Tag Archives: goetzel

Shattering the Wellness ROI Myth

There is a saying: “In wellness, you don’t have to challenge the data to invalidate it. You merely have to read the data. It will invalidate itself.” Indeed, if there is one thing you can take to the bank in this field, it’s that articles intending to prove that wellness works inevitably prove the opposite. Another saying is that the biggest nightmares of leading wellness promoter Ron Goetzel and his friends (the Health Enhancement Research Organization, which is the industry trade association) are, in no particular order:

  1. facts;
  2. data;
  3. arithmetic;
  4. their own words.

And Mr. Goetzel, writing in this month’s Health Affairs [behind a paywall], is Exhibit A in support of the paragraph above. To summarize the implication of this article, you, as brokers, need to take ROI off the table as an attribute of wellness. Instead, you’ll need to find wellness vendors who are willing to screen most employees much less often than once a year, just as government guidelines recommend.

No wellness vendor ever got rich by screening according to guidelines. As a result, willing vendors are hard to find. (Examples include It Starts with Me and Sterling Wellness, as well as my own company, Quizzify, whose outcomes don’t rely on screening.) The lower screening frequencies also mean lower commissions. Weighed against that is the advantage of doing the right thing for your customer and their employees.

See also: There May Be a Cure for Wellness  

The Collapse of the ROI Myth

The subject of Mr. Goetzel’s article was specifically employer cardiac spending vs. cardiac risks in an employer population. He found that cardiac risks correlated the “wrong” way with cardiac spending, meaning that companies with healthier employees somehow incurred more cardiac-related spending.

But that correlation — and it was only a correlation, not cause-and-effect — by itself didn’t cause the death of wellness ROI, though it didn’t help. As is typical in wellness, and as was mentioned in the first paragraph, the proximate cause of the death of wellness ROI was that this breathlessly pro-wellness author accidentally provided the data proves that wellness loses money.

Specifically, they didn’t separate the average employer cardiac claims spending of $329 per employee per year (PEPY) into “bad” claims (spending on events like heart attacks), vs. “good” claims (spending on preventive interventions to avoid heart attacks).

How big a rookie mistake is combining these two opposite claims tallies — prevention expense and event expense — and calling it “average payment for all cardiac claims”? It would be like saying the average human is a hermaphrodite.

Splitting that average into its two opposite components would have revealed that spending on actual avoidable events is much lower than spending on wellness programs implemented to avoid those events. That, of course, is exactly the right answer, as we showed 15 months ago.

Let’s do the math

How much do employers spend on “bad claims” like heart attacks? Here is the number of heart attacks, spelled out so that people can replicate this analysis using the official government database, tallying all the admissions for heart attack-related DRGs:

  1. DRG 280 — 12,825
  2. DRG 281 — 15,404
  3. DRG 282 — 18,365
  4. DRG 283 — 1,800
  5. DRG 284 — 275
  6. DRG 285 — 160

This totals to 48,829. Roughly 100,000,000 adults are insured through their employers. That means that about 1 in 2000 employees or spouses will have a heart attack in any given year. Let’s double that to generously account for any other cardiac events that could be prevented through screening employees, to 1 in 1000.

Now let’s equally generously assume a whopping cost of $50,000 per heart attack. So of the $329 PEPY that Ron calculated for prevention and events combined, only $50 ($50,000 per event and 1 in 1000 working people suffering one) is spent on events. The rest is spent on prevention and management expense, like putting people on statins, diuretics etc., doctor visits, lab tests etc.—things done specifically to avoid these events.

These latter expenses are not avoidable. Nor are they even reducible through wellness. Just the opposite– wellness vendors are always trying to close “gaps in care” by sending people to the doctor to get more of these interventions.

See also: A Proposed Code of Conduct on Wellness  

According to Mr. Goetzel’s own data, a wellness program — health risk assessments, screening, portals etc. — costs about $150 PEPY. An industry that spends that much to get what Mr. Goetzel himself states is at best a 2% reduction in a $50 PEPY expense can’t save money. This mathematical fact explains the industry’s constant need to lie about savings (and about me).

Anyone care to claim my $2 million reward for showing wellness saves money? I didn’t think so…

fat tax

Should You Announce How Fat Workers Are?

