Best Health Best Value Why Wellness Makes Sense

Best Health, Best Value: Why Wellness Makes Sense 2009 State Agency Wellness Conference Moving Agencies into Action Eduardo Sanchez, MD, MPH, FAAFP Vice President and Chief Medical Officer Blue Cross and Blue Shield of Texas October 12, 2009

Our mission is to promote the health and wellness of our members and communities through accessible, cost-effective, quality health care. The most trusted brand in health care. 2

Health A state of complete physical, mental, social, and spiritual well-being 3

The Healthcare Spectrum Today Understanding the Impact and Opportunity Population Distribution Healthy At Risk Acute Conditions Chronic Conditions Severe Illness and Complex Disease / End-of-Life Care Healthcare Cost Distribution 4 4

Causes of Death, United States 2005 26. 6% Diseases of the heart All cancers 22. 8% 5. 9% Stroke 5. 3% Chronic lower respiratory disease 4. 8% Unintentional injuries Diabetes mellitus 3. 1% Alzheimer’s disease 2. 9% Influenza and pneumonia 1. 8% Septicemia 1. 4% 0% 9% 18% 27% 36% Source: cdc. gov 5

The Preventable Causes of Death in the United States: Comparative Risk Assessment of Dietary, Lifestyle, and Metabolic Risk Factors (Danaei, 2009) Deaths attributable to individual risk (thousands) in both sexes 6

What Drives Health Status and Health Care Costs? How Can We Encourage and Support Behavior Change? Source: IFTF and Center for Disease Control and Prevention, Health and Healthcare 2010, January 2000 7

How Can We Encourage and Support Behavior Change? Environmental and Policy Change Personal Responsibility Incentives Disincentives 8

Bending the Cost Curve: A Critical Component of Health Reform (JAMA, 9/16/09) • Really bending the cost curve will take: • Prevention, patient behavior change, and community changes • Changes in hospital and physician behavior • Accountable Care Organizations (ACOs) • Primary Care Medical Home • Comparative effectiveness – medical policy • Reduction of waste, fraud, and abuse • High performing clinicians, hospitals, and health plans 9

Cost of obesity Medical costs related to obesity in America in 2008 may be as high as $147 billion (Finkelstein, et al, Health Affairs on line, 2009). Average annual medical costs Healthy weight $3400 Obese $4900 (CDC. gov) 10

Improving Consumer Health: Burden of Disease Prevalence of Diabetes Number per 1, 000 population Millions of People in the U. S. Diagnosed Diabetes Note: Data on prevalence of diabetes is age adjusted. Source: Centers for Disease Control and Prevention, National Center for Health Statistics (2008) National Health Interview Survey (NHIS) 11 290104

Trends and projections The number of obese Texans will triple without prevention efforts, study says More than one-fifth of young adults ages 18 to 25 were obese in 2007 – up from 10 percent in 2000 “If people in their 20 s are already overweight, as we go forward and that [age group] ages into their 30 s and 40 s, the future obesity problem in Texas can be staggering, ” said Eschbach, a demography professor at the University of Texas-San Antonio. Dallas Morning News 12

Obesity in US Adults, by Race/Ethnicity (Ogden, et al, JAMA, 4/5/06) Whites 30% Blacks 45% Mexican-Americans 37% 14

U. S. Childhood Obesity Epidemic Trends Obesity prevalence in U. S. children and adolescents by age and time frame, 1963 -2004 I O (IOM) 15

2007 National Diabetes Facts Race and ethnic differences in prevalence of diagnosed diabetes 6. 6% of non-Hispanic whites 7. 5% of Asian Americans 10. 4% of Hispanics • • • 8. 2% for Cubans 11. 9% for Mexican-Americans 12. 6% for Puerto Ricans 11. 8% of non-Hispanic blacks CDC government 16

Latest Numbers 40% More than of American adults aged 20 years and older have hyperglycemic conditions – prediabetes or diabetes. Dallas Morning News 17

