Caterpillar

Healthy Balance^SM Program Goals

• Motivate positive change in modifiable health risk behaviors
• Reduce health risks, improve health status-long term
• Promote self-efficacy and informed decision-making
• Reduce healthcare and related costs/trends
• Achieve exceptional participation via strong incentives

Intervention

The Healthy Balance Program (the Program) was developed over a three-year period, and incorporates best practice features. The health promotion literature was reviewed; 21 companies with outstanding health promotion programs were benchmarked. The Healthtrac® Program, significantly modified and enhanced by Caterpillar, is the Program's foundation.

Key features

• Strong incentives
• Top-down management "buy-in" and involvement
• Spouses included
• Continuous evaluation/improvement

Components

(DR = demand reduction strategy; BC = behavior change strategy)

• Low-cost confidential health assessment (HA) ^{(DR, BC)}
• Focus on modifiable risks (BC) and increasing self-efficacy^{(DR, BC)}
• Personalized health education messages^{(DR, BC)}
• Stratification: low/high risk (BC), periodic assessment based on risk^(BC)
• Individualized interventions, targeted to health risks and readiness-to-change^(BC)
• Intensive high risk/chronic condition interventions, including disease management phone counseling^(BC)
• Serial tracking^(BC), ongoing monitoring/adjustment of interventions^(BC)
• Coordination with related interventions (on-site classes, referral to community programs, etc.) ^{(DR, BC)}
• Self-care book^(DR) and quarterly newsletters to all eligibles^(DR)
• Toll-free health information line and audio library^(DR)
• Intranet website regularly updated, linked to sites providing scientifically validated information (e.g., drkoop.com)^{(DR, BC)}
• Ongoing evaluation-using integrated data warehouse (claims, absenteeism, HA, etc.); communication of summary results to employees

Target Population

All U.S.-based non-union employees (49% of workforce) and spouses (N = 41,500+). To be added: retirees, union workers (pending contract changes).

Funding Source

Executive Office.

Staffing

A division of Corporate Medical Department. Full-time staff: Health Promotion Manager, Program Administrator, Data Analysis Administrator, Communicator, and two Health Promotion Analysts. Part-time staff: nurses (diabetes, cardiac care), health educators. Guided by Corporate Medical Director, Director of Managed Care, and physicians representing (clinical psychology, infectious disease, public health, and occupational health). Additionally, 91 staff with part-time health promotion-related responsibilities and 5 full-time health promotion specialists coordinate the Program through local programs at more than 142 U.S. and international locations.

Based upon analysis of the population's baseline health risks, and the success of the Healthy Balance^SM Program to date, we anticipate long-term savings of more than $700 million by 2015. Evaluation—led by Caterpillar's Corporate Medical Director and drawing on external reviewers—of participation, retention, self-reported risk and use of healthcare services, satisfaction, and baseline vs. current claims expenditures reveals that the Program has achieved outstanding results:

• High participation: 96%—incented eligible employees, 74%—eligible spouses.
• Reduction in risk factors: The health risk score, as determined by Healthtrac, decreased 6% for the low risk population (N = 22,114). For the population (N = 2,321) completing the entire high risk program (a series of 5 HAs and health education interventions), health risk declined by 14%. Decrease in aggregate risk represents improvement in the major risk factors: physical activity, cigarette smoking, stress, fat and fiber consumption, etc.
• Savings: Participants who completed the high risk program reduced their doctor office visits by 17% and hospital days by 28%-a 23% decrease in direct costs, validated by claims data.
• Reduction in claims costs: Between 1997 and 1999, average claims for non-eligible employees (N = 13,291) increased at a much higher rate (40% faster) than did those for participants (N = 12,932). Annual trends were 35% (non-eligibles), and 25% (participants). (Note: High overall trends were due to scheduled re-negotiation of provider contracts and industry-wide prescription drug rate increases. These anticipated increases were a major driver in our decision to implement a "demand-side" strategy: the Healthy Balance Program.)
• Cost savings for those with heart disease: Heart disease is Caterpillar's highest driver of healthcare costs. In a small case/control (age/gender matched) study of employees who had heart disease prior to the Program start, participants who completed more than one health assessment (N = 8) had lower medical claims costs than did non-participants (N = 50). Over the 3-year study period, average per person claims costs were $16,121 lower for participants than non-participants.
• Smoking cessation: More than 1,144 participants quit smoking cigarettes.
• Reduction in body mass index (BMI): Overweight is Caterpillar's #1 preventable health risk. At Program start, more than 60% of eligibles had a BMI > 25. Since Program implementation, more than 4,700 of this group have lost weight.
• External recognition: The Program won the Dr. Solovy Community Health Award, given by a panel of business leaders and University of Illinois professors.
• Internal review/CQI processes: Continuous improvement is achieved by ongoing evaluation and dissemination of Program results. A satisfaction survey is being conducted.
• Data accessibility: A secure internal data warehouse, housed in the Corporate Medical Department, supports Program evaluation. It includes self-reported data and medical/drug claims data (from our self-insured, self-administered medical benefits program).

Conclusion

The Program has vastly exceeded initial savings projections. It has the proven-effective Healthtrac program at its core. In-depth evaluation has revealed results similar to the randomized published studies of the Healthtrac program. Moreover, Healthtrac has substantially modified its programs to incorporate many of the customized features requested by and developed for the Caterpillar Healthy Balance program. We believe this adjustment to accommodate the culture of the target population is a critical requirement for improvement in need and demand reduction programs.

• Caterpillar Healthy Balance

Reviewers found this program strong, comprehensive, and well-institutionalized, with well-stated goals, uniquely strong methods of intervention, and evidence for cost reduction. Participation rates of over 90% are in part driven by a creative incentive structure. The program is built around a strong program health assessment base that has resulted in four Koop awards and multiple published positive randomized controlled trials. The before-after comparison and participant-non-participant comparison represent a good quasi-experimental design. Current results are positive, with projections of savings through 2015. The program is specifically designed and culturally focused for the Caterpillar population. The program has won a number of externally judged awards.

Reviewers raised concerns about some projections and felt that the claims data analyses could be strengthened. The number of subjects in the heart disease analysis was small. An experimental design would be helpful.

Overall, an excellent program growing out of strong and proven programs, well-designed for the population, comprehensive, responsive, and evaluated with continuous improvement processes. Participation rates of 96% (and 74% of spouses) is extraordinary, and effectiveness and cost-savings are well documented.