Posts from — June 2010

The most common screening performed in wellness 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, smoking, and weight.

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

The backbone of wellness programming at the worksite is health testing. It’s the first major activity a company ought to do when first beginning a wellness program.

Biometric screening is often used joined with the administration of a Health Risk (Assessment|Appraisal} .

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 expert 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 may 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 betterment programs based on their interests and identified health risks.

Biometric testing can be done annually and used as a means of monitoring health risks within the worksite.

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

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

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

Goals are broad-based statements about what the program is expected to do. the goal of the wellness program is to enhance the health of the individual and the organization. Goals like mission statements provide direction in a program.   

Goals are specific and provide a means of measurement of the program to determine effectiveness. There are two kinds of goals, process and outcome.    

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

Examples of process goals are -

• Number of participants screened

• Number of participants in and completing health betterment programs

• Satisfaction of program participants

• Number of participants who were medically referred and saw their doctor

• Number of promotional activities

• Number of participants seen in follow-up

Example of outcome goals are -

• Number of participants who improved fitness level

• Number of participants who decreased cholesterol level

• Number of participants who lost weight, body fat

• Number of participants who quit use of tobacco

• Number of participants with high blood pressure (BP) who decreased their blood pressure (BP)

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

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

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

The committee must be composed of a cross-section of workers representing various occupations, levels, and subgroups with the organization.

A common mistake is filling the committee with the most health/fitness-conscious people  in the corporation. Do not rely solely on volunteers to fill a committee. Make certain that your committee members have enough power in the corporation to run an effective wellness program.

The wellness committee is made up of workers from the workplace. It oversees the wellness 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 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 medical information. Wellness experts perform these tasks.

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

Planning the programs can include -

• Locating space for activities

• Planning and organizing worksite-wide events such as contests

• Evaluating reports prepared by the program staff and making recommendations

Promoting the program can include -

• Recruiting employees to participate in screening and health betterment programs

• Encouraging workers to participate in follow-up counseling

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

Assisting to run the program can include -

• Establishing up equipment for various activities

• Helping to conduct worksite-wide activities

• Monitoring all activities and analyzing  the performance of the expert staff

• Acting as wellness mentors to fellow employees

The size of the wellness committee will be dependent on the size of the organization. Choose members by asking day management to nominate or appoint employees.

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 participate in programs at a decreased cost. Hold appreciation breakfasts/lunches/dinners.

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

Purchase 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 may be used as a guide for committee size -    

• Less than 300 employees   2 to 4

• 300 to 1,000 employees   4 to 6

• 1,000 staff members or more   6 to 12

Effective wellness programs recognize the importance of building a supportive cultural environment. the workplace culture includes shared values/heartfelt beliefs about what is important. It includes social standards of expected and accepted behavior called “cultural norms.”

It includes colleague support from family, friends, and colleagues. This support can help one adopt healthful lifestyles. Tools are available to audit a company.

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

Some healthy culture signs in a business are -

• Staff Members communicate openly

• Leaders support diversity and opinion

• Employees have fun

• Policies support wellness

• Employees are encouraged to grow

• Staff Members work together as a team

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

• Flexible work schedules are available

• Corporations consider staff members as their most valuable asset

Effective wellness programs try to create healthful workplace climates. A healthful workplace climate is one which encourages teamwork, cooperation, and empowerment of the individual.

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

• Effective programs identify ways that corporation policies and organizational traditions encourage wellness.

• Effective programs work at the group and organizational level to build support for healthy lifestyle choices.

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

An initial medical 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 staff members.

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

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

• Ask primarily closed-choice questions, especially if you’ll be sending the survey to a large number of workers. Closed-choice questions provide specific choices and are easy to tabulate. You could want to use a computer for data entry and analysis.

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

• Include a brief explanatory cover letter with the survey with the signature of the corporation president. Make certain to include a statement about confidentiality and anonymity.

• Ask a group of representative staff members to review the survey before it’s distributed. Find out when the questions will be understood by staff members and will not be objected to.

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

When considering who should get the survey, a simple rule is when you have under 500 staff members, everybody should receive one. the public relations advantage of everybody receiving a recent survey may be significant.

Over 500 staff members, 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 management is critical to the success of the program.

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

When 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. Provide 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 could be used immediately to make decisions about the program.

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

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

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

Robust wellness programs emphasize follow-up and offers support for the employee since he/she is employed. Studies have shown this approach to be highly successful. Key components are planning, implementation, and examination.   

