DEPARTMENT OF HEALTH AND HUMAN SERVICES
Meeting of: Secretary's Council on National Health Promotion and Disease Prevention Objectives for 2010
September 12, 2000, Proceedings

Agenda Item: Panel: Use of the 2010 Objectives by the Business Community

DR. SATCHER: We come to our third topic of the day, which is the use of the 2010 objectives for the business community, or by the business community. I think during the last few years, under the leadership of the Partnership for Prevention, we have certainly made notable advances in involving the business community in Healthy People. One of the signal achievements was the creation of the Partnerships for a Healthy Workforce by the Partnership for Prevention.

So today, to moderate this panel, we have with us Gary Lindsay of Partnership for Prevention, who will introduce the panelists. As before, there will be an open discussion following the panelists. We are asking the panelists to make their presentations as concise as possible.

Gary Lindsay, Partnership for Prevention (Moderator)

MR. LINDSAY: Thank you, Dr. Satcher. I'm Gary Lindsay, Director of Business Partnerships with Partnership for Prevention in Washington, D.C. I'm pleased to moderate this panel on use of the 2010 objectives by the business community.

The way companies do business has changed enormously in the past decade. With information technologies, e-commerce and global markets, it's easy to forget that a company's most important asset is its employees, that a commitment to employee health can be the company's most promising investment opportunity.

More than anything else, a healthy and productive workforce enables businesses to grow and keep their competitive edge. By investing now in health promotion and disease prevention, we know that employers can reap a range of short and long term benefits, including reduced medical expenses, increased productivity, longer employee retention, and a more positive corporate image.

As Director of Business Partnerships, I staff Partnerships for a Healthy Workforce, a project that is funded by the Robert Wood Johnson Foundation. Partnerships for a Healthy Workforce is a follow-up effort to the Healthy People Business Advisory Committee which, you may recall, provided private sector input into the development of Healthy People 2010 objectives.

Worksites are where adults spend the majority of their waking hours and can have a powerful impact on individual health behaviors. Healthy People includes two specific worksite health promotion objectives. The first is that all employers, regardless of size, offer a comprehensive worksite employee health promotion program. The second is to have all employees participating in those health promotion efforts.

That is just two worksite health promotion objectives. With 467 objectives in a two-volume set, as big as the telephone directories in Chicago, we need to give some guidance to businesses on what objectives they can really focus on.

First, you will hear from the panel presentations that businesses in most cases do not recognize the connection between Healthy People 2010 objectives and the range of short- and long-term benefits that employers desire and health promotion programs can deliver. Secondly, if employers recognize the connections between Healthy People 2010 and all of the benefits of worksite health promotion, they still need guidance on how to adopt the employer-related Healthy People objectives.

As many of you know, the 467 Healthy People 2010 objectives, while not specifically addressing employers, are perfectly suited for worksite health promotion programs. Using Healthy People 2010 as a guide, Partnership for Prevention identified a small set of leading health objectives for employers, which are included under Tab 7 in your hand-out. These objectives are based on several criteria, including high burden of illness and injury among U.S. working-age adults, availability of effective and, in some cases, low-cost health promotion and disease prevention opportunities to address these issues, and the importance and relevance of these issues to both employers and employees.

This set of leading health objectives is diverse. Some aim to improve individual health behaviors, while others focus on physical and social and environmental factors in important health systems issues.

Now I would like to introduce the panelists. Speaking first, on my far left, is Dr. D. W. Edington, Professor, Division of Kinesiology, and Director of the Health Management Research Center at the University of Michigan. Following Dr. Edington, and sitting next to him, is Miss Pam Witting, Manager of Health Services, Engines and Systems for Honeywell, and the last panelist, Ken Holtyn. Kenneth Holtyn is the owner of Holtyn and Associates, a health promotion consultant. I will provide a more full introduction to each when I introduce the speakers.

What I have asked is, drawing upon their knowledge of worksite health promotion and their experience, I have asked the panelists to take 10 minutes each to address two objectives. The first is to describe the extent to which their business or companies that they work with have adopted the Healthy People objectives, either deliberately, when they plan a worksite health promotion program, or unintentionally, when their existing worksite health promotion objectives coincide with the Healthy People objectives. Second, to describe the challenges facing business in adopting Healthy People 2010 objectives.

I also asked them to add one more thing, that is, to come up with their top two, three, maybe four recommendations. Some of them have been writing frantically as they've been listening to the earlier presentations. I think that is what you should really target in on.

D. W. Edington, University of Michigan

So let me introduce Dee now. Our first presenter is Dee Edington. Again, he is Professor of the Division of Kinesiology and Director of the Health Management Research Center at the University of Michigan. He is a research scientist in the School of Public Health and a frequent faculty member at the Michigan School's Executive Education Program. Dee's research focuses on the precursors of disease and vitality. His interest is in the relationship between healthy lifestyles, vitality, and the quality of life as they benefit both individuals and the organization.

Dee has authored and co-authored over 300 articles and presentations, and several books, including my favorite, The One-Minute Manager Gets Fit, which I have an autographed version of.

