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Workplace Wellness Programs: Continuing The Discussion

January 27th, 2014

Editor’s note: One of the most-read Health Affairs articles last year was “Wellness Incentives In The Workplace: Cost Savings Through Cost Shifting To Unhealthy Workers,” by Jill R. Horwitz,.Brenna D. Kelly, and John E. DiNardo. The article engendered a Health Affairs Blog discussion between the authors and Ron Goetzel. (See herehere, here, and here.)  Below is another installment of that discussion, from Ron Goetzel.

I have had several back and forth conversations with Professors DiNardo and Horwitz.  I won’t bore the readers with a re-hash of old arguments.  We don’t need to re-litigate the basic premises of our debate, from either point of view.  Those interested in following that discussion can review our previous posts.

I would, however, like to respond to a central point made by DiNardo and Horwitz that employers should not interfere with the private lives of employees.  I agree with this assertion to a certain point.  It should be noted that many employers do “interfere” with employees’ private lives by not allowing them to smoke on premises, requiring them to wear seat belts when driving company vehicles, mandating that they wear protective gear (hard hats, work boots, gloves) at construction sites, and so forth.

Certainly, an employer cannot and should not tell workers what to eat or how much to exercise.  However, an employer can provide guidance, education, skill building, and support programs to workers who wish to eat healthy foods and become more physically active.  That, in my mind, is not interfering in workers’ lives but rather supporting their efforts at leading a healthy lifestyle.

The other examples of potential employer interference in workers’ lives cited by DiNardo and Horwitz are nonsensical.  No employer in this country would limit the number of children a family should bring into the world, whether or not people should read newspapers or books, or whether employees should be allowed to vote in elections.  These are examples of reductio ad absurdum, a reduction to absurdity of an otherwise reasonable position.  Also, no one in the health promotion community would advocate these kinds of rules or restrictions being imposed upon workers.

What health promotion professionals do advocate is providing theory-based programs designed to make workers more aware of health issues through awareness and education initiatives.  These programs help workers develop skills needed to maintain good health (e.g., meal preparation, smoking cessation, weight management, stress reduction).  The programs also offer motivational interviewing by health coaches to guide workers in making informed and meaningful changes to their health habits.  Finally, good individually directed programs are embedded within a healthy company culture where good health is supported by the norms established by the organization, its health-related policies, every day practices, and physical and social environment.  These are the hallmarks of best practice health promotion programs.

In contrast, programs that coerce, intimidate, threaten, cajole, bribe, or otherwise undermine individual choices related to health improvement are viewed by workers as self-serving and not in the employees’ self-interest.  Poorly designed programs do not work.  In fact, they often backfire because employees become resentful of management’s underhanded methods of compelling individuals to do what they would not otherwise do on their own accord.  Poorly designed programs — ones not based on best practices — are doomed from the start and will self-destruct in no time.

Returning to DiNardo and Horowitz’s basic premise that employers should play no role in employees’ private lives, let’s look at some ways that can be accomplished.  A truly laissez faire employer would eliminate employee assistance programs (EAPs), which are there to help workers cope with their personal as well as work-related problems.  These employers would also eliminate such benefits as on-site or subsidized childcare, pension and savings plans, sabbaticals, tuition reimbursement, free flu vaccines, subsidized food in cafeterias, on-site fitness centers, legal assistance programs, commuter assistance, profit sharing and 401k plans, sports teams, dental benefits, and, yes, even health care benefits.

Why do employers offer all of these wonderful benefits to their workers?  Certainly, altruism plays a role, as does the notion of corporate social responsibility.  But more importantly, employers offer these services because they want to attract and retain the best talent.  They also want to keep their workers healthy and productive.  Workplace health promotion programs are but another tool from the benefits toolbox that employers can use to maintain a healthy workforce — healthy, in broad terms, physically, mentally, socially, and financially.  And, by design, these programs “interfere” with their workers’ lives, by improving the quality of workers’ lives, not by denigrating them.

One final point.  The example cited of an employer interfering in workers’ private lives — the Ford Sociological Department Program — is outrageous.  The program was set up by Ford in 1915, close to a hundred years ago.  To increase workforce efficiency and output, Ford sent investigators to workers’ homes to examine employees’ living conditions and ask intrusive questions about marital infidelity, spending habits, and alcohol use.  In those days, there were very few work rules protecting workers’ health and safety, never mind rules guarding against employer meddling in people’s private lives.  The program failed miserably.  As Ford found out, dissatisfied workers are less efficient, not more efficient, than satisfied ones.

Fast-forward 100 years to the current period.  No one today is advocating reinstating the Ford Sociological Department Program.  This is another example of taking an extreme case study and presenting it as a moral equivalent of workplace health promotion programs.  If DiNardo and Horwitz claim that health promotion and health protection programs send us on a slippery slope that will lead us back to the days of the Ford Sociological Program, they are mistaken.  Reinstating the principles of the Ford program would not be a slippery slope — it would shove American business over the edge of a cliff, with severe legal and moral consequences.

