Editor’s note: This is part of a periodic series of Health Affairs Blog posts discussing the Culture of Health, the topic of a November Health Affairs theme issue.  In 2014 the Robert Wood Johnson Foundation announced its Culture of Health initiative, which promotes health, well-being, and equity. The initiative identifies roles for individuals, communities, commercial entities, health care entities, and public policy that extend beyond the reach of medical care into sectors not traditionally associated with health. In addition, a cluster of articles in our upcoming February issue will also focus on the relationship between work and health.

Kristin Madison’s article in the Health Affairs November Culture of Health theme issue highlights many of the problems found in single-focus wellness programs that are based on the premise that paying people to improve their health is all that is needed to create a healthy workforce. However, the headline “risks of using workplace wellness” may send the wrong message to employers and policymakers. Yes, poorly designed workplace health promotion programs, founded exclusively on providing financial incentives for achieving targeted health outcomes, may result in unintended consequences. But, workplace programs founded on a strong culture of health can positively influence workers’ health and well-being, and do so in a practical, ethical, and legal manner. There is much more to wellness than the individual regulatory components discussed in Dr. Madison’s article.

As Dr. Madison’s article highlights, there is controversy over the various design elements of wellness programs and whether they, in fact, “work.” Employers are right to question which set of outcomes to accept or reject. However, as we point out in our research, a foundational difference between effective and ineffective programs is their intervention focus.

Traditional wellness programs target employees who need to reduce their health risks such as being overweight, not exercising enough, or consuming tobacco products. Addressing these issues is a worthy endeavor and few would argue with the premise that adopting healthy habits leads to lower incidence of disease, lower health care spending, and improved quality of life. Indeed, there is sufficient or strong evidence that workplace health promotion programs, when done right, exert a positive influence on health behaviors, biometric measures, health care utilization, and worker productivity. There is also evidence that many of these programs may generate savings that outweigh investment costs.

However, we share Dr. Madison’s concern about narrowly focused designs whose primary purpose is to move financial liability on a spreadsheet from employers to employees. We believe that improving population health should be the main purpose of workplace health promotion, not cost savings. In fact, if health improvement could be achieved for most workers at a worksite in a cost-neutral manner (i.e., with a return-on-investment [ROI] of 1:1), that, in our mind, would be an important achievement of the program and one that would most adequately justify its business rationale.

It should be noted that many companies are now moving away from a traditional ROI model to one that emphasizes value-on-investment (VOI) metrics (e.g., attracting and retaining top talent, improving employee engagement, heightening job satisfaction, and boosting morale) and we believe that is the right way to go. To achieve a VOI, you need to build a strong culture of health.

How to Build A Culture of Health

To move the needle on workforce health, employers need to establish and maintain comprehensive, multi-component, evidence-based health promotion programs that improve organizational health (discussed below) alongside individual health. So, how does an employer build a culture of health that is broader than any individual wellness program component?

To answer that question, we spent two years studying companies that successfully built cultures of health for a project supported by the Robert Wood Johnson Foundation, Promoting Healthy Workplaces. In late 2014 and early 2015, our research team and a journalist visited nine businesses with exemplary workplace wellness programs to see, first-hand, how this was accomplished. Our site visits consisted of interviews with senior executives, program implementers, and focus groups with a cross-section of workers. Our observations were chronicled in a series of media stories, blog posts, videos, and a peer-reviewed article highlighting the key ingredients of success — the “secret sauce” for these programs.

Essential Elements for Culture of Health Programs

Much has been written about the factors that constitute best- and promising-practices for workplace health promotion programs. Here, we don’t attempt to describe these in detail. Briefly, the “secret sauce” ingredients usually include:

  • Developing leadership commitment and support;
  • Establishing specific program goals and expectations;
  • Employing ongoing strategic communications;
  • Involving employees in the design and implementation of programs;
  • Putting in place behavior change programs that are scientifically sound;
  • Employing effective screening and triage services;
  • Injecting behavioral economic principles and fun into initiatives; and,
  • Measuring and monitoring program achievements across multiple dimensions on an ongoing manner to ensure maximum effectiveness.

It should be noted that many success factors extend well beyond improving physical health and reducing risk factors of individual employees. Employers also view the organization as the “patient” requiring interventions that contain psychosocial elements. For example, an employer cannot expect employees to adopt healthy lifestyles if the work climate is toxic, meaning that there are unreasonable job demands, low levels of personal autonomy in meeting those demands, and non-supportive supervisors. Health promotion only works in a culture where the employer places a high value on employee health and well-being as part of the company’s core mission, in an environment that fosters trust, open communications, and reliance on employees to shape wellness programs aligned with their personal needs and interests.

The bottom line is that establishing a healthy company culture cannot be viewed as just another initiative introduced by management to save money. To be effective, workplace wellness programs need to be woven into the fabric of the organization. To employees, they need to be experienced as a “way of life” that integrates a Total Worker Health model into every aspect of business practices and supports physical, emotional, career, financial, social, and even spiritual well-being.

Addressing Dr. Madison’s Concerns

Because of newly enacted provisions of the Affordable Care Act, and the EEOC’s recent interpretation of those provisions, employers may believe that a wellness program is no more than a series of financial incentives that reward health achievements, with very little support or involvement on part of the employer. While “smart” incentive designs may play a role in raising awareness of health issues among workers, increasing their participation in health-promoting activities, and even spurring behavior change efforts, incentive programs alone cannot improve population health. To move the needle on workforce health, employers need to build cultures of health.

We agree with Dr. Madison’s call for greater public funding of carefully designed and objective evaluations of alternative workplace program designs conducted in real-world settings. Such research is necessary to build an evidence base for what works—or does not work—from both employer and employee perspectives.

On Dr. Madison’s point related to data security, we have seen no evidence that routine collection of employee data through health risk assessments or biometric screenings leads to invasions of privacy, stigma, or discrimination, but agree that unethical practices may result in these outcomes.

We agree that federal policies, rules, and regulations are fragmented, confusing, and at times contradictory. Dr. Madison focuses on components of the Health Insurance Portability and Accountability Act (HIPAA), the Genetic Information Nondiscrimination Act (GINA), and the Americans with Disabilities Act (ADA) as illustrations of how provisions appear in several statutes but are not integrated to establish continuity among them, despite the fact that they are all ostensibly designed to address workplace wellness. We believe the most recent Equal Employment Opportunity Commission (EEOC) guidelines balance employer and employee interests and move us a step closer toward common sense integration of policies and practices employers can follow.

In sum, we commend Dr. Madison and her handling of this thorny topic in an even-handed, thoughtful, respectful, and responsible manner. Her recommendations provide a useful template for future research, which, in turn, should drive program design, policy recommendations, and legislation. An “integrated regulatory regime that targets workplace wellness programs” may remove barriers for employers who have avoided offering health promotion to their workers for fear of landing in legal hot water because the regulatory landscape has been so difficult to navigate. The more employers strive to create and provide cultures of health, the greater the likelihood that the business community will play a transformative and important role in improving population health and workforce productivity.