Over one and a half million individuals have completed the Health Management Research Center's Health Risk Appraisal. The concepts and the materials from the Center have influenced health promotion and wellness programs in over a thousand corporate worksites.

Current research is concentrated on eight organizations and nearly two million persons who have been in the Health Management Research database for seven to 15 years. These longitudinal studies continue to provide leading-edge research and learning opportunities. You can find a research update on the Health Management Research Center in your hand-out behind Tab 7.

Again, Dee will draw on several years of work with Steelcase, Bank One, Progressive, Xerox, Detroit Diesel, Genesys Health Systems, Honeywell, United Auto Workers and General Motors. Dee Edington.

DR. EDINGTON: Thanks, Gary. I appreciate the opportunity to be here today. I'd like to talk pretty fast today. Many of my slides are already in the review of our last 20 years of research, so I'll go reasonably fast.

I'll concentrate mainly on the Leading Health Indicators, rather than on the occupational health and safety guidelines. In the corporate world, a lot of this stuff often falls under health and safety, and these guidelines emphasize the safety part of health and safety more than the health side. But they are well written; they're relevant; they're understandable; they're measurable; and they're enforced by OSHA and NIOSH, which gets peoples' attention.

So this is what we are talking about today, the issue around large corporations. This is us at the University of Michigan. We have a house across the Power Center if you get on the Ann Arbor campus. There are 30 of us in there that are studying these issues.

The materials in the briefing books are primarily a result of our last 20 years of research. The purpose of the papers is to illustrate the type of outcome measures that corporations are interested in as they have driven this research over 20 years. Our research is funded by about two and a half to three million dollars a year by these corporations.

The purpose of today's short presentation is just to emphasize the importance of developing relevant objectives and targets for corporate health managers. Corporate health managers need achievable targets. Corporate health managers need appropriate objectives, and corporate health managers need cost-effective strategies. That's what they are crying for out there.

The outline: I'll go over some of our corporate consortium members. I won't talk about all of them, although I'll hit you with the worst one first. The contrast in development of Healthy People 2010 -- as you developed Healthy People 2010 -- and what was happening out in the corporate world. Then you'll see the differences and why there are some problems between 2010 and the corporate needs. And compare the Healthy People 2010 objectives with the objectives of corporate health managers.

Basically, corporations work on a population-based management, like public health, from low risk people over to people with existing diseases. One of the opportunities is to have disease management programs. Another is to do preventive services and screening. The third opportunity for these programs is low-risk maintenance programs and risk reduction. Often we focus on risk reduction but -- I will show my research and you should read the materials -- I think the real opportunity is how you maintain the low-risk population.

The basic model we have been following is related to healthier people, better employees; everybody necessarily agrees with that. Most of the issues around 2010 are over here, related to health management or population-based programs related to healthier people. Corporations are interested in these. Of course, they're interested in health status and life expectancy, but these are the things that really drive corporations.

You can't go into a corporation with a 10-year objective. You can't go into an HMO with a 10-year objective. You can't go more than six months or a year, or two years, or three years at the very most, where you have any kind of attention.

These are the participants in our health management program. These are the companies that I work with. The first one was in 1980...during those years when we started the longitudinal studies. It includes two million people, as Gary said, two million people in our database since 1980, and in some cases '85. We have health risks and behaviors; we have all their health care costs by ICD-9/CPT codes. We have all personnel data; we have absenteeism data, disability data. So it's a pretty robust data set.

I now want to talk about the first one. This comes from one of those companies. There are five of them here, this one and the next slide. The objectives are not very usable. They are not applicable to the workplace. We target issues driven by data from the health risk appraisal, disability claims, drugs, and medical costs. The objectives are academic and bureaucratic silos. That's the worst case. It gets better from there, but I won't talk about the rest of these. You can read them; you have the hand-outs. By the way, for others, hand-outs are outside.

Basically, the information is good information, but it's not applicable to us. I'll show you some reasons why that's the case.

This is what was happening in the Healthy People project from 1979 to 2000. I've been involved in this project from early on. This is an interesting model and we all like the model. People who have been designing the models -- it's more appropriate for them than for those who read them. So it's sometimes hard in the corporations for people to read that model. It's a wonderful model, but it is not very applicable to the outside world.

Here is physical activity. Let me talk about three, the first ones that you have listed in 2010. Physical activity -- you see you've got good data tracking; you'll see what's happening over these past 10 years. I'll focus on the seniors, on adults. Then you go to your objectives, and you say, the objective is 30 percent over the next 10 years. From a statistician's point of view or from a corporation's point of view, there's no way you can reach that. That's not a very reasonable objective. So the corporations have a look at that and say, that's impossible. All your data show you haven't moved at all; in fact, you've even gone down a little bit. And now you're going to double the participation rate.

When we look at obesity, we see the same thing. Obesity right now is 23 percent. Every corporation we were looking at is losing the obesity battle. No one is winning in, not one corporation. In not one piece of data I have seen is anyone winning the obesity battle. We are all getting heavier; we are all getting less exercise and so forth. So to say we are going to go from 23 percent obese to 15 percent obese doesn't have any credibility.