To summarize, employers today are providing workplace health promotion and disease prevention programs to help workers lead a healthy and productive life , at work and at home.  Employers do this because they see health promotion programs as benefiting workers as well as the organization providing these programs.  Workplace health promotion programs are an expense that employers bear with the anticipation that these programs will achieve meaningful rewards — most notably, a more committed workforce, lower healthcare spending, reduced absenteeism, fewer accidents, and higher productivity.

But the main benefits accrue to workers who gain personally, especially if they are successful at quitting smoking, becoming more physically active, eating well-balanced and nutritious meals, better managing their stress, and lowering their blood pressure, cholesterol, glucose and triglyceride levels .  And, by the way, money saved on health insurance premiums and related expenses can be re-invested by the organization to create new jobs, boost salaries, and provide training opportunities — all of which benefit workers and their families.

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1 Trackback for “Workplace Wellness Programs: Continuing The Discussion”

  1. Week of February 4, 2014
    February 4th, 2014 at 12:44 pm

9 Responses to “Workplace Wellness Programs: Continuing The Discussion”

  1. Matthew Roberts Says:

    Here’s part of the abstract on DiNardo’s and Horwitz’s article: “research results raise doubts that employees with health risk factors, such as obesity and tobacco use, spend more on medical care than others”. I would say that if you agree with this, you are clearly delusional. And if you’re going to jump on here and bash wellness programs, please present clear, well thought out alternatives. It’s easy to criticize.

    There is no absolute blueprint when it comes to designing wellness programs and calculating the metrics of ROI. If you want to say we’re in the trial and error phase, I can agree with that. How long it lasts really depends on how committed we are to tackling the problem of poor health (or lifestyle behaviors if you want to call it that). What I do know is that there’s a mountain of data and studies out there that shows poor employee health adversely impacts medical, disability and worker’s compensation insurance, as well as absenteeism and presenteeism.

  2. George Van Antwerp Says:

    First, I would agree that employers do invade employee’s privacy. We trade some sense of privacy for the opportunity to work there and our compensation. That doesn’t mean they can invade our personal life but they can monitor what we do on the clock and using their equipment and facilities. They also have a vested interest in us being health and present to be able to do the work that we’re paid to do. And, by moving to consumer directed health care, employers have already brought healthcare into the workplace. I can no longer just go to my PCP. I have to understand my plan design. I have to try to get health literate. I have to find out information about my options. Now that I’ve pushed that responsibility to me as a consumer, shouldn’t the employer have the responsibility to give me tools to get healthy and minimize my out-of-pocket spend?

    Second, I agree that there is a difference between evidence-based and theory-based. We should be focused on programs that are evidence-based. Employees and employers should welcome that. There is a lot of research from places like Weight Watchers about what works and what doesn’t work. There is lots of research about how and when to use incentives.

    Third, I think one of the key issues here is that wellness programs have typically over-sampled the population. We treat everyone the same. We create generalized messages. They are the antithesis of personalized medicine, but that’s been the objective. With Big Data, companies should be able to be much smarter. If I have your claims data, your demographic data, and your device data (FitBit, smartphone), I should know a lot about you. If you answer a few questions for me (mini-HRA), I should be able to determine how (or if) to nudge you to improve your behaviors and health.

  3. Jon Says:

    I just want to add my voice here by responding to a couple comments that Ron has made that are a bit confusing to me.

    1)”What health promotion professionals do advocate is providing theory-based programs designed to make workers more aware of health issues through awareness and education initiatives.”

    Providing a theory based program is not the same as providing an evidence-based program. In his list following this comment Ron includes weight management programs (one of the most popular of all worksite so-called behavior change programs) – while these may be “theory based” – calories in vs. calories out – they are certainly not evidence-based – in fact they are diametrically the opposite of what the evidence shows – there is nothing in the health related literature that is more conclusively supported by the literature than that these programs do not work for the vast majority of people who participate – So, Ron from either a financial or health perspective, how do we justify offering these programs at the worksite – about which by the way Dee Edington has said “they are money down the toilet) ? (ps lots of iatrogenic consequences for these programs as well – but that is for another time)

    2)”In contrast, programs that coerce, intimidate, threaten, cajole, bribe, or otherwise undermine individual choices related to health improvement are viewed by workers as self-serving and not in the employees’ self-interest. Poorly designed programs do not work.”

    I add my voice to Vik and Al on this. Really, How is it that you don’t consider the Penn State debacle to have been a perfect example of this. But on a more general note, the health promotion establishment of which you are a part fought long and hard to get the Safeway Amendment passed. The recommendations from that amendment fit your definition of “poorly designed programs” – to use your words “programs that coerce, intimidate, threaten, cajole, bribe, or otherwise undermine individual choices related to health improvement.” to a tea! Three questions Ron: 1) did you and the others know when you supported (lobbied for) this amendment that the results (data) were completely fabricated? and 2) how is the latest round of worksite programs spurred on by this amendment not the coercive programs that you decry above? 3) Are you on record as being opposed to carrot and stick approaches to “getting people to change”? 4) If not, can you cite the evidence base for the use of extrinsic motivation to change any but the simplest of health behaviors?

