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How to Identify Psychosocial Risks

We know that early intervention is critical to prevent delayed recoveries for injured workers. One of the challenges has been to identify those at higher risk of poor outcomes.

Fortunately, we have the tools to determine which patients are more likely to develop chronic pain and languish in a disability mindset. The process is fairly simple and backed by strong, research-based evidence. With increased awareness among payers, providers and other industry stakeholders, we can prevent creeping catastrophic claims, help injured workers regain function quicker and significantly reduce workers’ compensation costs.

Reasons for Getting Stuck

Psychosocial risk factors used to be little more than a buzz term among workers’ compensation professionals. While those of us who’ve worked extensively with chronic pain patients understood that psychological issues can easily derail a workers’ compensation claim, the research that proves this to be true has become widespread only in recent years.

In fact, some of the most recent research says that psychological factors can be more of a predictor of poor outcomes than the underlying medical conditions. We now know for certain that the biomedical model of disease does not hold true for everyone, and the biopsychosocial model of illness must be considered.

Where the first is based on the idea that a physical ailment can be cured through medical solutions, the second acknowledges that some people have an underlying psychobiological dysfunction that has clinically significant distress or disability. They are the injured workers who can greatly benefit from early identification and intervention.

Inadequate coping skills and a lack of knowledge of what is causing their pain can drive delayed recoveries and overuse of treatments and medications. Chronic pain is the final common pathway of this delayed recovery.

See also: A Biopsychosocial Approach to Recovery  

Research validated through meta analyses, prospective studies and control group studies shows that injured workers with delayed recoveries typically have:

  • Catastrophic thinking
  • A history of anxiety or depression
  • Anger and perceived injustice about their plight
  • An external locus of control
  • Minimal resilience

They may also have fear avoidance, meaning they engage in little to no physical activity out of fear they will injure themselves more and experience increased pain.

There are myriad reasons why some people have these issues. The cause could be childhood and life experiences, their relationship and interactions with their environments, issues in the workplace or home or other reasons altogether. It’s important that we identify injured workers with these issues as soon as possible after their injuries.

Pain Screening Questionnaires

One of the most effective ways to pinpoint injured workers with psychological issues is through specially designed, self-administered questionnaires. The one we use to identify patients at risk of developing chronic pain and disability is the Pain Screening Questionnaire (PSQ).

The PSQ was developed by a Swedish professor of clinical psychology and is used in many countries. It has been shown through studies to accurately predict time loss, medical spending and function — but not pain.

The PSQ takes about five minutes to complete and consists of 21 questions that focus on the injured worker’s:

  • Pain attitudes, beliefs and perceptions
  • Catastrophizing
  • Perception of work
  • Mood/affect
  • Behavioral response to pain
  • Activities of daily living

The injured worker is asked to rate on a scale of 1 to 10 things such as, “How would you rate the pain you have had during the past week?”; “In your view, how large is the risk that your current pain may become permanent?”; and “An increase in pain is an indication that I should stop what I’m doing until the pain decreases.”

Depending on the score, the injured worker is categorized as low risk, moderate risk, high risk, or very high risk. Those on the lower end of the scale are most appropriately managed through take-home educational materials on chronic pain. Moderate-risk injured workers are good prospects for a self-managed workbook style intervention. High- and very-high-risk injured workers should be referred for additional assessment and an intervention program, such as cognitive behavioral therapy (CBT).

See also: Impact on Mental Health in Work Comp  

In a program of early identification and intervention, Albertson’s Safeway found 12% of injured workers scored high. Those affected were referred to CBT. After an average of just six CBT sessions, a large percentage of them were able to return to work. Because of the results, primary treating physicians who work with Albertson’s injured workers have been referring them to the program earlier in the claims process.

Conclusion

It is estimated that 10% of workers’ compensation claims consume at least 80% of medical and indemnity resources. The vast majority of these are injured workers with delayed recoveries due to psychosocial risk factors.

With solid science backing up the successful identification and interventions of these employees, we can prevent needless disability and substantially reduce workers’ compensation costs.

