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On Workplace Wellness, Don’t Throw The Baby Out With The Bath Water: A Reply To Lewis And Khanna

January 29th, 2013

This commentary is in response to a January 16, 2013 Health Affairs Blog post entitled “Is It Time to Re-Examine Workplace Wellness ‘Get Well Quick’ Schemes?” by Al Lewis and Vik Khanna. After the initial blog appeared, my email box was filled with messages asking for a rebuttal to the initial posting, which, to many, seemed like a condemnation of the worksite health promotion (wellness) field and its lack of credibility and honesty in reporting program savings. Instead of just immediately posting a response, I called Al Lewis to discuss the value of worksite health promotion in order to “set the record straight.” It turns out that we agree on many issues but there are also differences.

We agree that there are unscrupulous wellness vendors who claim very large and often implausible savings from worksite health promotion programs. The return-on-investment (ROI) figures bantered about, sometimes as high as 10:1, are not credible. At the same time, I believe it would be wrong to “throw out the baby with the bath water.” In this case, the “baby” refers to well-designed, evidence-based, comprehensive, appropriately resourced, non-gimmick, and well-executed worksite health promotion programs.

Stated positively, good worksite programs deserve credit and should be supported by the business community, not condemned. This is because there is good and growing evidence, reported in a rigorous scientific literature, that “best-practice” worksite health promotion programs improve population health and save money for businesses. Savings are realized from lower health care cost trends, reduced absenteeism, and heightened worker productivity.

Getting To A Culture Of Health And An Effective Workplace Wellness Program

It should be noted that it’s not easy to achieve those positive outcomes. Success is achieved when workers are made aware of the program, participate actively and willingly in it, are given the tools and resources to change their behaviors, and are situated in a workplace environment that supports healthy lifestyles. And, it takes several years, typically three to five, to realize cost savings.

Al and Vik appropriately note that you can’t expect workers to do all this on their own. Workers need a workplace “ecology” where company leadership encourages the adoption of healthy behaviors and creates what is referred to as a “culture of health.” This means providing access to healthy foods, making it easy to be physically active, allowing for flexible work arrangements, making available coaching and health education programs, helping workers manage physical and mental health problems, and so forth. The list is long — it contains well over 100 “interventions” employers can offer to create a work environment where living a healthy life is a “given,” the default condition.

The above sounds simple, but it isn’t. Achieving a healthy company culture requires sustained effort and takes many years to accomplish. A comprehensive workplace health promotion program is more than sending workers to a website where they can complete a health risk assessment. A “comprehensive” workplace health promotion program, as defined by Healthy People 2010, includes the following five elements: 1 ) health education, focused on skill development and lifestyle behavior change along with information dissemination and awareness building, preferably tailored to employees’ interests and needs; 2) supportive social and physical environments, reflecting the organization’s expectations regarding healthy behaviors, and implementing policies promoting healthy behaviors; 3) integration of the worksite program into the organization’s benefits and human resources infrastructure; 4) linking related programs like employee assistance programs (EAPs) into worksite health promotion; and 5) screening programs followed by counseling, linked to medical care to ensure follow-up.

Beyond these broad categories, effective programs have strong senior- and middle-management support, include employee input when developing goals and objectives, are grounded in behavior-change theory, are adequately resourced, have dedicated staff, include “smart” incentive programs, and are regularly evaluated using well-defined metrics of success. Some positive examples of best practice programs can be found at The Health Project website, a collection of C. Everett Koop Award Winners spanning the past 20 years.

Despite increasing numbers of workplace wellness programs, as reported by employers, many are indeed ineffective due to underinvestment and poor design. While recent surveys report that about two-thirds of all companies offering health care benefits offer at least one wellness program, far fewer offer comprehensive programs. In the most recent study of this topic, Linnan et. al. found that just 6.9 percent of U.S. employers offer comprehensive worksite health promotion programs.

The Evidence That Good Programs Work

What, then, is the evidence that well-constructed programs work? A systematic literature review conducted by The Community Guide to Preventive Services, housed at the Centers for Disease Control and Prevention (CDC) and led by Dr. Robin Soler, evaluated carefully screened studies of health promotion programs and policies introduced by employers over the course of the past thirty years. Applying Community Guide systematic review methods, Soler et al. examined behavioral, biometric, and business-relevant outcomes reported in 51 studies that met inclusion criteria established by the Task Force.

