We imagine that reading a point-by-point reply to Professor Ron Goetzel’s lengthy rebuttal to our previous reply, which responded to a previous lengthy rebuttal by Professor Goetzel to our original article, would try the patience of even the most dedicated readers of Health Affairs. Therefore, beyond reminding readers of the original article’s scope, here we use Professor Goetzel’s last response as a touchstone to summarize our difficulties with the arguments by advocates of workplace wellness programs based on financial incentives. We ask weary readers who do not wish to continue with this exchange, but are interested in workplace wellness, to look at the evidence we provide in our appendices, and make their own judgments.
First, we must remind Professor Goetzel that we wrote our original article to address the assumptions underlying workplace wellness programs based on substantial financial incentives — those encouraged by the Affordable Care Act — and not any of the other types of programs. That article did not comment on the myriad other public health interventions that might take place at the worksite, although some of our arguments could be applied to those programs as well. Unfortunately, many of Professor Goetzel’s comments are directed at claims we never made about those other programs, and we find his continued advocacy for those programs in the guise of a response to our work distracting.
Second, Professor Goetzel’s most recent posting helpfully outlines ACA wellness regulations that were released after we published our article. Like other commentators, he is right to highlight the new, expansive “reasonable alternative standard,” because it may mean that many more employees can access alternatives to the program standards. Once again, however, he is more optimistic than we and other researchers are that such protections will be easily accessed by employees. We are skeptical that it will be nothing more than a simple matter for an employee to exempt themselves from the general program. Among other things, the employee needs to know about the possibility of an alternative and to feel that asking for an alternative will not harm her, and her employer must be willing to comply.
Professor Goetzel’s most recent comments display at least three problems with the case often made by advocates of incentive-based, workplace wellness programs:
- Commitment to the faulty logic that if some attribute of an employee has an effect on the business, the employer has a compelling reason, or even a right, to interfere with the private lives of its employees.
- Unwarranted faith that improvements in the biometric measures often used to gauge an employee’s success in a wellness program indicate improved health. Rigorous empirical researchers must always remind themselves that correlation is not causation and that relying on positive evidence and ignoring negative evidence will not help reveal the underlying truth.
- Insufficient concern for the material consequences of such programs on low-wage workers and for equity across socio-economic status. Goetzel’s latest response blog exhibits a troubling, continued resistance to consider the potential negative consequence of incentive-based workplace wellness such as implicit, regressive cost shifting.
Private Lives And Employment
As we have suggested before, neither we nor Professor Goetzel are ethicists or philosophers. But we seem to disagree about the appropriate role of the employer. As we noted in a response letter published in Health Affairs last month, there are grave risks to employers interfering in the private lives of employees. We pointed to the Ford Sociological Department as another ambitious workplace wellness program, one that is among the most discredited in US history. The program granted access to the $5-per-day, profit-sharing plan for participating in a program that merely advised “employees as to their living conditions … No man was urged to change his mode of living if he did not willingly so elect.” In language echoing today’s discussion, Ford didn’t aim “to pry into family affairs…but rather…to help those who… desire to seize opportunities, but… are unschooled and unskilled in being able to seize the best opportunities when they present themselves.” Intrusion by company police and spies followed, and Henry Ford later conceded the program failed.
Despite such examples, Professor Goetzel responded with an even stronger claim than in earlier posts, one that suggests he thinks employers are justified in intervening in their employees’ private lives if doing so has a business justification. We could not disagree more, but we find even the (slightly) narrower claim that if employers offer health insurance because they want “to keep their workers healthy and productive,” then those employers are justified in interfering in their employees’ private lives nothing short of shocking.
We’ll leave our response to a few hypothetical questions. Let’s suppose that people without children were healthier and more productive than those with children. It’s plausible. After all, those people have more time to exercise, aren’t held hostage to the culinary tastes of toddlers so can eat kale, and aren’t exposed to all the illnesses of the schoolyard. Is the employer justified in telling its employees to not have children? In limiting the number of children an employee has? In another example, what if we would be more attentive to our work if we didn’t read distressing news in the newspaper? Or if we didn’t vote — then we wouldn’t spend the day disappointed that our candidate lost. Or reading a thought-provoking book that makes us question our employer’s practices — that wouldn’t be so good for business. You get the point. There has got to be something more than a mere business effect to justify an employer getting involved in what employees do at home.
The potential ethical conflicts of wellness programs are not limited to the role of employers, but also the role that doctors assume in them. Will, or should, doctors or their patients be comfortable with doctors participating in what is essentially a determination about a patient’s work compensation? To whom are the doctor’s duties owed, the patient or the employer? These conflicts even exist in public payer systems; Germany, which instituted incentives aimed at individuals as part of its health insurance system in 1989, has experienced problems with conflicts of interest. Considerable controversy surrounded programs “for early detection and treatment of chronic diseases” because doctors were “uncomfortable with their policing position.”
Faith v. Evidence: Biometric Measures, Easy Fixes, And The Politics of Wellness
Professor Goetzel has reiterated that the “point of workplace wellness programs is to inspire people to improve their health behaviors and biometric measures so that they do not suffer from illnesses that are to a large degree attributable to lifestyle practices.” Unfortunately, the relationships among biometric measures, lifestyle practices, and illness are not as straightforward as Professor Goetzel continues to assume.