    3) “One final point. The example cited of an employer interfering in workers’ private lives — the Ford Sociological Department Program — is outrageous.”

    Well, perhaps that is true. However, if I am not mistaken – the Penn State program – with which I understand you were intimately involved – aside from all the other craziness about it – was all set to ask women if they planned on getting pregnant next year. Questions again: 1) did you know about this? 2) If not, why not and 3) If so, how does this not represent a slippery slope? (of course what I really want to say here is something different – but I am guessing it would not get published anyway! Look forward to hearing your responses

  4. Ron Ozminkowski, Ph.D. Says:

    The notion that wellness or other health and productivity management programs “work” or “don’t work” is beginning to be exposed as a blunt instrument and should be regarded as way too simplistic, in my view. Usually this notion is predicated on a single return on investment (ROI) statistic. It may help to consider, though, that this statistic is almost always an average value. As such, there can be a lot of variation around that average, with many participants served in ways that promote better health and financial savings and many others less so. We have seen programs with “poor” ROI values (less than 1.0, for example) for which the ROI values resulted from a small proportion of people who had bad results, and much larger proportions with good results. We’ve also seen the reverse. Rather than glorifying or denigrating a program based on a single number, we would be better off investigating the variability around the ROI figure so that we can find the subsets of people who fare better and worse, and revise our programs according. Let’s find better candidates for our programs, and generate better programs for those who do not do as well.

  5. Rik Warren Says:

    Why is the employer discouraged from offering education to the benefits of healthy living? No one can coerce another into changing behavior (Military excluded) to benefit themselves. Either they are convinced such a change will enhance their life or they are not. Either they have the motivation to comply with a reasonable program or they don’t. I can not imagine most suffering from a chronic health challenge would not accept help for a better outcomes. And some of this can only be accomplished if the program addresses issues when the worker is away from work. Why is this controversial? Why is it only viewed through the lens of employer selfishness? It is immaterial. With compliance the employee will benefits. The rest is jousting at windmills.

  6. Vik Khanna Says:

    I am struck by these lines in the Professor’s essay: “programs that coerce, intimidate, bribe…or are not designed using best practices are doomed from the start and will self-destruct in no time.” How does the author then explain his vocal and visible support of the Penn State wellness disaster last summer, which was easily the most ridiculous and embarassing wellness debacle to date? Are these lines an admission that he was wrong to support PSU, whose wellness program easily met (even exceeded) all the articulated standards of being coercive, intimidating, and unburdened of anything resembling a best practice.

  7. Al Lewis Says:

    The fallacy in Mr. Goetzel’s argument is that there is an upside to employers shoehorning themselves into employees’ private lives (as opposed to an EAP, which is there if people need it, but doesn’t force themselves on people). if there were an upside to this unwanted interference in employees’ lives, there would be a cost-benefit analysis that could be debated.

    However, by this point all the major arguments that somehow cost can be reduced through screening people far more often than the USPSTF recommends and sending employees for checkups that JAMA and others have shown to have no value have been refuted. Even the program that Mr. Goetzel gave an award to, the state of Nebraska, was acknowledged by its sponsors to have been built on falsified data.

    So I think we end this here, award game, set and match to Professors Horwitz and DiNardo, and move on.

  8. Linda Riddell Says:

    The key point of this post is: “However, an employer can provide guidance, education, skill building, and support programs to workers who wish to eat healthy foods and become more physically active.”

    I would highlight that it is for workers who ALREADY wish to improve their health. If so, they would turn to credible sources of information and support. Their own employer is highly unlikely to be such a source. And employers should not distract themselves from their core business with things that are not their business.

    Employers can do hundreds of things that have an impact on health — how people are treated at work, whether they are confident in their bosses, how much control they have other their workday. These are more subtle, but more powerful than any fruits-vegetables-and-sit-ups program. This should be the core focus of employers who want to have healthy workers, rather than focusing on their behavior after hours.

  9. Linda Bergthold Says:

    It is completely naive to think that employers do not already invade an employee’s privacy. Many employers monitor employee internet usage and as you point out, require employees to smoke outside or drug test employees upon occasion. It is completely within an employer’s right as well as responsibility to encourage a healthy workforce. The key term is “encourage”. We do have laws that help ensure the privacy of employee health information — HIPAA for example. Unfortunately, and sometimes with good reason, employees fear filling out surveys or participating in wellness programs because they worry that their information will be shared with their employer and used to penalize them in some way. It is an ongoing challenge for employers to convince their workforce that they are just trying to keep them “healthy” by offering these programs.

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