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Is It Time To Re-Examine Workplace Wellness ‘Get Well Quick’ Schemes?



January 16th, 2013

Editor’s note: Readers interested in sources listed as available from authors, or in other information relating to this post, may contact Al Lewis at alewis@dismgmt.com or Vik Khanna at vik.khanna.health@gmail.com. And for a response to this post, see Ron Goetzel’s January 29 Health Affairs Blog post.

Virtually unheard of thirty years ago, workplace wellness is now embedded in large self-insured companies. These firms pay their workers an average of $460/year to participate in worksite wellness programs. Further, wellness is deeply enough engrained in the public policy consciousness to have earned a prominent place in the Affordable Care Act, which allows large employers to tie a significant percentage of health spending to employee health behavior and provides direct subsidies for small businesses to undertake these workplace wellness programs.

Yet the implausible, disproven, and often mathematically impossible claims of success underlying the “get well quick” programs promoted by the wellness industry raise many questions about the wisdom of these decisions and policies.  In this post, we lay out the evidence demonstrating that the industry consistently mis-measures and overstates the direct healthcare cost savings.  We suggest several strategies to prevent this and to re-allocate wellness dollars from “get well quick” schemes to the much more challenging, but ultimately more rewarding, task of truly creating a culture of wellness, a workplace that can attract and retain healthier, presumably more productive, people than competitors do.  There is no guarantee that strategy would work and no easy way to implement it, but clearly the easy approach isn’t working.

Creating a culture of wellness begins by establishing standards, practices, policies, and procedures that inculcate a particular set of wellness values in employees.  Employers advised by some of the leading benefits consultants and wellness vendors in the US routinely fail at this crucial step.  Consider one Fortune 1000 company, for example, that annually renews its long-running wellness program, while it simultaneously surrounds employees with vending machines filled with chips and soda and serves up pizza daily in its commissaries.  Ironically, this company’s workforce has recently declined by 5 percent while aggregate medical care spending rose by an equivalent amount during the same period, producing an 11 percent increase in per capita spending.  Yet, the wellness program — foisted upon leadership by benefits consultants — proceeds unchallenged by human resources (HR) executives.

Another Fortune 1000 company recently held open health insurance enrollment for the next benefits year.  In a conference call with employees, an HR executive told them that their answers to health risk appraisals (HRA) questions would not matter; the mere fact of completing the HRA would produce a discounted premium, no matter whether the answers (including entry of blood pressure and cholesterol measurements) were truthful or not.

The most pointed, but very instructive example, of having a high impact wellness culture is actually the military.  There are very few active duty obese members in the four major services; everyone gets required immunizations, and the consequence is that the military has much lower incidence rate of wellness-sensitive events among the active duty than do private sector employers, even after adjusting for age.  The military’s medical spending inflation dilemma stems from civilian employees, dependents, and retirees who account for 83 percent of covered persons and, unsurprisingly, are not subject to the same physical standards as active duty personnel.

While we do not believe that employers need to adopt military-style standards, we do propose that it is illogical to expect sustainable reductions in medical care spending if corporate leaders treat their environments, personnel policies, practices, and procedures with the insouciance of people who believe that they can just wish something into existence.

The Wrong Track

It is crucial that we move in the direction of culture-driven and evidence-based wellness programs, since the current wave of wellness programs are taking us wildly off course by promising substantial short-term reductions in health spending. This is clear whether one looks at the peer-reviewed literature, outcomes measurement generally, marketing claims, or the “face validity” of the broader impact of wellness on population health status.

Peer-reviewed Literature

In the peer-reviewed literature, studies consistently claim savings in medical claims far more substantial than any other category of health benefit initiative (an average of 24.5 percent according to one meta-review of 62 studies), resulting in returns-on-investment (ROIs) of 3.27:1 according to another meta-analysis, or roughly $340 per person) that themselves are also far higher than any other voluntary managed care initiative.

These results are completely inconsistent with marketplace behavior, meaning both can’t be right.  Why, if medical expenses fall so much, don’t insurers — for whom medical expenses are front and center — routinely offer and incentivize wellness for their fully insured populations?   Savings of that magnitude would dramatically multiply their profits on these fully insured members.   Yet, it appears that none of America’s roughly 1,000 private health plans routinely incentivize wellness programs for fully insured members with their own cash and/or premium discounts.  Nor do they routinely require their fully insured members to take HRAs or biometric screens, which underlie most corporate wellness programs.