Research on evidence-based medicine often uses the term POEMs — patient oriented evidence that matters. Unfortunately, it is expensive, time consuming, and hard to collect this kind of evidence. That’s why workplace wellness programs use surrogate outcomes for health measures, like the biometric measures we discuss. As we documented in our last blog, the evidence indicates that measures do not always correspond to better health and vice versa. As a recent publication explained,
The grand assumption underpinning this approach—that helping a person’s numbers [“biometric measures” or “surrogate outcomes”] will automatically improve their health—is a delusion as dangerous as it is seductive. Use of flecainide to reduce the number of irregular heart beats, for some people also raised their risk of an early death, killing tens of thousands just decades ago. Long term hormone replacement therapy lowered “bad” cholesterol and raised “good” cholesterol for generations of women, but it also lifted their chances of heart attacks and strokes. Prescribing pills to aggressively decrease blood sugar in high risk diabetes patients has been increasing their risks of disease and premature death rather than reducing them.
Notwithstanding Goetzel’s beliefs in the weight loss goals set by workplace wellness programs, the findings that being overweight is correlated with increased longevity, and that both being severely obese or underweight are correlated with decreased longevity, are quite common.
In our earlier response, we noted how difficult it is to change behaviors. It is also difficult to get across any message that contradicts the widely accepted assumptions about the ease of changing behavior (like losing weight) and the wealth of positive effects that will surely flow from doing so (like living longer). Had Goetzel not dismissed, without reading, the work of respected scholar J. Eric Oliver (which we cited in passing about the possibility that exhorting people to lose weight might do more harm than good), because “it sounds rather conspiratorial,” he might have learned more about the politics of obesity research.
Oliver did not say, as Professor Goetzel assumed, than anyone was “paying off” CDC researchers to say bad things about obesity. Instead he documented the story of CDC staff who had conducted careful research showing that previous estimates of the mortality attributed to obesity were possibly overstated by a factor of almost 15 (among other important findings), and how they were met with a highly unusual and very public PR attack by people who have dedicated careers to making the case for obesity being a major factor in premature mortality.
Indeed, only recently, the journal Nature came to the defense of Kathryn Flegal, a researcher at the National Center for Health Statistics — part of the CDC – who had published a statistically sophisticated meta-analysis in the Journal of the American Medical Association. The paper concluded that being overweight was associated with lower mortality, and that there were no differences in mortality for those with “grade 1 obesity (BMI 30 – <35) relative to an ideal BMI. The Nature editorial admonished the chair of the Harvard School of Public Health’s nutrition department, Walter Willett, for his unfounded, negative comments about that research, promoting oversimplification of scientific results in the name of public health, and engaging in unseemly behavior towards those who venture conclusions that differ to his.” It is not easy to publish quality research that goes against the wellness grain, and publications with the heft of Nature are not always available to defend researchers who try.
Low Wage Workers, Equity, And Cost-Shifting
In our original article, we presented enough evidence to raise the concern that incentive-based wellness programs may be unacceptably inequitable. In addition, the much-discussed RAND report stated:
We consistently observed that shift, part-time, and off-site employees could not take full advantage of their employer’s program, because of limited flexibility in their schedules, remote location, and less understanding of program goals and benefits. Thus, the combination of the higher prevalence of health risk factors and more limited access to interventions that can ameliorate those risks may lead to a differential shifting of cost to such employees, when substantial incentives are tied to lowering health risks.
Although Goetzel describes wellness programs as a boon for employees, “it is well established that people who are better off [financially] are more likely to participate in preventive measures than poorer people.” Given this evidence, we simply do not understand how, as Professor Goetzel suggests, wellness programs can be equitable in principle. If actions the well-off are more likely to engage in, with or without a wellness program in place, will enable them to avoid penalties or make them eligible for rewards, while actions more likely to be engaged in by the less well-off will subject them to penalties or ineligible for rewards, where is the equity? These problems do not disappear when the rewards or penalties involved aren’t primarily monetary, but require extra effort.
But even if lower-income employees did participate at equal rates as higher-income employees, the results might still be unfair. There is strong evidence that having low income or wages is itself a substantial health risk that may be more important than some of the lifestyle practices to which Goetzel refers. A study by Professor Paula Lantz and colleagues divided people into three household income groups, which we translate into 2013 dollars: groups earning more than more than $64,000 per year of household income (call them rich), more than $21,313 but less than $64,000 (call them middle class), and less than $21,313 (poor). The authors’ estimates suggest that that the rate of increase in the instantaneous risk of death is 53 percent higher for the poor relative to the rich, and 30 percent for the middle class relative to the rich. They also find that being overweight and obese are protective of mortality risk, despite controls for physical activity and such. Mortality is, of course, not the only outcome that matters, but lowered mortality risk is a minimum threshold for any program that is supposed to be helping its subjects.
Finally, even assuming such programs helped poor people improve their health, it is not clear that putting almost ten percent of an employee’s household income — 30 percent allowed by the ACA times the average cost of an employer health plan for a family (about $16,000) is $4,800, or just under 10 percent of median income in 2011 — is the best way to help them. What low-income, or even medium-income, families have this kind of money to put at risk? Just recall the widely reported budgeting advice from McDonald’s (which assumed that their workers were working two jobs, and paid merely $20 dollars a month for health insurance, and paid nothing for groceries, clothing, childcare, or gasoline for transportation) that left workers with a mere $25 dollars per day to spend. Is it equitable to make the same demands of a worker, possibly with others to support, who has $25 dollars a day to spend and works two jobs as someone who earns ten or twenty times as much from one job? Which gyms are they going to attend and when?
Might there be better ways to help these families? We have not seen an evaluation that compares the expense of running a wellness program to an alternative that would take that money and raise the wages of the lowest paid workers, and we doubt we ever will.
Let us stress that we hope that leveraging the workplace to improve wellness can “inspire(s) people to improve their health behaviors” Our primary concern is that advocates take more seriously the cliché that “wishing doesn’t it make it necessarily so.” Or, perhaps exercise the necessary caution suggested by a remark sometimes attributed to Saint Bernard, “[the road to] hell is paved with good intentions.”