Posts from — November 2010

The most common screening performed in health promotion programs is heart health assessment.

The screening can include a written heart health test, blood pressure (BP) measurement, cholesterol/HDL-cholesterol test, glucose (blood sugar), weight, educational materials specific to diet, nutrition, exercise, cholesterol, use of tobacco, and weight.

The health professional conducting the screening then provides a consultation and assists set objectives with the participant.

The backbone of wellness programming at the worksite is health screening. It’s the first major activity a corporation should do when first starting a wellness program.

Biometric testing is often used in conjunction with the administration of a Health Risk Assessment (HRA) .

The most effective way to screen is to utilize a health specialist trained in wellness screening techniques and counseling to privately and individually assess participants.

This wellness professional takes a brief health history and measures blood pressure (BP) and cholesterol. With computerized cholesterol desktop analyzers, results are obtained in about four minutes.

Immediate feedback, consultation, and educational materials are provided. for those identified at-risk, follow-up appointments could be scheduled at this time.  The whole process takes about twenty minutes per individual.

The screening also provides an immediate opportunity to register participants in various health promotion programs based on their interests and identified health risks.

Biometric testing could be done on an annual basis and used as a means of monitoring health risks within the worksite.

A health testing program needs to provide multiple opportunities for participation.  The service must be provided for all the various shifts of a organization.  The screening program must be conducted in highly visible areas so the process may be observed.

Reluctant staff often like to be able to see what the wellness program is about before they participate. When wellness screeners are not busy, they ought to perform outreach going to areas where staff gather and attempt to recruit staff.

When well-planned and promoted, health testing can attract participation rates of 60 percent to 100 percent. These high participation rates have a positive impact on senior management producing support for further wellness programming.

Objectives are broad-based statements about what the health promotion program is expected to do.  The goal of the health promotion program is to enhance the health of the individual and the corporation. Objectives like mission statements provide direction in a health promotion program.

Objectives are specific and provide a means of measurement of the wellness program to determine effectiveness. There are two types of objectives, process and outcome.

Process goals state the activities that need to occur to achieve a desired outcome.

Examples of process goals are -

o  Number of participants screened

o  Number of participants in and completing health promotion programs

o  Satisfaction of wellness program participants

o  Number of participants who were medically referred and saw their physician

o  Number of promotional activities

o  Number of participants seen in follow-up

Example of outcome objectives are -

o  Number of participants who improved fitness level

o  Number of participants who decreased cholesterol level

o  Number of participants who lost weight, body fat

o  Number of participants who quit tobacco use

o  Number of participants with high blood pressure (BP) who lowered their blood pressure (BP)

o  Number of participants whose initial level of alcohol consumption put them at-risk who are no longer at-risk

o  Number of participants with risk factors who saw their physician and are being treated for high blood pressure (BP) or cholesterol years later

Wellness committees are important in that they create a sense of ownership in the health promotion program, and facilitate various tasks involved in health promotion programming at the worksite.

The committee should be composed of a cross-section of staff members representing various occupations, levels, and subgroups with the business.

A common mistake is filling the committee with the most health/fitness-conscious individuals  in the organization. Don’t rely solely on volunteers to fill a committee. Make sure that your committee members have enough power in the organization to run an effective wellness program.

The wellness committee is made up of workforce from the workplace. It oversees the health promotion program and helps carry it out.

The committee should meet about once a month to review the previous month’s activities and plan future ones. When the health promotion program is just starting, the committee may meet each week until things get going.

Committee members do not carry out medical procedures, counsel patrons, or handle confidential health information. Wellness specialists perform these tasks.

In general, the committee’s duties fall into three areas –  planning, promoting, and helping to run health promotion programs.

Developing the health promotion programs can include -

o  Finding space for activities

o  Developing and organizing workplace-wide events such as contests

o  Reviewing reports prepared by the wellness program staff and making recommendations

Promoting the health promotion program can include -

o  Recruiting personnel to take part in screening and wellness programs

o  Encouraging personnel to participate in follow-up counseling

o  Organizing promotional strategies using newsletters, signs, bulletin boards, computers, and other media available within the workplace

Helping to run the wellness program can include -

o  Setting up equipment for various activities

o  Assisting to conduct worksite-wide activities

o  Monitoring all activities and investigating  the performance of the specialist staff

o  Acting as wellness mentors to fellow workforce

The size of the wellness committee are going to be dependent on the size of the corporation. Select members by asking day management to nominate or appoint workers.