A shockingly serious proposal has been floated to first persuade (and later possibly compel) publicly traded companies to disclose to shareholders quite literally how fat their employees are.

Also, how much they drink, how well they sleep and how stressed and depressed they are.

This proposal, advocating what is known as a fat tax, shouldn’t even merit a discussion among rational businesspeople, and yet here we are, discussing it. Even Harvard Business Review (HBR) is discussing this.

Why? Because the well-financed, well-organized cabal behind this fat tax proposal include corporate names like Johnson & Johnson, PepsiCo, Humana, Merck, Novo-Nordisk and Unilever. The leader of this group is a South African insurer called Discovery Health.

If you guessed that any critique written by me would also implicate Ron Goetzel, you would be correct. Despite having now himself admitted that most wellness programs fail, he is the one justifying this entire scheme by claiming that wellness programs increase stock prices — even though they don’t. We’ve already offered a completely transparent analysis to the contrary.

He also made a rookie mistake in his own analysis. The stock prices of companies in his study diverged greatly in both directions from the averages, and he didn’t rebalance existing holdings annually. It’s simple compounding arithmetic. Suppose the stock market rises X% a year. If every stock in your portfolio increases at that rate, you’ll match the averages. However, if half your stocks increase 2X% a year while the other half don’t appreciate at all, and you don’t rebalance, you’ll beat the averages. Simply by doing nothing.

Goetzel’s study appeared right before the fat tax proposal was floated at Davos. No coincidence here — Discovery Health (the sponsor of the Vitality Institute) cites the study as a basis for wanting shareholders to “pressure” companies into disclosing the number of fat employees they have. And the more fat employees a company has, the more shareholders will insist on wellness programs, thanks to this study. Johnson & Johnson and Discovery both sell wellness programs, while Merck and Novo-Nordisk sell drugs for various wellness-related conditions.

We urge reading the HBR link in its entirety to see why a fat tax would be even worse than it sounds. Some highlights:

Most importantly, though – and you don’t need Harvard to learn this – it’s just not nice to stigmatize employees for their weight or other shortcomings unrelated to job performance. Basic human decency should have been taught to this cabal a long time ago.

We’ve pointed out many times in ITL that these wellness people were absent the day the fifth-grade teacher covered arithmetic. This proposal suggests that they were also absent the day the kindergarten teacher taught manners.

Common Ground on Wellness? Not So Fast

[Editor’s Note: A debate about the effectiveness of corporate wellness programs began on this site in late November, with the publication of a piece arguing that rigorous analysis showed no savings. A prominent proponent of wellness responded with a piece acknowledging some common ground but pushing back on the need to have wellness programs show a return on investment (ROI). Two of the authors of the original piece then raised 11 questions for the proponent. Now, one of them, Al Lewis, forwards an email he sent to the proponent, Ron Goetzel, that does a solid job of laying out what I see as the common ground — including an agreement not to sell wellness based on claims of ROI. The hope is to forge an agreement on how wellness should be sold and administered. As of this writing, Lewis says Goetzel has not responded.

We’ve attached the email, which was sent Jan. 5.]

Ron, based on your posting I think we have enough common ground to stop arguing and sign a joint open letter like the one below.  Feel free to edit it. Let’s aim to have it out in a week. If people haven’t had a chance to sign it by then, they can add signatures. Eventually, we should get a lot because there isn’t really any major controversy left, if ROIs are no longer an issue and we agree on adherence to guidelines.

Al

 

The signatories of this note, leaders in the wellness field who have previously been unable to find common ground, now agree on many key aspects of workplace wellness and would like to share that consensus.

First, instead of what are known as “pry, poke, prod and punish” programs that require financial forfeitures (large penalties or loss of large incentives) by employees who refuse to (1) divulge personal health information on health risk assessments; (2) participate in overly frequently blood draws or (3) be sent to the doctor when they aren’t sick, we would encourage employers to adhere to USPSTF [U.S. Preventive Services Task Force] screening/checkup guidelines and frequencies (once every three to five years for most working-age adults). Aside from these infrequent screenings, we recommend that employers stay out of employees’ personal medical affairs unless they ask for help, because overdoctoring produces neither positive ROIs nor even healthier employees. There is also strong anecdotal and behavioral economics evidence that morale is adversely impacted by interference in employees’ personal medical affairs.

