The United States spends too much money on health care, and most of it goes to treatment of preventable chronic diseases. Approximately half of all Americans suffer from at least one chronic condition. Roughly two-thirds are overweight, approximately one-third is obese, and we spend 84% of our entire health care bill on treating chronic diseases. That comes out to be about $2.2 trillion per year or about 18% of our annual gross domestic product.
For all this expense, we actually receive very little health. The United States ranks very low on the list of healthiest nations partly because we invest very little in social programs (such as early childhood education, housing, and income supplements) designed to support the investment in health care. Whereas other Organisation for Economic Co-operation and Development countries invest in social programs compared with medical programs, with a ratio of about 2:1, the United States does so at a ratio of about 0.9:1. Shifting investments in the health of our population so it produces a better social to medical program investment ratio, while simultaneously applying resources to primary prevention and health promotion, is likely to do a lot of good.
Primary prevention includes engaging people in healthy behaviors before they are diagnosed with disease. Health promotion includes the same but doesn’t stop at the diagnosis of disease. Treatment of disease typically starts with a diagnosis for the individual and is followed by a treatment plan. Prevention usually follows a reverse order — it tends to start at the population level and works backward to engage the individual. The idea is to shift the entire population-wide risk distribution to a healthier level. In effect, it changes the norm.
The common modifiable risk factors, including physical inactivity, poor diet, tobacco use, and alcohol misuse, are related causally to as much as 40% of all deaths in the United States and the major preventable chronic diseases. According to the World Health Organization, if these modifiable risk factors could be eliminated, as much as 80% of all diabetes, heart disease, and stroke would be prevented. Furthermore, according to studies conducted in the United Kingdom, people who adhere simultaneously to all 4 of these behaviors live 14 more healthy years as compared with those who do not. Extra years of healthy life are those years that you receive right away, not at the end of your life…which are the not-so-healthy years.
Applied to the worksite setting, primary prevention and health promotion can make a major impact on the health of all employees, the families of these employees, the company, and the broader community. However, to make this happen, the impact of prevention and health promotion must be made visible, needs to be both persistent and financially attractive, and so easy to “consume” that it doesn’t require a conscious decision (3). Evidence demonstrating the effectiveness of prevention and health promotion requires measurement — because without metrics, the effort is invisible. Because of the population health nature of prevention, statistics, and aggregate-level data will be used to describe results and, hence, will lack emotional effect. Translating the estimated impacts at the population level into compelling personal stories can ease the challenges of showing a program’s worth profoundly. An example of making the impact of a population-based program visible is provided in the Figure. In this graphic, individual employee changes in health status are modeled across five health categories and presented as the percent of population change of each of those categories during the course of 2 years. This shows the dynamic shift in moving the population as a whole along the health continuum. Because these employees were exposed to a comprehensive worksite health promotion program, the changes in health status in this population indicate that 13% increased their risk level (“Got Worse”), as defined by moving down by either one or more categories. A total of 66% of the population did not change health status category during this time frame, whereas 21% reduced their risk factors (“Got Better”) and shifted up into lower risk categories. In total, the net change in health for this population is 8%, a positive net number represents improvement in the health of the population. This graphic represents an interesting way to depict population-level results after 2 years of health promotion and disease prevention. However, the translation of this figure into a compelling personal story that stirs the emotions of people, attracts media coverage, and makes people realize the power of prevention is clearly lacking.
Persistence is necessary because prevention and health promotion involves behavior change or maintenance of already healthy behaviors. The effect of the program takes time to emerge. Population-based health promotion results at the workplace are associated with significant net savings (1). However, when health promotion efforts that support the entire population are analyzed by carving up the population into subgroups with or without disease, it is not surprising that the healthy subgroup without a chronic disease doesn’t generate a lot of savings — because they were low cost in the first place. Health promotion includes engaging people across the entire continuum of health in healthy behaviors. This is an integral and major component of disease management programs, a design feature that tends to receive little attention in financial analyses (2). Prevention and health promotion are population health strategies, not targeted subgroup analyses applied only to those who are healthy and low cost. In fact, primary prevention and health promotion generate a lot more value than only those outcomes that can be monetized. For example, it is difficult to monetize the value of improved social cohesion of work teams or the willingness of employees to stay those extra hours to get the product out the door because they take pride in their company.
Probably more important than any other strategy is to create an environment in which individuals don’t have to make decisions about what option is best for their health but rather allows them to enjoy an engineered solution that keeps them from being harmed, minimizes avoidable risks, and optimizes their chances for maintaining health and well-being. Examples of such engineered solutions include airbags in cars for physical health, opt-out choices for automatic pretax 401-K contributions for financial well-being, and equipment guards to protect workers from workplace hazards. Organizational policy can make a major difference in the physical and psychosocial environments at work and provide a high level of ease for workers to make the right choice. Examples of prevention policies at the workplace include smoking bans, ensuring that only healthy food and snack options are provided at company-sponsored lunches and providing locker room facilities and bicycle storage to promote active commuting to work.
Prevention and health promotion programs can have major positive impacts on the organization and its people; however, such impacts are easy to miss when they remain invisible. Perhaps the time has come to shine a light on those things that did not happen, were avoided, and altogether invisible — yet at the same time generated savings, kept people active and productive, and produced real value. We need to find them through metrics and stories, communicate them, and celebrate them. Tell the stories that bring prevention to life!
1. Baicker K, Cutler D, Song Z. Workplace wellness programs can generate savings. Health Aff
. 2010; 29 (2): 1310–31.
2. Caloyeras JP, Hangsheng L, Exum E, Broderick M, Mattke S. Managing manifest diseases, but not health risks, saved PepsiCo money over seven years. Health Aff
. 2014; 33 (1): 124–31.
3. Fineberg H. The paradox of disease prevention. JAMA
. 2013; 310 (1): 85–90.