Finally, in cigarette smoking, the data is pretty stable. We made some early gains before 1990, but it's been pretty level ever since then. Yet the goal will say, we're going to go from 24 percent smoking to 12 percent smoking. So the objectives are not very achievable and don't carry credibility.

In the meantime, in the corporate world, the issues changed from 1979. The corporation was somewhat more involved with public health in the early '70s. In the early '70s, when we started health promotion and health management programs in corporations, these were our goals. They were very much in sync with public health goals. But then, from 1985 to 2000 the world changed. Measurable outcomes changed to these goals -- health status and health care costs, absenteeism, disability, and cost effectiveness. So the goals changed in the corporate world from the public health goals we shared in the 1970s to more measurable goals, outcome measures.

Part of the reason for the change out there in the world is that corporations are seeing their costs for health care rise. Corporations don't argue that we don't have the best health care system in the world. Every corporation I know agrees with that. But the cost was the problem. So this was what was happening with the Gross National Product; this was going on overall. We had no problem over here when we started this. In early 1979, we started with the 1990 objectives, but then it went off. So we changed our goals.

Basically, what are the corporations looking at? They look at their population. They see that 15 percent of the population are high risk; that's five or more risk factors. It turns out that, as you look at the relationship of risk to cost, it's not the single individual risk factors that are making the difference. It's the combination of risk factors, the co-morbidities. That's where you make the difference in terms of cost, especially if you control for age and gender.

So 15 percent of the population has five or more risk factors; 27 percent have three or four risk factors, and 60 percent have zero to one or two risk factors. These are the champions. Those are people that are not costing you a lot of money. We'll show you that later.

So when we talk about corporations, the primary outcome measure is, what is your percent of low-risk population? What is your percent of market share? Market share and low risk population -- those are the winners. And how do you keep them there?

Now, this slide suffers, and many of the data we see in the 2010 objectives suffer, from the theory of the uncertainty principle. The uncertainty principle, as all of you know, is that, if you get a piece of data, you don't know which way that data is going. The only way you can know where it's going is over time. What happens to that single person over time? That's the kind of data that we've been collecting.

Even though you're very good at risk reduction, these numbers never change, because there's always somebody going from low risk to high risk. So the only way you win is to stop the low risk to high risk migration. You will never win by just going high risk to low risk, because there's always a continuous supply of high-risk people.

This is a slide that changed a lot of peoples' minds in the corporate world. It was first developed at Steelcase. Now this particular slide has 600,000 people on the slide. Here's the financial cost of low-risk people, zero, one or two risk. And of course, you don't want to get old; even if you stay low-risk, the costs still go up.

These are the non-participants. What this shows is that there's not much of a bias in the data. Here are the three or four risk factors and their costs. Even with age, it still goes up. Then here are the five or more risk factors. These are prospective costs. We do the risk in one year and measure the costs over the next three years. So do risks predict costs? The answer is yes.

So there are three learnings. One learning is, don't get old. The second learning is, within any one age group, maintain your low risk. In any one age group, as soon as risks go up, costs go up. The third learning is that health promotion and health management can win. For example, here's a 45- to 54-year old at $4600 a year. If they stay the same and go to 66 over the next 10 years, if they add risk, they go to $10,000. If they reduce risk, they go to $3700.

It's also a way to calculate excess costs. What are the excess costs due to excess risk? It turns out, about 30 percent of the costs are due to excess risk. If you take risk out of the system, you'll decrease your costs by 30 percent.

Here are two examples of appropriate objectives, three-year objectives for corporations. Corporations are interested in actives. Most health promotion programs are for actives, but we also cover dependents and retirees less than 65. That's the biggest problem for employers right now, retirees less than 65. If they could just shift the cost over to 65, then they get into Medicare, and it's not their problem. But it's still society's problem.

So there are three groups of people. If you look at just the actives, in three years, if you can get 40 percent of your eligibles participating, that's a success. The real winners are the ones that get multiple years and get 20 percent of participants. That would be a reasonable goal. Another goal would be a risk behavior change -- what is the percent of low risk; what is your percent of market share? First of all, you maintain your current 60 percent, hold on to your winners, and then also reduce the medium and high risk. If you can reduce by two percentage points in three years, that would be a terrific win.

So, to make the document relevant to large corporations, first, provide achievable objectives and targets. The second is, write objectives with appropriate outcome measures for corporations. Third is, consider the cost-effectiveness strategies. We don't see anything in 2010 that refers to cost. What is the cost to achieve those kinds of objectives? If it's going to get accepted into a serious business model, it has to have costs attached to it. What are the benefits? What are the costs? And then, provide targets relevant to corporate populations.

That's as fast as I can talk, Gary.

MR. LINDSAY: You did a great job. Thank you very much.

Pamela Witting, Honeywell Corporation

Our next presenter is going to be Pam Witting, who is currently Manager of Health Services, Engines and Systems, for Honeywell, reporting to the Director of Health, Safety, Environment and Remediation. She is responsible for the design, implementation, evaluation and integration of Honeywell's health and productivity strategies and processes. She has direct responsibility for two wellness on-site facilities, four on-site medical clinics, and absence management, which is workers comp and short-term disability management -- very important to employers.