As is often the case when there is a gap between marketplace behavior and pundits’ views of what should be the case, the marketplace is likely right and the gap can be explained.  One reason for this gap is that, unlike insurers who are immersed in this field and accustomed to hearing implausible outcomes claims, their employer counterparts who champion wellness programs typically rose through the corporate ranks in the non-quantitative HR field.   This creates an asymmetry of information, because both justifying a wellness program and defining its ROI are data-driven processes.  (Wikipedia contains extensive, hyperlinked, information on why information asymmetry will distort a marketplace.)

Further, these HR professionals are often advised on quantitative matters by benefits consultants for whom new program procurement, implementation, and evaluation are profit centers, and who themselves also lack training in outcomes measurement analytics. (Of the 176 people who have earned certification in Critical Outcomes Report Analysis, only 2 list their occupation as benefits consultant.)  Thus, when the contracted consultants evaluate the wellness programs that they themselves advocated, it is far easier to “find” that the client was correct, even when there is overwhelming evidence to the contrary.  A finding that a client made a significant mistake could lead to the loss of the client and/or the sponsor’s loss of a job. This conflict of interest creates an insurmountable moral hazard.

To help resolve this dichotomy and understand why the market is “right,” consider the above-mentioned meta-reviews and analyses.  As appropriately noted by the authors of both meta-evaluations, the studies proclaiming wellness program success are subject to more than the usual set of limitations, because by definition there is no “intent to treat” control.   Almost invariably, all voluntary participants are in one group and those who didn’t want to participate comprise the control, or else the control is a passive matched control on paper, with no indication of whether the control group consists largely of motivated or unmotivated people.  In both cases, only motivated participants are included in the study group.   This limitation is especially problematic in wellness, because unlike a drug trial, motivation is by far the most important factor in success in wellness, which is basically an incentivized self-help program.

Marketing claims made by vendors

This critical flaw in the analytic framework produces the anomaly that virtually every desirable wellness outcome is found in voluntary participants only.  This aberration permeates not only the peer-reviewed literature, but also the claims made generally by wellness vendors and their corporate customers.  Some vendors even show results that specifically require two years of repeat participation (example available from authors), all but ensuring that only the volunteers most dedicated to improvement will persevere long enough to be counted.

While common sense would dictate that putting all the motivated people in one group would skew results in a program genre largely dependent on people’s motivation, it is also fortuitously possible to measure what happens to medical claims when participants and non-participants are placed in separate cohorts.  A keynote presentation at the 2011 Care Continuum Alliance (CCA) (available from authors) did exactly that.  Employees were separated in 2004 into two groups whose claims costs were almost identical.  In 2005, the non-participant group’s annual claims cost grew 9 percentage points faster than the participant cohort.  This was not a “program effect” because the program was not initiated until 2006.

A second classic mistake in outcomes measurement is to focus only on the downward risk migration of high-risk (or high- and medium-risk) people.  Most of the studies cited in the meta-analyses did that, and some websites even tout it. (Example available from authors.)  That this is simply claiming credit for regression to the mean should be self-evident.  If not, Dee Edington, the acknowledged leader in the field of risk migration, has clearly documented it.  Consider this hypothetical:  suppose smoking is the only risk factor in an organization, and that everyone smokes.  Further suppose that everyone also quits periodically, meaning that the average person smokes half the time.  Annual measurements, done as the industry does them, meaning on high-risk people only (in this case, current smokers), will therefore show 100 percent declines in smoking every year, even as the percentage of smokers remains unchanged.

Despite its obvious invalidity, this methodology is almost universal among wellness vendor marketing claims.   In at least one case it isn’t even a mistake:  One health plan’s program guarantees high-to-low risk migration, which its brochure illustrates using artwork that no knowledgeable observer could consider accidental.  Even though low-risk people constitute two-thirds of the population and high-risk people one-eighth, the bar chart shows all three segments (medium risk comprising the remainder) to be of equal size.  The health plan also shades the low-risk segment in a light color, so that the untrained eye focuses on the high-risk segment’s guaranteed decline and doesn’t pick up that upward risk migration of two-thirds of the population is not counted as an offset to the downward migration of the one-eighth. (Bar graph with carrier’s name removed available from authors.)

