By Brad R. Harvey
The fire service has been in a renaissance with regard to wellness: Thirty years ago, firefighters were playing cards, smoking cigarettes, and frying pork chops. Today, officers use portable tablets, guacamole is prepared for lunch, and physical fitness is routine. In 2004, the first Firefighter Life Safety Initiative Summit was held and acknowledged “… the most significant reductions in line-of-duty deaths (LODDs) are likely to be achieved through increased medical surveillance and physical fitness programs.”1 This project analyzed the costs and benefits of a mandatory physical fitness program in the Raleigh (NC) Fire Department (RFD). Career fire departments have the choice to implement a mandatory departmental fitness program, which requires a commitment of capital and personnel resources, which impacts the firefighters and citizens. Some would ask, “Is it worth the costs?”
RFD’s Mandatory Fitness Program
RFD’s mandatory fitness program is based on National Fire Protection Association 1583, Standard on Health-Related Fitness Programs for Firefighters, and focuses on wellness, safety, cardiorespiratory fitness, flexibility, and muscular endurance.2 The department’s 544 firefighters are required to perform a minimum of 30 minutes of exercise during normal shift days, excluding weekends and city holidays.3
Our 28 fire stations, the mechanics’ service hub, and the training facility are equipped with commercial-grade fitness equipment. The department-issued workout clothing includes shorts, T-shirts, sweatshirts, and sweatpants.
The annual fitness assessment occurs in the spring. Units report to the training facility along with three additional department members who serve as test proctors. Once a proctor records the individual’s blood pressure and resting heart rate, the firefighter begins the first leg of the timed eight-station circuit. The circuit components, in chronological order, are the following:
- Stair mill: three minutes (min) with turnout pants @ 60 steps per min. Rest for 60 seconds.
- Don turnout coat, hood, helmet, gloves, and self-contained breathing apparatus (SCBA) and proceed to the tire drag.
- Tire drag: Pull 60 feet of 1½-inch fire hose attached to a large tire.
- Ladder carry: Pick up a 16-foot straight ladder and place it on the drill tower 100 feet away.
- High-rise carry: Pick up 200 feet of bundled two-inch hose and proceed up two flights of stairs. Stop. Pull 50 feet of rolled three-inch hose to the second floor and then lower it, hand over hand. Proceed to the fourth floor and return the bundle to its original position on the ground.
- Tool carry: Pick up a chain saw and a K-12 saw; walk 50 feet around the cone and return.
- Ceiling prop: Grab a pike pole and push 30 pounds (lbs) up three times; pull 30 lbs down five times. Repeat the process three times.
- Keiser sled: Strike a Keiser weight a distance of 12 inches with a 10-lb hammer.
No running is allowed except during the tire drag and the high-rise carry. Members who do not complete the circuit within 17 minutes meet with an exercise physiologist, who develops a personalized fitness plan for the members, who are scheduled for retesting in four months. Immediately on completion of the fitness circuit and then again 60 seconds later, a test proctor measures and records the member’s heart rate. A heart rate reduction greater than 13 beats per minute is desired.
Excellence awards are given to members who have completed the fitness circuit within a time frame considered “exceptional,” after being adjusted for age and sex, as determined by an internal committee. Wellness is a personal commitment all uniformed fire service personnel must make to survive and to sustain a successful career.4
Program Objectives
Leaders made informed decisions concerning investment in the fitness program based on a cost-benefit analysis. Cost figures were taken from fiscal year (FY) 2014. Short-term impacts reflect data retrieved from FY 2015 fitness results. A sample of the costs analyzed included fitness equipment, increased workers’ compensation claims, fitness clothing, expert consultants, and travel expenses to the annual spring fitness assessment.
We arrived at figures for short- and long-term benefits of items like weight loss and diabetes prevention. Contingent value surveys were used to derive figures for items such as using the equipment. These values are based on a combination of research, expert opinions, and comparisons with public safety organizations that do not have a mandatory fitness program. Estimating the value of an item like reducing the odds of one heart attack solely through physical fitness was less certain because of factors like age, heredity, gender, and the uniqueness of personal health; therefore, we used a 30-year time frame over which to evaluate the benefits of one firefighter’s avoiding a heart attack. Discounting represents the value of future money or the opportunity cost. Simply put, if the money were invested elsewhere, what would the value be in the lost opportunities? A higher discount rate represents a high rate of return on invested money. A cost-benefit analysis with a discount rate of two percent is considered optimistic and a six percent rate is considered pessimistic to the program. A well-done robust cost-benefit analysis will apply a four to six percent discount rate.