Second, we also all believe that employers should respect the dignity of employees not just by no longer economically forcing these programs upon them, but also by not shaming employees who can’t lose weight.

Third, we would jointly like to apologize to Penn State, Honeywell, Nebraska and others for not helping them recognize the importance of adhering to guidelines and/or of respecting employee dignity.

Finally, we recommend that future programs be undertaken without regard for return-on-investment (ROIs) in medical spending since there is too much controversy surrounding the calculation of those ROIs.  Journals and consultants supporting wellness find positive ROIs from wellness whereas other journals and consultants do not, while no vendored program has ever been validated by the industry’s gold standard, the Validation Institute, for medical claims savings, though it is possible this happens in the future.

Instead, we propose that wellness programs be done for employees rather than to them, in order to enhance the engagement and productivity of America’s workforce, which ultimately is what will keep America competitive in international markets for the foreseeable future.  Because of the importance to corporate America of having an engaged workforce, we urge the Business Roundtable and other wellness influencers to support us in this new direction.

11 Questions for Ron Goetzel on Wellness

We thank Ron Goetzel, representing Truven Health and Johns Hopkins, for posting on Insurance Thought Leadership a rebuttal to our viral November posting, “Workplace Wellness Shows No Savings.” Paradoxically, while he conceived and produced the posting, we are happy to publicize it for him. If you’ve heard that song before, think Mike Dukakis’s tank ride during his disastrous 1988 presidential campaign.

Goetzel’s rebuttal, “The Value of Workplace Wellness Programs,” raises at least 11 questions that he has been declining to answer. We hope he will respond here on ITL. And, of course, we are happy to answer any specific questions he would ask us, as we think we are already doing in the case of the point he raises about wellness-sensitive medical events. (We offer, for the third time, to have a straight-up debate and hope that he reconsiders his previous refusals.)

Ron:

(1)    How can you say you are not familiar with measuring wellness-sensitive medical events (WSMEs), like heart attacks? Your exact words are: “What are these events? Where have they been published? Who has peer-reviewed them?” Didn’t you yourself just review an article on that very topic, a study that we ourselves had hyperlinked as an example of peer-reviewed WSMEs in the exact article of ours that you are rebutting now? WSMEs are the events that should decline because of a wellness program. Example: If you institute a wellness program aimed at avoiding heart attacks, you’d measure the change in the number of heart attacks across your population as a “plausibility test” to see if the program worked, just like you’d measure the impact of a campaign to avoid teenage pregnancies by observing the change in the rate of teenage pregnancies. We’re not sure why you think that simple concept of testing plausibility using WSMEs needs peer review. Indeed, we don’t know how else one would measure impact of either program, which is why the esteemed Validation Institute recognizes only that methodology. (In any event, you did already review WMSEs in your own article.) We certainly concur with your related view that randomized controlled trials are impractical in workplace settings (and can’t blame you for avoiding them, given that your colleague Michael O’Donnell’s journal published a meta-analysis showing RCTs have negative ROIs).

(2)    How do you reconcile your role as Highmark’s consultant for the notoriously humiliating, unpopular and counterproductive Penn State wellness program with your current position that employees need to be treated with “respect and dignity”? Exactly what about Penn State’s required monthly testicle check and $1,200 fine on female employees for not disclosing their pregnancy plans respected the dignity of employees?

(3)    Which of your programs adhere to U.S. Preventive Services Task Force (USPSTF) screening guidelines and intervals that you now claim to embrace? Once again, we cite the Penn State example, because it is in the public domain — almost nothing about that program was USPSTF-compliant, starting with the aforementioned testicle checks.

(4)    Your posting mentions “peer review” nine times. If peer review is so important to wellness true believers,  how come none of your colleagues editing the three wellness promotional journals (JOEM, AJPM and AJHP) has ever asked either of us to peer-review a single article, despite the fact that we’ve amply demonstrated our prowess at peer review by exposing two dozen fraudulent claims on They Said What?, including exposés of four companies represented on your Koop Award committee (Staywell, Mercer, Milliman and Wellsteps) along with three fraudulent claims in Koop Award-winning programs?

