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The alignment is a classic example of the "strange bedfellows" of which politics in made. Could the employer stakeholder be CAM-IM's best ally in moving toward a more rapid presence for CAM-IM in the health care system? This analysis of the award-winning worksite wellness program developed by Bernie Noe, ND, for the Vermont Automobile Deals Association (VADA), is offered to bring practitioners more deeply into the cost perceptions, tools and strategies for health outcomes which are meaningful to thoughtful employers. These may appear mundane. But learning this "employer speak" may be useful to CAM-IM practitioners, to integrative clinics, to hospitals and researchers willing to think out of the box to cross the CAM-IM-employer gap.
Determining the Employer's Global Costs of Health Green Mountain Wellness Noe's approach was based on a concept that is not familiar to many practitioners, CAM-IM or conventional: "global costs of health" to an employer. Costs to employers of an employee's poor health go far beyond the direct costs of medical treatment or insurance. These include absenteeism, disability, low productivity and even the costs to replace and train new workers. As much of a challenge as the direct costs of paying for medical benefits can be to employers, the "indirect costs" are typically far more damaging to an employer's bottom line. To gain a picture of these global costs, Noe used the following tools.
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Global Costs of Health to an Employer by Risk Factor: Direct and Indirect
(1) Only medical expenses associated with the risks. (2) Noe's note states: "Examples of these indirect costs include presenteeism (low productivity), absenteeism, worker's compensation, short and long term disability, and employee turnover. (3) Noe's reports to VADA, shared with IBN&R, only references "other studies." (4) Multiple cardiovascular disease risk includes at least 3 of hte following risks: tobaccco, blood pressure, cholesterol, exercise, bloob sugar, body weight, and stress. In Noe's reports, he did not include those individuals in hte CVDz Risk in the other categories which counted as among the individual's 3+ risk factors. (4) NA indicates either that Noe could not find data or, on hte case of "Body weight" and "Obesity & Overweight," a different category was used.
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Noe then paired these estimates with outcomes of the HRA. These identified the total number of participating employees with different risks. Through simple multiplication, VADA's members gained a powerful snapshot of their likely global costs due to modifiable risks. These data also gave Noe some ballpark, baseline numbers against which he could compare risk-associated cost estimates after a year of the program and its interventions. Using Prochaska's Stages of Change Model: Shifting the Employee Psyche Noe added to this basic analysis a survey tool developed through the Stages of Change Model developed by James Prochaska, PhD on a person's readiness to make changes in their life. Individuals self-describe which of the following stages represents their relationship to modifying their risk factors:
These findings allow an employer's wellness resources and lifestyle change intervention to target those who are most likely to benefit. Noe also gained a useful secondary measure of program outcomes. Would education about, attention to, and treatment of, these risk factors shift the employee population toward more awareness and action? The first phase of the VADA program, which received the Gold Award for Worksite Wellness from Vermont Governor James Douglas, might be characterized as intervention light. The chief tools were:
Noe felt the pedometer challenge was particularly beneficial in achieving the outcomes. In the 12 week program, 1100 employees and their family members participated. Each received a free pedometer and an informational/motivational handout each week. The goal was for each participant to walk 10,000 steps per day. The structure was a group competition between the auto dealerships. Each weekend the winning dealership in various categories was given a sign "celebrating their success," Noe notes. At the end, cash prizes were awarded for highest step counts, greatest employee participation, greatest family participation and the most improved individuals. Noe notes that "the goal was to get co-workers and family members to support each other and to shift the work and family environments toward encouraging physical activity." He adds that survey-based self-reports after the challenge showed weight loss, sleep improvement, decreased fatigure and other possitive outcomes. Sample Shifts in Health Risks and Readiness from Phase 1 Based on second year data, provided by Noe to IBN&R - and as a basis for the Vermont award - the simple program showed a positive pattern of impact toward lowering the economic risk to VADA's members. Positive changes were witnessed in compliance with various testing procedures. Participation in screenings jumped for colon cancer (13.1%), prostate specific antigen (36.9%), testicular self-exam (25.9%), mammogram (14.7%) and self breast exam (4.2%). More important ot VADA, a pattern of reduction of risks was found for numerous conditions.
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Changes in Employee Health Risks: 2005 to 2006
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The chart shows changes of all screened employees, 2005 to 2006, then just those screened both years, allowing an apples-to-apples comparison. The last column is those who were screened both years and participated in the pedometer challenge. With a very few exceptions - notably eating sweets and being overweight - the number of employees with a specific risk factor decreased. (Noe notes that the increase in those "overweight" can be accounted for by the decrease in "obesity," a separate category, and thus is a positive outcome.) For many factors, the percent of participating employees found to have the risk factor fell between 15% and 25%. More significant diminutions were found in the "pedometer challenge" group. Noe is particularly pleased with the hypertension and cardiovascular risk findings. The second year's data on Prochaska's readiness for change scale also produced a positive wave of movement. The percentage in the "pre-contemplation" and "contemplation" stages tended to fall. Those moving toward doing something -- from "preparation" to "action" and "maintenance" tended to go up.
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Changes in Employee Readiness for Change: 2005 to 2006
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The principal outcomes from these measures, for Noe's business, Green Mountain Wellness Solutions, is an expanded contract for the coming year. This will include the Phase 2 pilot interventions, using naturopathic physicians, with 43 high-cost employees, as reported earlier. Noe is clear that the outcomes will be more valuable if changes hold over two or three years.
Some thoughts and lessons from Noe's work:
Readiness for Change and the Care-Givers Dilemna Two comments on the use of the Prochaska tool. Evaluating "readiness for change," which, when applied, focuses resources on those who are ready to make change, is anathema to many practitioners. Many, by nature, want to help everybody -- which of course sets up the old paradigm verticality in practitioner-patient relationships: I can do this for you. To take
I am reminded of a loss of innocence I had while walking, or rather running, precincts with my brother Tom during his campaign for Seattle City Council 17 years ago. We passed by many houses in our doorbelling. I asked him: "Aren't there voters living there? Why are we passing them?" He waved the precinct map and list of targetted addresses to me: "We don't have the time to go to all the houses. We are targeting 'perfect voters' - those who have voted in each of the last three elections and who we're pretty sure will be voting again." Prochaska's model asks a similar, hard-headed economy of all who respect its findings. One targets resources on, if not "perfect patients," then at least those who are moving toward action in making changes. Increased consciousness among CAM-IM practitioners of, and comfort with, the cold efficiencies in the evidence supporting Prochaska's work may be a key to a employer kingdom. (Thanks again to David Matteson for bringing Noe's work to my attention.)
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