The Cost of an Annual Fitness Program
A thorough analysis includes all costs that impact the firefighters and the citizens of Raleigh. Ongoing expenses include exercise counseling to individuals not completing the annual fitness assessment within 17 minutes. Additionally, workout clothes for new recruits are estimated to be $24,160 annually, and constructions costs for a 600-square-foot fitness space are estimated at $165,000.
The City of Raleigh plans to either renovate or relocate a fire station each year beginning in FY 2016 and add a new fire station each fifth year, beginning in FY 2019, based on growth estimates. New construction costs for a 600-square-foot fitness area at $275 per square foot was estimated at $165,000. The cost of a full complement of exercise equipment for future fire stations is estimated at $10,000 per station. An increase of $138,653 was incurred from FY 2013 to FY 2014. This amount was attributed to the physical fitness program in FY 2014.
Outcomes of the Physical Fitness Program
Weight loss. Research indicates there are many benefits in having physically fit uniformed personnel, including greater strength and stamina; weight reduction; lower cholesterol and lower blood pressure; and decreased risk of death, injury, or disability from disease. (4) The Raleigh Police Department did not implement an annual fitness assessment. Comparison data of the fire and police departments were used as one factor to arrive at estimates for the effectiveness of the RFD program.
The city’s occupational health nurse reported “significant improvement” in the firefighters’ weight, blood sugars, and cholesterol levels. She estimated that 40 percent (218) of our firefighters are overweight compared with 60 percent of the police officers.
These findings suggest that 20 percent (108) of our firefighters experienced a 2½-pound weight loss. We applied a conservative assumption: Half of the 20 percent of firefighters (54) who had a weight loss did so as a result of the RFD fitness program. Additionally, according to one research study, 25 percent of a participating study group maintained a four-year loss greater than 10 percent of their initial weight.5 Consequently, based on this research, we projected that 14 RFD firefighters maintained their weight loss as a result of the RFD fitness program.
In terms of obesity, a body mass index (BMI) >32 is considered obese, and an estimated half of the original 108 firefighters were obese. Applying the same conservative assumptions to the 54 obese firefighters suggests the fitness program prevented seven firefighters from being obese. The estimated average weight of the RFD firefighter was 205 lbs, and the average age of a RFD firefighter was 35; all sworn RFD members are between the ages 23 of and 59.
Summarizing immediate outcomes from RFD’s fitness program suggest that 14 firefighters will maintain a weight loss of at least 2½ lbs and will have lower blood sugars and improved total cholesterol. Out of the 14 firefighters who lost weight, seven will avoid obesity. The average age of an RFD firefighter is 35.
Blood work and diabetes. Exercise improves many aspects of glucose metabolism, including insulin sensitivity and glucose tolerance in current diabetics.6 In March, 108 firefighters showed notable improvements in their blood work and cholesterol limits. Applying earlier assumptions, it is projected that RFD’s annual fitness program resulted in 14 firefighters with improved blood work and two firefighters who had avoided diabetes.
Heart attacks. Studies suggest moderate physical activity of 30 minutes at least five days a week lowers your chances of getting a heart attack by 30 to 50 percent.7 Anecdotal evidence from the annual physicals indicates that 14 firefighters demonstrated weight loss and two firefighters had improved blood work. However, RFD’s irregular work schedule prohibits five days of participation in the exercise program. We, therefore, assigned a conservative percentage to the cardiac benefits derived from the program. We assumed that one of the two firefighters avoided a heart attack by participating in the fitness program.
Workers’ compensation claims. In FY 2015, the cost of claims fell below the FY 2014 level by approximately $5,000; however, to remain conservative, we did not apply this cost savings in FY 2016. These data support research indicating that firefighters are three times more likely to file a claim with a BMI > 30.8 Additional research found that significantly fewer and less serious injuries occurred in a recruit class that had a fitness program compared with three classes without a fitness program, resulting in a claims cost savings of $33,000.9
Fire Station Impacts
Equipping all RFD facilities with fitness equipment necessitates precious space. Stations built 30 years ago were not designed for fitness equipment, and we were forced to squeeze equipment into existing stations. New station up-fits and design now allocate 600 square feet for fitness areas. Fitness is a personal commitment all uniformed personnel must make to survive and sustain a successful career in the fire service. (4) In terms of estimating the outcomes, some members within the department will choose to be physically fit even if no program exists, and some will do the minimum. The true impact of the fitness progress may be evident in the improved longevity of the members during the golden years.
