Tag Archives: workplace wellness

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.

‘Surviving Workplace Wellness’: an Excerpt

Our series of excerpts from Surviving Workplace Wellness starts with the epilogue, because Aetna managed to incorporate everything that is wrong with workplace wellness, as described in the book, into one press release. It is the book’s epilogue because Aetna’s announcement followed the completion of the text. We actually held up publication of the print version to squeeze this epilogue in.

The caveat for brokers: Be careful what you sell. Your commission checks may come from the seller, but your business value comes from retaining your clients.  As your clients grow more skeptical of wellness vendor claims, you need to be a step ahead, anticipating their skepticism rather than being blindsided by it.

Dr. Aetna Is In

Imagine how you’d feel if you got a letter saying basically:

Dear Fat Person,

We aren’t doctors, and you’re not sick, and you never asked for our help and probably never would, but we’ve got the solution for you anyway: Arena’s Belviq and Vivus’s Qsymia, obesity drugs made by companies we’re partnering with. True, these drugs are expensive, have side effects that you may not tolerate (the nasty outcomes in clinical trials included a 20% incidence rate of paresthesia, a 5% incidence of high blood pressure and a 12% incidence of back pain) and lack a generally accepted treatment protocol, but nonetheless we’d like you to give them a try.

Sincerely,

Dr. Aetna

This is basically what Aetna has in mind. They essentially made a list of all the things wrong with wellness programs — unwanted interference in people’s lives, playing doctor, unproven therapies, opaque relationships with “recommended” suppliers, high expense and “diagnosing” people who aren’t sick — and packaged them all into one press release (1/14/14).

This release came out after our e-book, and we considered holding our two cents for Surviving Workplace Wellness: The Sequel. Yet naïve optimists that we are, we decided that by the time any sequel would be published, wellness will have gone the way of the Edsel, pet rocks, Netscape, colon cleanses (we hope) and Sarah Palin (see “colon cleanses”), thus rendering us obsolete along with the rest of the industry. Hence we are squeezing them into an epilogue now.

To summarize, Aetna is pitching specific name-brand drugs — not just any name-brand drugs but name-brand prescription drugs that consumers have rejected (Arena’s Belviq and Vivus’s Qysmia) to the point where one Wall Street analyst described them as ”flailing” — to “selected Aetna members” who aren’t even sick, just obese. So this is a wellness first two different ways. No health plan has ever pitched name-brand drugs to its members before, let alone to members who aren’t sick.

But wait…there’s more.  Because it’s likely that not a lot of obese people would ever call Aetna to ask: “What specific flailing drugs from manufacturers you’ve made side deals with would you recommend for me even though I’m not sick?” Aetna isn’t taking any chances by just sitting by the phone. Instead, it is providing “outreach” to those members (maybe not using that exact letter above but not far from it) — combined with an incentive that is really hard to come by, a totally free app — to convince people to take these drugs.

In your eagerness to get this free app and lots of drugs that don’t work, you’re probably asking: “How do I get to be a ‘selected Aetna member’? I bought a policy from them.” Haha, good one. You didn’t seriously think Aetna would actually spend its own money covering its own insured members for its own program covering its own partners’ drugs endorsed in its own press release, did you? Hello? Have you actually read this book? Obviously, Aetna executives don’t believe this program can save money any more than you and I do, so participation is a privilege they reserve for their self-insured employer customers who want to follow Harvard Professor Katherine Baicker’s advice in Chapter 3 to ”experiment” on their employees, taking the advice a step farther by using flailing drugs.

After you’re done wondering how something could be good enough to sell to Aetna’s customers but not for Aetna’s insured members themselves, you may also be excused for then wondering whether Aetna knows anything about weight control in the first place, as the release demonstrates a failure to understand the difference between short-term weight loss and long-term weight loss maintenance, an overreliance on anecdotal outcomes and an insufficient disclosure of product side effects.

However, the misunderstanding of the basics of study design and weight control — along with the ignoring of any consequences of Aetna’s actions such as any potential liability if these drugs turn out to be another fen-phen (phentermine of fen-phen fame is one of the two active ingredients in Qsymia) — is not the lead here. The lead here is that Aetna is playing doctor with a license it doesn’t have, pushing drugs that no one seems to want on people who aren’t actually sick, without even taking the financial consequences of its own actions but rather foisting those consequences on the very same employer customers whose financial risks and whose employees’ health it is supposed to be protecting.

Now you see why we couldn’t wait for the sequel even if there is one, and why there’s likely to be one.

Three Surprising Hazards of Worksite Wellness Programs

Here's a proposal for the plot of a new comic book.

Perry White summons Clark Kent and Lois Lane into his office one day in Metropolis.

“I have bad news,” White barks. “Health costs at the Daily Planet are through the roof. And it's all your fault. You're unhealthy!”

White tells Clark and Lois to fill out a questionnaire, which he assures them will be kept “private.” Once they complete it, they will receive free advice on running their personal lives better. “And we're docking your pay $1,200 if you don't fill it out and see a doctor,” White warns.

The questionnaire asks about smoking, exercise, weight, feelings of depression, financial problems, marital problems and stress. Clark's questionnaire asks whether he examines his testicles regularly. Lois must answer whether she plans to get pregnant. And they get lots of valuable guidance on their misguided lifestyles. Eat your vegetables. Cheer up. Calm down. Don't smoke. Pay your bills on time.