Metabolic Syndrome: A Public Health Problem Approximately 50 million adults (25%) in the United States have Metabolic Syndrome is defined as a clustering of risk factors that increase your chances for developing heart disease, diabetes and/or stroke. 1) high triglyceride level, 2) low high-density lipoprotein (HDL) cholesterol level, 3) high fasting blood glucose level, 4) presence of central obesity (waist circumference), and 5) high blood pressure. The more risk factors, the greater chance to develop heart disease, diabetes or stroke. Research shows that a person with Metabolic Syndrome is twice as likely to develop heart disease and five times as likely to develop diabetes as someone without Metabolic Syndrome. 18

Environmental Change and Metabolic Syndrome 3 X 2 X +527 kcal/day 3 X 2. 5 million years Obesity Rare 1950 s 2007 200 million overweight Metabolic Syndrome 50 million patients 19 19 19

The Progression of Metabolic Syndrome Controllable Causes. Metabolic Syndrome Complications Severe Conditions / Events Indications • Hypertension • Heart Attack • Poor Diet • Coronary Artery Disease • Heart Failure • Inactivity • Abdominal Obesity • Diabetes • Aortic Aneurysm • Stress • High Triglycerides • Vascular Disease • Stroke • Low HDL Cholesterol • High Cholesterol • Kidney Failure • Elevated Blood • Osteoarthritis • Vision Loss Pressure • Overweight / Obesity • Nerve Damage/ • Glucose • Sleep Apnea Amputation • Aging Intolerance • GERD • Cancer • Genetics • Intraocular Pressure • Knee & Hip Replacement • Chronic Liver Disease • Liver Failure Uncontrollable Causes Poor Work Performance Disability Left untreated, Metabolic Syndrome can be a contributing cause or aggravating factor in a host of conditions that limit or disable the individual and negatively impact their productivity and quality of life. The most trusted brand in health care. 20

Clinical and Economic Risks of Metabolic Syndrome Working-age individuals with Metabolic Syndrome had significantly higher medical costs compared to those without Metabolic Syndrome: • With Metabolic Syndrome: $626 per member per month (PMPM) 21 * Source: Metabolic Syndrome and Employer Sponsored Medical Benefits: An Actuarial Study, Kathryn Fitch R. N. , Med, Bruce. Pyenson, FSA, MAA, Kosuke Iwasake, FIAJ, MIAA, Milliman, New York, NY September 2007 The most trusted brand in health care.

Clinical and Economic Risks of Metabolic Syndrome Working-age individuals with Metabolic Syndrome had significantly higher medical costs compared to those without Metabolic Syndrome: • With Metabolic Syndrome: $626 per member per month (PMPM) • Without Metabolic Syndrome: $367 PMPM Of the $259 excess medical cost: • $46 is attributed to additional cardiovascular events • $213 is related to expenses of higher prevalence of co-morbidities, particularly cardiovascular disease and diabetes * Source: Metabolic Syndrome and Employer Sponsored Medical Benefits: An Actuarial Study, Kathryn Fitch R. N. , Med, Bruce. Pyenson, FSA, MAA, Kosuke Iwasake, FIAJ, MIAA, Milliman, New York, NY September 2007 22

Clinical and Economic Risks of Metabolic Syndrome Working-age individuals with Metabolic Syndrome had significantly higher medical costs compared to those without Metabolic Syndrome: • With Metabolic Syndrome: $626 per member per month (PMPM) • Without Metabolic Syndrome: $367 PMPM Of the $259 excess medical cost: • $46 is attributed to additional cardiovascular events • $213 is related to expenses of higher prevalence of co-morbidities, particularly cardiovascular disease and diabetes An analysis of claims from 2 million adult patients aged 20 and older found that individuals taking medications for at least 3 of the risk factors associated with Metabolic Syndrome had an annual drug spend more than 4 times that of all other patients. * Source: Metabolic Syndrome and Employer Sponsored Medical Benefits: An Actuarial Study, Kathryn Fitch R. N. , Med, Bruce. Pyenson, FSA, MAA, Kosuke Iwasake, FIAJ, MIAA, Milliman, New York, NY September 2007 23

