Effectiveness of Health and Wellness Initiatives for Seniors

Introduction

O ver the past 50 years, health care spending in the United States has increased as a percentage of gross domestic product (GDP) nearly 240%, from 5.2% in 1960 to a projected 17.5% in 2010. ^1,2 Of the estimated $2.6 trillion that will be spent on health care goods and services in 2010, ¹ only an estimated 8.6% will be spent on prevention and wellness, which includes research, primary prevention, early detection screening, and public health initiatives. ³ Further, 20% of national health expenditures was spent by the Medicare program in 2008, a percentage that is projected to grow by at least 6.9% per year through 2019. ⁴ According to the Trustees, Medicare alone could account for 11% of GDP by 2084 as a result of current and projected trends. ⁵ Medicare, however, only comprises 45% of seniors' total health spending. ⁶ Another 19% is paid out of pocket, ⁶ so participation in effective programs yields a direct benefit to both seniors and the government.

Today, there are approximately 46 million Medicare beneficiaries; in 2030, more than 78 million people will be enrolled. ^7,8 Over 95% of the amounts currently spent by Medicare on the nation's senior population is consumed by beneficiaries with 1 or more chronic diseases. ⁹ These factors, taken together and notwithstanding the reduced costs projected as a result of health care reform, have led the Medicare Trustees to estimate that the program will be insolvent by 2029. ⁵

While some of the growth in health care cost is likely the result of better treatments, the single largest contributor to escalating cost is the significant increase in the population with risk factors associated with future health compromise. Perhaps the most significant evidence of this increase can be found in Centers for Disease Control and Prevention (CDC) statistics that show an increase in the percentage of the population that is obese from 16% in 1995 to approximately 27% in 2009. ¹⁰ Driven in no small part by this growth in obesity, the CDC estimates that the number of new diabetes cases each year will increase from 8 per 1000 people in 2008, to 15 per 1000 in 2050, resulting in an estimated prevalence rate of 20%–33%. ^11,12

In this article, we review the literature on health promotion and wellness programs for seniors. Our criteria for including studies in our review was that they were conducted as a randomized controlled trial or, for retrospective analyses, that there was a sample size greater than 1000 and that matching or statistical methods were utilized to control for between-group differences. Using this approach, we identified a meaningful body of evidence indicating that properly designed, implemented, and operated health, wellness, and prevention programs for Medicare populations improve the health of participants and reduce future health care expenditures.

Wellness Programs and Health Care Expenditures

As a likely consequence of Medicare's current and future economic challenges, the majority of studies have as a common outcome metric the impact of the program on participants' health care spending. In this section, we review those reported outcomes.

Nguyen et al conducted a 2-year longitudinal study of participants in a fitness-based wellness program, available through several Medicare Advantage plans. The program provides members with access to a network of fitness centers that offer exercise classes designed specifically for the needs and physical abilities of seniors. The study demonstrated that participants had $500 (P = 0.01) lower adjusted health care claims costs in the second year of enrollment compared to insured persons who did not participate in the program, after controlling for covariates, although no significant differences were observed between the two groups after the first year of enrollment. ¹³ The majority of the cost difference between the groups was driven by inpatient expenditures in the second year of the study, which were $270 lower, on average, among participants (P = 0.05). ¹³

Two studies examined the reduction in health care-related expenses associated with participation in a community-based physical activity program for which the health plan pays for each fitness class attended. ^14,15 In a retrospective cohort study, Ackermann et al found that the average increase in total health care expenses for the 1114 enrollees in the study was significantly less than for matched controls ($642 vs. $1,175; P = 0.05). Total costs for the groups in this study, not accounting for level of participation, were not significantly different after adjusting for relevant covariates. ¹⁴ A subsequent retrospective cohort study analyzed costs after the first and second year of enrollment; average total adjusted costs were significantly lower (−$1,186; P = 0.005) for participants compared with control group members after 2 years of enrollment and trended lower, but were not statistically significant, after the first year (−$666; P = 0.12). ¹⁵ These results are generally consistent with the results of the Nguyen study. ¹³