While one vendor acknowledges that it doesn’t save money in the short term through wellness (noting that others who purport to do so are simply wrong or dishonest) and some websites are silent on the ROI issue, many other websites show ROIs whose invalidity is indisputable.  One vendor claims $350/year in savings even when risk factors are not reduced (citation available from authors), a result possible only if one measures participants against non-participants, as shown at the aforementioned CCA presentation.   Another vendor claims near-term ROIs of 4.8:1 for screenings and 14.3:1 for HRAs (citation available from authors), even though screenings initially generate higher costs as people seek additional care, and HRAs are completed anonymously, making it impossible to calculate savings at all, let alone at that level of precision.

Two more vendors claim total savings of 17 percent to 22 percent 8 to 12 months after implementation.  (One company showed a 17.3 percent relative improvement in total costs after one year for participants, while another reports a case study showing 22 percent savings for the year for a program not implemented until May.  (Both citations available from authors.)  At least three companies have simply announced savings in excess of the mathematical limitation of 100 percent, as does the author of the meta-review himself.  (All three vendors have removed the claims on their website after the impossibility of reducing a number by more than 100 percent was brought to their attention.  Screen shots are available from the authors.)

A vendor proposing to establish a wellness program for an elite intellectual services consultancy promised to produce medical cost savings in excess of $5 million in a year.  The vendor never asked to see any demographic or claims information for the employees.  The promised savings are nearly equal to the company’s entire annual medical spend.

A large health system launched its wellness program with the proclamation that the inflation rate for its aggregate medical care spending would slow by one-third within one year. Many factors can slow the growth of aggregate medical care spending, but the most important ones are completely disconnected from wellness.  These include: a reduction in the number of employees; cost-shifting that inhibits (both appropriate and inappropriate) care; and the retirement, death, or transition to disability income, of older, sicker, and costlier employees.

Finally, one vendor almost explicitly acknowledges that its methodology is worthless.  Its White Paper says it “targets those individuals who have high health confidence and the highest motivation to change their health situation.”   This vendor then “provides incentives to participate.”  It then compares this cohort with non-participants.  In other words, they do precisely what a health services researcher would never do: They (1) find motivated volunteers, (2) bribe them to participate, and then (3) compare them to people so unmotivated they couldn’t even be paid to play along.  They admit:  “This approach is used because there is a need to compare the program participants to something [emphasis theirs] in order to judge whether there have been improvements.” (Citation available from authors.)  Thus, they believe that they must offer an obviously invalid ROI analysis rather than none at all. This is presumably because their customers demand to know: “What’s my ROI?”

Even the iconic Safeway story of achieving a zero medical cost trend through wellness — the inspiration for the wellness provisions in the Affordable Care Act -– turns out to be made up:  Safeway’s zero trend predated its wellness initiative by several years.  Further, after Safeway did institute wellness, its trend increased sharply.  The Safeway success story is further undercut because only 11,000 of the company’s roughly 200,000 employees participated once the program did roll out.

Outcomes Measurement

One could argue perhaps that this commentary cherry-picks the literature, presentations, and vendor websites, and that generally valid wellness program results abound.  We’ve already established that no company has ever controlled for motivation by separating volunteers into two groups to determine whether health-risk-sensitive medical events declined significantly more relative to other events in the motivated cohort allowed to participate in the program.  Hence, perhaps a less exacting test is needed.  Perhaps there has been a situation in which the participation proportion was high enough (and the total “n” was high enough) that when the company tracked spending on health-risk-sensitive medical events against all other spending population-wide, it found favorable separation.  This would “control” for the participation bias by including everybody and having the “control” be the targeted events vs. the non-targeted events.

This type of “plausibility test” is commonplace in disease management, especially among insurers, who recognize the validity of the approach.  The 10th Annual Report (2012) on the Disease Management and Wellness Industries offers an extensive list of insurers using such methodologies.  The Care Continuum Alliance Outcomes Guidelines describe the test as well.