(5)    Perhaps the most popular slide used in support of wellness-industry ROI actually shows the reverse — that motivation, rather than the wellness programs themselves, drives the health spending differential between participants and non-participants. How do we know that? Because on that Eastman Chemical-Health Fitness Corp. slide (reproduced below), significant savings accrued and were counted for 2005 – the year before the wellness program was implemented. Now you say 2005 was “unfortunately mislabeled” on that slide. Unless this mislabeling was an act of God, please use the active voice: Who mislabeled this slide for five years; where is the person’s apology; and why didn’t any of the analytical luminaries on your committee disclose this mislabeling even after they knew it was mislabeled? The problem was noted in both Surviving Workplace Wellness and the trade-bestselling, award-winning Why Nobody Believes the Numbers, which we know you’ve read because you copied pages from it before Wiley & Sons demanded you stop? Was it because HFC sponsors your committee, or was it because Koop Committee members lack the basic error identification skills taught in courses on outcomes analysis that no committee member has ever passed?

wellness-article

(6)    Why doesn’t anyone on the Koop Committee notice any of these “unfortunate mislabelings” until several years after we point out that they are in plain view?

(7)    Why is it that every time HFC admits lying, the penalty that you assess — as president of the Koop Award Committee — is to anoint their programs as “best practices” in health promotion? (See Eastman Chemical and Nebraska in the list below.) Doesn’t that send a signal that Dr. Koop might have objected to?

(8)    Whenever HFC publishes lengthy press releases announcing that its customers received the “prestigious” Koop Award, it always forgets to mention that it sponsors the awards. With your post’s emphasis on “the spirit of full disclosure” and “transparency,” why haven’t you insisted HFC disclose that it finances the award (sort of like when Nero used to win the Olympics because he ran them)?

(9)    Speaking of “best practices” and Koop Award winners, HFC’s admitted lies about saving the lives of 514 cancer victims in its award-winning Nebraska program are technically a violation of the state’s anti-fraud statute, because HFC accepted state money and then misrepresented outcomes. Which is it: Is HFC a best practice, or should it be prosecuted for fraud?

(10)    RAND Corp.’s wellness guru Soeren Mattke, who also disputes wellness ROIs, has observed that every time one of the wellness industry’s unsupportable claims gets disproven, wellness defenders say they didn’t really mean it, and they really meant something else altogether. Isn’t this exactly what you are doing here, with the “mislabeled” slide, with your sudden epiphany about following USPSTF guidelines and respecting employee dignity and with your new position that ROI doesn’t matter any more, now that most ROI claims have been invalidated?

(11)    Why are you still quoting Katherine Baicker’s five-year-old meta-analysis claiming 3.27-to-1 savings from wellness in (roughly) 16-year-old studies, even though you must be fully aware that she herself has repeatedly disowned it and now says: “There are very few studies that have reliable data on the costs and benefits”? We have offered to compliment wellness defenders for telling the truth in every instance in which they acknowledge all her backpedaling whenever they cite her study. We look forward to being able to compliment you on truthfulness when you admit this. This offer, if you accept it, is an improvement over our current Groundhog Day-type cycle where you cite her study, we point out that she’s walked it back four times, and you somehow never notice her recantations and then continue to cite the meta-analysis as though it’s beyond reproach.

To end on a positive note, while we see many differences between your words and your deeds, let us give you the benefit of the doubt and assume you mean what you say and not what you do. In that case, we invite you to join us in writing an open letter to Penn State, the Business Roundtable, Honeywell, Highmark and every other organization (including Vik Khanna’s wife’s employer) that forces employees to choose between forfeiting large sums of money and maintaining their dignity and privacy. We could collectively advise them to do exactly what you now say: Instead of playing doctor with “pry, poke, prod and punish” programs, we would encourage employers to adhere to USPSTF screening guidelines and frequencies and otherwise stay out of employees’ personal medical affairs unless they ask for help, because overdoctoring produces neither positive ROIs nor even healthier employers. And we need to emphasize that it’s OK if there is no ROI because ROI doesn’t matter.