Of particular interest is how both the duration and the frequency of program participation appear to relate to programs' impact on participants' health care costs. Nguyen found that 61% of the initial enrollees continued health club attendance in the second year. ¹³ Of those participants, those who attended 2 or more classes per week had average total health care costs that were $1252 lower in the second year of enrollment compared to seniors who attended the health club less than once a week (P < 0.001). ¹³ Similarly, 2 studies by Ackermann of another fitness program for Medicare Advantage members found that participants who attended classes ≥1 time per week had lower total health care costs than controls. The first study found that higher frequency users (average frequency of 1.74 visits per week) had 20.7% lower health care costs than controls (P < 0.001). ¹⁴ Similarly, a later study found that enrollees who averaged 1 or more visit per week had lower adjusted total health care costs in year 1 (−$1,929; P < 0.001) and year 2 (−$1,784; P < 0.001) than nonusers. ¹⁵

Interestingly, the significant 2-year savings in total health care costs observed by both Ackermann and Nguyen was achieved despite an initial increase in primary care costs. ^13,15 This finding is encouraging because it suggests that enrollees are seeking appropriate preventive care that also should decrease future inpatient costs. This effect was, in fact, found in these studies, which reported a decrease in inpatient costs in the second year of participation. ^13,15

A study by Ozminkowski et al also demonstrated a trend toward greater savings with a higher level of participation, as was seen in the reviewed fitness programs. In this case, the specific purpose was to evaluate outcomes with respect to the number of programs in which a participant enrolled. This retrospective study assessed how senior participation in an employer-based health promotion program affected Medicare expenses for nearly 60,000 retirees who were previous employees of the sponsoring company. ¹⁶ Claims data over a 6-year period were used to determine the annual Medicare expenditures for seniors who participated in varying interventions as compared to nonparticipant controls. Interventions included health risk appraisal (HRA) survey, biometric assessment, telephone-based nurse advice, work-based educational classes, and telephone-based lifestyle management counseling for high-risk individuals. Weighted regression analysis on the entire study sample found average annual savings were $408 for participants who took the HRA without additional program participation (P < 0.001). There was a trend toward increased savings with participation in 1 program subsequent to the HRA, and savings were estimated at $569 for those who participated in the HRA and 2 or more programs (P < 0.001). ¹⁶

Effect of Programs on Health Care Utilization

The second most common outcome metric among reviewed studies was change in health care utilization among participants in senior wellness initiatives. Given the strong link between utilization and cost, these outcomes provide information about the source of any demonstrated changes in health care costs. Accordingly, the rate and frequency of hospital admissions and primary/specialty care visits have been compared preentrollment and postenrollment in several senior wellness programs.

After controlling for covariates including demographics, previous utilization, risk factors, and preventive behaviors, participants in the Nguyen et al study of a Medicare Advantage fitness center benefit program had a significant decrease in the percentage of individuals admitted to a hospital after 2 years in the program compared to nonparticipants (−2.3%, P < 0.001). ¹³ After only 1 year of enrollment, a 1% decrease was observed compared to nonparticipants, although this difference was not statistically significant. ¹³ These results suggest that reductions in utilization as a result of healthy behaviors, such as fitness, begin to accrue early and that the benefits become more substantial over time.

Ackermann and colleagues demonstrated a similar effect of a senior fitness program on hospital utilization. In their first study, a significant decrease in the percentage of participants who were hospitalized was observed among individuals who visited a fitness center over a 27-month period compared with those who did not (−3.8%; P < 0.001). ¹⁴ A follow-up study confirmed the effect of the program on hospital admissions; the percentage of hospitalized participants was 0.4% lower than controls in the first year (P = 0.002) and was 0.2% lower in the second year, although the difference in year 2 was nonsignificant (P = 0.07). ¹⁵ This result was somewhat in opposition to the other primary result of this study, a trend of increased cost savings over time, compared to controls, that was statistically significant in the second year, but not in the first year. These results together indicate that there must have been other reductions in utilization that were not specifically measured, such as total number of admissions or hospital bed days, that resulted in the cost savings in year 2. The decrease in cost was not found to result from primary or specialty care utilization, as these measures either increased (primary care) or did not change significantly (specialty care) for participants compared to controls in both years. ¹⁵ The utilization result of this study is also different from the result in the Nguyen study, ¹³ in that the impact on hospitalization rate did not grow over time, as it did among participants in the Nguyen study; however, the cost outcomes over both years of each of these 2 studies were consistent.

