Citibank (1998)

Narrative Description of Program

Citibank is a global financial services company with 95,000 employees worldwide and 42,000 in the U.S.  The strategic goals of the company’s health promotion programs and services are to optimize employee health and productivity, reduce or stabilize costs associated with employee illness and injury (e.g., medical, disability, workers’ compensation, absenteeism) and contribute to Citibank’s efforts to be the “employer of choice” in the communities where we do business.

During the past eight years, Citibank’s Corporate Health Services (CHS) department has spearheaded a variety of health, demand and disease management programs, with the primary targets being all U.S. and expatriate Citibankers.  Funding and program delivery occurs at both the corporate and local levels.  Services include: consumer health education (via print, classroom and intranet-based delivery); preventive screenings and immunizations; behavior change, fitness and work conditioning programs; and targeted interventions for those at risk or with chronic medical conditions.  A major corporate-sponsored health risk appraisal/high risk intervention program initiated in 1994 has produced a 6.7:1 financial return on investment, as more fully described in the following pages.  A number of other programs, including the Taking Care consumer health education newsletter, mammography screening and on-site fitness centers, have also been very successful in meeting Citibank’s broad program goals.

In addition to programs delivered at the corporate level, the corporate health promotion staff supports a network of 40 “wellness coordinators” at major U.S. work locations (reaching 76% of U.S. employees) in the design and delivery of programs which meet the needs and interests of site employees and management.  Fourteen of these wellness coordinators are health/fitness professionals who manage on-site fitness centers.

Six medical clinics- three in New York, two in Florida and one in London- provide a variety of clinical services, including primary care, screenings and immunizations, and international business travel medical services.  In addition, the medical staff provides expert advice on regulatory compliance issues, including FMLA, ADA, etc.  CHS also manages the Employee Assistance Program and works cooperatively with Citibank’s work/life initiatives to provide ongoing support to employees and their families in dealing with behavioral health and work-life management concerns.

All CHS staff are health professionals who have strong business and communications skills, are focused on our “customers-” Citibankers, their families and line management- and are committed to quality and continuous improvement.  CHS’s services are fully integrated with other environmental and organizational initiatives to provide a safe, healthy and high-performing work culture throughout Citibank.

Citibank partnered with the Healthtrac organization in 1994 to introduce a comprehensive health, demand and disease management program for all 42,000 U.S. and expatriate Citibankers.   An independent study conducted by The Medstat Group, Inc. found that the program produced a financial return on investment of 6.7:1, with the majority of the savings coming from the difference in medical expenditures of approximately $12,000,000  between participants and non-participants.  A separate analysis of health risk appraisal data also showed positive changes in a number of health status measures.

Program Overview

Citibank initiated the Healthtrac program in 1994 in response to analyses of medical claims and health risk appraisal (HRA) data from selected pilot sites in 1990-92.  Both data sources suggested that significant opportunities existed to improve employee health and reduce costs, particularly related to lifestyle behavior improvement, health risk factor reduction and chronic disease management.  The structure of the Healthtrac program is to use a short HRA to provide personalized feedback about lifestyle behaviors and health risk factors to all participants, and then more importantly, to use the HRA results to identify the “pareto group” of individuals at high risk for poor health outcomes or high medical expenditures and invite them to participate in more in-depth targeted intervention programs.  Citibank chose Healthtrac because Healthtrac had produced positive results with selected populations at other organizations, and also because Healthtrac would customize certain program components for Citibank and would handle all aspects of the “direct-to-consumer” distribution of the program to employees via home mailings.

Two key questions were of interest to Citibank:

1. Does high risk = high cost?
2. What’s the impact of a health management/high risk intervention program on costs and health outcomes?

Two program “cycles” were completed (1994 and 1996), with 16,500 employees, or approximately 40% of the eligible population participating each time the HRA was offered.   Participation in the Healthtrac program was voluntary, with the only financial incentive to participate being a $10 wellness credit towards the employee’s next year’s benefits enrollment costs.   3,000 individuals from each year (6,000 total) were classified by Healthtrac as “high risk” and were channeled into Accent modules which provided more in-depth, personalized educational programs over a twelve month period.  Accent modules included: arthritis, diabetes, coronary disease, high blood pressure, smoking, obesity, low back problems and combined risk.

Citibank asked the Medstat Group of Ann Arbor, Michigan to conduct an independent cost-benefit analysis of the Healthtrac, a.k.a., The Citibank, N.A. Health Management, Program.  Program costs were measured against savings (benefits) in health care expenditures and absenteeism.

