high-risk individuals, Telephone services: Toll-free help lines
education programs to increase employees can call for informational
individuals’ readiness to change and support, guidance and encouragement to
organization-wide health promotion motivate healthy lifestyle change.
programs to motivate people to consider Fitness center enrollment and
the benefits of improved behaviors. individualized fitness programs.
Armed with such information, Single-session workshops
interventions and incentives can be targeted
Intensive group and self-study education
and the effectiveness of an employer’s
program can be closely monitored. Periodic general and specific health
Health-Risk Assessment Follow-up Safety training
Once an initial assessment identifies a Program management: Your health
company’s needs, various health promotion promotion partner can help with program
programs can be implemented. These design and development, marketing,
include: promotion, implementation management
HEALTH INK & VITALITY COMMUNICATIONS 20
Some elements of health promotion contribute to the overall cost-effectiveness of an
programs can be hard to track, such as the established health promotion program,”
percentage of employees who read a Edington says. “Newsletters, bulletin boards and
newsletter or take part in a fitness activity. telephone numbers are all part of maintaining
In an early UAW-GM study, the recorded low-risk employees and creating an overall
cumulative participation rate after three environment that keeps healthy lifestyle and
years was just 40 percent. But when quality-of-life issues in front of people all the
employees responded to a randomly time.
administered survey, self-reporting pushed “They are a way to improve knowledge,
that percentage to over 80 percent. awareness and attitudes, and once people move
“These nontrackable components through those these phases, you get behavior
provide an important benefit and likely change.”
HEALTH INK & VITALITY COMMUNICATIONS 21
The average annual health insurance productivity, wellness programs represent a
premium in 2000 was $2,655 for single significant, cost-effective tool.
coverage and $6,772 for family coverage in Therefore, companies that purchase
private-sector companies, according to the insurance plans, says Kenneth Sperling, health
Agency for Health care Research and care practice leader at Hewitt Associates’
Quality. Those levels represent increases of Norwalk, Conn., should select health plans that
33.3 percent for individuals and 36.7 have adequate disease management capabilities,
percent for families since 1996. Despite since that can result in lower premiums based on
these increases, the percentage of private- claims experience.
sector companies that offered health
insurance also increased, from 52.9 percent
to 59.3 percent. As a result, almost 90 “Those who don’t make time
percent of all employees worked for for wellness will be forced
establishments that offered such coverage,
compared with 86.5 percent in 1996.23
to take time for illness.”
Given such cost and participation
increases, it has become increasingly urgent Likewise, Sperling says, the growing number
for both employers and employees to seek of self-insured companies now have few options
ways to curb the spiraling cost of health beyond health promotion programs.
care, which continues to significantly "How am I possibly going to beat the
outpace inflation. inflationary trend if I don't manage the claims?"
“Those who don’t make time for he wonders. "In one sense, the market is driving
wellness will be forced to take time for toward health promotion because that is all we
illness,” Jeff Null, manager of Dow have left other than prescription drug strategies
Chemical’s South Charleston, W. Va., and cost sharing. Cost sharing changes the way
fitness center, asserts in the National Safety the pie is divided up, but disease management is
Council’s Safeworker.24 one of the biggest arrows in the quiver to reduce
Clearly, as a means to reduce employees’ the size of the pie."
health risks, curb health care costs and
improve employee well-being, morale and
HEALTH INK & VITALITY COMMUNICATIONS 22
The Union Pacific Story
Union Pacific Railroad opened its first offers informational packets on key health
employee fitness center at its Omaha, Neb., numbers everyone should know in relation to
headquarters in 1987. It soon began to outfit a good health, such as:
number of rail cars as fitness centers; the cars 80: Minimum desirable HRA score
would follow crew members who were
30: Recommended minutes of exercise
responsible for track repair. Since crew
most days of the week
members who used to live in bunk cars now
get a lodging per diem, Union Pacific has 24: Desirable body mass index
retired its fitness rail cars. 8: Recommended hours of sleep
But a program that originally started out Union Pacific also conducts an active
just for rail workers now has grown to more information campaign. Ten times a year
than 500 exercise facilities (mostly vendor workers receive an exclusive Union Pacific
contracted) spread across 25 states. “We newsletter, Well Workplace. It also produces
believe it’s the largest employer-sponsored and distributes an on-line newsletter three
exercise program in the country,” says Joseph times a week that features one or more health
A. Leutzinger, Ph.D., Union Pacific’s director tips, a health article and news about the
of health promotion. company’s health promotion programs.