A pattern of early improvement was also found by Leveille and colleagues in their randomized controlled trial of a senior center-based wellness program. Results showed a significant decrease in the number of days in the hospital after 12 months (33 days for participants vs. 116 days for nonparticipants, P < 0.05). ¹⁹ Additionally, there was a decreasing trend in the number of hospitalized participants, which increased by 69% among the controls and decreased by 38% in the intervention group (P = 0.083). Second-year results of the program have not yet been published.

A different result was found in a 2-year randomized study by Munro et al of the impact of the provision of free, twice-weekly fitness classes for low-activity seniors in the United Kingdom. This study found no difference in hospital admissions between control and enrolled groups, although 74% of the intervention group never attended the available classes. ²⁰ The authors attributed the lack of significant effect to the low level of program participation.

Behavior Change, Health Status, and Quality-of-Life Outcomes

While financial and utilization-based outcomes of wellness programs are important, primarily to the payer, participants in these programs also have been shown to benefit from improved physical functioning, emotional health status, and ultimately quality of life, in addition to the benefits of improved health and reduced costs. ²¹ In this section, we describe the effectiveness of several senior wellness programs to improve 1 or more of these factors.

One approach to quantify changes in health-related quality of life is use of the 36-item Short Form (SF-36) Health Survey, which includes items that measure physical and emotional health and functioning. ^22,23 Several studies have used results from this survey to understand the effect of participation on these metrics. ^20,24,25 For example, an overall increase in health-related quality of life (P = 0.03) was observed by Munro and colleagues in the 2-year cluster randomized exercise study in the United Kingdom. ²⁰ Specifically, this program resulted in patients experiencing increased energy, less of a decline in health status, and improved emotional health. ²⁰

Similarly, the Department of Veterans Affairs recently developed a health coaching program to improve physical performance in older veterans (>70 years) and to explore the premise that improvement would decrease the burden of chronic disease. Behavioral clinical trials found the program to be effective over a 1-year period. ^{24,26 –28} Participants demonstrated a greater increase in rapid gait speed, the primary outcome metric, over the course of the intervention compared to a usual care control group (P = 0.04). ²⁷ This outcome is particularly noteworthy given that improvement in gait speed has been shown to predict a substantial reduction in mortality. ²⁹ Changes also were observed in secondary outcome metrics including increased time engaged in physical activity for participants compared with those receiving usual care (P < 0.001), ²⁷ and a trend toward improvements in caloric expenditure (P = 0.054) ²⁶ and frailty status (P = 0.08) for participants. ²⁸

In another study related to functional outcomes, Phelan and colleagues evaluated the impact of a senior center-based health promotion program on activities of daily living, defined as difficulty or inability to perform self-care activities, which have been shown to increase the risk for hospital admission, nursing home admission, and death. ^{30 –32} In a small randomized trial, participation in the disability prevention and self-management program resulted in a greater likelihood of improvement in activities of daily living after 12 months (adjusted hazard ratio, 1.84; P = 0.02). ³³

Long-term cancer survivors, particularly those who are overweight, often have an increased risk of developing co-morbid diseases, including diabetes, osteoporosis, arthritis, and cardiovascular disease. ^34,35 In an effort to reduce these statistics, Morey and colleagues initiated a randomized trial to evaluate the effectiveness of a wellness program to improve quality of life for a senior cohort of this population. The program provided education and counseling to help enrollees develop an exercise plan and to support adherence to a low-fat, plant-based diet via telephone and mailed material. Among the prostate, breast, and colorectal cancer survivors included in the study, SF-36 physical function score declined less rapidly among participants compared with controls (P = 0.03) and participants also had greater weight loss (P < 0.001). Participants also achieved significant improvements in multiple measures of physical activity, dietary behaviors, and overall health-related quality of life after only 12 months of adherence to the diet/exercise program, compared with controls. ²⁵

Because smoking also increases the risk of developing a number of diseases, ³⁶ the Medicare Stop Smoking Program was established to aid seniors in smoking cessation. A longitudinal randomized control trial of the program evaluated the impact of various levels of intervention on smoking cessation rates: (1) usual care, (2) reimbursement for counseling from a health care provider, (3) reimbursement for provider counseling with pharmacotherapy (nicotine patch or bupropion), and (4) telephone counseling with nicotine patch. The approach that demonstrated the highest percentage of cessation after 12 months was the telephone quitline with a provision for nicotine patch use (19.3% vs. 10.2% for usual care). ³⁷