However, not once — in any peer-reviewed journal, lay publication, or vendor website — has a study attempted to determine whether a population’s health-risk-sensitive medical events outperformed non-risk-sensitive medical events over time.  This is largely because no one has ever even made a list of health-risk-sensitive medical events analogous to the list of 16 prevention-sensitive medical conditions published by the Agency for Health Quality and Research (AHRQ) to determine the effectiveness of ambulatory care (Agency for Health Policy and Research, Prevention Quality Indicators Technical Specifications, Version 4.4, March 2012), or the list of ICD-9 “plausibility indicators” used to determine the effectiveness of the five common chronic conditions that comprise most disease management.  (Lewis A, Why Nobody Believes the Numbers, John Wiley & Sons, 2012, p. 48)

Consider the import of this research gap:  this industry sells $6 billion worth of services to American corporations and governments based on the premise that some medical events caused by high-risk behaviors will be avoided — and hence claims dollars saved — if people are incentivized to use the industry’s programs.  Yet this list of medical events does not exist, let alone used to determine if these events declined.

Let us assume that such a list existed.  How much in annual claims would it cover?   In other words, what is the theoretical maximum beneficial impact on claims of a wellness program that eliminates every health-risk-sensitive event; we will generously assume no offsetting increase in medical care expenditures caused by people seeking more care after HRAs and biometric screens, no cost of incentives to visit primary care physicians (Lewis A, Why Nobody Believes the Numbers, p. 132), and no costs for the screens themselves?

Since no such list exists, we can only speculate about the scope of impact.  However, according to the Healthcare Cost and Utilization Project (HCUP) database, neither the AHRQ prevention-sensitive indicators nor the disease management “plausibility indicators” account for more than 8 percent of primary-coded inpatient and emergency room (ER) events and (because inpatient/ER events account for about half of all spending) only about 4 percent of claims in the commercially insured population.

Therefore, for a company to save the 24.5 percent cited in one of the meta-analyses as the “average” savings, the risk-sensitive medical event list would have to be six times the magnitude of either of those established lists.  Further, in contrast to the small percentage inpatient reductions achieved over the years through ambulatory care-intensive projects or the controversial reductions consistently cited for disease management and related activities, the wellness program would have to achieve an unprecedented 100 percent reduction in these services.

Face Validity Questions

In addition to the specific issues raised by the studies in the meta-analyses and by wellness outcomes measurement and marketing in general, there is a “face validity” gap in macro wellness outcomes that advocates never address:

  • Why, if so many companies offer wellness and achieve such tremendous results, are we the fattest country on earth (and getting fatter), and why does our smoking rate decline at a slower pace now than twenty years ago when employer-sponsored smoking cessation programs were much rarer?
  • Why has no wellness company been able to find an independent validator who will vouch for company-wide healthcare cost savings and stand behind that validation?
  • Why does health care inflation continue to significantly exceed the rate of inflation in the broader economy, reflecting a persistent deterioration in population health status?

It is reasonable to conclude that the marketplace-vs.-pundits dichotomy posed at the beginning is indeed due to asymmetric information and/or moral hazard: the marketplace of 1,000 health insurers is right.  The “evidence” for the impact of wellness on health care expenses – whether journal articles, industry practices, or face validity — fails to pass even cursory reasonability tests.

Getting Back On Track  

The implications of this re-examination are significant.  At the federal level, the taxpayer-financed wellness incentives should be removed from the Affordable Care Act.   The Federal Employee Plan, which is poised to spend many millions on an employee wellness vendor, should reconsider that decision.

Private employers can also improve their chances of avoiding this fate by taking these three suggestions. First, HR departments need to reconfigure their benefits consulting relationships, since with few exceptions the latter have not provided critical thinking about wellness (and other “value-added” programs) on a par with that of insurers, who have universally shunned these programs for their fully insured members. (Most insurers will happily sell them to self-insured employers even so, because they clearly understand that “invalid” is not the same as “unprofitable,” especially when you do not bear risk for the outcomes and the customer’s consultants are demanding the service.)

Second, it is also time for employers to change the roles and responsibilities in health benefits administration. Human resources is fundamentally a process-oriented department being burdened with analytic responsibilities that their executives simply aren’t trained to do.

