Prelude: Employers have an economic interest in employee health. The costs are direct, and indirect. These interests are remarkably coincident with the outcomes many CAM-IM providers claim to achieve in their work to create health with the individuals they serve.

Motivations are likely to differ. Some might call them polar opposites. The employer stakeholder in health will be interested in the individual's contribution to corporate profitability. The CAM-IM practitioner stakeholder will focus on the individual's mind-body-spirit. The practitioner may be repelled by the thought of allowing notions of profitability to infiltrate the presumed sanctity of the practitioner-patient relationship. Yet the outcomes each seeks are remarkable concordant.

Corporate Interests in an Employee's Health Global costs of health	CAM-IM Practitioner Claims re: a Patient's Health Whole-person health
Increased functionality	Person's ability to do more, get around better
"Presenteeism"/ worker productivity	Less tiredness, depression, diminished pain
Lower absenteeism	Less tiredness, depression, diminished pain
Job satisfaction	Quality of life, enjoyment of life
Lowering medical costs	Fewer needs for depleting parmaceuticals and medical interventions

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.

CAM-IM clinic leaders, practitioners and researchers,
ask yourselves:

Can you show societal value of your whole practice
by reducing an employer's global costs of health?

---

Determining the Employer's Global Costs of Health

Green Mountain Wellness

When Noe received his challenge, from VADA, to develop a worksite wellness program (see prior IBN&R article), he chose to go to school on other successful programs then develop his own. His reasoning was that he wanted to be able to generate and easily evaluate program outcomes he and his client established, rather than those of an outside vendor.

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.

• A health risk appraisal (HRA) to provide baseline health data. (Much of this may be imbedded in a whole-person intake form.)
  
• Proven data from the Health Enhancement Research Organization (HERO) on the relationships between 10 modifiable risk factors and direct excess medical expenditures which are associated with them.
• Data from other studies on indirect costs associated with various health risks.
  

Health Risk	Excess Medical Spending (1) (direct)	Presenteeism Costs (2) (indirect)	Absenteeism and Disability Costs (2) (indirect)
Source	H.E.R.O.	Other studies (3)	Other studies
Multiple cardio- vascular dz risk (4)	$4609	NA (5)	NA
Depression	$2630	$7559	$5333
Blood sugar	$1580	NA	NA
Body weight	$1301	NA	NA
Stress	$1235	$2050	NA
Tobacco	$777	$1399	NA
Exercise	$773	$950	NA
Blood pressure	$709	$3509	$191
Cholesterol	$495	NA	NA
Diabetes	NA	$5669	$411
Obesity & Overweight	NA	$749	$353
Back pain	NA	NA	$850

(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.


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:

• pre-contemplation - no plan for change within the next 6 months
  
• contemplation - intends to make a change within the next 6 months
  
• preparation - intends to make a change within one month
  
• action - has made a change within the last month
  
• maintenance - has made a change between one and 6 months earlier.
  

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 Simple Interventions in Phase 1

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:

• Education and awareness to one's own risks, through the HRA process.
• On-site screening coupled with the HRA. Referral to primary care providers of those found to have hypertension, high cholesterol, diabetes and pre-diabetes.
• Referral to an employee assistance program and a "Quitline," provided through all hospitals in the state, which offers telephonic counseling or in-person programs. Participation was not monitored. (Noe's firm recently added a smoking cessation program through the Quitline, with first enrollees in June 2006. This program offeres cash incentives for those who stay smoke free through their participation.)
  
• A "pedometer challenge" to get employees, and their family members, to begin exercising more, and to be aware of how much they walked in a given day.

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.

Under Noe's strategy, a second phase, described in the previous article, will involve focused medical interventions, by licensed naturopathic physicians, on a limited population. Noe states that the selection of naturopathic physicians is because "they are experts in helping those with chronic disease to manage their conditions with low-cost, preventive therapies such as diet, lifestyle and exercise therapies, as well as natural medicine - and there is evidence that these can reduce health costs." The services will be provided by a statewide network Noe has credentialed. Outcomes will be monitored.

