Bethuel Best

Workplace

WORKPLACE WELLNESS PROGRAMS

RIGHT OR WRONG? ■ Kent Bottles, MD

in this article... Do you think wellness programs save money for employers? on both sides.

"It's a no brainer. ...Laypersons believe that wellness programs, thanks to prevention and health promotion, should translate into lower premiums.

Jaan Sidorov, MD former health plan medical director

"Wellness programs are so worthless that em­ ployers basically have to force their employees to lose money if they don't participate."

Al Lewis president of Disease Management Purchasing Consortium

WORKPLACE WELLNESS PROGRAMS IN TU I- tively make sense, are encouraged by the Affordable Care Act (ACA) and have been embraced by 75 percent to 93 percent of American employers.

Five years ago only 57 percent of companies participated in some kind of corporate wellness program, but today most employees are being asked by their employer to participate in programs designed to make them healthier and to reduce the cost of medical care. Wellness programs are now the fastest growing area in employee benefits, and a $6 billion industry that is a gold mine for benefit consultants and brokers.

Most workplace wellness programs use biometric screen­ ings, incentives, ROI evaluations and health risk appraisals as

Read the arguments

the foundation of their approach. With calls for transform­ ing the American clinical delivery from a sickness system to a wellness system, increasing support for prevention, and agree­ ment that fee-for-service should be replaced by value-based payments, many consider investing in a wellness program to be "a no brainer."

But do they work? Do they cut costs for employers and do they make employees healthier and happier?

Proponents of workplace wellness programs immediately point to a Harvard meta analysis published in Health Affairs with an abstract describing a $6 return for every $1 invested in such programs ($3.27 via wellness programs and $2.73 via reduced absenteeism).

Another study revealed about a 25 percent reduction in sick leave, health insurer costs and worker compensation and disability costs.

Champions of such programs also quote Safeway CEO Ste­ ven A. Burd, who wrote in the Wall Street Journal, "Safeway designed just such a plan in 2005 and has made continuous improvements each year. The results have been remarkable" and "our health care costs fo r four years have been held constant."

Burd is credited with impressing Senate Republicans and Democrats who incorporated a "Safeway Amendment" in the ACA that President Barack Obama praised.

Another workplace wellness success story often cited is Community Care of North Carolina, a Medicaid program that consulting firms have claimed saved the state $1 billion over three or four years.

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Dr. Soeren Mattke believes lifestyle management programs do not save money, but wellness programs can reduce health risk factors. The prob­ lem for employers is that the cost savings would accrue to the com­ pany so far in the future that it is hard to justify the ROI.

WHOA — Against this backdrop of widespread employer and government acceptance and studies documenting a return on investment, it might seem that the above basic questions have been answered in the affirmative. A vocal minority of critics has responded, "Not so fast."

The conventional wisdom that workplace wellness pro­ grams are successful and should be an important component of any employer's response to health care reform and cost cutting has been challenged on several fronts:

■ The employer cost-cutting numbers that vendors and executives proclaim as evidence of success do not stand up to intense scrutiny.

■ The Penn State University employee uprising rejecting a wellness program and a CVS employee lawsuit against CVS' coercive penalty for not submitting to screening has highlighted employee objections and resistance.

■ Incentive-based wellness programs may be inequitable and discriminate against blue-collar workers compared to white-collar workers.

■ Employer wellness programs may invade workers' rights to privacy.

Although the critics acknowledge that wellness programs can, over the long term, decrease cost and improve health among those with chronic diseases, they insist that vendors and advocates promise short-term gains that are simply not believable.

A close examination of the Safeway claims shows that the company did not keep medical costs flat for four years and that the wellness program was not offered to its union employees.

At the time Safeway was lobbying Congress to support its Healthy Measures program, the company would not reveal how medical costs for participating employees compared to expenses for the rest of the workforce.

A careful reading of the entire Harvard meta analysis and not just the abstract also reveals that the famous $3.27 return for every $1 invested in wellness programs is not based on a firm footing.