Third, start the reconsideration of wellness by looking at the big picture.  The signals your firm sends have greater impact when they relate cogently to a corporate culture that has openly embraced wellness as an organizational value and not just as a fill-in-the-blank HRA accompanied by a large financial incentive.

We agree that workplace wellness is a useful construct, providing morale and productivity benefits.  However, where large financial incentives are offered in the hopes that health expenses will decline, measurement of health expense reductions is a critical responsibility that is almost invariably lacking in today’s wellness marketplace.  If employers continue to rush to buy workplace wellness programs, they will soon find themselves doing what the health care system itself has done for so long, to its great detriment: consecrating standard practices without clear evidence drawn from sound analytics.  This will result in more money spent on services of uncertain value that produce invalid outcomes, and misallocate resources away from more valuable endeavors and discussions.

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11 Responses to “Is It Time To Re-Examine Workplace Wellness ‘Get Well Quick’ Schemes?”

  1. Rick Riley Says:

    Great article, Al – having been Vice President of Underwriting for a large health plan and a proponent of game-changing wellness cultures and programs, I appreciated your comments related to marketplace evidence – if wellness programs, in their most common/commercial form, were so effective in controlling claims expense, why wouldn’t health plans mandate them for their fully insured business?

    This isn’t a reason to abandon the effort – it makes a difference – we need to keep learning and pushing – with a focus on cultural transformation.

  2. KenG Says:

    Wow, all this energy over ROI, which is nothing more than a distraction and increasingly a waste of time. Wellness companies began obsessing with numbers about five years ago as a response to pressure from CFOs on HR to prove ROI. Forget proving what’s common sense and focus on the issues, e.g. how our societies and workplaces define or ignore wellbeing, how workplaces can cultivate wellbeing (rather than feeding the high salt-fat-sugar-caffeine habit), and how individuals can learn more and take more responsibility for self-managing a whole-person approach to wellbeing rather than the outdated notion of “preventing disease.”

    Let’s focus on solutions on a social, employer, and individual levels — the Excel zealots will be happy with the results without debating a single study.

  3. Cyndy Nayer Says:

    Al, Vik, distinguished commenters, and Vitality:
    I’m so glad you mentioned the health plans that offer fully-insured options to improve personal health, what some call wellness. I also very much appreciate Vitality’s efforts to quantify real ROI in wellness (I do hate that word). What’s interesting is forced ROI in 3 years, which is what I’ve found to be disturbing as well. In all of the surveys I’ve done, I have asked “how are you measuring outcomes,” and the time to achieve. Interestingly, wellness programs, like value-based designs and onsite clinics, are rarely dismantled even when cost-savings are not demonstrated. The real advantage of all of these tools is in the performance and engagement levels of the beneficiaries. It’s fundamental to human behavior change: find some successes, build on the feeling of success, set new goals, etc. To Vitality and my friends at Humana, I’d really like to discuss more of your findings.

  4. The Vitality Group Says:

    Hi again Al and Vik,

    Just to continue the interesting dialog here in the comments section, we wanted to respond further, in this case speaking from our newly formed Vitality Institute.

    Perhaps not surprisingly, our own review of published ROI research comes to a similar conclusion as yours– many studies are fundamentally flawed. We also agree that it is not uncommon to see unsubstantiated claims in some wellness companies marketing materials. Hopefully, your careful analyses of these points encourages the industry and its customers to develop evidence based workplace wellness programs better able to serve peoples’ health.

    The epidemiological evidence does support the proposition that health promotion and disease prevention does, over time, reduce the incidence and severity of certain costly medical conditions, including CVD, lung cancer, diabetes, and injuries associated with alcohol abuse and unsafe driving. The operative phrase here is “over time.” It concerns us that too strong a focus on a three-year ROI from workplace wellness programs sets expectations too high, the result of which is skewed marketing and program analyses that in turn drive the conventional wisdom in an unhealthy direction. Our recent paper in JOEM demonstrates that there are in fact scientifically valid ways to answer important questions about what makes health promotion and wellness ‘tick’ and what outcomes might be expected from effective programs. Much useful information and data are already available in the epidemiology literature and US population health surveys.