Planning extensive wellness programs involve performing a needs and interest assessment, appointing a wellness committee, choosing  wellness providers, setting goals/objectives for the wellness program, marketing and advertising/promoting the program, and establishing procedures to ensure confidentiality.   

Implementation of extensive wellness programs consist of five major tasks -    

1   Biometric screening and referral

2   Follow-up and counseling staff members

3   Follow-up with doctors

4   Health betterment programs

5   Organizing worksite-wide activities.

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

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

Robust wellness programs emphasize follow-up and offers support for the worker as long as he/she is employed. Studies have shown this approach to be highly successful. Key components are planning, implementation, and investigation

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

Implementation of robust wellness programs consist of five major tasks -

• Medical screening and health risk (assessment|appraisal}

• Follow-up and counseling employees

• Follow-up with doctors

• Health improvement and illness avoidance programs

• Organizing worksite-wide wellness program activities.

Analysis involves monitoring wellness programs to find out if it’s working and to help you refine it.

Measuring success shows what you’ve achieved, helps justify costs, and provides information for management to support continued 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 employees became more widespread during the following decade, and credible evidence for their economic viability began 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 medical insurance costs escalate with both age and number of risks present.8,10   the number of risks is also strongly related to sick time absenteeism, Employee’s Compensation costs, short-term disability, and lowered productivity (”presenteeism”).

Early staff member wellness programs were relatively basic and ordinarily produced a return on investment (ROI) of less than one dollar for every dollar spent operating the program (ROI = <1 - 1).8

Such programs might  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 are not customized, and there is no emphasis on the management of healthcare costs.  These programs are typically site-based only, lack choices to address all the major behaviorally-related health risks, and lack multimodal presentation.  

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

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

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

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

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

Such programs are strongly focused on the reduction of namely identified high risks and the management of medical costs.  They are generally voluntary, but use strong financial and other incentives to promote participation.  

They are multi-component in nature (address all major risks), and have both on-site and virtual modalities of operation.  The interventions are highly targeted and individualized, and offered to spouses in addition to staff members.

For companies, the cost of providing health insurance for their staff members is of great importance.  Those costs have been increasing at annual rates between 6 percent and 14 percent.

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

Absenteeism due to illness is another cost driver.  Chapman’s review7 reports an average reduction in sick time of 25.3 percent.   Cost for Employee’s Compensation was lowered by 40.7 percent, and disability costs by 24.2 percent.

There’s 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

Some businesses have achieved a zero% increase in healthcare costs across at least brief periods of time.10  Doing so requires 90-95% participation of the worker population in focused wellness programs, with 75%-85% of the workers falling into the low risk category.10     

Although comprehensive efforts to lower the risk status of those in moderate or high risk categories ought to be made, the needs of currently healthy staff members ought to 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 staff members could be achieved if a majority of that population were participating in active wellness programs.     

Similarly, improvements in absenteeism, employee’s compensation, disability, presenteeism, and turnover as a result of comprehensive worker wellness programs would yield substantial fiscal benefits for the government.   

References   

1   Aldana, Steven G.  (2001)   Financial Impact of Wellness Programs -   A Comprehensive Review of the Literature.   Am J Wellness 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-Examination of Corporate Wellness Economic Return Studies -  2005 Update.  The Art of Wellness, July/August, 1-15.

5   Chapman, Larry.   (2006)   Staff Member Participation in Corporate 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 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 Corporations” Conference, Orlando, FL, January 23-24.

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

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

11   Pelletier, Barbara, Boles, Myde, and Lunch, Wendy.  (2004)  Changes in Health Risks and Make sure 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 comprehensive 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 Unhealthy 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.

Corporate America is increasingly investing in staff member wellness because it’s 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 establishings have documented the economic benefits of employee wellness programs, including reduced absenteeism, reduced injuries and workman’s compensation costs, reduced healthcare costs, reduced employee turnover, in addition to increased productivity, greater employee satisfaction, and improved morale.1-10  

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

To enhance their effectiveness federal government worker wellness programs might  be able to incorporate some features described.  Worker 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 tobacco use, lack of exercise, excess weight, unhealthful diet, high cholesterol, high blood pressure, stress, depression, and so on.     

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

2   Health risk (assessment|appraisal}

Use of a computerized health risk (assessment|appraisal}  instrument with individualized feedback and recommendations is nearly universal in successful programs.  Employees take the questionnaire each year in many cases.     

The HRA serves to elevate awareness, provide direction, and motivate person to improve specific behaviors.  In some cases, the customized report is directly linked to appropriate resources related to identified risks.     

Research indicates that the use of an HRA is effective if it’s followed by some kind of educational or therapeutic intervention for identified risks.  It often serves as the entry point into wellness programs.   