Make an announcement through flyers, memos, and meetings to recruit potential members. Explain the purpose of the committee, duties and responsibilities, and the time commitment.

Recognize your wellness committee volunteers. Allow them to take part in wellness programs at a reduced cost. Hold appreciation breakfasts/lunches/dinners.

Print names of committee members on organization communications about the wellness program.

Buy special T-shirts, caps, and buttons for them. Write letters to supervisors saying that you appreciate the member’s service. Develop awards certificates for members.

The following could be used as a guide for committee size -

o  Less than 300 employees   2 to 4

o  300 to 1,000 employees   4 to 6

o  1,000 employees or more   6 to 12

Effective health promotion programs recognize the importance of building a supportive cultural environment.  The worksite culture includes shared values/heartfelt beliefs about what’s important. It includes social standards of expected and accepted behavior called “cultural norms.”

It includes peer support from family, friends, and peers. This support can help one adopt healthful lifestyles. Tools are available to audit a organization.

The long-term success of any health promotion program is dependent on the corporate culture.

Some healthful culture signs in a organization are -

o  Staff Members communicate openly

o  Leaders support diversity and opinion

o  Workers have fun

o  Policies support wellness

o  Employees are encouraged to grow

o  Workers work together as a team

o  Employees’ skills and talents are matched to their jobs.

o  Flexible work schedules are available

o  Corporations consider workforce as their most valuable asset

Effective health promotion programs try to create healthy worksite climates. A healthy worksite climate is one which encourages teamwork, cooperation, and empowerment of the individual.

People  have a sense of community, a shared vision, and a positive outlook. Policies promote and support wellness efforts within the workplace.

o  Effective wellness programs identify ways that organization policies and organizational traditions encourage wellness.

o  Effective health promotion programs work at the group and organizational level to build support for healthful lifestyle choices.

o  Effective health promotion programs set clear target goals and goals for the health improvement of the worksite.

An initial biometric screening can include a recent survey of employees’ interests as part of the assessment. Successful wellness programs are designed to meet the needs and interests of the workforce.

The information you need to get from a recent survey depends on the scope of your wellness program. A sample survey can be obtained in the HOPE Publications Web site.

When you plan to adapt this sample survey or create your own survey, keep the following hints in mind -

o  Ask mostly closed-choice questions, in particular if you will be sending the survey to a large number of workforce. Closed-choice questions provide specific choices and are easy to tabulate. You may want to use a computer for data entry and analysis.

o  Invite comments, suggestions and recommendations, or ask open-ended questions at the end of the survey. Open-ended items are more challenging to summarize.

o  Include a brief explanatory cover letter with the survey with the signature of the organization president. Make sure to include a statement about confidentiality and anonymity.

o  Ask a group of representative workforce to review the survey before it is distributed. Find out when the questions are going to be understood by workforce and will not be objected to.

o  Include demographic information at the beginning or end of the survey. Consider various ways that you could analyze the responses by demographic characteristics (gender, age, shift, site, department, etc.).

When considering who ought to get the survey, a simple rule is if you have under 500 employees, everybody ought to receive one.  The public relations benefit of everybody receiving a recent survey may be significant.

Over 500 workers, a sample of the work population will suffice. A sample saves on costs and time. You could want to consider consulting with a statistician to determine an appropriate sample size for your worksite.

Needs surveys are confidential and anonymous; they don’t request information that may identify a individuals.

Getting support from senior level management is vital to the success of the health promotion program.

One way to do this is to survey managers (see forms) and conduct interviews with decision-makers in the corporation. You can use the surveys here or make up your own.

If you decide to do your own, keep the survey short. It should not take more than ten minutes to complete.

The interview process can also serve as a means of educating management. Give concise fact sheets on the advantages of wellness programs for management.

When surveys and interviews are completed, tally the surveys and write brief summaries of the interviews. Give these reports to management.

Once completed present a brief executive summary to management. Highlight a few interesting findings that can be used immediately to make decisions about the health promotion program.

Utilize charts and graphs to make your points. Put together a detailed report for wellness committee members itemizing each response. Provide a short article about the survey in the business newsletter.

The higher the response the more precise and reliable the results. A minimum response of 40% to 50% is acceptable.

Extensive wellness programs involve all staff, deal with all major health risks, offers choices, and target both the staff and the worksite environment; provide periodic evaluation of its results.

Extensive health promotion programs emphasize follow-up and offers support for the staff member as long as he/she is employed. Studies have shown this approach to be highly successful. Key components are planning, implementation, and evaluation.

