Health Affairs

This commentary is in response to the March 5, 2013 Health Affairs article, “Wellness Incentives in the Workplace: Cost Savings through Cost Shifting to Unhealthy Lifestyles.” In that article, Jill Horwitz and coauthors express concerns about new rules governing workplace health promotion (wellness) programs due to take effect in 2014 as part of the Patient Protection and Affordable Care Act of 2011, Public Law 111-148 (“ACA”). In addition to increasing access to health care services for all Americans, the ACA aims to place greater emphasis on health promotion and disease prevention and to encourage employer adoption of workplace wellness programs.

As I discuss below, some of the concerns raised by Horwitz et al. are legitimate points that I agree with. However, I believe that Horwitz and her colleagues go too far when they appear to question the basic idea that employees with modifiable health risks cost more than those without such risks, calling into question the entire concept of workplace wellness programs and indeed of prevention in general. In this post, I explain how well-designed wellness programs can benefit both employers and employees, and I offer some suggestions to ensure that such programs are both effective and fair.

A specific provision of the ACA (Section 2705), which is at the heart of the controversy addressed by Horwitz et al., will allow employers to design incentive-based wellness programs that reward not only participation in health promotion programs but also “outcomes” related to having healthy habits and managing biometric values within “normal” ranges. Under the new rules, financial incentives (e.g., different health plan designs, payment terms, premiums levels, deductibles, co-insurance or co-payments) could be offered to workers who are nonsmokers, are at a given weight or BMI, or are effectively controlling their blood pressure, total cholesterol, and blood glucose. Rewards or incentives would also be made available to employees who eat a healthy diet or are physically active.

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.