    For those that have not read it or don’t have access, our approach for that paper was to draw on the epidemiological evidence that demonstrates the links between lifestyle risk factors and consequent medical conditions. Using findings from the Global Burden of Disease 2004 and MEPS, we were able to estimate that 18.4% of the current cost of illness in the adult working age population is attributable to lifestyle risk in excess of their theoretical minimums. However, as most here will surely understand, even the best designed and implemented wellness program will not achieve risk factor reductions down to their theoretical minimums. Even if one could reduce an entire population down to these values, the time frame for capturing the savings is measured in years. Further, as you might well agree, even the most effective workplace program requires synergistic population policies and programs to be in place for them to realize their full impact.

    We remain committed to participating in the scientific analysis of health promotion and wellness, and to using our own and others findings to create an ever-improving (and always evidence-based) Vitality workplace wellness program. To that end, we will use the updated data from the Global Burden of Disease 2010 study (published in December in special issue of The Lancet—http://www.thelancet.com/themed/global-burden-of-disease), to update our results in the JOEM paper. Our new Vitality Institute will help us continue these initiatives and explore other fundamental questions of interest to the workplace wellness community.

    And one final point—you ask in the post why insurers do not incentivize wellness for their fully insured populations, and we just wanted to call out that in fact many US health insurers have embedded wellness plans, although the extent to which wellness is embedded with medical coverage does vary. Shameless plug ahead, but just an examples, Humana has actively rolled out a comprehensive wellness offering (Vitality) to a large portion of its membership. Farther abroad, the largest health insurer in South Africa and the third-largest in the United Kingdom similarly use this program. It is challenging to make sure these programs are effective and evidence-based, but that’s what we come to work for every day. :)

    From the Vitality Institute,

    Howard Bolnick Francois Millard Jonathan Dugas, Derek Yach

  5. richardcitrin Says:

    Al and Vik,

    Thanks for this great post. Chock full of goodies

    Being a fan of “Why Nobody Believes the Numbers”, I have no difficulty in agreeing with the key aspects of this post. The bigger question for me relates to your last paragraph and how we move the ball forward in wellness.

    While I agree with your ideas about changing the nature o f benefit consulting relationships, I doubt there is much hope for changing those relationships.

    I think a better play regarding HR oversight is to actually engage HR specialists in this kind of discussion. HR professionals are looking for ways to make themselves strategic partners with their business units and to move away from their transactional roles. I believe that many of them intuitively know that their health improvement programs miss the mark and are looking for answers that will accelerate what they believe is a good idea into truly meaningful outcomes.

    Finally, while the Culture of Health approach is a sound model for improving health outcomes over the long term, it is imperative to begin thinking of what are realistic outcomes that measure whether this approach is also working. Perhaps we can avoid the same mistake by determining even modest markers from the get go.

  6. marvinlzinn Says:

    Al & Vik,

    You are correct about assumptions from complex attempts not valid. Trying to save costs often has higher expense than can be returned. Cheap food, for example, costs a lot more with medical bills.

    Almost all business in done for money, not health or safety, even if they claim to have that purpose. There are conflicts between customers, employees and management. A drug company, for example, makes profit from sick customers, and sells food that causes it.

    At a drug store where I worked, I received a bonus for selling mostly candy bars at the counter. For many years of health improvement I never eat such junk. One was banned in Maryland for a preservative ingredient, and another in most of Asia because of dried milk from China. Maybe they were trying to get rid of dangerous things before they had to be removed from the market. (I bought all with China milk that we had in the store and threw them into the dumpster. I would certainly feel guilty of selling any.)

    Most businesses try to save money from materials and activity, while less expense causes injury. In the same store, from trying to put things too high above a ladder I had a cracked skull and seven weeks coma. After recovery from when I was expected dead, I went back to work a few more years, and still saw the same danger every day; the operation never changed. When I assisted someone else to do what I had fallen from, I gave it some thought a few days, and just quit the job. My workman’s compensation medical cost was probably over a million dollars, but they would not spend a couple hundred on a better ladder.

    Competition and fast speed should be replaced with customer concern and time for reasonable logic.