As a gesture to mend fences, we will offer a 50% discount to all Koop Committee members for the Critical Outcomes Report Analysis course and certification, which is also recognized by the Validation Institute. This course will help your committee members learn how to avoid the embarrassing mistakes they consistently otherwise make and (assuming you institute conflict-of-interest rules as well to require disclosure of sponsorships) ensure that worthy candidates win your awards.

The Value of Workplace Wellness

The recent blog post by Al Lewis, Vik Khanna and Shana Montrose titled, “Workplace Wellness Produces No Savings,” has triggered much interest and media attention. It highlights the controversy surrounding the value of workplace health promotion programs that 22 authors addressed in an article published in the September 2014 issue of the Journal of Occupational and Environmental Medicine, titled, “Do Workplace Health Promotion (Wellness) Programs Work?” That article also inspired several follow-up discussions and media reports, including one published by New York Times columnists Frakt and Carroll, who answered the above question with: “usually not.”

There are certainly many points of contention and areas for continued discussion on this topic. It turns out that Lewis et al. and I agree on many things, and there are other areas where we see things differently.

Where we agree…

Biometric screenings. Biometric screenings are important for collection of baseline health risk data and are often viewed as an added value by employees participating in workplace health promotion programs. Lewis et al. and I agree that employers should screen their workers for health risks in accordance with guidelines recommended by the U.S. Preventive Services Task Force (USPSTF). These guidelines are clear about the necessity and periodicity of biometric screenings for high blood pressure, obesity, cholesterol, glucose, triglycerides, cervical cancer, colon cancer, breast cancer and other conditions.

We agree that over-testing people is not a good idea and may lead to false positives, as well as unnecessary medical interventions that are costly and add little value. For readers seeking guidance on biometric screenings in a workplace setting, I refer them to a peer-reviewed article published in the October 2013 issue of the Journal of Occupational and Environmental Medicine.

Incentives. Workplace health promotion programs are not the same as incentive programs. “Smart” incentives are part of a well-designed program, but such programs need to be embedded in healthy company cultures where employers encourage and reward healthy behaviors. Comprehensive wellness programs often use financial incentives to attract participation and, in some instances, encourage behaviors that lead to risk reduction.

Most experts in workplace health promotion agree that creating intrinsic motivation for health improvement is an essential component of an effective program. As Daniel Pink points out in his book Drive, people are motivated to behave a certain way when they feel a sense of autonomy, when they are able to master certain skills needed to change a behavior and when they can connect changing that behavior to a larger purpose in life. This applies to individuals wishing to achieve certain health goals, such as quitting smoking, being more physically active and eating a healthier diet.

Paying people to improve their health in an unhealthy work environment is a futile strategy. Workers will expect higher payments each year, will view “non-compliance” as a penalty and will mistrust their employer for trying to do things to them instead of with them.

To summarize, incentives need to be practical, ethical and legal. The Affordable Care Act (ACA) legislation should not be used as a vehicle or excuse for “blaming” workers for poor health habits, or to penalize them financially for not achieving certain health outcomes. Employers share responsibility for the health and well-being of workers and can do much to create a healthy company culture.

For readers interested in a more in-depth discussion of health promotion incentive programs, I refer them to a series of Health Affairs blog posts and a guidance document prepared by the Health Enhancement Research Organization, American College of Occupational and Environmental Medicine, American Cancer Society and American Cancer Society Cancer Action Network, American Diabetes Association and American Heart Association.

Culture of health. We also agree that effective workplace health promotion programs need to be embedded within a culture of health that respects workers’ rights to make informed choices about personal health matters. Without question, workplaces need to be safe, and employees need to be treated with respect and dignity. Workers also have a right to be in a healthy work environment where positive health behaviors are encouraged and supported. That means making healthy food available in vending machines and cafeterias, encouraging physical activity, prohibiting on-site smoking, offering vaccination programs and providing health insurance.

The list of programs, policies and environmental supports for a healthy workplace is long, and there are hundreds of environmental and policy interventions available to employers who wish to send a clear message that the company encourages and supports good health. For a more complete discussion of how companies can achieve a healthy culture, see the May 2013 issue of The Art of Health Promotion.