Healthcare: When a Win-Win Is Lose-Lose

“Workplace Wellness Programs Are a Sham“ is a good article in Slate by L.V. Anderson. This is a must read for people who remain true believers that workplace wellness will improve worker health.

“The idea behind wellness programs sounds like a win-win,” Anderson writes. Alas, history is full of “win-win” ideas that were destructive, costly or ineffective.

She describes the infamous “doublespeak” of Safeway CEO Stephen Burd’s description of success with Safeway’s wellness program. Anderson writes, “As it turns out, almost none of Burd’s story was true.” (Regular readers of my blog will know I’ve written about the Safeway nonsense before.)

For decades, everyone knew that an annual physical was a great way to stay healthy, but various studies, including the famous New England Centenarian Study, have exposed that as a myth, too.

See also: A Proposed Code of Conduct on Wellness  

Antibacterial soap, anyone? Sounded like a great win-win, no? The FDA finally outlawed it. In my book, An Illustrated Guide to Personal Health, written in 2015 with UNLV Professor Robert Woods, Chapter 4 was titled, “Avoid Antibacterial Soaps and Gels.” Why? “Overuse of antibacterial soaps and gels can reduce the effectiveness of antibiotics you may need someday…. They are helping create antibiotic-resistant germs.”

Back to wellness failures. Companies in the U.S. have spent huge dollars trying to keep employees healthy through methods that are shams. It’s time to move on.

I immodestly include the following quote from Anderson’s article: “You might think of Al Lewis, Vik Khanna and Tom Emerick as the Three Musketeers in the fight against wellness programs.“* Al and I are co-authors of the Amazon best seller, Cracking Health Costs. It describes flaws in typical corporate wellness schemes, which while profitable to wellness vendors are useless at best and can actually be harmful to workers health at worst, not to mention the inconvenience and costs of going to doctors for all that screening. Concerns about wasted productivity, anyone?

How can wellness programs harm worker health? One way is by promoting gross over-testing and excessive screening by tools that have very high error rates and rates of false positives, e.g., PSA screens.

One good byproduct of dumping your wellness program is to avoid all the costly and burdensome reporting ACA requires. Yet another good byproduct is letting your employees do their work at work instead of spending non-productive time every year in wellness lectures, filling out health risk assessments, reading wellness-related emails and brochures, etc., etc., ad nauseum.

How can “wellnessophiles” in companies truly believe that their employees don’t already know that smoking, overeating, lack of exercise and excessive consumption of concentrated sugars are not good for them? Do wellness proponents truly believe that the employees’ doctors haven’t already addressed those issues…not to mention public service announcements, health classes in high school and so on? Do proponents think their employees who smoke have never noticed warning labels on cigarette packs?

I meet a lot of people from various walks of life. Occasionally, I ask them if their employer has a wellness program and, if so, what do they think about it. The typical first reaction is they roll their eyes. The most common comment is that the company’s wellness program is “just another [insert unflattering adjective here] HR program.” That’s usually followed by comments best described as lampooning the programs, as in “you’re not gonna believe this but…” type of comments.

Interestingly, I meet HR executives who admit their wellness program are ineffective and costly, yet they cling to them. They usually give one of two reasons. One is that they don’t want to admit that their program is a big waste of money. Another common rational is some version of “Too many of our employees are unhealthy; we gotta do something.” (I put that in roughly the same category as, “the beatings will continue until morale improves.”) That line of thinking is bureaucracy at its worst. You would never spend your own money that way…or maybe they would?  Hmm.

I get asked, if not wellness then what? My reply is anything that might actually save money or get better care for your workers, e.g., centers of excellence and direct contracting with providers. There is some promising work on reference-based pricing and better pharmacy management. Also, I believe we may have a surge of international medical travel in the future, too, especially to places like Health City Cayman Island (HCCI), about an hour’s flight from Miami and one of the best-quality hospitals and clinics in this hemisphere. I have visited HCCI a number of times and met a number of their surgeons. They are excellent.

See also: EEOC Caves on Wellness Programs  

I tried various forms of wellness in my career of running large sell-insured plans. I tried to make them work, but in the end none of them were effective, and some actually drove up health costs in a way a steely-eyed CFO would quickly understand. For about half my career, I reported through the CFO chain, not HR. CFOs really get the numbers and ask the tough ROI questions.