That exercise program has remained the Employees also receive region-specific
foundation of Union Pacific’s health newsletters, and employees at the
promotion program — but it is by no means headquarters can see a billboard-type TV that
the only health promotion element. In 1992 delivers about 100 health messages, usually
Union Pacific introduced Health Track, a risk text messages, every five minutes.
identification/risk reduction program that During the mid-1990s, Union Pacific also
targets 10 lifestyle risk factors and chronic implemented a company-wide medical self-
conditions. Last year the company modified care program. Five years ago it began to
its Health Track program to offer workers a integrate its health promotion program with its
broader menu of approaches that vary in time, alertness management initiatives — an
intensity and commitment. The modification important priority for a company with railroad
is an attempt to reach workers who haven’t operations. Integrating health into the core
completed a health-risk assessment and also to operations of the railroad, the company
encourage those who’ve completed an endeavors to help its employees see the link
assessment to do so regularly — every six between lifestyle habits and fatigue, and the
months or at least annually for those with critical relationship between health, alertness
identifiable risk factors. and productivity. Data still being analyzed,
So far, 18,000 of Union Pacific’s 50,000 says Leutzinger, shows a relationship between
employees have completed at least one health some of the risk factors identified through the
-assessment. But Leutzinger notes that is not health-risk assessment, such as being
the only way employees can interact with the overweight, and injury rates and severity of
company’s health promotion programs. To injuries.
build health awareness, it also offers a “Know The results of Union Pacific’s health
Your Numbers” promotion four times a year. promotion initiatives have been impressive. In
It conducts presentations, produces videos and 1990 the company concluded 29 percent of its
HEALTH INK & VITALITY COMMUNICATIONS 23
health care dollars were spent on known health and health care,” says Leutzinger. The
lifestyle-preventable causes. Five years later, ROI Union Pacific measured was similar to
after implementing several programs to the results of other peer-reviewed, published
provide employees and spouses with self-care initiatives: a benefit-cost ratio of
assistance in reducing their respective risk $2.77:$1.
factors, just 24 percent of the railroad’s health It all adds up. Union Pacific also recently
care costs were related to poor lifestyle habits. used the HERO database to project its health
Data just in indicates such habits contributed care cost increases over the next 10 years
to only 19 percent of Union Pacific’s 2001 based on changing demographics and risk
health care costs. factor profiles. The study tested four different
The self-care program, meanwhile, was scenarios. They ranged from what would
designed to help workers understand when it’s happen if the company eliminated its health
appropriate to self-treat conditions, rather than promotion program, to achieving a 1 percent
going to a doctor or emergency room, and to annual reduction (or 10 percent total reduction
make sure that when they do visit a doctor over the 10-year period) in total risks. The
they make the best use of that visit by being result: a $77 million difference between
prepared for it. “We’re simply trying to make eliminating the program and cutting risks just
the employee a more proactive consumer 1 percent per year, which, Leutzinger notes,
when it comes to his or her own personal Union Pacific has been achieving.
HEALTH INK & VITALITY COMMUNICATIONS 24
The Northeast Utilities Story
Northeast Utilities (NU), New England’s lifestyle habits. Between 1998 and 2000,
largest utility company, won a C. Everett 4,125 individuals at NU participated in the
Koop National Health Award for its HRA. Based on their modifiable health risks,
WellAware programming. 25 StayWell estimates these participants
After instituting the program for its generated $8.8 million in avoidable direct and
employees in 1994, the company analyzed its indirect costs.
impact on 1996 medical claims. It wanted to During that same three-year period, 2,577
know: participants completed a second HRA. Their
Does the program produce a positive overall average lifestyle score improved from
ROI? 70 to 73, and they also experienced significant
reductions in risks, including:
Did the estimates for how much the
program would save the company jive 31 percent decrease in smoking
with its actual health claims experience? 29 percent decrease in lack of exercise
Have initiatives targeted at specific 16 percent decrease in mental health risk
lifestyle and behavioral risks produced 11 percent decrease in cholesterol risk
their intended results?
10 percent improvement in eating habits
Examining annual per capita health
5 percent decrease in stress
benefits costs for the years 1992 through
1996, an analysis concluded that — during a Also, the number of health risks for these
time when most employers were experiencing repeat HRA participants improved.
per capita health care cost increases of 15 Participants with:
percent to 20 percent — NU experienced flat less than three risk factors increased 6 percent.
per capita costs. Of the total savings, NU less than two risk factors increased 9 percent.
experienced a $1.4 million reduction in six or more risk factors decreased 4 percent.
lifestyle and behavioral claims.