Pam is also the team leader for Honeywell's corporate health and productivity initiatives and serves on the Arizona Governor's Council for Health, Physical Fitness and Sport. Prior to joining Honeywell, Pam managed health services for one year with Adolph Coors in Colorado, 11 years with Steelcase in Grand Rapids, Michigan, where she was also a counselor in the employee assistance program.

In 1994, the health and productivity program at Steelcase was recognized by the C. Everett Koop National Health Project Award. Pam lives the lifestyle she hopes to promote in Healthy People 2010. She enjoys climbing to 14,000-plus feet; she swims, runs, hikes and plays tennis. Pam is here to provide the perspective of health promotion from a large corporation. Pam.

MS. WITTING: Thank you, Gary. It's nice to be here. I am going to talk quickly, as Dee did.

What I did is -- I was asked to represent large companies like corporations. I work for Honeywell, which has 120,000 employees in 95 countries. I also worked for Coors, which had about 6200 employees at the time, and then Steelcase. It has about 15,000 employees.

Through my 20-plus years of working in this field, I have networked quite a bit. So I did a quick survey to 18 large companies, asking them if they, first of all, know about Healthy People 2010 objectives; where did they find out about them if they did know about them; and then, are they using them in planning their health promotion programs at the worksite. I spoke to eight companies specifically about how they were using the objectives. The other 10 companies either did not know about the objectives or do not use them in planning health promotion at the worksite.

The two questions I asked, I just reviewed that. So the first question -- to what extent do business adopt Healthy People 2010 objectives? First of all, I am going to repeat a little bit what Dee said; I'll be brief. Businesses tend to prioritize internal needs first. Needs are generally determined through health risk appraisals, disability costs, medical claims costs, workers compensation costs. That is how needs are identified as far as what internal needs are at the companies.

Where the business needs match or coincide with Healthy People 2010 objectives, they are used to validate existing programs. So if a company is doing a lactation program, they may use the lactation Healthy People 2010 guideline to validate what they're doing. Or if they're running a smoking cessation program, they may look at the Healthy People objectives to validate that smoking cessation program. I only found one of the companies that I talked to that actually used Healthy People 2010 for future planning.

An interesting part is the challenges. Why aren't more companies using these? Why aren't people paying attention to these in a corporate worksite? The first one is what we have already talked about, that the 2010 objectives do not necessarily match corporate strategies. So there is one disconnect. The second one is that, because they don't match corporate strategies, they tend to focus on internal objectives versus Healthy People 2010 objectives.

The financial restrictions may limit a comprehensive program. Like what Dee said, the cost- effectiveness of the objectives is not clear in the documents that we receive about Healthy People 2010. And cost-effectiveness -- I've been working at corporations for over 15 years. Cost-effectiveness is very important to corporations, as I'm sure you know. So if there's any way, as a recommendation, you can create some cost-effectiveness around those Healthy People 2010 objectives, especially the 10 Leading Health Indicators, for businesses, that would be very helpful. We would appreciate that work. It would really help us in doing what we're doing at the worksite at the local level.

The perception is that some of the objectives are not under direct control of the health promotion function. There are ways to get around that, but I am just emphasizing the perception of the feedback that I received.

Objectives are sometimes difficult to interpret. Again, we need specifics -- this is what you need to do; this is when; this is how. What are the strategies to get there? That kind of information needs to be a little more elaborate, I think, in the Healthy People document, at least for the business sector.

The perception is that -- and this is very common -- that people assume in the corporate world that Healthy People 2010 objectives are for the public health departments, that they don't really have anything to do with businesses. I guess any kind of information we see about it is usually from the local health departments.

One of the recommendations I would make is that we have a great opportunity for public health departments to work with local businesses. I have lived in three states, and each time I have gone to the public health department and said, I am interested in these Healthy People 2010 objectives; how can we partner together? -- the feedback I get is that the Healthy People objectives don't necessarily relate to business. It's more for the community and what's going on in the homes. So any kind of language or any kind of support that you can give to businesses cooperating with public health departments, I think, would be very useful.

I've got some examples. These are the companies at Expo II. I won't mention each company, but Motorola is the first one. They set an objective of meeting three of the Healthy People 2010 objectives a year. So they're planning for the future. They're saying, next year this is what we want to target, next year. Maybe it will take us six years to get to this Healthy People objective, but they're setting those targets.

Quaker Oats uses the objectives when they're planning program design. They look at internal needs first, but then they look at the Healthy People 2010 objectives as well.

What we've done at Honeywell -- we've done this for quite awhile -- we've taken the health objectives, and before the 10 leading indicators for employers were identified, we picked out the objectives that fit our company. We've used those objectives as measurement for outcomes for Honeywell.

Then Adolph Coors Company -- they focus on Healthy People objectives that coincide with business needs. They do a monthly -- they pick a Healthy People objective and they do a monthly campaign around that objective at the corporate site in Golden, Colorado.

So there are all different ways that people are doing it. Scottsdale Health Care focuses on physical activity; so they're focusing on that one objective. It's community-based, so anyone can join this physical activity incentive program.