HR executives, take note: You can increase your status and respect if you just get out of wellness. Again, it’s time to move on. While wellness at work was a noble notion and one that made sense to many on the surface, it’s time to “fess” up to your bosses. They will appreciate your message and appreciate the reduction of wasteful spending.

Tom Emerick’s latest book is An Illustrated Guide to Personal HealthFor further information on this topic, see the They Said What blog by Al Lewis and Vik Khanna.

Is Change Really Happening So Fast?

Lots of people are saying these days that the insurance industry, after essentially not ever changing, is suddenly moving too fast to follow — for instance, the recent ITL article, “Feeling Like a Keystone Cop.” But in my 37 years in the industry, insurance has evolved continuously.

Insurers have changed from the days where syndicates consisting of individuals provided insurance coverage through the Lloyds market; today, China Re with a majority ownership by China’s ministry of finance, has a syndicate at Lloyds. Today, a large number of insurers are owned by multinational conglomerates.

Other types of evolution include Berkshire Hathaway’s use of insurance premiums as a means of financing its investment interests. Similarly, Fairfax Financial Holdings of Canada uses premiums collected from its insurance companies around the world to finance investment interests.

Financial services groups such as Suncorp Group in Australia now offer insurance through a number of brand names, such as Shannons (classic car insurance), APIA (Australian Pensioners Insurance Agency) and AAMI. Rand Merchant Insurance Holding Group of South Africa offers insurance in Australia under the name of Youi (https://www.youi.com.au).

In addition, some insurance companies, like Progressive, are taking a technology-only approach to offer motor vehicle insurance in Australia without a “brick and mortar” presence. Apart from the option of reporting a claim by phone, all other communications are through email or a web page. With this approach, Progressive in Australia will only attract those who use technology. Here is the link http://www.progressiveonline.com.au/car-insurance.aspx

People talk about Google, Walmart, Amazon and others possibly entering the insurance market — again, this isn’t something new. Brand names have been used by insurers for many decades. Coles, a large supermarket chain in Australia (https://financialservices.coles.com.au/insurance) (similar to a Safeway or Ralphs here in the U.S.), offers various insurance polices to its customers that are underwritten by Insurance Australia Group.

Whether Google, Walmart or Amazon actually decides to underwrite risks, act as channels for insurance or simply provide a means to compare insurer premiums remains to be seen, but, regardless, none of this is new. For example, InsWeb has offered car insurance price comparisons since the mid-1990s. Here is the link: http://www.insweb.com.

One thing that is certain, however, is that the insurance market will continue to be driven by price and service, especially service at the time of a claim. In his 2013 annual report, Warren Buffett made the following comment, “GEICO in 1996 ranked number seven among U.S. auto insurers. Now, GEICO is number two, having recently passed Allstate. The reasons for this amazing growth are simple: low prices and reliable service.”

Over time, risk types change, and insurance coverage follows. Boiler explosion insurance for example, was a major type of insurance through the 1800s and into the mid-1900s. It still exists but is only a very small percentage of the insurance market.

We will see changes to vehicle insurance coverage when driverless vehicles appear on our roads, as mentioned in the recent ITL article titled, “Beginning of the End for Car Insurance.” There are many risk coverage issues for potential exposures with driverless cars. Imagine if a child runs onto the street to retrieve a ball without looking (a common occurrence for those living in the suburbs). With advanced technology built into driverless vehicles, the vehicle would be programmed to make a decision about which action to take in the best interest of all parties (i.e. the child, occupants in the vehicle or nearby vehicles as well as pedestrians): (1) brake but still hit the child or (2) brake and avoid the child but possibly hit another object such as another vehicle or lamppost, injuring the occupants of the vehicles as well as nearby pedestrians.

All this will need to be addressed by laws and road rules when driverless vehicles are introduced, with insurance following on. Premiums and who pays are the least of the insurance complexities involved with driverless vehicles. If a manufacturer is required to obtain insurance coverage or volunteers to obtain insurance coverage, the premium would be factored into the price of the vehicle; otherwise. it would be paid by the owner of the vehicle. Regardless, insurers will receives premiums from one source or the other.