The importance of studying “wellness-sensitive” events…in addition to overall utilization and costs. Lewis et al. highlight the need to focus on “wellness-sensitive” medical events when conducting cost analyses. I agree but ask the authors: What are these events? Where have descriptions been published? Who has reviewed them? Why do they only apply to in-patient claims? Are there not any “wellness-sensitive” events that would appear in out-patient settings?

The idea of analyzing claims for conditions likely to be most readily influenced by health promotion programs is sensible. In many of our studies, we have analyzed utilization and cost patterns for what we call “lifestyle diagnosis groups,” or LDGs. For example, in a 1998 peer-reviewed study, we evaluated Procter & Gamble’s health promotion program and found a 36% difference in lifestyle-related costs in the third study year when comparing 3,993 program participants with 4,341 non-participants.

Although it’s important to analyze a subset of diagnoses when evaluating wellness programs, it is equally important to analyze utilization and costs for all conditions. After all, one’s actual well-being and perception of well-being influences health holistically, not just any one particular organ or body system.

Where we disagree…

Whether only randomized trials can determine whether workplace programs are effective. Health services research and the field of epidemiology have a long track record of studying naturally occurring phenomena and drawing conclusions from observations of those phenomena. That’s how we have learned what causes hospital-acquired infections. We have also learned from long-lasting epidemiological investigations like the Framingham studies that a sedentary lifestyle, smoking and obesity are causes of heart disease, diabetes and cancers.

These “natural experiments” inform the scientific community about what happens to individuals or groups “exposed” to a condition, where others are not. Natural experiments are employed when a randomized controlled trial (RCT) is impractical or unethical.

How does this apply to evaluation of workplace health promotion programs? Imagine trying to convince the head of human resources of a company to approve a double-blinded randomized trial that would test the effectiveness of a wellness program, over three to five years, by randomly assigning some workers to a comprehensive health promotion program that includes health coaching on smoking cessation, weight management, physical activity and stress reduction while other workers are denied access to the program. Not only that, the HR executive would be asked to allow the researcher to administer a series of blood tests to participants and non-participants, access their medical claims and ask workers to complete periodic health surveys. The employer would also be prohibited from instituting organizational policies promoting health while this experiment is underway.

It’s hard to imagine a situation in which a company executive would allow this, never mind an institutional review board at a university.

Alternatively, when health services researchers conduct natural experiments, care is taken to control for any confounding variables and address alternative hypotheses. In our research, we use statistical techniques such as propensity score matching and multivariate regression to compare the health and cost experience of “treatment” workers (those offered health-promotion programs) and “comparison” workers (those not offered the programs). Most often, when comparing participants with non-participants, we match entire populations exposed to a program (whether or not individuals participate in that program) and those not exposed. In that regard, we are investigating program impacts on population health and not only comparing outcomes for motivated participants in programs compared with less motivated non-participants.

We publish our analyses in peer-reviewed journals so that the scientific community can review and critique our methods. We are also transparent about the limitations to our research in these peer-reviewed articles.

By the way, there are experimental studies focused on large populations (not necessarily at the workplace) demonstrating the value of health-promotion programs. One such trial was recently concluded by the Centers for Medicare and Medicaid Services (CMS) as part of the senior risk reduction demonstration (SRRD). Two vendors were involved in the demonstration, which lasted two to three years.  Beneficiaries participating in Vendor A’s risk-reduction programs achieved statistically significant improvements in stress, general well-being and overall risk, and beneficiaries participating in Vendor B’s program achieved statistically significant improvements in back care, nutrition, physical activity, stress, general well-being and overall risk.

Interestingly, the interventions were determined to be “cost-neutral,” meaning that Medicare spending for participants in the intervention group was not statistically different from spending for participants in the control group. This was a large-scale study where about 50,000 beneficiaries were recruited and approximately 20,000 participated in the health-promotion program in any given year. The bottom line: Significant health improvements were achieved at no cost to the government.

Interpreting the data. Lewis et al. highlight errors in others’ presentation of results. I have no argument with that. That is, after all, what a peer review process is all about: Conduct the study, subject it to peer review and publish the findings. The problem is that Lewis et al. have not (yet) published any studies in which their interventions are evaluated, nor have their methods been subject to peer review. That is unfortunate because I believe (truly) that all of us can learn from vetted research studies and apply that knowledge to future evaluations.