In summary, the Healthy People 2010 objectives are primarily used to validate internal business needs, giving credibility to existing and future program designs. I love having these 10 indicators for businesses, because I can take that to my VP of operations -- because that's where you want to get this thing going, in operations and manufacturing settings -- and say, these are the 10 items that the Department of Health and Human Services has identified for us to meet. That's very valuable information. Inevitably, the business strategy does link somewhat to the Healthy People 2010 objectives.

The third thing is that we feel, by addressing the business needs, what the internal needs are, we are probably mirroring the greater risks of the U.S., since we are a sub-set of that.

Then the last thing I want to talk about is a couple of recommendations that we got together at our company with our human resources and our operations folks, trying to figure out how we can incorporate Healthy People objectives in our company.

The first recommendation, what I already mentioned, is getting businesses and public health departments together, partnering to develop on-site activities. I think public health departments have a great opportunity. They have a basically controlled population in the business setting. The majority of the people work, so you are going to have the majority of folks in the business setting. If you can target different activities and that kind of thing at the business setting, I think that will really help in achieving the Healthy People 2010 objectives.

Another point is, establish a grant program where employers apply for a certain percentage of money from the tobacco settlement that they can use towards low-risk maintenance and risk reduction programs, a little bit of what Dr. Edington was talking about. We know we want to use the low-risk people. We want to keep them low-risk, and we want to reduce the people with high risk. Let us apply for grant money that we can use in the corporate setting to implement those kinds of things, or at least get research done to see what's effective and what's not effective.

Another recommendation that I would really like to see eventually happen is, we as a corporation want to partner with our health plans. We believe health plans are treating the sick; they are an acute model, generally, is what health plans are talking about. Nowadays, we're starting to see more preventive guidelines encouraged. We get mailers to our home that say, have you had your mammography? That kind of thing.

That's great, but what health plans should really be doing -- I think there need to be incentives for health plans to be case-managing the asymptomatic high-risk people, the people that have three, four, five, six risk factors, but are not spending necessarily the costs yet. I really think that the health plans -- because I try to engage them. Our medical director at Honeywell, Dr. Connie Hanna, tries to engage the health plans in managing people that have multiple risk factors. You saw from Dr. Edington's research, that's where the money is spent, on those people with multiple factors. I would really like to see health plans engaged as part of the process of managing those high- risk people. It's really hard to get them motivated to do that right now, so I need your help with that.

And then another thing, which is an easy thing to do, is establishing an incentive for businesses to implement and support on-site risk reduction and risk maintenance activities. I know we provide incentives for the communities, different things for the communities. I would like to see the same emphasis being placed in the business setting.

That's it. Thank you.

Kenneth Holtyn, Holtyn and Associates Consultants

MR. LINDSAY: Our final panelist is Mr. Kenneth Holtyn. He is the owner of Holtyn and Associates, Health Promotion Consultants. Since 1985, Holtyn and Associates have consulted with and provided health promotion services to over 400 companies. Most all of them are small ones. He is here to represent small employers.

Ken Holtyn and his company have received many awards. In 1994, Holtyn Associates' program called One to One was selected as one of the most innovative programs in the state of Michigan by the Governor's Council on Health and Physical Fitness. Holtyn and Associates was the 1993 honoree of the C. Everett Koop National Award for Excellence in Worksite Wellness. Ken co-authored Health Promotion in Small Businesses: What Works and What Doesn't Work, which was published in the Journal of Occupational Medicine.

Rather than hearing from a single perspective when we are discussing this, having one small employer come in, we wanted to bring someone in with experience with 400 small companies. Ken, who is a small employer himself, a small businessman, has learned from his work with hundreds of these companies, and by definition, since he is a small employer, I think he is very well qualified to represent this area. Ken.

MR. HOLTYN: Good afternoon, and thank you for the invitation to address the Secretary's Council.

What I would like to quickly describe is just a perspective on small business. Sixty percent of all private-sector employees work in small companies, so they're not all in the big companies like we hear about all the time, and 80 percent of private-sector employees work in companies of 50 or less people. Twenty-five percent of those small businesses offer health promotion services, as opposed to what you see in the national surveys. There is a kind of ubiquitous feeling that there's worksite health promotion going on in these large companies, which there is, but the small companies are not seeing that.

I have delivered services, as you heard in the introduction, to over 400 companies, and not one of them has ever heard of Healthy People. However, all is not lost. This will go into a little bit about what Pam was talking about. I'd like to tell you about a program that I am a provider in, in the state of Michigan, called the Michigan Worksite and Community Health Promotion Grant Program. This program at its inception incorporated Healthy People into its program design, so it's getting to worksites, although they don't know it.

It exists as a partnership between the public and the private sector. The health department administers the program. There are approximately 200 private vendors that do programming. It specifically targets small business, less than 500 employees. Written into its program design are program standards of best practice that providers have to conform to in order to deliver services.