Developing comprehensive health promotion programs involve performing a needs and interest assessment, appointing a wellness committee, selecting  wellness providers, setting goals/objectives for the health promotion program, advertising and marketing/promoting the health promotion program, and establishing procedures to ensure confidentiality.

Implementation of comprehensive health promotion programs consist of five major tasks -

1   Biometric screening and referral

2   Follow-up and counseling personnel

3   Follow-up with physicians

4   Health improvement programs

5   Organizing workplace-wide activities.

Evaluation involves monitoring wellness programs to find out if it is working and to help you refine it. Measuring success shows what you’ve achieved, helps justify costs, and provides information for upper management to support continued wellness programming.

Extensive wellness programs involve all workers, deal with all major health risks, offers options, and target both the workers and the worksite environment; provide periodic examination of its results.

Comprehensive health promotion programs emphasize follow-up and offers support for the staff member since he/she is employed. Studies have shown this approach to be highly successful. Key components are planning, implementation, and investigation

Creating comprehensive health promotion programs involve performing a needs and interest assessment, appointing a wellness committee, choosing  wellness providers, establishing goals/objectives for the health promotion program, advertising/promoting the health promotion program, and establishing procedures to ensure confidentiality

Implementation of robust wellness programs consist of five major tasks -

o  Medical screening and health risk appraisal

o  Follow-up and counseling employees

o  Follow-up with physicians

o  Health improvement and disease prevention programs

o  Organizing workplace-wide wellness program activities.

Evaluation involves monitoring health promotion programs to figure out if it’s working and to help you refine it.

Measuring success shows what you have achieved, assists justify costs, and provides information for executive management to support continued wellness programming.

Initially introduced by Halbert Dunn in the 1950’s, wellness became a well-liked buzzword during the late 1970’s and received considerable academic attention in the 1980’s.

Wellness programs for workers became more widespread during the following decade, and credible evidence for their economic viability started to be published.

There have now been over 100 published studies on this topic and a number of systematic reviews.

Health risks increase costs.  Medical and health insurance costs escalate with both age and number of risks present.8,10   the number of risks is also strongly related to sick leave absenteeism, Employee’s Compensation costs, short-term disability, and reduced productivity (”presenteeism”).

Early employee health promotion programs were relatively basic and usually produced a ROI of less than one dollar for every dollar spent operating the health promotion program (ROI = <1 - 1).8

Such wellness programs could  be characterized as “fun-oriented”.  Participation is entirely voluntary, and there’s no particular focus on the reduction of specifically identified high risks.

Interventions and activities aren’t customized, and there is no emphasis on the management of health costs.  These wellness programs are typically site-based only, lack choices to address all of the major behaviorally-related health risks, and lack multimodal presentation.

Minimal or no incentives are provided to workforce for participation, and services to spouses and family members aren’t available.  Most such wellness programs lack meaningful examination.

More conventional health promotion programs are “activity-oriented” and have shown an ROI of between 1 – 2.5 and 1 – 3.5.8 These health promotion programs may have a greater emphasis on health and risk reduction, although the efforts are relatively broad and not personalized.

They could have some generalized emphasis on medical cost management, although not necessarily aimed at specific high risks.  Most are site-based and voluntary, with spouses included only rarely.

Modest incentives may  be utilized to encourage participation.  Formal analysis may  be weak.

The newest and most economically viable health promotion programs are “results-oriented” and exemplify the health and productivity management model.  These health promotion programs consistently produce return rates of 1 – 4 or greater within a 12-24 month period.8

Such health promotion programs are strongly focused on the reduction of namely identified high risks and the management of healthcare costs. They’re typically voluntary, but use strong financial and other incentives to promote participation.

They’re multi-component in nature (address all major risks), and have both onsite and virtual modalities of operation.  The interventions are highly targeted and individualized, and offered to spouses in addition to workforce.

For corporations, the cost of providing health insurance for their staff is of excellent importance.  Those costs have been increasing at annual rates between 6% and 14%.

Chapman’s 2007 systematic review7 announced an typical reduction in healthcare costs of 26.5% thus of employee wellness programs.  His review covered 60 of the most scientifically accurate studies, with an typical of 3.77 years of study.

Absenteeism because of illness is another cost driver.  Chapman’s review7 reports an typical reduction in sick leave of 25.3%.   Cost for Employee’s Compensation was reduced by 40.7%, and disability costs by 24.2%.