The overall conclusion of the review was that comprehensive, well-conceptualized, and theory-based worksite programs do exert a positive influence on certain health behaviors, biometric measures, and financial outcomes important to employers. The Task Force found strong or sufficient evidence that comprehensive programs can reduce rates of tobacco use, dietary fat consumption, seat belt non-use, high blood pressure, total serum cholesterol levels, high-risk drinking, and the number of days absent from work because of illness or disability among participating employees. They also found improvements in workers’ physical activity, overall health and well-being scores, and health care use, especially in terms of reduced hospital admissions and days of care.

The Community Guide Task Force performed an economic analysis to determine whether these programs save money and whether they deliver a positive ROI. The results were promising, underscoring the potential for evidence-based programs to achieve a financial payback to employers implementing worksite programs. Estimates by researchers and economists at Harvard cite a $3.00 return for every dollar invested, over a three-year time horizon, from effective worksite health promotion programs.

In sum, it is important to distinguish here between the baby and the bath water. The “baby” is a well-functioning worksite health promotion, which can, as the Community Guide review demonstrates, improve workers’ health in many important ways. Not only that, good programs also have the potential to produce a positive ROI, probably in the range of 1.5-3.0 to 1.0, over 3-5 years.

The “bath water” discussed by Lewis and Khanna contains unsubstantiated and often phantasmagorical claims of significant ROIs from worksite programs, many of which are not constructed using best-practice principles. Evaluations of these programs are also lacking, as they note. It is therefore appropriate to be skeptical of large ROI claims. However, good programs do produce good results, and they should continue to be supported by smart public policy and private investment.

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2 Responses to “On Workplace Wellness, Don’t Throw The Baby Out With The Bath Water: A Reply To Lewis And Khanna”

  1. Morgan Downey Says:

    I filed extensive comments on employer wellness plans as they relate to weight management. Bottom line: they don’t work. I cite 6 systematic reviews and meta-analyses and 2 specific studies, one with over 9.000 subjects. And these, presumably, were voluntary programs with motivated participants, not mandatory health-contingent health plans. The proposed regulations are probably unconstitutional, under Chief Justice Roberts opinion in NFIB v Sebelius. They break 3 specific promises from President Barack Obama. And they create conflicts with the Americans with Disabilities and consumer protection laws used by the Federal Trade Commission to crack down on weight loss frauds and scams.They render useless billions of dollars in NIH funding spent on the metabolic syndrome for hypertension, type 2 diabetes and obesity. They state that they are approving human experimentation on persons without the protection of the federal regulations protecting human subjects. Animals in research get more protection than these regs. Did I mention these programs don’t work for motivated employees? Oh, and then there is the fact that white women with obesity working in firms providing health insurance, experience a wage penalty vis a vis their normal weight peers. So, they are already paying for their health insurance through reduced wages. Conclusion: Throw the baby out. Start over See, for the full, 27 page brief.
    Morgan Downey

  2. Vik Khanna Says:

    Al, Ron and I have much common ground. We all support creating workplaces that value wellness. I myself make my living doing exactly that.

    Indeed, we could focus employer efforts and budgets on doing exactly that if vendors and consultants weren’t (very profitably) convincing HR departments to do precisely the opposite: bribe people to complete forms, take unnecessary blood tests, and talk to coaches. If perpetual individual incentives are the price of workplace wellness, then the model is unsustainable.

    We have much respect for Ron Goetzel, but the rest of the wellness industry is not Ron Goetzel. It’s people who routinely design studies incorporating three blatant violations of basic study design principles. First, they compare voluntary, motivated, incentivized participants to non-participants to evaluate interventions whose success depends on motivation.

    Second, risk factors ebb and flow on their own. The best research shows that fully half of high-risk people will migrate to lower risk categories without an employer-based wellness intervention. Therefore, a cohort of people who start with multiple risk factors will always migrate downward, but the wellness industry assiduously ignores upward migration of people with low or no risk factors, failing to count them as an offset. Preventing this upward migration should be the grail quest for wellness because that is the largest pool of modifiable population attributable risk.

    Finally, without having predicted which wellness-sensitive events would decline and then seeing if the savings were in those events, it’s not enough to just say that wellness programs produce savings. This would be like a drug company saying “whatever diseases you had were cured by taking our pills.”

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