Conservatively attributing 70 percent, or Based on the risk reductions of the 2,577
$1 million, of those savings to the positive repeat HRA participants, StayWell estimated
effects of the WellAware program yielded a annual savings to NU of more than $1 million.
return on investment of 1.6:1. The C. Everett While completing an HRA alone has been
Koop National Health Awards concluded shown to reduce health care costs, NU’s
WellAware’s expected impact on reducing experience illustrates that completing an HRA
claims would grow greater with time. and participating in a wellness activity
Broadening participation in programs, the lag reduces risks even further. For example, NU
between the change in unhealthy behaviors employees who completed an HRA,
and reduced health care claims for many participated in at least one health education
preventable conditions, and opportunities to activity and completed at least 12 weeks of
address high cost claimants all were thought cardiovascular activity experienced greater
to be factors that could improve NU’s ROI in risk reductions than those who just completed
the future. a HRA in the following categories: blood
The first step in participating in NU’s pressure, cholesterol, eating habits, exercise,
WellAware program is the completion of smoking and stress.
StayWell’s HealthPath Health-Risk Finally, NU’s program illustrates the
Assessment (HRA). The HRA provides an effectiveness of telephone-based
assessment of important health risks that intervention programs for workers at high
participants can reduce through changes in risk in two or more health areas.
HEALTH INK & VITALITY COMMUNICATIONS 25
1 Healthy Workforce 2010: An Essential Health Promotion Sourcebook for Employers, Large and Small.
Partnership for Prevention. Fall, 2001. Page 3.
3 Aldana, Steven G. "Financial Impact of Health Promotion Programs: a Comprehensive Review of the
Literature" in American Journal of Health Promotion, May/June 2001, Vol. 15, No 5: 296-320.
Healthy Workforce 2010: An Essential Health Promotion Sourcebook for Employers, Large and Small.
Partnership for Prevention. Fall, 2001. Page 5.
5 Health Enhancement Research Organization, www.the-hero.org/research.htm.
Golaszewski, Thomas. "Shining Lights: Studies That Have Most Influenced the Understanding of Health
Promotion's Financial Impact" in American Journal of Health Promotion, May/June 2001, Vol. 15, No.5:
Anderson, David R., Seth A. Serxner and Daniel B. Gold. "Conceptual Framework, Critical Questions,
and Practical Challenges in Conducting Research on the Financial Impact of Worksite Health Promotion" in
American Journal of Health Promotion, May/June 2001, Vol. 15, No.5: 281-288.
Healthy Workforce 2010: An Essential Health Promotion Sourcebook for Employers, Large and Small.
Partnership for Prevention. Fall, 2001. Page 5.
9 Healthy Workforce 2010: An Essential Health Promotion Sourcebook for Employers, Large and Small.
Partnership for Prevention. Fall, 2001. Page 6.
Lippman, Helen. "Healthier Communities on the Horizon" in Business & Health: The State of Health
Care in America 2002, The Business and Health Institute:38,40.
Edington, Dee W. "Emerging Research: A View From One Research Center" in American Journal of
Health Promotion, May/June 2001, Vol. 15, No.5: 341-349.
Aldana, Steven G. "Financial Impact of Health Promotion Programs: a Comprehensive Review of the
Literature" in American Journal of Health Promotion, May/June 2001 Vol. 15, No 5: 296-320.
Goetzel, R.Z., T.R. Juday and Ronald J. Ozminkowski. "What's the ROI? A Systematic Review of
Return-on-Investment Studies of Corporate Health and Productivity Management Initiatives." AWHP's
Worksite Health. 1999;6(3):12-21.
17 Healthy Workforce 2010: An Essential Health Promotion Sourcebook for Employers, Large and Small.
Partnership for Prevention. Fall, 2001. Pages 6-7.
19 Healthy Workforce 2010: An Essential Health Promotion Sourcebook for Employers, Large and Small.
Partnership for Prevention. Fall, 2001. Page 4.
20 Healthy Workforce 2010: An Essential Health Promotion Sourcebook for Employers, Large and Small.
Partnership for Prevention. Fall, 2001. Page 5.
21 Edington, Dee W. "Emerging Research: A View From One Research Center" in American Journal of
Health Promotion, May/June 2001, Vol. 15, No.5: 341-349.
Healthy Workforce 2010: An Essential Health Promotion Sourcebook for Employers, Large and Small.
Partnership for Prevention. Fall, 2001. Page 29.
Agency for Health care Research and Quality, "Health Insurance Premiums Rose More Than 30 Percent
Between 1996 and 2000," AHRQ press release, September 12, 2002.
National Safety Council, Safeworker, August 2002.