Another evolving insurance coverage relates to a disability occurring from a work-related, motor-vehicle or non-work-related incident. While U.S. jurisdictions ponder whether coverage for a work-related injury or illness should be through a workers’ compensation policy issued by a property/casualty insurer or through the opt-out option (a hot topic in the U.S. at the moment), Europe, Asia and Australia are focusing on what people with a disability can be doing and deciding on how best to achieve this, including funding. In this case, the evolution relates to who will pay the premiums. Will employers continue to pay for work-related injuries, or will individuals buy personal injury coverage to cover their recovery costs, no matter whether associated with a work-related, motor-vehicle or non-work-related incident?

In the evolution of insurance, technology has always played an important role in areas such as deciding which segment of a market companies want to attract, meeting reporting obligations and improving processing efficiencies. In workers’ compensation, a number of U.S. carriers have chosen to outsource many of their claims functions, as I outlined in my last article. Whether this practice continues remains to be seen, but something needs to change in the way the workers’ compensation insurer or its representatives (e.g.. third party payer) handle claims, because clearly what they are doing is not producing the desired outcome for the injured worker or the employer, and no form of state legislature or technology change will address this shortfall.

Products like IBM’s Watson and Saama that are able to use unstructured data in addition to structured data to perform analytics are part of the technology evolution, and there is high probability of success. But we saw something along the same lines during the early 1990s, when all the buzz was about neural networks.

In closing, I don’t feel as if I’m a Keystone Cop when it comes to professional development, either relating to insurance or the technology used now or offered in the future. I also don’t think the major players in the insurance industry (like Berkshire Hathaway, Fairfax, Suncorp and others around the globe) feel they or their personnel are operating like Keystone Cops. If they were, I’m sure their share prices would not be as high as they are.

CEOs Defy Common Sense on Wellness

By now, readers of this and many other outlets know that conventional workplace wellness doesn’t work. Period. It’s not that there is no evidence for it. It’s that all the evidence is against it. The “evidence” in favor of conventional wellness is easily disproven as being the result of gross incompetence or dishonesty. Occasionally, as in the American Journal of Health Promotion, investigators even manage to disprove their own savings claims without intending to. As we say in Surviving Workplace Wellness: “In wellness, you don’t have to challenge the data to invalidate it. You merely have to read the data. It will invalidate itself.”

Just before Thanksgiving, both Health Affairs (with our blog post) and Soeren Mattke, the often-misquoted author of multiple RAND studies (in a comment to that post), weighed in with the same conclusion, as described in the headline: “Workplace Wellness Produces No Savings.”

No longer can anyone claim with a straight face that “pry, poke, prod and punish” wellness programs saved money, or were even beneficial for employee health.

And yet…

Within one business day of the posting, Reuters’ Sharon Begley reported that on Tuesday, Dec. 2, the Business Roundtable’s (BRT) CEO is having a sit-down meeting with President Obama to demand exactly the opposite of what all the evidence shows: He wants more flexibility on wellness. In particular, the BRT wants the administration to call off the EEOC watchdogs, who have recently attacked Honeywell  and others for forcing employees into medical exams that appear to violate the Americans with Disabilities Act.

The BRT’s goal is to allow companies to punish unhealthy workers to the limits of the Affordable Care Act’s wellness provision. (Recall from our earlier postings that the ACA wellness provision was modeled after the Safeway wellness program, which Safeway later admitted did not even exist during the period for which the company claimed it saved money.) In essence, the BRT leadership wants to make their employees love wellness whether they like it or not.

This complete disconnect between the data and the BRT demands can be explained only one of two ways.

(1)    The CEOs who compose the Business Roundtable have been duped into thinking wellness saves money, because they aren’t bright enough to Google it for themselves and learn that it doesn’t.

(2)    The CEOs who compose the Business Roundtable are very bright and have figured out that the only way they can seriously manage their healthcare costs is by fining or shaming employees with chronic disease or obesity into leaving their companies…or at the very least collecting large fines from them.

