American Institute for Preventive Medicine

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The Evaluation of an Employee Self Care Program
New Page 1 The Evaluation of an Employee Self-Care Program
Don R. Powell, Ph.D., Carla Breedlove-Williams, RN, MS

Reprinted from Health Values: The Journal of Health Behavior, Education, & Promotion

Vol 19. No. 5, September/October 1995

Copyright 1995 PNG Publications

A self-care program that helped employees make better medical decisions to increase efficient and appropriate use of medical care was implemented at a large hospital in Orlando, Florida. Hospital employees were given a low-cost 72-page booklet called the HealthyLife Self-Care Guide. An evaluation of 801 employees demonstrated a $75.30-per-employee savings in five months. This savings resulted from 265 fewer physician visits and 99 fewer emergency room visits. Employees also experienced 167 fewer days of absence from work. Based upon the cost of the booklet and the savings that occurred, the hospital experienced a 55:1 Return On Investment. In addition, 63% of the employees stated that the Guide had positively affected their families. It appears that this self-care guide can reduce an organization's health-care costs.

The nation's health-care bill has continued to spiral throughout the 1990s. According to the Department of Commerce, in 1993 health-care costs rose 12%, totaling over $942 billion or about $3,900 per capita. The agency expects a similar increase in 1994, bringing health-care costs to over $1 trillion, or about 14% of the gross national product. 1

The program described in this article took place at Florida Hospital in Orlando, a 1,478-bed facility with approximately 7,500 employees. Like many corporations, Florida Hospital has been adversely affected by escalating employee health care costs. In 1987, health insurance cost $805 for each fulltime equivalent (FTE). In 1991, this cost had risen to $2,360 per full time equivalent, and although this is less than the national average, it increased by 293% in only five years (see Figure 1).

Also, an analysis of the hospital's January to June 1991 "Ten Most Costly ICD-9 Codes" reveals that approximately 17.4% of inpatient and 22.4% of outpatient charges were potentially lifestyle related (LIFE Program Proposal, Florida Hospital, Orlando, internal publication). Based upon this information, Florida Hospital implemented a health-promotion program for its employees. The "LIFE" (Lifestyle Improvement for Everyone) Program is a comprehensive lifestyle-management program that focuses on the demand side of health-care costs by influencing the health-related behavior of the employee -- the health-care consumer.

The goal of the LIFE Program was to reduce health-care costs through

  • the maintenance and/or adaptation of healthy behaviors.
  • an increase in skills and motivation to seek the most appropriate and cost effective medical care.
  • the recruitment and retention of health-oriented employees.
This study will provide the results of one component of the LIFE Program, the implementation of a self-care program. Medical self-care refers to a decision-making process that helps increase efficient and appropriate use of medical services. It includes a number of skills that include knowing

  • when and when not to see a physician,
  • when to use outpatient rather than inpatient services,
  • when diagnostic tests are appropriate, and
  • when and how to question a physician's recommendation.
Self-care has occurred naturally in our society for hundreds of years. A study conducted by Williamson and Danaher found that people in a rural population treated 79% of their symptoms without a physician visit. 2 DeFriese and Woomert estimated that 75-90% of symptoms experienced by the elderly are treated without professional care. 3 Even though these studies indicate that the practice of self-care is very common, research also shows that a large number of physician visits are unnecessary. 4-6

The result is that employers end up paying for inappropriate, ineffective treatment. One solution is to reduce overall demand for medical care by helping individuals make appropriate health-care choices. Self-care materials are an effective tool in helping employees to become informed consumers of health care. Such materials have been proven to reduce health-care costs by reducing the demand for unnecessary medical services.

A number of studies have shown a reduction in utilization of health-care services when self-care programs have been implemented. A study by Moore et al. in an HMO setting showed a 21-24% reduction in physician office visits. 7 Kemper, also in an HMO setting, demonstrated an 11% decrease in clinic utilization, a $100 reduction in the cost per visit, and a 35% reduction in referrals to specialists. 8 Vickery et al. showed a 17% reduction in first doctor visits for minor problems and a 21% reduction in upper respiratory infection visits. This amounted to a savings of approximately $2.50 to $3.50 for each dollar spent on the self-care intervention. 9 Vickery et al. also showed a cost savings of $30.29 per person in a Medicare population group. In comparing this savings to the cost of the self-care materials, a benefit-cost ratio of 2.19 to 1.0 was realized. 10 Leigh et al. found that per person claims in a retiree group decreased by $74 for the experimental group and increased by $266 for the control group. 11,12


