As director of the University of Michigan Health Management Research Center, Dee W. Edington, PhD, has been measuring the effects of corporate attempts to help employees live healthier lives for three decades. He’s been called the “rock star of wellness,” seen well-heeled human resources managers jump up and down when telling him about a successful program, and heard that health plan sales representatives keep well-used copies of his charts tucked into their day planners. At the heart of it all is Edington’s data, assembled over the years through a patient, steady trek toward proving that managing employees’ health risk factors can make a difference in the cost of health care. This month, Edington is releasing Zero Trends: Health as a Serious Economic Strategy, a book he says is a culmination of his work so far — and one that offers his newly refined plan for accomplishing the goal of a healthy workforce. “We have to create a culture of health,” he says. “We have to get to the point where people start valuing the energy and vitality that health brings, instead of only thinking they are healthy because they don’t have diabetes yet.”
Edington’s background is a combination of training in mathematics, kinesiology, and biochemistry. He completed his undergraduate work and PhD at Michigan State University and his master’s degree at Florida State University. He taught at the University of Massachusetts before joining the University of Michigan’s faculty in 1976. Edington is an international speaker and consultant, and he has authored or co-authored more than 500 articles and several books, including Biology of Physical Activity, Biological Awareness, Frontiers of Exercise Biology, and The One Minute Manager Balances Work and Life. In addition, Edington has contributed to such national efforts as creating a model wellness program for NASA.
He spoke recently with Managed Care Editor John Marcille about his latest publishing effort and corporations’ growing demand for health management services from health plans.
Managed Care: You’ve been studying health management for a long time. What have been the milestones? Where does the new book come in?
Edington: We have spent a lot of time asking, “How do Americans move through their lives?” We found that people naturally flow to high risk, and they naturally flow to high cost. So we established what we call the natural flow. If a company does nothing, what will happen to their employee population in terms of risk and cost? That’s what we measure everything against — the natural flow. If you change risk, costs will change in the same direction. We thought the next step would be pretty simple. All we had to do was get people to reduce their risks. But that isn’t so easy. Wellness programs have been focusing on behavior change, and I’ve come to the conclusion that that’s been a waste of time. Because even if you do get somebody to change, you put them back in the same environment and they go right back to doing what they were doing before. That led us to think about the overall environment of the workplace and the possibility of creating a culture of health in corporations and communities. So we took our research and the best practices of our clients, and we did a lot of modeling to see what would happen if the successes we did have could be multiplied throughout a population. We’ve now come up with a solution. We’ve outlined the five pillars of a culture of health, identifying important roles for CEOs, managers, employees, incentives, and measurement. Almost half of the book is about what to do going forward.
MC: So not everything we’re doing has been wrong? We just have to reach more people?
Edington: You are absolutely correct and that has been one of our major learnings. One of the limitations of interventions is that they reach one person at a time. It’s almost impossible to get to everyone involved without a change in the culture of an organization. Interventions have typically been done for 10 or 15 percent of the population, so by the time you did get someone to change, someone else had gone to high risk. The best you can do in that case is break even. You’ve got to get to a point where you have total population engagement. My suggestion is that we bring health into the conversation as energy, vitality, well-being and high-level performance rather than the absence of disease as it is often thought about presently.
MC: How do you differentiate between programs for individuals and programs for populations?
Edington: We like to start with cultural or environmental interventions. We ask senior leaders, “Do you have a healthy environment?” Then we talk to the employees and say, “What do you think the environment is like in terms of health and productivity?” And then we look at the differences and do a gap analysis. An example would be stairwells. The company says, “We have these stairwells but nobody uses them.” The employees say, “The stairwells are locked.” So a workplace intervention would be to clean up the stairwells. Put carpet in there, add music, paint some murals on the walls. And then maybe people will use them. That’s a cultural intervention. I don’t mean to come across with the idea that we are going to get rid of individual interventions. We have to have balance.
MC: But don’t companies still operate under the silo principle, where keeping the benefits costs low is the goal?
Edington: That’s exactly right. When you shift costs to employees, you haven’t changed the cost of disease, you’ve just shifted the cost to somebody else. Companies have to approach this in a comprehensive way.
MC: Do high-deductible, consumer-directed health plans have the potential to improve the situation?
Edington: Consumer-directed health plans could be the solution if you approach it right. That’s a huge if. You have to spend a lot of time on education on the front end. You have to cover preventive services and a bunch of things around wellness, and then you have to fund it. What I like about consumer-directed plans is that they help people understand the value of health status. They understand the value of taking care of themselves, and then they become their own self-leaders and they make the right decisions.
MC: Where do health plans fit in overall?