There is also an emerging literature on the costs of presenteeism (reduced productivity).11,13  In one study, every risk lowered through a wellness program yielded a 9 percent reduction in presenteeism (and a 2 percent reduction in absenteeism).11

Many companies have achieved a zero% increase in healthcare costs across at least brief periods of time.10  Doing so requires 90-95% participation of the staff member population in focused health promotion programs, with 75%-85% of the personnel falling into the low risk category.10

Despite the fact that comprehensive efforts to lower the risk status of those in moderate or high risk categories must be made, the needs of currently healthy workers must be addressed as well to avoid increases in risk-status.

Given the size of the federal workforce, significant cost savings in the government’s contribution to medical insurance premiums for workforce could be achieved when a majority of that population were participating in active wellness programs.

In like fashion, improvements in absenteeism, worker’s compensation, disability, presenteeism, and turnover then of comprehensive employee health promotion programs would yield substantial fiscal benefits for the government.

References

1   Aldana, Steven G.  (2001)   Financial Impact of Health Promotion Programs –   A Robust Review of the Literature.   Am J Health Promotion 15(5) – 296-320.

2   Chapman, Larry.  (1998)   the Role of Incentives in Wellness.  The Art of Wellness  2(3) – 1-8.

3   Chapman, Larry.   (2003)   Biometric Screening in Wellness –   is it Really as Important as We Think?  the Art of Wellness  7(2) – 1-12.

4   Chapman, Larry.  (2005)   Meta-Analysis of Employee Health Promotion Economic Return Studies –  2005 Update.  The Art of Wellness, July/August, 1-15.

5   Chapman, Larry.   (2006)  Staff Member Participation in Employee Wellness and Wellness Programs –  Exactly how Important are Incentives, and Which Ones work Best?   North Carolina Medical Journal   67(6) –   431-432.

6   Chapman, Larry, Lesch, Nancy, and Passas Baun, Mary Beth.   (2007)   the Role of Health Promotion Coaching in Company Health Promotion.   the Art of Wellness, July/August, 1-12.

7   Chapman, Larry.  (2007)   Proof Positive –   an Analysis of the cost-Effectiveness of Corporate Wellness.  Northwest Health Management Publishing, Seattle, WA.

8   Chapman, Larry.  (2007)   an In-Depth Look at the Economic Evidence for Rewarding Health Behavior Change.   Workshop presentation at the World Research Group “Rewarding Healthy Behaviors for Health Plans and Businesss” Conference, Orlando, FL, January 23-24.

9   Edington, Dee.   (2001)   Emerging Research –   A View from One Research Center.  American Journal of Health Promotion 15(5) –  341-349.

10   Edington, Dee W.  (2007)   Health Management as a Serious Corporation Strategy.  Presentation at the World Research Group “Rewarding Healthy Behaviors for Health Plans and Corporations” Conference, Orlando, FL, January 23-24.

11   Pelletier, Barbara, Boles, Myde, and Lunch, Wendy.  (2004)  Changes in Health Risks and Be certain to work Productivity.   Journal of Occupational and Environmental Medicine, 46(7) –  746-754.

12   Pelletier, Kenneth R.  (2005)   A Review and Analysis of the Clinical and Cost-Effectiveness Studies of extensive Health and Illness ManagementPrograms at the Workplace –  Update VI 2000-2004.  JOEM 47(10)1051-1058.

13   DeVol, Ross, Bedroussian, Armen, et.  Al.  (2007)  an Unhealthful America –   the Economic Burden of Chronic Disease.  Report released by the Milken Institute.   www.milkeninstitute.org.

14   Partnership for Prevention.  (2008) Investing in Health –   Proven Health Promotion Practices for Workplaces.   http – //www.prevent.org/images/stories/2008/investinginhealth_finalfinal.pdf.

Corporate America is increasingly investing in worker health promotion because it is good business.  In order to meet productivity demands, companies must rely on a healthy, productive workforce to succeed in the highly competitive global marketplace.

Over a hundred studies in both corporate and governmental settings have documented the economic benefits of employee health promotion programs, including decreased absenteeism, decreased injuries and workman’s compensation costs, decreased healthcare costs, decreased employee turnover, as well as increased productivity, greater employee satisfaction, and improved morale.1-10

The more recent literature reflects improvements in health promotion programming along with greater return on investment.  In general, the more focused and intensive the health promotion program, the greater benefit realized.