After reviewing most of the self-care products available, Florida Hospital selected the HealthyLife Self-Care Guide, published by the American Institute for Preventive Medicine in Farmington Hills, Michigan. 13 The 72-page Guide addresses 25 of the most common health problems (see Table 1). These 25 medical conditions account for the majority of acute-care physician office visits according to National Center for Health Statistics data (Facts About Family Practice, The American Academy of Family Physicians, unpublished data). 14

HealthyLife Self-Care Guide Topics
1. Acne 14. Flu
2. Asthma 15. Hay Fever
3. Backaches 16. Headaches
4. Bronchitis 17. Heartburn
5. Chest Pain 18. Ingrown Toenails
6. Common Cold 19. Laryngitis
7. Coughs 20. Premenstrual Syndrome (PMS)
8. Cuts, Scrapes, and Punctures 21. Sinus Problems
9. Diarrhea 22. Sore Throat
10. Earache 23. Sprains and Strains
11. Eczema 24. Urinary Tract Infections
12. Fatigue 25. Vomiting and Nausea
13. Fever

The Guide also contains information on how patients can communicate effectively with their physicians and how to set up a home pharmacy. Because consumers vary greatly in educational background, the Guide was written in a style that is easy to read and understand, using simple language and an easy-to-follow flowchart format. By answering "yes" or "no" to various questions, readers can readily determine whether their symptoms require emergency treatment, a physician visit, a call to their doctor, or simply at-home measures. (See Figure 2 for sample flowchart on headaches.) The Guide was also selected because it is much less expensive than the other self-care materials that were reviewed.

Headache Flow Chart
Is the headache associated with a serious head injury?
Is the headache associated with pain in one eye, blurred vision, double vision, slurring of speech, mental confusion, personality change or problem in moving arms or legs?
Is the headache associated with fever, drowsiness, nausea, vomiting and a stiff neck?
Has the headache come on suddenly, and is it more serious than others you have had?
Has the headache been occuring for more than 2 to 3 days, increased in frequency and intensity or occurred at the same time of day, week or month?

To reward healthy behavior change, Florida Hospital offered their employees who attended an annual lifestyle screening, a $10-per-month reduction in their insurance premium. The Guides were given to hospital employees at this screening. A health educator also provided a 1 to 2 minute orientation to the Guide by going over the Table of Contents and discussing a sample "symptom flowchart." Initially, 3,874 Florida Hospital employees received the HealthyLife Self-Care Guide at the screenings. An evaluation survey was mailed to their home five months later, and 801 employees (21%) returned it.

The results of the survey were noteworthy.

  • For 25% of the employees, using the HealthyLife Self-Care Guide enabled them to avoid one or more visits to the doctor. The total reported number of reduced physician visits was 265. The hospital's insurance records show the average doctor visit costs $55. Thus a savings of $14,575 was realized from reduced physician visits.
  • For 14% of the employees, using the Guide decreased their number of visits to the emergency room. The total reported number of reduced emergency-room visits was 99. The hospital's insurance records show the average emergency room visit costs $462. Thus a savings of $45,738 resulted from reduced emergency room visits.
  • The hospital's total savings in five months from reduced physician visits and emergency room visits was $60,313, or $75.30 per employee. Because the booklets cost the hospital $2 per employee, the Return On Investment for the self-care program was 38:1 or $38 for every $1 spent in only a five-month period. If this same savings is realized by the entire 7,500-employee population, the hospital's five-month savings would be $564,750. The total one-year savings would be $1,355,400 or $180.72 per employee.
  • For 14% of the employees, using the Guide prevented absences from work during the last five months. The total number of reduced absences was 167 days. This comes out to an average of 1.5 fewer days of missed work for employee who stated he or she would have been absent.
  • Sixty-one percent of the employees stated that they had used the HealthyLife Self-Care Guide in the last five months. They referred to the Guide a total of 896 times.
  • Forty percent of the employees felt the Guide would help them decide when to see a physician.
  • Thirty-five percent of the employees used the Guide before contacting a physician.
  • Fifty-seven percent of the employees felt the Guide better prepared them for physician visits.
  • Sixty-three percent of the employees felt the Guide positively affected their family.
  • Thirty percent of the employees said the Guide was used by other family members (see Tables 2, 3 and 4).
Medical Utilization Changes
Activity Percent of Employees
Decreased Doctor Visits
Decreased Emergency Room Visits
Decreased Absenteeism
Referred to Guide
Helped Make Decision About Physician Visit
Used Guide Before Contacting Physician
Better Prepared for Physician Visit