I am the first to admit that the methods we use to evaluate wellness programs have evolved over time and are still undergoing revisions as we learn from our mistakes. I invite Lewis et al. to reveal their methods for evaluating workplace programs and to publish those methods in peer-reviewed publications — we can all benefit from that intelligence.

Lewis et al. point to a study conducted by Health Fitness Corp. (HFC) for Eastman Chemical, which earned the company the C. Everett Koop Award. (In the spirit of full disclosure, I am the president and CEO of the Health Project. which annually confers the Koop prize to organizations able to clearly and unambiguously document health improvements and cost savings for their employees.) Eastman Chemical’s application is online and subject to review.

In their analysis of the Eastman Chemical application, Lewis at al. complain that costs for participants and non-participants diverged in the baseline years of the program; therefore, it was not the program that explains cost savings. Here’s the real story: Eastman Chemical’s program has been in place since the early 1990s. The chart found on the website (unfortunately mislabeled) shows participant and non-participant medical costs at baseline (2004), in subsequent years and in the final year of the study (2008).

The study compares medical and drug claims for minimally engaged (non-participant) and engaged (participant) employees matched at baseline (using propensity score matching) on age, gender, employee status, insurance plan, medical costs and other variables. No significant differences were found between participant and non-participant costs at baseline, but their claims experience differed significantly at follow up. Although not a perfect study, the economic results, coupled with significant and positive health improvements in many of the health behaviors and risk factors examined for a multi-year cohort of employees, convinced the Health Project board that Eastman Chemical earned the C. Everett Koop prize in 2011.

Whether return-on-investment (ROI) is the only metric for evaluating workplace health promotion programs. It seems that too much of the debate and controversy surrounding workplace health promotion is focused narrowly on whether these programs save money. If that were the aperture by which we judged medical care, in general, we would withhold treatment from almost every patient and for almost every procedure, with the exception of a few preventive services that are either cost-neutral or minimally cost-saving. That makes no sense for a compassionate society.

In a February 2009 Health Affairs article, I argued that prevention should not be held to a higher standard than treatment; both should be evaluated on their relative cost-effectiveness (not cost-benefit) in achieving positive health outcomes and improved quality of life.

Take a simple example of two employees. One has just suffered a heart attack and undergoes a coronary bypass. If the individual is willing, he is then engaged in counseling that encourages him to quit smoking, become more physically active, eat a healthy diet, manage stress, take medications to control blood pressure and see the doctor for regularly scheduled preventive visits. For that individual, I would be surprised if an employer providing medical coverage would demand a positive ROI.

How about a second employee? That person is overweight, smokes cigarettes, eats an unhealthy diet, is sedentary, experiences stress at work and has hypertension. He has not (yet) suffered a heart attack, although most would agree he is at high risk. To justify a health promotion program for that employee and others in the company, many employers insist on a positive ROI. Why is that a requirement? If a well-designed program can achieve population health improvement (as demonstrated using valid measures and an appropriate study design), and the program is cost-neutral or relatively inexpensive, why wouldn’t an employer invest in a wellness program, especially if is viewed as high value to both workers and their organization?

It’s time to change the metric for success. Instead of demanding a high ROI, employers should require data supporting high engagement rates by workers, satisfaction with program components, population health improvement, an ability to attract and retain top talent, fewer safety incidents, higher productivity and perceived organizational support for one’s health and well-being. That’s where program evaluations should be focused, not simply on achieving a positive ROI.

I appreciate the reality that some employers may still require an ROI result. Fortunately, there is evidence, published in peer-reviewed journals, that well-designed and effectively executed programs, founded on best practices and behavior change theory, can achieve a positive ROI. I won’t re-litigate this point, other than to point newcomers to a large body of literature showing significant health improvements and net cost savings from workplace heath promotion programs. (See, for example, studies for Johnson & JohnsonHighmark and Citibank and several literature reviews on the topic).

I challenge proponents and opponents of workplace wellness to direct their energy away from proving an ROI to measuring one or several of the important outcomes of interest to employers. Achievement of these outcomes is only possible when management and labor work toward a mutually beneficial goal — creating a healthy workplace environment. Health promotion programs require time to take root and be self-sustaining, but the benefits to employees and their organizations are worth the effort.