Applying a Dollar Value to Fitness
Monetizing is assigning a consumer dollar value to an intangible benefit—for example, being physically fit. Public policy analysts use this intermediate goods approach or contingent value survey to arrive at a monetary value.10 Using the contingent value approach, firefighters were asked, “What are you willing to pay for the opportunity to exercise and be healthier?” The intermediate goods approach determines the value of later results that derive from the initial outcome—for example, the future value of current weight loss or lower blood pressure. All financial amounts represent current dollars.
Weight loss. Researchers estimated the average person will spend $316,600 on lifetime health care expenditures with nearly one-third of the expenses being incurred during middle age and nearly half during the senior years.11 Assuming 35 to 65 years old is considered middle age, data suggest a total of $105,333, or $3,511 annually, will be spent. Seniors between the ages of 65 and 85 will spend $7,925 annually, and those under the age of 35 will spend a total of $52,767, or $1,551 annually. Assuming that 40 percent of 14 RFD firefighters are over the age of 36 suggests that six firefighters 36 years or older lost 21/2 lbs in FY 2015. In 2014, the Centers for Disease Control and Prevention (CDC) suggested annual medical costs for those suffering from obesity were $1,429 higher than for those of those of normal weight.12 Further research suggests seven firefighters will avoid obesity, resulting in an immediate cost savings of seven firefighters’ avoiding obesity, resulting in an immediate cost savings of $10,003. K. Thorpe suggests impacts to those ages 65 and above who maintain a 10 percent weight loss experience a savings of $1,077 annually.13 Therefore, forecasting long-term health care savings results suggests that six members currently over the age of 36 will keep 2½ lbs off.
Diabetes. Recent studies show that the health care expenditures are as much as five times higher for individuals with diabetes compared to individuals without diabetes.14 Applying fitness program results that prevent two firefighters from developing diabetes suggests that one firefighter below the age of 34 will save $6,204 and the firefighter over 35 will save $14,044. Recognizing a cost savings of $20,248 in diabetes-related expenses resulting from RFD’s annual fitness program was applied in FY 2019.
Heart attacks. According to the National Business Group on Health, the average total direct and indirect cost of a severe heart attack is about $1 million vs. $760,000 for a less severe heart attack.15 One firefighter’s avoiding a heart attack implies a cost savings of $1 million. However, because of the large amount of indirect and direct costs associated with heart attacks, a cost savings of $500,000 will be applied. Additional assumptions of two firefighters’ suffering a less severe heart attack from the fitness program are projected to save an additional $480,000 by preventing two severe myocardial infarctions ($240,000 apiece).
Further methods in determining the dollar value of RFD’s fitness program included asking our members, “What would you be willing to pay annually to reduce by 15 percent your odds of having a heart attack at age 65?” The weighted average individual value amount was $278.85; the total value annual amount for the entire department was $151,694. Members had assigned monetary values ranging from $50 to $1,000.
Firefighter benefits. A second contingent value survey assessed the value members placed on the opportunity to use the fitness equipment monthly. The average COR firefighter put that value at $14.62; RFD’s 544 sworn members placed a total annual value of $7,953 on the physical fitness program.
Discounting, or the Opportunity Cost
A six percent discount rate was applied to a 30-year time frame, and all values represent FY 2014 current dollars in determining the net value of RFD’s fitness program. The initial cost of $365,091 represents the initial startup costs and the increased claims. FY 2015 represent $37,918 in costs. In FY 2016 to FY 2018, the total cost of $202,918 includes annual renovation expenses and new workout clothing. Beginning in FY 2019, total costs of $212,918 include equipment for additional stations. This trend continues every fifth year; total costs of $202,918 represent all other years.
The FY 201-FY 2018 benefit of $169,650 includes $10,003 in obesity savings; $7,953 from the “What are you willing to pay for equipment?” survey; and $151,694 for the decreased odds of experiencing a heart attack. In FY 2019, the cost savings in diabetes and the less severe heart attack increase the benefit to $429,898. During the period of FY 2020-FY 2023, the benefit shifts downward to $189,898; the heart attack savings are discontinued. In FY 2024, the benefit of $1,077 is applied as RFD’s first senior citizen realizes the benefit of weight loss totaling $190,975.
Beginning in FY 2025 and continuing through FY 2045, benefits trend up and down attributable to interval cost savings of five additional firefighters, saving $1,077 in weight loss, one additional firefighter saving $240,000, and the firefighter who avoided a heart attack in FY 2037. Marginal analysis from the table indicates negative trending; however, the cost savings of heart disease prevention and the prevention of one heart attack maintain a positive net benefit.