Changes in Medical Costs
Medical Activity
Decreased Doctor Visits
Decreased Emergency Room Visits

Return on Investment
Booklet Cost
Per Employee Savings

Three limitations of the study must be noted. First of all, if a greater number of employees had responded to the survey, the reliability of the demonstrated savings would be increased. Florida Hospital is in the process of surveying 3,000 additional employees who received the Guide so that a larger subject pool can be studied.

Second, the study relied on employees' self-reported perceptions of reductions in physician office visits and emergency room visits. The study would have greater credibility if pre- and post- study employee health-care utilization data had been analyzed. However, even if the self-reported data is overstated by 50% (which is unlikely), the demonstrated savings would still be $90.36 per employee in one year. Because Florida Hospital paid only $2 per employee for the HealthyLife Self-Care Guide, it still would have produced a 45:1 return on investment in one year. Also adding to the Guide's cost effectiveness is that no dollar savings was placed on the reported 167 days of reduced absences. The hospital's average employee per diem multiplied by this number of days would produce a significant savings. The ratings that showed a high percentage of employees used the Guide before contacting their physician and felt better prepared for physician visits also give credence to the benefits of the self-care intervention.

Third, the study would have benefitted if the evaluations covered a one-year time period rather than five months. Another part of the study will do just that. A second survey will be sent to all employees who received the Guide so that one-year data can be gathered.

Although some methodological limitations exist within the present study, it appears that the HealthyLife Self-Care Guide is a cost-effective tool for reducing an employee population's health-care costs. Studies are presently underway to replicate the results in an HMO and corporate setting. By managing the demand for health-care services with self-care materials, employers may make a significant impact on their annual healthcare costs. Only then will we start to control the runaway medical expenses that we have been experiencing for the past 15 years.


  1. National Center for Health Statistics: Health United States, 1992. Hyattsville, MD, Public Health Service, 1993. (DHHS publication no. (PHS) 93-1232.)
  2. Williamson JD, Danaher K: Self-Care in Health. London: Croom Helm, 1978
  3. DeFriese GH, Woomert A: Self-care among the U.S. elderly. Research on Aging 1983 5:3.
  4. Sui A, Sonnenberg F, Manning WI et al: Inappropriate use of hospitals in a randomized trial of health insurance plans. N Engl J Med 1986; 315:1259-1266.
  5. Chassin M, Kosecoff J, Park R, et al: The Appropriateness of Selected Medical and Surgical Procedures: Relationship to Geographic Variations. Ann Arbor MI Health Administration Press, 1989.
  6. Schoenbaum S: Toward fewer procedures and better outcomes. JAMA 1993; 269:794-796.
  7. Moore SH, LoGerfo J, Inui TS: Effect of a self-care book on physician visits. JAMA 1980; 243(22):2317-2320.
  8. Kemper DK: Self-care education: impact on HMO costs. Med Care 1982; 20:710-718.
  9. Vickery DM, Kalmer H, Lowry D, et al: Effect of a self-care education program on medical visits. JAMA 1983; 250(21):2952-2956.
  10. Vickery DM, Golaszewski TJ, Wright EC, et al: The effect of self-care interventions on the use of medical service within a Medicare population. Med Care 1988; 26(6):580- 588,
  11. Leigh JP, Richardson N, Beck R, et al: Randomized controlled study of a retiree health promotion program. The Bank of America Study February 1990.
  12. Leigh JP, Fries JF: Health Habits, Health Care Utilization and Costs in a Sample of Retirees. California: Blue Shield of California Grant, May, 1990.
  13. Powell DR, Karwan J: HealthyLife Self-Care Guide, 4th edition. Farmington Hills MI AIPM Publishing, 1994.
  14. Public Health Service: National Center for Health Statistics: Vital and Health Statistics: 1989. Hyattsville MD, 1992.

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