Now, what has this program done? I think it is truly amazing. Again, this is a partnership between the public health department and private, for-profit and nonprofit vendors. This program is specifically designed to be a CVD prevention and risk reduction program. It has delivered preventive and risk reduction services to over 11,000 small worksites. It has screened, counseled and educated over 400,000 employees, and it has achieved a 98 percent high-approval rating from the companies that do the programs. It's a very, very successful program model that businesses just love.

I bring this slide up because -- and I wasn't the recipient of the C. Everett Koop award; Duncan Aviation was, formerly called Kal-Aero, of Kalamazoo, Michigan. This is an example of what can happen in a small business worksite. This is from a 12-year period of looking at measured risk factors within the worksite. This company in its early days was given a grant by the state of Michigan. We are looking at lifestyle-related risk factors. We directly measured fitness at this worksite with bike ergometer tests. We started in 1998 and this is current 2000. The red is where we are at now and the start is the blue. Look how it matches with the state of Michigan, looks like, right now, too, based on behavioral data. So again, this is an outstanding example of risk elimination, risk reduction.

But the key thing I really point out here is that that's half the battle, reducing the risk. The next big part comes with, can you maintain the risk reduction over a long-term period of time? That's where the benefit starts to come in.

We don't do cost-benefit studies in small business. What they're mainly interested in is, what does my health insurance cost me? This is an interesting statement made by Rich Skouge from Duncan Aviation. This was to the business community in Western Michigan. When he was at the podium he was asked, does your program save you any money? He said, while the health insurance premiums of everyone around us have gone up by seven to 10 percent this past year, ours went down by three percent. He got a lot of attention from people in that audience.

However, I see challenges. I see health promotion as a vehicle for Healthy People 2010 to be delivered into worksites. The challenge that I see in small businesses that they face is financial. They simply can't afford these programs.

Secondly -- and this goes along with the top one -- in order to get a benefit from the program, it has to be in place for about three to five years. Most research will tell you that. Most small business worksites cannot support the program for three to five years, so it's like Catch-22. On the one hand you say, if you do these health promotion programs, we're going to lower your risks. But at the same time, their health insurance costs are going up and they're paying more money, which makes it difficult for them to invest in their employees.

The other thing I see is that there is -- I've heard the words best practices mentioned several times here. Well, in health promotion, we need to take a look at national adoption of program standards which can be formulated around Healthy People 2010 that the small business community can sink their teeth into.

Some of the opportunities that I see. Obviously, this grant program -- and I don't know how many of you here that are in the public health sector know about it, but it's an outstanding program. It has done an immense benefit to the community in Michigan. That could possibly be a model to take a look at, that could be developed country-wide.

Secondly, I would say, create a performance-based tax incentive -- we found it takes about $150 per employee per year to do effective programming at a worksite -- where companies who meet recommended participant and risk- reduction rates can get that $150 per employee, so there's accountability in the program.

Make sure that funded programs meet nationally recommended guidelines. The Association for Worksite Health Promotion has drafted a document of program standards, which about 20 national organizations have bought into. So there's a document out there that exists, which by the way does incorporate 2010 into the document.

Then lastly, you need to keep these grants or incentives in place for about three to five years, so that the benefits can come back, the economic benefits related to the program of risk reduction. Then I think we can have literally hundreds of thousands of small businesses like Duncan Aviation with very positive results, saving lives and dollars throughout the nation.

Thank you.

MR. LINDSAY: Thanks, Ken. That concludes the panelists' remarks. I'm just going to wrap it up in the interest of time. We do have a lot of challenges that face the Healthy People Business Advisory Committee that were outlined by the panel in trying to get Healthy People 2010 implemented in the business community. But I think it's doable, hopefully working with this group and others to see that happen.

Thank you.

MR. KAMEROW: I'm Doug Kamerow, here for Dr. John Eisenberg, who is the Director of the Agency for Healthcare Research and Quality, who unfortunately, although he was scheduled to be here, was consumed by the press related to medical errors in patient safety. There was a big summit over the weekend and yesterday, and they can't get him out of the studio. So I hope Dr. Satcher will be sympathetic to that. We beg your indulgence.

I wanted to ask two of the presenters, Mr. Lindsay and Ms. Witting, about the dynamic and the tension between two kinds of health promotion and disease prevention activities as it relates to business. That would be, first of all, the kind of traditional health promotion related to exercise, diet and nutrition kinds of things that are often delivered through some sort of a special office that's in a corporation, as opposed to clinical kinds of services, screening tests, that are often delivered through the medical part of the corporation and relate to health insurance and all kinds of other things.

How do you deal with the way these are sometimes split? Is one preferred over the other? They're both involved in trying to get Healthy People 2010 objectives accomplished.

MS. WITTING: I think that at the companies I've worked at, medical -- we call it medical, occupational health -- and health promotion are not necessarily together, just like what you've experienced. There's an internal struggle between those two departments as to who should be doing prevention and who should be doing treatment.

At Honeywell, where I am now -- I've been there for two and a half years -- medical and health promotion and workers comp and disability management all report under health and safety. So I've had the experience where we're all together. I'm the manager of medical and wellness, so it's one department. So we really work together. We know what the medical staff does, that they provide screening, PSA screening, cholesterol screenings, any kind of screening that is required that we need to do at the worksite.