Let’s examine each possibility in turn.

As to the first, people don’t get to the C-Suite by simply accepting information that their vendors tell them, especially when the numbers obviously don’t add up. Events that can be prevented by wellness programs, like heart attacks, account for only about 8.4% of  hospital spending, or less than 4% of total medical spending in the commercially insured population. The C-suite also must know that, as with the tobacco industry years ago, when the only people defending an industry are people who make their living from it, then the industry is a wholly illegitimate enterprise. The first possible explanation would therefore need to be termed an impossibility.

The second alternative seems like something only a conspiracy theorist could conjure, but as Sherlock Holmes said: “When you have eliminated the impossible, whatever remains, however improbable, must be the truth.”

These CEOs must know that these “let’s play doctor” programs and fines are expensive, intrusive, ineffective and embarrassing for the employees…and take a major toll on morale. One organization, Penn State University, faced an employee revolt and backed down. Vik is currently in a wellness program that is eerily Penn State-like, and he is documenting his experiences.

And surely someone has informed the BRT that the heart attack rate is only about 1 in 800 annually in the commercially insured population, while using wellness programs to identify all the other diseases they hope to prevent or control will merely drive up employers’ drug spending; these nascent conditions wouldn’t become debilitating until years into retirement. Guidelines promulgated by the U.S. Preventive Services Task Force (USPSTF) call for judicious use of clinical screenings in various at-risk subpopulations, (with a few exceptions, such as blood pressure). By contrast, wellness screening is done to all employees usually at least once a year. That screening frequency multiplies the odds of false positives, especially in younger populations.

So why go to the mat with the president over these programs? Perhaps CEOs believe that fatter employees have lower productivity, which is probably the case – if you happen to own a package delivery service or a ballclub. Otherwise, it’s hard to imagine that weight affects one’s ability to answer the phone, conduct a meeting or handle almost any other task commonly required in today’s workplace. And these CEOs’ own actions contradict any claims about how weight loss leads to greater productivity: Most of the growth in line manufacturing jobs takes place in states with high obesity rates…but lower wages. Obviously, the tangible benefit of the latter overwhelms any offset by the former, or hiring practices would be different.

Unless there is an alternate explanation (or the BRT simply doesn’t understand the data), this BRT demand of the president must be interpreted more cynically: It’s the opening salvo in an attack against aging and chronically ill employees whom employers simply aren’t allowed to fire any more. Employers want to get rid of these employees because – often due to circumstances beyond these employees’ control – their healthcare expenses are believed to be higher.

Workplace Wellness Shows No Savings

During the last decade, workplace wellness programs have become commonplace in corporate America. The majority of US employers with 50 or more employees now offer the programs. A 2010 meta-analysis that was favorable to workplace wellness programs, published in Health Affairs, provided support for their uptake. This meta-analysis, plus a well-publicized “success” story from Safeway, coalesced into the so-called Safeway Amendment in the Affordable Care Act (ACA). That provision allows employers to tie a substantial and increasing share of employee insurance premiums to health status/behaviors and subsidizes implementation of such programs by smaller employers. The assumption was that improved employee health would reduce healthcare costs for employers.

Subsequently, however, Safeway’s story has been discredited. And the lead author of the 2010 meta-analysis, Harvard School of Public Health Professor Katherine Baicker, has cautioned on several occasions that more research is needed to draw any definitive conclusions. Now, more than four years into the ACA, we conclude that these programs increase, rather than decrease, employer spending on healthcare, with no net health benefit. The programs also cause overutilization of screening and check-ups in generally healthy working-age adult populations, put undue stress on employees and provide incentives for unhealthy forms of weight-loss.

Through a review of the research literature and primary sources, we have found that wellness programs produce a return-on-investment (ROI) of less than 1-to-1 savings to cost. This blog post will consider the results of two compelling study designs — population-based wellness-sensitive medical event analysis and randomized controlled trials (RCTs). Then it will look at the popular, although weaker, participant vs. non-participant study design. (It is beyond the scope of this posting to question vendors’ non-peer-reviewed claims of savings that do not rely on any recognized study design, though those claims are commonplace.)