To enhance their effectiveness federal government staff member wellness programs might  be able to incorporate some of the features described. Staff Member wellness programs shown to have positive returns on investment often include the following features -

1   Health and productivity management model

Programs characterized by this model focus attention on identification and reduction of specific risks or behaviors such as smoking, lack of exercise, excess weight, unhealthy diet, high cholesterol, high blood pressure, stress, depression, and so on.

High-risk staff members are in particular targeted for intervention, although the most successful wellness programs also direct efforts towards healthful staff members in order to maintain their low-risk status.  This model emphasizes outcomes as opposed to simply offering wellness activities for their own sake.

2   Health risk appraisal

Use of a computerized health risk assessment  instrument with individualized feedback and recommendations is nearly universal in successful health promotion programs. Staff Members take the questionnaire annually in many cases.

The Health Risk Appraisal (HRA) serves to raise awareness, provide direction, and motivate individuals to improve specific behaviors.  In some cases, the personalized report is directly linked to appropriate resources related to identified risks.

Research indicates that the use of an Health Risk Assessment (HRA) is effective if it’s followed by some type of educational or therapeutic intervention for identified risks.  It often serves as the entry point into health promotion programs.

3   Biometric analysis

Many wellness programs combine the results of the health risk appraisal with measurement of each employee’s biometrics, including weight and Body Mass Index , blood pressure, cholesterol, fasting glucose, and assorted other metrics.

Combining the results of the Health Risk Assessment (HRA) with biological measures leads to a more exact risk profile.   Computerized health risk appraisals often incorporate biometric data in their risk analysis.

4   Wellness Program Incentives

Workers are frequently given monetary or other significant rewards for completing an HRA, participation in a wellness program or class, specific accomplishments such as stopping tobacco use, losing weight, or exercising, and for maintaining healthful status and/or behaviors.

In many cases the monetary incentives are associated with reductions in medical insurance premiums.  Some health promotion programs use disincentives as well as incentives, such as charging staff who smoke higher rates for their medical insurance contribution.

5   High wellness program participation rates

Successful wellness programs use incentives to drive participation rates up.  They also market their wellness programs extensively, and may use contest or challenge strategies to heighten enthusiasm and encourage participation.

6   Health Promotion coaching

Staff Members with identified risks or desire to improve their health habits may  be periodically coached via telephone by trained wellness Coaches.

Coaching assists workers set and achieve realistic lifestyle-related objectives including those addressing stress, work life balance, use of tobacco, weight, exercise, and various behavior modifications.

Three or more sessions are generally offered.  In some intensive health promotion programs, the coaching extends to actual disease management (DM) intervention for employees with identified high-risk diseases.

7   Multiple formats

Programs might offer wellness content in online, paper, and seminar formats to provide stimulating variety and alternatives for accommodate the needs of all employees.

In addition to on-site exercise and healthful consuming events, on-line health promotion programs, e-mail reminders and notices, printed newsletters and materials, and workplace courses and workshops are common dissemination strategies.

8   Upper-level management support

Enthusiastic and frequent endorsement by executive management is vital to achieving high rates of participation.  When senior executives are wellness role models themselves the effects of endorsement are enhanced.

9   Frequent contact

Successful health promotion programs have frequent contact of some sort with every staff member.  This might  be through marketing and advertising efforts (e.g., posters, e-mail notices, reminders, or messages, etc.), bulletin boards, newsletters, staff meeting presentations, discussion in new staff member orientation, supervisory sessions, etc.

The key is to enhance worker awareness of wellness opportunities and reinforce the corporate emphasis on wellness through frequent and multiple “touches”.

10   Open enrollment

To encourage high participation rates staff members must have easy access to the health promotion programs and activities.  Open and uncomplicated enrollment processes achieve this.

A number of organizations automatically enroll all staff and then allow those who do not wish to participate to “opt-out”.  This practice has been proven to boost enrollment rates in some establishings.

11   Family involvement

Many wellness programs encourage spouses and other family members to participate in the business wellness activities and to adopt a healthy lifestyle along with the designated employee. It’s far easier for the employee to have a healthy lifestyle if his/her family does so as well.

12   Smoking cessation

Because smoking and other smoking is the number one threat to health it is critical to offer workforce effective and convenient assistance with quitting.

Access to tobacco cessation pharmaceuticals is usually part of such wellness programs.  In-house wellness programs provide the most convenient access to these services, although on-line or telephone-based wellness programs could  be available as well.

13   Physical Activity

Regular exercise is a core component of every health promotion program. Workers ought to be strongly encouraged to engage in regular exercise.