Bob Merberg in a blog post explains how a careful read­ ing of this 2010 article shows that the investigators found 100 articles over a 30-year period, but analyzed only the 14 that showed a cost saving for the participants in the wellness programs.

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The Harvard investigators included all the appropriate ca­ veats about not making too much of their $3.27 conclusion, but that is not how proponents of wellness programs have talked about the study.

Perhaps, most telling, is the 2013 radio interview by Harvard lead author Katherine Baicker in which she states that "it's too early to tell" whether such programs produce a positive ROI.

Two RAND studies on workplace wellness programs led by Dr. Soeren Mattke have provided the critics w ith more evidence that the industry has often oversold the success of such programs.

Mattke believes that lifestyle management programs do not save money, but wellness programs can reduce health risk factors. The problem for employers is that the cost savings would accrue to the company so far in the future that it is hard to justify the ROI.

Mattke also discovered that many companies do not evalu­ ate whether their programs work or not. Another problem that these studies found was that it is hard to account for the bias introduced by the likelihood that participants in voluntary wellness programs are more motivated and healthier to begin with than their nonparticipant coworkers.

W ELCOME HERE? — Employees have not always welcomed workplace wellness programs. The most famous example that caught the attention of the national press was the rebellion by faculty and staff to the Pennsylvania State University wellness program in 2013.

The school wanted employees to complete an online health risk assessment, obtain a preventive physical examination and undergo screening. Those who refused to participate would have to pay a $100 a month surcharge for their benefits. Professor Matthew Woessner issued "A Call for Action and Civil Resistance for Penn State Employees."

"Penn State has crossed so many ethical lines, I believe that the only reasonable response is to dutifully create the 'wellness profiles' and fill them with junk. I, for one, plan to stack my profile with ludicrous information that neither discloses my personal medical history, nor provides the website sponsor (WebMD) w ith useful information."

After weeks of protest, President Rodney A. Erickson an­ nounced, "We have decided to suspend the $100-per-month surcharge so that people who are uncomfortable with any as­ pect of the survey will not feel as if they are being penalized."

CVS is being sued by an employee who objects to paying $600 more for health insurance because she refuses to be screened.

A 2014 Health Affairs article titled "Wellness Incentives In the Workplace: Cost Savings Through Cost Shifting to Un­ healthy Workers," by Jill. R. Horwitz, Brenna D. Kelly, and John E. DiNardo, resulted in a remarkable ongoing debate between the authors and prominent workplace wellness proponent Ron Goetzel. DiNardo and his colleagues summarized their concerns in one of their replies to a Goetzel rebuttal:

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■ 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.

■ 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 con­ sider the potential negative consequence of incentive- based workplace wellness such as implicit, regressive cost shifting.

Goetzel defends the conventional wisdom of wellness pro­ grams when he responds:

"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 be­ come more physically active. That, in my mind, is not inter­ fering in workers' lives but rather supporting their efforts at leading a healthy lifestyle."

Reading the back and forth between these two sides which includes two replies by the critics and three rebuttals by Goet­ zel, provides the reader w ith an appreciation for the tension and high stakes involved in the debate about whether the $6 billion spent in this part of the health care industry provides value to employers and employees.

There is no denying that workplace wellness programs continue to gain in popularity. A May 2014 article outlined the conventional wisdom about wellness and listed the following benefits for employees:

■ The potential for improved health.

■ Support in the form of encouragement, goals, or even team activities.

■ A focus on healthier choices.

■ Maybe a reduction in cost.

It listed the following advantages for employers:

■ Improved employee health can mean fewer absences for illness and higher employee productivity levels.

Investing in employees can improve employee morale.

■ Over time, this can even reduce turnover.

Healthier employees often cost less to insure over time.

However, critics of such programs are pointing out that the evidence supporting all of the above benefits are sadly lacking. More research and evaluation will need to be done to make sure that wellness programs do indeed save money

for employers, are fair and equitable for all employees, and do not invade workers' privacy and decrease morale. ■

Kent Bottles, MD, is chief medical officer at PYA Analytics in Knoxville, Tennessee [email protected]

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