Despite declines in physical health that occur later in life, recent research found that emotional health and well-being actually increase as seniors age. ³⁸ Although not a common end point in the literature on wellness programs for seniors, there is some evidence to suggest that physical health-focused programs may help to further improve or maintain the emotional health of seniors. For example, Nguyen and colleagues evaluated the impact of a Medicare Advantage fitness program on depression. Results showed that nondepressed participants who attended fitness classes at least 2 times per week in the first year of the program were 46% less likely than control subjects to become depressed in the following year (P = 0.002); a similar effect was observed among previously depressed participants but this did not achieve statistical significance (P = 0.06). ³⁹ Further, because physical activity has been shown to mimic the effects of antidepressants, ⁴⁰ these findings suggest the possibility that programs may enable a reduction in prescriptions, and the associated costs, for these types of medications.

Discussion

The studies highlighted in this review article demonstrate clear positive health and financial outcomes as a result of implementation of senior wellness programs. Because each program differs in design and focus, it is difficult to compare the precise health and financial benefits among programs; however, all of the studies reported herein document that intervention most often improves health care outcomes, both in the general senior population and for those seniors with specific diseases.

These studies also indicate that these programs can be effective in reducing overall health care costs for the participant populations. Even in the one study in which absolute costs increased, the rate of increase for participants was significantly less than the rate of increase for the nonparticipants. ¹³ These results support Shortell's and Antos and colleagues' guidance that disease prevention and wellness are a critical component of any reform aimed at “bending the cost curve.” ^41,42 They also demonstrate that slowing and/or halting progression can generate positive financial outcomes among participants along the continuum of health and disease. Therefore, wellness programs for seniors should be considered an essential part of an integrated, population-based approach that helps participants to (1) adopt or maintain healthy behaviors, (2) reduce health-related risks, and (3) optimize care for health conditions.

Although the preponderance of evidence suggests that these programs are beneficial with respect to the outcomes reviewed, there was some variation in the effectiveness of programs. For example, a fitness program that provided early reductions in hospital utilization among persons with diabetes ¹⁸ did not impact this outcome among the general membership until the 2^nd year of participation. ¹³ Additionally, Munro and colleagues did not find that a fitness program for seniors in the United Kingdom had a significant impact on utilization in a 2-year study. ²⁰ These results demonstrate, not unexpectedly, that uniform results cannot be expected across programs that differ with respect to level of participation, what they offer, and/or how they are delivered to participants.

Our review shows relatively consistent findings with respect to the benefits of frequent and sustained participation in the programs, underscoring the importance of strategies to maintain adherence. Some studies demonstrate that financial outcomes begin to improve after the first year in a program, and that the magnitude of effect increases and reaches statistical significance after the second year. ^13,15 More frequent participation appears to have a synergistic effect, increasing the program benefit, and allowing these to become evident sooner. ^{13 –15,18} In further support of promoting participation, as opposed to just enrollment, one of the few studies that did not find measurable improvements in outcomes (Munro et al) was an intention-to-treat design in which 74% of the treatment group did not actually participate. ²⁰

Success in increasing enrollment and sustaining engagement will result in a larger positive impact for a larger proportion of eligible seniors. Programs that foster social ties and create a community or social network among members may serve to encourage continued participation and improve participant outcomes. ^43,44 Efforts to increase engagement may be particularly important for seniors diagnosed with depression, who are more likely to have a lapse in participation than nondepressed seniors. ³⁹

In conclusion, multiple studies have demonstrated the overall effectiveness of senior wellness initiatives at improving health and quality of life while reducing cost. Furthermore, these studies show that these outcomes are materially influenced by frequency of participation. The clear benefits of participation in these programs, which often increase over time, demonstrate the value to both Medicare and its beneficiaries of extending availability of health promotion and wellness programs. Furthermore, given the high level of health risk that has already accumulated among most Americans by the time they reach the age of 65, an even greater impact is possible by extending wellness initiatives to younger individuals to even further mitigate the negative impact of chronic disease and functional limitations on future Medicare spending. ⁴⁵