Most health promotion programs provide either periodic or continuous onsite opportunities, and some locations have onsite health and fitness centers, swimming pools, walking trails, etc.  Discounted or paid memberships to community exercise facilities is a common alternative to onsite facilities.

14   Weight management

Because obesity is a major threat to health it’s critical that programs offer effective assistance with weight control. Robust encouragement from upper-level management to shed excess weight is important.

Online wellness programs, workplace programs, or discounted access to weight control programs in the community may all be available.  Long-term follow-up is critical for maintenance of weight loss.

15   Stress management

Worksite stress is perhaps the most common complaint among personnel and a major contributor to absenteeism, presenteeism (reduced productivity), and low morale.

Almost all successful wellness programs offer assistance with personal and worksite stress.  Some programs refer workers to outside resources for more serious conditions like depression and anxiety disorders, but most offer online or frequent onsite general stress reduction programs.

Many businesses endeavor to structure the work environment to minimize stress, both physically and operationally.

16   Medical screenings/immunizations

Workers are actively encouraged to complete recommended health screenings for blood pressure, cholesterol, Body Mass Index (BMI), colorectal and breast cancer, and others.

Annual influenza immunizations are also encouraged.  Some sites provide these services at the workplace.  Incentives are often awarded for completion of these screenings/immunizations.

17   On-Site health care

Actual provision of onsite primary care medical services is a growing trend.  The rapidly escalating costs of medical care insurance for personnel has stimulated this trend.

A number of organizations have found that it is less costly to provide primary care services themselves than to fund those services through health insurance.

Onsite care also lowers the amount of time workers would otherwise spend away from the workplace getting such services.

References

1   Aldana, Steven G.  (2001)   Financial Impact of Health Promotion Programs –   A Comprehensive Review of the Literature.   Am J Health Promotion 15(5) – 296-320.

2   Chapman, Larry.  (1998)   the Role of Incentives in Wellness.  The Art of Wellness  2(3) – 1-8.

3   Chapman, Larry.   (2003)   Biometric Screening in Wellness –   is it Really as Important as We Think?  the Art of Wellness  7(2) – 1-12.

4   Chapman, Larry.  (2005)   Meta-Evaluation of Employee Wellness Economic Return Studies –  2005 Update.  The Art of Wellness, July/August, 1-15.

5   Chapman, Larry.   (2006)  Worker Participation in Employee Wellness and Wellness Programs –  How Important are Incentives, and Which Ones work Best?   North Carolina Medical Journal   67(6) –   431-432.

6   Chapman, Larry, Lesch, Nancy, and Passas Baun, Mary Beth.   (2007)   the Role of Wellness Coaching in Corporate Wellness.   the Art of Wellness, July/August, 1-12.

7   Chapman, Larry.  (2007)   Proof Positive –   an Analysis of the cost-Effectiveness of Company Health Promotion.  Northwest Health Management Publishing, Seattle, WA.

8   Chapman, Larry.  (2007)   an In-Depth Look at the Economic Evidence for Rewarding Health Behavior Change.   Workshop presentation at the World Research Group “Rewarding Healthful Behaviors for Health Plans and Businesss” Conference, Orlando, FL, January 23-24.

9   Edington, Dee.   (2001)   Emerging Research –   A View from One Research Center.  American Journal of Health Promotion 15(5) –  341-349.

10   Edington, Dee W.  (2007)   Health Management as a Serious Corporation Strategy.  Presentation at the World Research Group “Rewarding Healthy Behaviors for Health Plans and Corporations” Conference, Orlando, FL, January 23-24.

11   Pelletier, Barbara, Boles, Myde, and Lunch, Wendy.  (2004)  Changes in Health Risks and Make certain to work Productivity.   Journal of Occupational and Environmental Medicine, 46(7) –  746-754.

12   Pelletier, Kenneth R.  (2005)   A Review and Analysis of the Clinical and Cost-Effectiveness Studies of robust Health and Disease Management (DM)Programs at the Worksite –  Update VI 2000-2004.  JOEM 47(10)1051-1058.

13   DeVol, Ross, Bedroussian, Armen, et.  Al.  (2007)  an Unhealthful America –   the Economic Burden of Chronic Illness.  Report released by the Milken Institute.   www.milkeninstitute.org.

14   Partnership for Prevention.  (2008) Investing in Health –   Proven Wellness Practices for Workplaces.   http – //www.prevent.org/images/stories/2008/investinginhealth_finalfinal.pdf.