Metabolic Syndrome Program Down Under • 10 Australian Aborigines • Overweight • With diabetes • Living a western lifestyle • Returned to traditional homeland for seven weeks • Average weight loss of 18 pounds • Blood pressure reduction • Normal triglycerides 24

William Dietz, Jason Lee, Howell Wechsler, Sarath Malepati, and Bettylou Sherry, Health Plans' Role In Preventing Overweight In Children And Adolescents, Health Affairs, Vol 26, Issue 2, 430 -440 Copyright © 2007 by Project HOPE, all rights reserved. 25

Diabetes Prevention Program (DPP) • a multi-center trial that examined the ability to prevent or delay the development of diabetes in a population with pre-diabetes NEJM, 2002 26

Effect of Treatment on Incidence of Diabetes Placebo Incidence of diabetes 11. 0% Metformin Lifestyle 7. 8% 4. 8% (percent per year) Reduction in incidence ---- 31% 58% ---- 13. 9 6. 9 compared with placebo Number needed to treat to prevent 1 case in 3 years The DPP Research Group, NEJM 346: 393 -403, 2002 27

Diabetes Prevention Program: Lifestyle Modification vs. Metformin • Compared with the placebo intervention, the lifestyle and metformin interventions both increased the quality-adjusted life years (QALY) by: • $31, 300 per QALY for metformin • $1, 100 per QALY for lifestyle interventions • A quality-adjusted life year or QALY is a year of life adjusted for its quality. Saving one QALY through prevention is equivalent to extending a life for one year in perfect health March 2005 Annals of Internal Medicine Vol. 142 #5 28

Metabolic Syndrome Workshop: Intensive Lifestyle Management • The Metabolic Syndrome workshop runs for 10 weeks and can be delivered in either a group or online setting. • Individuals in either the online or group setting program are assigned a health coach who monitors progress, weekly dietary habits, exercise and other factors. • The first class typically runs for two hours, with the remaining 9 sessions lasting one hour each. • Classes focus on clinical health improvement by addressing habits around eating, hunger and hydration. • The workshop covers other topics including exercise and fitness, stress management, health education, and psychological and emotional fulfillment. 29 The most trusted brand in health care.

BCBSTX Employee Metabolic Syndrome Pilot Program Results Program Participation Summary • 200 BCBS employees, located in four states, started the 10 -week program: – 100 employees enrolled in the online module (Albuquerque and Tulsa) – 100 in the onsite mode (Chicago and Richardson) • 185 out of the 200 participants successfully completed the program % that showed improvement Triglycerides (N=162) 67. 9 Glucose (N=162) 63. 0 Blood Pressure (Systolic) (N=147) 73. 5 Blood Pressure (Diastolic) (N=147) 68. 0 HDL (N=160) 43. 1 Waist Circumference (N=147) 77. 6 Weight (N=149) 91. 0 30 The most trusted brand in health care.

BCBSTX Employee Metabolic Syndrome Pilot – High Touch Population Impact Health and Lifestyle Impacts 100% Reported improvement in sleeping 37. 6% Of at-risk participants reversed their Metabolic Syndrome in 10 weeks (74. 6% of total group) 91. 9% Experienced average weight loss of 12. 9 lbs 39. 5% Reported they started exercise, 40. 1% maintained existing activity levels 29. 9% Reported reduction in medication usage 31 The most trusted brand in health care.

Benefits of Employee Wellness Programs • • • Increased productivity Decreased employee absenteeism Increased motivation to practice healthy behaviors Lower health care and insurance costs Increased employee retention Improved employee morale Fewer work-related injuries Fewer worker compensation and disability claims Attractiveness to prospective employees Positive community image Healthy role models for children 32

Thank you! 33