And then we have health promotion. So what we do is, we do an internal referral system. So if medical sees someone acute who can use an exercise rehab program for an injury, we refer them to wellness. If wellness identifies somebody who's obese, who needs medical clearance, that person is referred back to occupational health. It works fairly well.

But in the two other companies that I've been in, where it wasn't together, it was quite a struggle. The occupational health nurses especially felt like they were doing wellness, when in reality they were doing screenings, which is part of wellness, but that's all they were doing, whereas the health promotion department is doing the nutritional counseling, the exercise prescription, the cholesterol education. Wellness really is doing more patient education than the medical staff was, because they're doing patient treatment, acute.

So the goal is to blend those two together, whether they report to the same function or not.

DR. SATCHER: How did people get to health promotion?

MS. WITTING: How did people get to health promotion when they went to medical?

DR. SATCHER: Medical sent them to health promotion? So only the people that were referred by medical went to health promotion?

MS. WITTING: Well, health promotion does a lot of marketing, so employees can get to health promotion in many different avenues.

MR. KAMEROW: But in small business you don't have any -- usually you're not going to have an on-site medical team, so it's going to be totally through insurance. So if you add on a program that is related to health promotion, will that have the clinical aspects in it as well?

MR. HOLTYN: The clinical -- as close as we come to that would be through a screening program. If we identify an at-risk participant with high blood pressure or high cholesterol, we refer that person medically to the primary care person. But we also take that a couple of steps further, with their permission. We do follow-up; we do letters to the physician. We do follow-up both to the client at the worksite and the physician to see to it that they're receiving the appropriate care they need.

So that's kind of how that aspect works. My real focus was primarily CVD risk reduction at worksites, which is a pretty big chunk to take on.

MS. WITTING: I think wellness is becoming more medically-based in corporations. I think it's a good thing.

MR. LINDSAY: Actually, in the 1999 National Worksite Health Promotion Survey, which is from the Office of Disease Prevention and Health Promotion, Mercer, and the Association for Worksite Health Promotion -- you may be familiar with it -- they looked at whether a risk reduction program or counseling was delivered by the worksite itself, by a managed care provider, or a combination. For more medically-oriented programs like smoking cessation, like weight loss, like substance abuse treatment and education, those are more likely to be delivered by a managed care company on behalf of a worksite than the other kind of programs like fitness and other areas.

I was with Mobil Corporation for 10 years prior to joining Partnership. I retired from Mobil when they merged with Exxon. There was an opportunity for -- when I started there in 1990, more people were in the indemnity plan. Consequently, we were providing the Health Partners program, which provided a lot of preventive health services that matched those recommended by the U.S. Preventive Task Force.

As we moved more people to managed care, there was the idea that, hey, we're paying for this twice. We're paying for health promotion services, a lot of screening services delivered by our occupational physicians and nurses, and we're also paying through our health plans for services that should be provided through primary care.

One example of a company that dealt with that very creatively is Chevron. Also, DuPont had done this, where, outside of the medical plan, they partnered with their managed care providers to offer the preventive services that are recommended, the screening services. They market that to employees with, like a birthday card that's sent every year that says, you're 50 years old; congratulations, you get to have a sigmoidoscopy this year.

So it's that kind of thing. They encourage people to take care of it through their health plan. They risk- share with the health plan, because they know costs are going to go up if more people actually go for the preventive services the health plans advertize. If they go, they actually look at the uptake rate and reimburse the health plans for seeing those employees.

MS. WITTING: One more thing. The idea about getting health plans to follow up on asymptomatic or symptomatic high-risk people -- that would be an outstanding way of getting some clinical-based information and testing and everything with the health promotion, if they partner together.

DR. KANG: I just wanted to follow this up, because there are two strategies. One is to superimpose or create a health promotion system that runs parallel to the health insurance system and the delivery system. The other -- really, I think what we are wrestling with is to actually translate health promotion and wellness into an insurance benefit. I think, in fact, if you can do that, it answers a lot of your small business problems, because you go to your health insurers.

I'll just put a plug in for what Medicare is doing. Medicare in fact is, under Healthy Aging, running several demonstration projects to look at exactly this issue of translating health promotion and wellness into an insurance benefit. Obviously, one of the evaluation criteria is going to be cost-effectiveness. If you can prove that it is cost-effective on the health insurance side and Medicare picks it up, my guess is, all other health insurers will pick it up.

MS. WITTING: An example of that is the health risk appraisal. A lot of companies are putting health risk appraisal into their benefit plan, so that when you enroll, you automatically complete a health risk appraisal.

MR. LINDSAY: This Friday, the Association for Worksite Health Promotion is sponsoring a leadership forum. I am going to be representing the Society for Public Health Education there. They are looking at ways to partner and looking at what health plans can do in delivering these health promotion services. They have Alcoa, the Wellness Councils of America, AWHP, and several other organizations that will be meeting around that and forming partnerships.