Though he can leap tall buildings in a single bound, Clark, according to the questionnaire, needs a number of tests and screenings to rule out serious health problems.

I probably couldn't sell this comic book proposal because the scenario sounds too preposterous, even for a guy with X-ray vision who flies. Surely, in real life it would be illegal or at least politically incorrect for your boss to demand to know your most private information, obtained under the threat of a pay cut.

Sorry to say, this plot isn't entirely fictional for thousands (if not millions) of Americans. Not only is it actually legal for your employer to require you to answer intrusive personal questions, it's encouraged by a little-known provision in Obamacare, which is embraced by a surprising mix of people and interests on both sides of the aisle. That provision allows employers to promote “worksite wellness” programs and require their employees to pay up if they don't participate.

A multibillion-dollar industry has grown up overnight, selling wellness programs to well-meaning employers. More than 90% of all large employers report offering one for employees. Some of these programs are excellent and welcomed by employees. It's nice for an employer to support exercising and quitting smoking.

But badly designed programs are not so nice, as Matthew Woessner learned. He received an email from his employer on July 17, 2013, instructing him to take the online questionnaire called a “Health Risk Assessment,” reporting on his personal life and habits akin to Perry White's grilling of Clark and Lois. Like the Daily Planet employees, if Woessner refused, he would lose $1,200.

This could happen to you, according to Al Lewis and Vik Khanna in a disturbing new book, “Surviving Workplace Wellness…with Your Dignity, Finances, and (Major) Organs Intact.” The book is so laugh-out-loud funny you may wonder if it's really serious, but actually it's a sobering exposé of hazards in the worksite wellness trend in American business. Think of the book as Dave Barry meets Rachel Carson.

The authors agree that the worksite wellness movement is not only a privacy hazard, but a health hazard and business hazard to boot. While some of us might be willing to tolerate a certain amount of privacy loss if we thought it would improve our health and save some money, Lewis and Khanna make a compelling case that poorly designed wellness programs don't help at all. In fact, these programs in the wellness business: 1) dismay and alienate employees, 2) fail to reduce health costs and 3) harm employee health.

How is this possible? Let's look at each in turn.

1. Dismaying and Alienating Employees

Bad wellness programs send the message that your boss thinks you're an idiot. This typically isn't a good strategy for improving morale, though it does improve motivation to update your resume.

Woessner's employer is a good example. That employer tells employees who smoke that tobacco use is not healthy. This implies that employee smokers are not educated enough to recall the Surgeon General's warnings or the mountains of studies over the past 50 years. Woessner's employer also believes that a good number of workers are too simple-minded to understand they should eat their vegetables and get some exercise.

What kind of company employs such a dim workforce? In Woessner's case, it is Penn State, which employs some of the world's leading researchers in science, technology, social sciences, humanities and health care. Despite their apparent stunning lack of knowledge about the most fundamental aspects of their health, a disproportionate number of them managed to earn PhDs.

Of course, the reality is that public health is a complex enterprise for which it is very easy to condescend and coerce when you mean to encourage. Bad wellness programs focus on the former.

2. Bad Programs Don't Save Money

Lewis and Khanna show examples of wellness vendors inventing savings numbers to sell their services to your employer. (I dare anyone to get through this section of the book without laughing.) Wellness marketers make claims that literally don't add up, such as proclaiming savings exceeding 100% (mathematically impossible) or, similarly, suggesting an employer saved more money than he spent in the first place.

Fundamentally, Lewis and Khanna make a compelling case that bad wellness programs don't save money because the programs themselves cost money, and the added cost of screenings and education and other services aren't free, either.

3. Potential Harm to Employee Health

Even if wellness programs may cost a bit more money in the short run, surely they improve health in the long run…right? Unfortunately, that's not evident either, the book argues.

Lewis and Khanna give us a case study of the state of Nebraska, which touts the success of an employee wellness program that won the national C. Everett Koop Award. The book shows convincingly that, not only are the proclaimed savings numbers impossible, but Nebraska's employees may have been exposed to hundreds of unnecessary and invasive tests. Many resulted in false positives that demanded even more invasive tests and treatments, which can scare patients for no reason and even lead to additional risk and harm.

I recommend this book because your employers – and the vendors and consultants that sell to them – aren't going to change without your input. Employees and business leaders need to do what the Penn State staff did and push back on poorly designed programs. In the process, they will be supporting, not undermining, the economic wellbeing of their employer.

Many of us may be reluctant to question the design of our company's wellness program because it sounds like we are challenging Mom and apple pie. How can you oppose something as pure-sounding as employee wellness? But what this book warns is that poorly designed wellness programs can violate the very essence of good management practice: namely, that management should focus on employee performance, not employees' personal lives. The latter can do much more harm than good.

A well-designed wellness program does not threaten to dock Superman's pay if he doesn't get a cholesterol test. A good one might instead add a salad bar to the Daily Planet cafeteria. The latter doesn't sound like something Perry White would do, but after all the Chief has never been the model of a good boss.

I don't come to this conclusion about the problems with wellness programs lightly. I worked in public health and dedicated much of my career to promoting prevention. My belief in the importance and the difficulty of prevention is precisely why I believe we must call out poorly designed programs that prey on well-meaning employers and other purchasers. Those programs apply equal measures of coercion and disparagement toward the people they are supposed to help. That discredits employer benefits programs and undermines employee loyalty and trust. Employers deserve better for the investment they make in the wellbeing of their employees.

This article first appeared on Forbes.com.