A separate, preliminary analysis of HRA data was performed by Healthtrac to determine whether there were any changes in lifestyle behaviors and health risk factors for employees who were classified as either “low risk” or “high” risk in 1994 and who also participated in the program in 1996.  It should be noted that the populations studied were not the same as for the Medstat cost-benefit evaluation.

Highlights of the Cost-benefit Evaluation, Conducted by the Medstat Group

The study of Citibank’s Health Management Program breaks new ground for financial analyses of health promotion programs for the following reasons:

• The study populations for both the medical and absenteeism analyses are quite large (N > 20,000 for each analysis), which is unusual for economic studies.
• Medstat used the most current econometric methods in conducting a rigorous non-randomized quasi-experimental cost-benefit analysis, using a before-after, intervention group vs. comparison group design.
• The multivariate analyses controlled for alternative explanations of program results.

Key Results

• A Return On Investment ratio of 6.7:1 was calculated using actual program costs and benefits.
• Most of the program benefits or cost savings (approximately $12 million) were derived from the difference in medical expenditures between program participants and non-participants. This analysis included only employees enrolled in the indemnity or point-of-service medical plans (HMO members were excluded).
• Approximately $400,000 in program benefits or cost savings were derived from differences in absenteeism hours between participants and non-participants (for non-exempt employees only).
• High Risk (HR) employees who incurred medical costs were 2.2 to 3.0 times as expensive compared to Low Risk (LR) employees before intervention, but only 1.7-1.9 times more expensive than low risk employees post intervention.
• This study has been submitted for publication.

Highlights of the Separate Analysis of Changes in Lifestyle Behaviors/Risk Factors

HRA data collected by Healthtrac was analyzed for groups of employees who participated in the program both in 1994 and 1996 and were classified as either “Low Risk/LR” (N=5,494) or “High Risk/HR ” (N=985) by Healthtrac.  Tests of statistical significance were not conducted,  however a comparison of pre-post data for selected health behaviors revealed some positive trends:

• The percentage of HR participants who smoked decreased from 16.5% to 14.8 % (a 10% decrease), which meets the Healthy People (HP) 2000 goal of 15%.  Among the LR participants, smoking levels reduced slightly, from 8.3% to 8%.
• Weekly exercise by HR participants increased by 26%, to 137.5 min./wk., while LR participants’ exercise habits remained steady at around 144 min./wk.  (HP 2000 target = 150 min./wk.)
• Seat belt use by HR participants increased by 12.4% , and by LR participants, 4%.
• Both HR and LR groups reduced total fat intake, by 14% and 8.4% respectively, reaching levels close to the HP 2000 target of no more than 30% of total calories from fats.
• Neither group showed  much improvement in body weight or intake of dietary fiber.

Next Steps

In the next major phase of evaluating the Healthtrac program, Citibank plans to conduct a more rigorous study to investigate changes in health outcomes by risk category (Accent module), as well as to evaluate the relationship between changes in risk with changes in medical expenditures.

Citibank partnered with the Healthtrac organization in 1994 to introduce a comprehensive health, demand, and disease management program for all 42,000 U.S. and expatriate Citibankers.  An independent study conducted by the MEDSTAT Group, Inc. found that the  program produced a financial return on investment of 6.7:1 with the majority of savings  coming from the difference in medical expenditures of approximately 12 million dollars between participants and non-participants.  A separate analysis in health risk appraisal data also showed positive changes in a number of health status measures.  The Citibank program emphasized use of programs directed at high-risk employees with individualized health assessment and interventions.

Specific Comments Included: The goals are to optimize health, reduce and stabilize costs and to be an employer of choice.  There is concern for customer satisfaction and continuing quality improvement is an operating principle.  There is a high-risk focus.  An incentive in the form of $10.00 Wellness credits towards benefits cost is included.  This is an impressive program that has been in place for eight years.  It serves a very large employee population throughout the world and 42,000 individuals in the United States.  They have used very sophisticated methods to assess ROI.  The application of Healthtrac methods are a strength.  Differentiating employees by risk status allows them to channel employees to the most appropriate methods. The use of MEDSTAT to apply current sophisticated econometric methods adjusting for alternative explanation of results is a great strength.  Results have been submitted for publication.  High-risk folks show greater improvements.  Excellent evaluation efforts.  Good directions and sound management.

Reservations Included: There is limited evidence of secondary and tertiary interventions for high-risk employees.  It would have helped to have some basic demographic characteristics by gender, race and age reported.  There is reliance on individual level interventions with minimum focus on policy or environmental changes to support healthier choices and behaviors.