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.

Risk Factor	Total Number 2006	Change from 2005 in all screened	Change in all screened both years	Change in those screened both years who were in the pedometer challenge
Hypertension	202	-38.7	-36.3	-47.2
High cholesterol	196	-19.1	-16.5	-13.2
Smoking	190	-12.9	-17.0	-6.9
Excessive work/ persona stress	178	-16.3	-24.5	-30.0
High risk stress	110	-15.8	-23.7	-15.3
Excessive fat intake	103	-17.9	-17.6	-15.3
Excessive alcohol intake	54	-30.6	-49.1	-56.0
Multiple CV risk	69	-26.3	-34.8	-42.9
Overweight	348	+6.0	+9.0	+10.2
Obesity	241	-14.4	-14.7	-20.7
Excessive intake sweets	309	+39.7	+29.7	+43.9

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.

Behavior Readiness	Year	Exercise more	Increase fruit & veggies	Reduce stress	Reduce fat intake
Pre- Contempation	2005	18.3%	34.0%	46.7%	37.8%
	2006	15.1%	30.7%	43.7%	33.0%
Contemplation	2005	23.6%	14.0%	11.2%	11.0%
	2006	18.7%	11.6%	10.5%	11.6%
Preparation	2005	27.5%	19.4%	12.0%	17.7%
	2006	32.6%	21.6%	16.5%	18.3%
Action	2005	11.1%	11.6%	7.7%	12.6%
	2006	14.8%	15.2%	6.9%	6.3%
Maintenance	2005	14.9%	15.0%	13.6%	14.2%
	2006	15.6%	16.5%	12.9%	15.9%

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.

Showing employers - including government agencies - the ability to lower the global costs of health may be the fast train to arriving at legitimary and increased usage of whole person care.

Comment: I have reported elsewhere - and will again! - that CAM-IM leaders and stakeholders, when surveyed, have indicated that, next to the consumer, the employer has the strongest alignment of interests with integrative medicine among stakeholders in health care (i.e., as compared to "hospitals and health systems," "government" and "insurers/HMOs"). The ability to lower the global costs of health to an employer may be the best and quickest way to show the societal legitimary of CAM-IM.

Some thoughts and lessons from Noe's work:

• Using the Intake for Outcomes A good intake form is a "health risk appraisal" for the patient. How many practitioners doing pre-posts of their intake findings? Outcomes on a patient pool -- using the estimated direct and indirect costs associated with risks, Noe uses -- may be a great and simple marketing/outreach tool to back the assertion that one's approach will save on health care costs.
  
• Don't forget the basics The apparent benefits of mere consciousness (becoming aware of risks) and of the "pedometer challenge" are intriguing. How many CAM-IM practitioners are prescribing pedometers to their patients to help them increase their awareness of their daily movement/exercise?
• NCCAM - more health services/whole practice funding, please ... The NIH NCCAM has identified both health services and whole practice research as priorities. Grants continue to be prioritized toward RCTs. This prioritization serves the present NIH hierarchy of values, which is an expression and outgrowth of a failing health system. The public good, harmed by escalating health care costs, suggests a re-direction is in order.
  
• Readiness for change Many CAM-IM practitioners are continuously, informally evaluating this in their patients/clients. What value may come through formally using a tool and sharing outcomes with patients? Viewing the Prochaska categories, and even knowing the science behind them, may be a lesson in tough love for patients about their role in a healthcare practice which requires changes in behavior for enduring success.
  

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

Increased consciousness of the efficiencies gained from applying Prochaska's work may be a key to the employer kingdom for CAM-IM.

the patient into the readiness-for-change dialogue enforces the horizontal nature of patient-centered care. It also may mean that a practitioner-patient duo might conclude: No point in us working on this now, then. Not necesarily firing a patient, but at least putting them on leave. There can be immediate economic repercussions to the practitioner, as difficult to stomach for the practitioner as the feeling of rejection may be to the patient.

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.)