*Originally posted by Naomi Freundlich on her Reforming Health blog on September 18, 2014
There’s been a lot of controversy recently about workplace wellness programs: Do they save money for employers on healthcare costs? Can they produce measurable benefits for employee health? Do they unfairly punish people who are unable to participate? Are these programs just a ploy to shift medical costs to unhealthy employees?
Recently Austin Frakt and Aaron Carroll revisited these questions in a piece for the New York Times’ Upshot column, “Do Workplace Wellness Programs Work? Usually Not.” As the title makes clear, Frakt and Carroll come down on the side of the skeptics. I have always appreciated Frakt and Carroll’s analysis of healthcare economics but this time I think they might have missed the mark. A recent analysis of the value of health promotion programs in the Journal of Occupational and Environmental Medicine (JOEM) has a similar title; “Do Workplace Health Promotion (Wellness) Programs Work?” Instead of answering “Usually Not,” the twenty-plus authors of the JOEM article—all experts in the health promotion field—conclude that some wellness programs work superbly while others are abysmal failures. What separates bad, good and great programs, according to the JOEM authors, is basically “a combination of good design built on behavior change theory, effective implementation using evidence-based practices, and credible measurement and evaluation.” In short, the answer to the question really should be “It Depends…”
Frakt and Carroll came to their conclusion based on a handful of high-profile studies that fail to distinguish the abysmal from the superb. This has been a long-running problem in the health promotion field. The $6 billion corporate health promotion industry is made up of multiple players, including some who promote their vision of “wellness” to executives by promising savings that never materialize. Although half of all companies with 50 or more employees report having health promotion programs, what qualifies as a “program” is poorly defined. A company that offers its employees a financial incentive to fill out a health risk assessment (HRA) questionnaire but offers no other services has a health promotion program. A firm that provides free flu vaccines and access to smoking cessation and Weight Watchers programs is considered to a have health promotion program too. But does anyone really believe that such token efforts will reduce healthcare costs or have any measurable impact on employee health, productivity or even company morale?
For the past year, I have witnessed some of the very good and even “great” programs firsthand. I’ve been working with Ron Goetzel, one of the authors of the JOEM article, and his team at Johns Hopkins University’s Institute for Health and Productivity Studies (IHPS) on a project funded by the Robert Wood Johnson Foundation to identify and visit companies with health promotion (or wellness) programs that truly do “work” and have convincing data to prove it. One of the goals of this project is to formulate a series of “best practices” to help guide businesses that want to create high-performing health promotion strategies.
Indeed, the companies identified by Goetzel’s team at IHPS are embracing a culture of wellbeing rather than offering isolated health promotion initiatives. This culture change begins with top executives and managers leading by example; encouraging employees to take time to exercise; eat healthier and focus on reducing stress. These best-practice companies use incentives as a carrot to build up participation, not as a stick to penalize employees for poor health or their inability to participate in programs. They offer a wide range of programs, including but not limited to healthy food in cafeterias and vending machines; on-site gyms, fitness classes and company-wide challenges, health coaching, walking paths, and stretching breaks for call-center and factory floor workers. At best practice companies, health promotion programs continue to evolve, inviting input from employees and using measurement and evaluation techniques to identify initiatives with the most impact on improving health and wellbeing.
Do these programs “work?” In the Times article Frakt and Carroll write; “More rigorous studies tend to find that wellness programs don’t save money and, with few exceptions, do not appreciably improve health.” The companies we visited would heartily disagree. These firms report increased productivity, reduced absenteeism, fewer accidents, lower turnover, increased ability to attract top talent, and medical costs that grow slower than industry norms. The JOEM authors dig deeper into the literature than Frakt and Carroll and identify well-designed studies that find financial benefits from corporate health promotion programs as well as improvements in employee health indicators that include reduced rates of obesity and progress in reducing risk factors like high cholesterol and blood pressure. A 2010 literature review on workplace wellness performed by the highly respected Community Guide to Preventive Services, housed at the Centers for Disease Control and Prevention also spells out the benefits of well-designed health promotion programs.
Finally, the Times authors voice the concern that health promotion programs are discriminatory—allowing employers to shift medical costs to workers in poor health. This is a real worry especially given new provisions in the 2010 Affordable Care Act (ACA) that allow employers to charge higher premiums to workers who choose not to participate in workplace programs or fall short on certain health outcomes (for example, continuing to smoke or being obese). Just to be clear, the ACA does not change the fact that it is illegal for employers to discriminate against workers because of their health status or disability. Also, the new regulations require employers to offer a “reasonable alternative standard” for workers unable to participate in wellness programs or achieve a specific health goal. For example, it is illegal for an employer to charge a higher premium to a smoker or someone who is overweight if the worker agrees to attend a smoking cessation clinic or healthy eating classes. Companies must be clear and consistent in communicating why they are collecting employee health data (to help design effective interventions and programs) and that all employees can benefit from participating in health promotion programs.
In the end, by focusing only on the shortcomings of corporate wellness programs, the Times piece misses the true potential of promoting prevention and healthy behaviors in the workplace. Businesses are faced with a workforce whose demographics mirror the American population as a whole; we are aging, have high rates of obesity, are inactive and have unhealthy diets that raise the risk of chronic disease like diabetes, hypertension, and cancer. Employers care about having healthy employees, who are “present” at work—engaged, happy, energetic, and committed to their jobs. Since Americans spend one-third of their time at work, promoting health and wellbeing while they are on the job can be an extremely powerful way to positively impact the overall health of our population. That benefit is neither questionable nor controversial.
Written with support from the Robert Wood Johnson Foundation