  7. TallBrit Says:

    Al, Thanks for your interesting article. I completely agree that one major flaw in most Employer health/wellness programs is a disregard for addressing health culture. If management isn’t on board to change their organizations attitude about health and to make it a strategic imperative then most health/wellness are frankly not going to come close to fulfilling their stated objective. Your second point about effective H/W measurement is also valid. If your measurement of success is how many complete an HRA a year and whether they have a primary care physician & or done a biometric screening isn’t a proper measurement of true engagement. People have to be actively engaged over a significant time period and understand that lifestyle change takes time, No quick fixes, its a journey that takes time. Saying that, there are organizations out there that are aiming to change health culture and to help management become effective proactive supporters of a positive health culture. CLG out of Pittsburgh is working with clients to do that – its early days but early evidence shows promise.

  8. Cyndy Nayer Says:

    Al, you are mostly correct. The real problem is lack of engagement in the beneficiaries AND the purchasers (usually employers). Requiring an HRA, not following up w actionable steps, and not demanding an outcomes-based clause– my surveys shows many companies getting less than 10% completion of the HRA and, worse, no report bank to the employer of real risks. This is true in disease mgt programs as well. There are millions of dollars being wasted on the promises of “health mgt” without holding vendors accountable. And when more people get involved in the system, even for prevention and appropriate care, they naturally will drive up costs. This was the pushback on VBBD and why, always, I’ve been diligent in saying the earlier, lower-cost care will drive down linger term cost trends. But there’s accountability for pull-thru that must be clear. That’s true for all the stakeholders, not just consumers. HRAs are not magic, nor are biometric screens, diabetes mgt programs, etc– they must have adherence to the recommended behavior changes, including care for financial or mental health issues.

  9. dogbonez Says:

    The most pointed, but very instructive example, of having a high impact wellness culture is actually the military. There are very few active duty obese members in the four major services; everyone gets required immunizations, and the consequence is that the military has much lower incidence rate of wellness-sensitive events among the active duty than do private sector employers, even after adjusting for age. The military’s medical spending inflation dilemma stems from civilian employees, dependents, and retirees who account for 83 percent of covered persons and, unsurprisingly, are not subject to the same physical standards as active duty personnel.
    You need to do more on this statement Like come visit us in Colorado Springs. Also some data review would be of value. The military population is not in any fashion similar to the free living population.
    They are also very much a single payer model, the basic care is not always but very frequently, deny injury or illness”the mentality is very macho and more like workers comp, “The solder does not want to be put on “profile”
    Al you are a great writer but your research was lacking. Vic nice try to go around me when I challenged this some months ago.
    .

  10. Al Lewis Says:

    Seen it , thanks — it’s getting a lot of buzz. We have a group that is trying to compile the ICD9 medical events avoidable via wellness, for the specific reason that no one has compiled this list. You are welcome to join us. Just write offline. I’d also caution that wellness can cost money too, as people go to the doctor more. And screens that find issues that need to be addressed may also find issues that should not be addressed. The state of Nebraska recently announced how its wellness program screened 20,000 employees and “found” 500 early-stage cancers in those 20,000 people. Ask any epidemiologist about this ratio and they’d say “yikes!” I’d recommend the book Overdiagnosis — its author would probably say 490 of those 500 should never have been found and subjected those folks to expensive, emotionally charged, painful and possibly harmful interventions.

  11. The Vitality Group Says:

    Hi Al and Vik, thanks for the great post here. Lots of food for thought, and it’s very timely relative to our own work.

    In the “Outcomes Measurement” section above, you write “. . what is the theoretical maximum beneficial impact on claims of a wellness program that eliminates every health-risk-sensitive event;. . .” We also wonder about these things, and made an attempt to account for this, the result of which was our paper in JOEM this month:

    Medical Care Savings From Workplace Wellness Programs: What Is a Realistic Savings Potential?
    Bolnick, Howard MBA, FSA; Millard, Francois FSA; Dugas, Jonathan P. PhD

    http://goo.gl/6cVGg

    Not sure if you have seen it yet, but interested to hear your thoughts on it and how it can help us move wellness forward on a solid evidence base.

    Thanks again for the interesting post!

    Howard Bolnick
    Francois Millard
    Jonathan Dugas

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