DR. MASON: I'm just a little perplexed. If I understood correctly, Dr. Edington, you said that the objectives were not realistic in terms of the workplace. I think you used smoking as an illustration in one of your charts. It's 24 percent; it has gone up for adolescents. Is this realistic? Then we heard Dr. Holtyn's presentation, and with Duncan Aviation, it had fallen down and was almost reaching the 2010 goal. I'd just like to see if I can reconcile the one statement, that some of these objectives are not realistic, with some of the data you showed with one company. They fell down and there were cost savings associated with that reduction. Where are we?

DR. EDINGTON: For one thing, the 2010 objectives that have a smoking cessation program represent all society. The working population is much different. The working population has different pockets. Some of the working population have a 10 percent smoking rate right now. So with the working population, that number is going to be about 12 to 15 percent smokers. The 24 percent smokers are the nation as a whole, and that includes a lot of people other than the working population.

DR. MASON: So you're saying the objectives are not pulling it down low enough to...

(Simultaneous discussion)

DR. EDINGTON: It is critical to define what the numbers represent.

DR. SATCHER: The only way you're going to get to 12 percent is -- the goal is to cut it by one half, so if you're at 10, you ought to be working toward five. That's the idea. It's not that, when you apply it to the population as a whole, you can say you want to go from 25 to 10 or 12 when you're already at 15. It means that we expect you to work towards seven, or else we will never get to the 10 to 12.

DR. EDINGTON: I'm somewhat on the public health side, but to state that as a 10-year goal -- and you've already shown you haven't made it the last two times -- why do you think we're going to make it in the next 10 years?

DR. SATCHER: We have new strategies. The reducing tobacco use presented new data and new strategies that we had not had before.

But let me just say, I found your presentation really sobering, and hopeful, because I think we really know what we have to do. Certainly, we're intent on following up. I think it's very sobering to know where we're starting. We need to do a much better job of communicating. We need to provide more incentives for the business community and really be clear about where they're starting from, as you're implying.

MR. HOLTYN: Duncan Aviation is a small business, actually a growing company. It expanded in the last two years from -- it's about 350 people now. There were 325 people in that slide there. Actually, for the past several years, their smoking rate was around 9-10 percent. A small worksite is a very, very different animal than a large work site, in terms of health promotion and delivery of services. I've seen where -- and I've worked with many, many companies, but probably about a dozen that have demonstrated up to 60 percent risk reduction in CVD and have maintained that for a long-term period. But these are small worksites. Their cultures can be impacted much, much quicker; the communication process is much easier. Everything is a lot easier than going to a worksite of several thousand and duplicate that. But it can be done.

DR. MASON: And yet most of our employees are in the small workplace.

MR. HOLTYN: You got it.

DR. SATCHER: We're getting a little tight on time, but Nikki --

DR. LURIE: One of the overarching goals of Healthy People is the elimination of disparities. I am curious about the degree to which the issues related to disparities are even on the radar screen for either small or large employers. And then, what are your thoughts of how to bring together the public health and business interests to work toward elimination of disparities?

MR. LINDSAY: Actually, if I could address that, it is a very tough area. I think multinational companies on the international side are more aware of that in terms of things that they do as a good corporate citizen. At Mobil -- a lot of the large companies actually that are present in small towns produce -- are trying to work towards that area.

I think that if that could become an awareness-raising that large corporations could do as a good corporate citizen in the community, to try to address some of those health issues by partnering with community organizations, that could be something that would be a really worthwhile goal to pursue.

It's done more on the international side with global issues, and by going to a Third World country and making sure that they meet some of the infrastructure needs and trying to be a good corporate citizen there. There's a big effort from the U.S. Chamber in dealing with that kind of thing, but not domestically. So I think that's a deficit that needs to be addressed.

DR. EDINGTON: Disparities in what dimension?

DR. LURIE: I would put on the table either disparities for different income distributions in your workforce or racial/ethnic disparities, for starters.

DR. EDINGTON: I think these are two slightly different --

DR. LURIE: They are different, but they overlap and are sometimes hard to disentangle.

DR. EDINGTON: In the large corporations, we found that there was very little discrimination. They are providing the health care coverage, so there's nobody without health care coverage in these populations. Most of them have pretty good health care coverage, the large corporations that I work with. So there's very little. The average at General Motors is 95 percent who have had blood pressure screenings in the last year. That's way above your objectives for the nation, even.

DR. SATCHER: How do they compare in terms of obesity?

DR. EDINGTON: Not so good.

DR. SATCHER: I'm sure we're getting there. There are some real opportunities here.

DR. EDINGTON: The issue is, the screening is provided by the organization through health and safety or health promotion and everybody gets it.

DR. SATCHER: We're going to adjourn now. Doug was talking about clinical prevention, and we have had the clinical prevention guidelines for years. We've not had community prevention guidelines, but we do have the Community Preventive Services Task Force developing those guidelines, and including studies of cost-effectiveness. So we are going to need those to really help us to move forward, because it does get beyond the medical care to the community and how the community impacts upon all of its members in the workplace as well as in other places.

Okay, the lunch is in Room 742. You go up to the next floor and you go south.

(The meeting recessed for lunch at 1:20 p.m., to reconvene at 2:20 p.m.)

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