Sensitivity Analysis: Pessimist vs. Optimist
Placing a value on the benefits of a fitness program is difficult because of the personal commitment. This project used a 30-year time frame with the most likely outcomes. A pessimist may disagree with Freedhoff’s findings and suggest 90 percent of the individuals regain their original weight; therefore, long-term benefits would indicate only two firefighters avoided obesity. (5) Perhaps the firefighters’ evaluating the odds of reducing a heart attack by 15 percent at $278.85 each was unrealistic and workers’ compensation claims continued to rise. Finally, in FY 2037, the firefighter did experience a devastating heart attack and there were no cost savings realized. Inserting these values represents a net value of -$697,113, indicating no value to the citizens or firefighters.
Conversely, an optimist could suggest that during the FY 2016 annual fitness assessment, a firefighter’s pulse rate did not decrease and further investigation found two arteries that were 90 percent blocked. Therefore, RFD’s fitness program prevented a firefighter from having a heart attack in FY 2016, saving $500,000 dollars. Additionally, Raleigh did not experience the growth anticipated; therefore, one fire station is renovated every other year. These optimistic values suggest a net value of $2 million of RFD’s annual fitness program.
The significant and realistic outcomes demonstrated the thoroughness of this cost benefit analysis, which further demonstrates the range of influence and the degree of sensitivity related to personal wellness. Given all the data input into RFD’s wellness program, a net present value of $651,709 is likely over the next 30 years.
Career fire departments have the choice to implement a mandatory fitness program. It is critical to determine the societal worth because of the investment of resources. This project reasonably and conservatively analyzed the costs and benefits of a physical fitness program to the firefighters and the citizens. Additional benefits not mentioned include reduced stress, improved job performance, and lower blood pressure. Medical expenses keep rising, and 64 percent of firefighter LODDs in 2014 were caused by heart attacks.Personnel are the greatest asset to a fire department; consequently, the RFD chose to institute a fire department physical fitness program.
References
1. National Fallen Firefighters Foundation, http://www.everyonegoeshome.com/16-initiatives/6-medical-physical-fitness/.
2. Implementation of a Physician-Organized Wellness Regime (POWR) Enforcing the 2007 NFPA Standard 1582: Injury Rate Reduction and Associated Cost Savings, http://journals.lww.com/joem/Abstract/2010/03000/Implementation_of_a_Physician_Organized_Wellness.14.aspx.
3. Raleigh Fire Department Policies, http://10.8.128.208/knowledgetree/browse.php?fFolderId=9.
4. International Association of Fire Fighters, The Fire Service Joint Labor Management Wellness-Fitness Initiative, 3rd Ed. 2008. https://www.iaff.org/hs/LODD_Manual/Resources/IAFF-IAFC%20WFI%203rd%20Edition.pdf.
5. Freedhoff, Yoni. Is it Really “Scientifically Impossible” to Keep Your Weight Off? http://www.weightymatters.ca/2014/06/is-it-really-scientifically-impossible.html.
6. Web MD, Understanding Cholesterol Numbers, http://www.webmd.com/cholesterol-management/guide/understanding-numbers#1.
7. American Heart Association, Obesity, http://www.heart.org/HEARTORG/HealthyLiving/WeightManagement/Obesity/Obesity-Information_UCM_307908_Article.jsp#.VuYJr30rKM8.
8. K Kuehl, Y Kisbu-Sakarya, D Elliot, et. al. Injury Prevention, Body Mass Index Predictor of Fire Fighter Injury and Worker Compensation Claims. Journal of Occupational and Environmental Medicine, 2012.
9. Evaluation of a fitness intervention for new firefighters: injury reduction and economic benefits, November 2015 http://injuryprevention.bmj.com/content/early/2015/11/11/injuryprev-2015-041785.full.
10. Treasury Board of Canada, Guide to Cost Benefit Analysis, 2007.
11. Alemayehu, Berhanu and Kenneth E. Warner. The Lifetime Distribution of Health Care Costs; http://onlinelibrary.wiley.com/doi/10.1111/j.1475-6773.2004.00248.x/full.
12. ”Adult Obesity Facts,” http://www.cdc.gov/obesity/data/adult.html.
13. Thorpe E, Kenneth , Zhou Yang, Kathleen M Long , W Timothy Garvey, “The impact of weight loss among seniors on Medicare spending,” Health Econ, 2013.
14. Bjork, Stefan. The cost of diabetes and diabetes care. http://www.sciencedirect.com/science/article/pii/S0168822701003047
15. http://www.cbsnews.com/news/how-much-would-a-heart-attack-cost-you/.
Thanks to Sandy Lepley, RN, Raleigh Employee Health Center; Frankie Hobson, Raleigh Fire Department safety officer; and Todd Erbst, exercise physiologist, for their assistance with this article.
Brad Harvey is assistant chief of operations in the Raleigh (NC) Fire Department.