Population Based Wellness-Sensitive Medical Event Analysis

A wellness-sensitive medical event analysis tallies the entire range of primary inpatient diagnoses that would likely be affected by a wellness program implemented across an employee population. The idea is that a successful wellness program would reduce the number of wellness-sensitive medical events in a population as compared with previous years. By observing the entire population and not just voluntary, presumably motivated, participants or a “high-risk” cohort (meaning the previous period’s high utilizers), both self-selection bias and regression to the mean are avoided.

The field’s only outcomes validation program requires this specific analysis. One peer-reviewed study using this type of analysis — of the wellness program at BJC HealthCare in St. Louis — examined a population of hospital employees whose overall health status was poor enough that, without a wellness program, they would have averaged more than twice the Healthcare Cost and Utilization Project (HCUP) national inpatient sample (NIS) mean for wellness-sensitive medical events. Yet even this group’s cost savings generated by a dramatic reduction in wellness-sensitive medical events from an abnormally high baseline rate were offset by “similar increases in non-inpatient costs.”

Randomized Controlled Trials and Meta-Analyses

Authors of a 2014 American Journal of Health Promotion (AJHP) meta-analysis stated: “We found a negative ROI in randomized controlled trials.” This was the first AJHP-published study to state that wellness in general loses money when measured validly. This 2014 meta-analysis, by Baxter et al., was also the first meta-analysis attempt to replicate the findings of the aforementioned meta-analysis published in February 2010 in Health Affairs, which had found a $3.27-to-1 savings from wellness programs.

Another wellness expert, Dr. Soeren Mattke, who has co-written multiple RAND reports on wellness that are generally unfavorable, such as a study of PepsiCo’s wellness program published in Health Affairs, dismissed the 2010 paper because of its reliance on outdated studies. Baicker et. al.’s report was also challenged by Lerner and colleagues, whose review of the economic literature on wellness concluded that there is too little credible data to draw any conclusions.

Other Study Designs

More often than not wellness studies simply compare participants to “matched” non-participants or compare a subset of participants (typically high-risk individuals) to themselves over time. These studies usually show savings; however, in the most carefully analyzed case, the savings from wellness activities were exclusively attributable to disease management activities for a small and very ill subset rather than from health promotion for the broader population, which reduced medical spending by only $1 for every $3 spent on the program.

Whether participant vs. non-participant savings are because of the wellness programs themselves or because of fundamentally different and unmatchable attitudes is therefore the key question. For instance, smokers self-selecting into a smoking cessation program may be more predisposed to quit than smokers who decline such a program. Common sense says it is not possible to “match” motivated volunteers with non-motivated non-volunteers, because of the unobservable variable of willingness to engage, even if both groups’ claims history and demographics look the same on paper.

A leading wellness vendor CEO, Henry Albrecht of Limeade, concedes this, saying: “Looking at how participants improve versus non-participants…ignores self-selection bias. Self-improvers are likely to be drawn to self-improvement programs, and self-improvers are more likely to improve.” Further, passive non-participants can be tracked all the way through the study because they cannot “drop out” from not participating, but dropouts from the participant group — whose results would presumably be unfavorable — are not counted and are considered lost to follow-up. So the study design is undermined by two major limitations, both of which would tend to overstate savings.

As an example of overstated savings, consider one study conducted by Health Fitness Corp. (HFC) about the impact of the wellness program it ran for Eastman Chemical’s more than 8,000 eligible employees. In 2011, that program won a C. Everett Koop Award, an annual honor that aims to promote health programs “with demonstrated effectiveness in influencing personal health habits and the cost-effective use of health care services” (and for which both HFC and Eastman Chemical have been listed as sponsors). The study developed for Eastman’s application for the Koop awards tested the participants-vs-non-participants equivalency hypothesis.

From that application, Figure 1 below shows that, despite the fact that no wellness program was offered until 2006, after separation of the population into participants and non-participants in 2004, would-be participants spent 8% less on medical care in 2005 than would-be non-participants, even before the program started in 2006. In subsequent presentations about the program, HFC included the 8% 2005 savings as part of 24% cumulative savings attributed to the program through 2008, even though the program did not yet exist.