Edington: Many insurance companies are changing into health plans, and I think that is one of the most encouraging movements of our time. Insurers have been transaction companies that just pay for sickness, and they are trying to get away from that. Moving away from the vendor concept of doing business to a partner concept is critical. Vendors provide their products to companies and make money regardless of how close the product fits the needs of the company. Partners provide the product needed by the company and they make money when the company makes money.
MC: Is this happening because the Fortune 500 companies are insisting upon it?
Edington: Absolutely. Health plans have become major supporters of our work, but the only reason they changed is because their customers demanded it. What companies want is health promotion and wellness. They want sickness coverage, of course. We are always going to pay for sickness. But they want to expand into wellness. This partnership, in my opinion, will make a major difference in the health status of the workforce and in the economic value to the company.
MC: You can do a lot with working conditions, but how do you get me to not have that Big Mac on my way home tonight?
Edington: I just say, “Go ahead and have it, but here are your consequences.” We have to get through to people with education and incentives. People have to understand that health is more than just the absence of sickness. Health is energy and vitality for yourself and for your children. That’s a social marketing thing.
MC: Are health plans going to be drawn into the social marketing part of it?
Edington: Some of the health plans we work with are sponsoring community health programs, and I think healthier community initiatives, which is the next step. You can’t have a healthy individual in an unhealthy company, and I don’t think you can have a healthy company in an unhealthy community. So the health plans are going to have to get all the way into the communities.
MC: A lot of communities have pretty fragmented health care systems. Are we talking about consortia?
Edington: Building a Healthier Chicago has a consortium of agencies that are focused on that effort. That’s exactly what it’s going to take: several health plans, the YMCAs, the health associations, the recreation departments. In Jackson, Michigan, they are doing the same thing. So people are moving in this direction. But how it gets funded is a question. In Indiana, they have passed a law that gives tax credits to companies that are doing wellness programs.
MC: We will be embarking on an incredible debate at the federal level about how we are going to organize health care. What do you see the role of the federal and state governments in health promotion and wellness efforts? And should we be looking for a certain ratio of expenditures for sickness and wellness?
Edington: From my biased point of view, we should spend 20 percent of our health care dollars on the wellness and prevention side, because sick people come from a pool of well people. I estimate that we spend between 1 percent and 3 percent on wellness, though some estimates are slightly higher. Healthy people are our champions. Everyplace else, we honor our champions. Not in health care. We wait until they aren’t champions anymore before we pay attention to them. I haven’t been encouraged by the debate so far. People talking about health care reform are still focusing on access and affordability, and the only thing that is going to do is drive up costs. Medical professionals are not going to work for any less money. I think the only solution is higher health status, and that’s why I’m so passionate about this. Treating wellness is much cheaper than treating sickness.
MC: Would this result in rationing care away from the very sick?
Edington: I don’t think so. Even if the cost of treating sick people remains the same, we’ll have fewer of them to treat. They may even be able to get better care in a real sense because we would have less sickness.
MC: Are wellness programs viable for Medicare and Medicaid populations?
Edington: Medicaid is a huge challenge because you sometimes can’t even get to the people to communicate with them. But we are doing a lot with the Medicare population. We have a half million people at General Motors on Medicare, and we have been able to make a difference in their health status. It’s better if they get started before they hit the age of 65. So Medicare should be thinking about helping companies turn over healthy people.
MC: In your book, you talk about not letting your health status get worse being a good approach.
Edington: The American lifestyle leads to high risk and high cost, and people are getting a little worse every day. You don’t exercise enough and you eat another Twinkie, and every day you get worse. And then one day you are diagnosed with diabetes, and you can’t come back. So if you have diabetes, we are going to take care of you. But if you don’t have diabetes, just stop getting worse. This simple idea takes the pressure off people. Now, if people don’t get worse, then maybe they will start to get better. And they do. We have data that show if an employee population doesn’t get worse and maybe gets a little better, the company can get to zero trend in their health care cost increases, which means health care costs will not rise higher than the rate of inflation.
MC: The psychological side is very interesting. So many of us have bad health behaviors that intellectually we know we should change, but we don’t.
Edington: You’re right. Why do people continue bad habits when they know they are bad? That’s a huge line of research that someone should spend a lot of time on. We are starting to think about that now because we are going to be changing our research direction somewhat. One of the reasons we are changing is because we know the precursors to disease. We’ve been studying that for a long time. But one of the interesting questions going forward is, “What are the precursors to wellness? Who is it that stays well or gets well and stays well?” That ties in with your question, and it would be good to understand that better. You know, I end all of my presentations, and the book, by asking, “What’s the point? Why are we doing this?” The point is not about economics or about productivity. The point is people helping people. We’re all in charge of our own lives, of course, but we have responsibilities to the people we live with and work with. How do we help each other have a better place to work? How do we help each other have a better community in which we can raise our children? How do we help people avoid unnecessary pain and suffering? That’s the point.