3   Biometric analysis

A lot of wellness programs combine the results of the health risk (assessment|appraisal} with measurement of each employee’s biometrics, including weight and Body Mass Index (BMI) , blood pressure, cholesterol, fasting glucose, and assorted other metrics.     

Combining the results of the HRA with biological measures results in a more precise risk profile.   Computerized health risk (assessment|appraisal}s often incorporate biometric data in their risk analysis.   

4   Wellness Program Incentives

Staff Members are frequently given monetary or other meaningful rewards for completing an HRA, participation in a program or class, specific accomplishments like stopping use of tobacco, losing weight, or exercising, and for maintaining healthy status and/or behaviors.     

In many cases the monetary incentives are associated with reductions in medical insurance premiums.  Some programs use disincentives in addition to incentives, like charging staff members who smoke higher rates for their medical insurance contribution.   

5   High wellness program participation rates

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

6   Wellness coaching

Workers with identified risks or desire to improve their health habits might  be periodically coached via telephone by trained health coaches.     

Coaching assists staff members set and achieve realistic lifestyle-related objectives including those addressing stress, work life balance, smoking, weight, exercise, and various behavior modifications.     

Three or more sessions are typically offered.  In some intensive programs, the coaching extends to actual disease management (DM) intervention for staff members with identified high-risk illnesses.    

7   Multiple formats

Programs may 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 onsite physical activity and healthful eating events, on-line programs, e-mail reminders and notices, printed newsletters and materials, and workplace classes and seminars are common dissemination strategies.   

8   Upper-level management support

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

9   Frequent contact

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

The key is to enhance staff member 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 wellness programs and activities.  Open and uncomplicated enrollment processes achieve this.     

Some corporations automatically enroll all staff members and then allow those who don’t wish to participate to “opt-out”.  This practice has been proven to improve enrollment rates in some establishings.   

11   Family involvement

A lot of programs encourage spouses and other family members to participate in the corporation wellness activities and to adopt a healthful lifestyle along with the designated worker.  It is far easier for the worker to have a healthful lifestyle if his/her family does so as well.   

12   Tobacco use cessation

Because smoking and other smoking is the number one threat to health it’s crucial to offer staff members effective and convenient assistance with quitting.     

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

13   Exercise

Regular physical activity is a core component of every wellness program.  Employees should be strongly encouraged to engage in regular physical activity.     

Most programs provide either periodic or continuous on-site opportunities, and some locations have on-site fitness centers, swimming pools, walking trails, etc.  Discounted or compensated memberships to community exercise facilities is a common alternative to on-site facilities.   

14   Weight management

Because obesity is a major threat to health it is imperative that programs offer effective assistance with weight control.  Robust encouragement from  executive management to shed excess weight is important.     

Internet Based programs, worksite programs, or discounted access to weight control programs in the community may all be available.  Long-term follow-up is crucial for maintenance of weight loss.   

15   Stress management

Workplace stress is perhaps the most common complaint among employees and a major contributor to absenteeism, presenteeism (reduced productivity), and low morale.     
   
Nearly all successful wellness programs offer assistance with personal and workplace stress.  Some programs refer staff members to outside resources for more serious conditions like depression and anxiety disorders, but most offer online or frequent onsite general stress reduction programs.     
   
Some businesses endeavor to structure the work environment to minimize stress, both physically and operationally.   

16   Health testings/immunizations

Workers are actively encouraged to complete advised medical testings for blood pressure, cholesterol, BMI, colorectal and breast cancer, and others.     

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

17   On-Site health care

Actual provision of on-site primary care medical services is a growing trend.  The rapidly escalating costs of medical care insurance for staff members has stimulated this trend.     

Some businesses have found that it is less costly to provide primary care services themselves than to fund those services through medical insurance.     

On-Site care also reduces the amount of time staff members would otherwise spend away from the worksite getting such services.    

References   

1   Aldana, Steven G.  (2001)   Financial Impact of Wellness Programs -   A Extensive Review of the Literature.   Am J Wellness 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 Corporate Wellness Economic Return Studies -  2005 Update.  The Art of Wellness, July/August, 1-15.

5   Chapman, Larry.   (2006)   Staff Member Participation in Corporate 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 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 Wellness 15(5) -  341-349.

10   Edington, Dee W.  (2007)   Health Management as a Serious Corporation Strategy.  Presentation at the World Research Group “Rewarding Healthful Behaviors for Health Plans and Companys” 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 comprehensive Health and Disease ManagementPrograms 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 Condition.  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.