Figure 1

Lewis-Figure 1

Source: http://www.thehealthproject.com/documents/2011/EastmanEval.pdf

The other common study design that shows a positive impact for wellness identifies a high-risk cohort, asks for volunteers from that cohort to participate and then tracks their results while ignoring dropouts. The only control is the cohort’s own previous high-risk scores. In studying health promotion program among employees of a Western U.S. school district, Brigham Young University researcher Ray Merrill concluded in 2014: “The worksite wellness program effectively lowered risk measures among those [participants] identified as high-risk at baseline.”

However, using participants as their own control is not a well-accepted study design. Along with the participation bias, it ignores the possibility that some people decline in risk on their own, perhaps because (independent of any workplace program) they at least temporarily lose weight, quit smoking or ameliorate other risk factors absent the intervention. Research by Dr. Dee Edington, previously at the University of Michigan, documents a substantial “natural flow of risk” absent a program.

Key Mathematical and Clinical Factors

Data compiled by the Healthcare Cost and Utilization Project (HCUP) shows that only 8% of hospitalizations are primary-coded for the wellness-sensitive medical event diagnoses used in the BJC study. To determine whether it is possible to save money, an employer would have to tally its spending on wellness-sensitive events just like HCUP and BJC did. That represents the theoretical savings when multiplied by cost per admissions. The analysis would compare that figure to the incentive cost (now averaging $594) and the cost of the wellness program, screenings, doctor visits, follow-ups recommended by the doctor, benefits consultant fees and program management time. For example, if spending per covered person were $6,000 and hospitalizations were half of a company’s cost ($3,000), potential savings per person from eliminating 8% of hospitalizations would be $240, not enough to cover a typical incentive payment even if every relevant hospitalization were eliminated.

There is no clinical evidence to support the conclusion that three pillars of workplace wellness — annual workplace screenings or annual checkups for all employees (and sometimes spouses) and incentives for weight loss — are cost-effective. The U.S. Preventive Services Task Force (USPSTF) recommends that only blood pressure be screened annually on everyone. For other biometric values, the benefits of annual screening (as all wellness programs require) may not exceed the harms of potential false positives or of over-diagnosis and overtreatment, and only a subset of high-risk people should be screened, as with glucose. Likewise, most literature finds that annual checkups confer no net health benefit for the asymptomatic non-diagnosed population. Note that in both cases, harms are compared with benefits, without considering the economics. Even if harms roughly equal benefits, adding screening costs to the equation creates a negative return.

Much of wellness is now about providing incentivizes for weight loss. In addition to the lack of evidence that weight loss saves money (Lewis, A, Khanna V, Montrose S., “It’s time to disband corporate weight loss programs,” Am J Manag Care, In press, February 2015), financial incentives tied to weight loss between two weigh-ins may encourage overeating before the first weigh-in and crash-dieting before the second, both of which are unhealthy. One large health plan offers a weight-loss program that is potentially unhealthier still, encouraging employees to use the specific weight-loss drugs that Dartmouth’s Steven Woloshin and Lisa Schwartz have argued in the Journal of the American Medical Association never should have been approved because of the drugs’ potential harms.

In sum, with tens of millions of employees subjected to these unpopular and expensive programs, it is time to reconfigure workplace wellness. Because today’s conventional programs fail to pay for themselves and confer no proven net health benefit (and may on balance hurt health through over-diagnosis and promotion of unhealthy eating patterns), conventional wellness programs may fail the Americans with Disabilities Act’s “business necessity” standard if the financial forfeiture for non-participants is deemed coercive, as is alleged in employee lawsuits against three companies, including Honeywell.

Especially in light of these lawsuits, a viable course of action — which is also the economically preferable solution for most companies and won’t harm employee health — is simply to pause, demand that vendors and consultants answer open questions about their programs and await more guidance from the administration. A standard that “wellness shall do no harm,” by being in compliance with the USPSTF (as well as the preponderance of the literature where the USPSTF is silent), would be a good starting point.