(Response to an editorial by Michael P. O’Donnell, MBA, MPH, PhD Editor in Chief, American Journal of Health Promotion)
By now most people involved in Workplace Wellness (WW) know that the claims made by the Safeway Organization, claims that formed the basis of the Wellness Provisions of the Affordable Care Act (ACA) and led to the explosion of what is now by some estimates an 8 billion dollar a year industry, were made up – never happened.
And we know from the research that the approaches promoted by this so-called Safeway Amendment, heavily lobbied for by WW industry leaders, do not save money and are likely to have damaging effects on employees who find the approaches quite distasteful.
And many in the industry and in business are aware of the debacles at Penn State, Nebraska, and more recently Boise where programs driven by some of the leaders in the field ended up backfiring with the potential for doing considerable harm.
Then there have been the outrageous claims of ROIs of 25-to-1, 40-to-1 and even 400-to-1 and decreases in various health-related variables of 100% or more, many of which turned out to be not only unlikely, but mathematically impossible. The research is now clear that these programs don’t save money and likely don’t even pay for themselves.
Finally, there are the faulty methodologies used to make these programs seem more effective than they are; comparing participants to non participants, ignoring the natural ebb and flow of risk factors, failing to include dropouts in the data, attributing almost any positive change to the wellness programs instead of assessing wellness sensitive medical events.
The Good News?
The good news is that many in the WW industry are beginning to see that ours is a barge on a potential collision course with extinction. Important issues are being raised and more and more people in the field and in the business community are questioning the validity and safety of what has passed for WW since the 2010 passage of the ACA. An actual Code of Conduct has been suggested by some industry leaders in an attempt to begin to have at least some guideposts for efficacy, safety, and good science – a long overdue move towards a more ethical workplace wellness.
The problems with the industry have more to do with paradigms than people. We believe the overwhelming majority of practitioners have the best of intentions at heart and are doing what they are doing because they truly want to help. Unfortunately, as is so often the case with “paradigm paralysis,” the “stuckness” to outdated beliefs is preventing the industry from moving forward and may in fact be threatening its very survival.
Orwellian Workplace Wellness
The bad news is that some in the field have dug in and refused to even engage in dialogue about the lack of efficacy and significant iatrogenesis engendered by these approaches. The most recent and perhaps saddest case in point is an editorial in the American Journal of Health Promotion entitled, Is It Time to Separate the Financial and Health Goals of Workplace Health Promotion Programs? It is a truly alarming step backward into a proposed scenario for WW that looks a lot more like an Orwellian novel than a manifesto for moving into the 21st century.
The editorial proposes three major suggestions for supposedly moving the field forward, each one a bit more disheartening than the last.
Employees should be required to pass a “job-specific” fitness test. The argument is that police, fire and military personnel already submit to these tests and that they would also be appropriate for employees in heavy labor jobs like construction and manufacturing. Then however, the author adds that perhaps they should also be applied to jobs that require “excessive walking, standing or even sitting.” That would cover pretty much everybody. It should not be hard to imagine the nightmare into which this approach would rapidly devolve. Think Animal Farm or Nineteen Eighty-Four.
Don’t hire smokers is not a new suggestion. The claims of money to be save aside (and these are anything but conclusive) at least the author does mention that the majority of states have had the good sense to make this illegal. Oh yes and by the way he also mentions to be careful if you use the suggested guidelines not to hire larger people because in some places that is also illegal. So, don’t hire people who smoke, don’t hire people who cannot pass a fitness test and don’t hire “overweight people” if you can get away with it. Who is next? – people over 40, people who have a glass of wine with dinner, people who watch soccer?
Implement an outcomes-based wellness incentive program. This is the most egregious, misguided recommendation of all. Just a reminder that it is precisely the type of approach promoted by the bogus Safeway Amendment (something the author of this editorial lobbied hard for in Washington) that turned out to be completely fabricated – what some might refer to less affectionately as a lie.
Nevertheless, the author presents a litany of reasons why this approach is a good idea for creating, as he puts it “an insanely good program” that will save money and improve health. At least one of the words in that sentence is close to the truth; because the rest fly directly in the face of the research, which is crystal clear that these types of interventions are a very bad idea that do not save money or improve health. The review of the relevant research in the New England Journal of Medicine by one the nation’s leading behavioral economists is quite clear:
“Although it may seem obvious that charging higher premiums for smoking (body mass index, cholesterol, or blood pressure) would encourage people to modify their habits to lower their premium evidence that differential premiums change health-related behavior is scant. Indeed, we’re unaware of any insurance data that convincingly demonstrate such effects.”
Interestingly, the article that the editorial references to demonstrate that these programs save more money than they cost (published perhaps not surprisingly in the same Journal) actually concluded that the better the research methodology, the lower the Return on Investment, so that in fact:
“We found a negative ROI in randomized controlled trials.”
(Note: the article does go on to say that when they combined the properly conducted studies with poorly conducted ones, they were able to come up with a positive ROI. Of course this would be like combining Ptolemaic and Copernican models of the solar system and reaching the conclusion that the earth actually revolves half way around the sun.)
Just Plain Mean Spirited
I will leave most of the other details of the questionable math aspects of these proposals to others. I will point out that with respect to companies hiring based on smoking status, if you follow the math presented in the editorial, adding the 29 states plus the district of Columbia that legally cannot to the 31 states that legally can, you have a interesting conundrum on your hands! (hint: how many states are there?)
It is most important for the future of our industry for those of us in the field to understand just how the mean spirited these recommendations are. Aside from the research demonstrating the lack of efficacy of these approaches, do we really want to treat people this way? Perhaps the most telling comment from the author in this regard is:
“Incentive levels will be set, so employees who meet all the outcome standards will not be forced to subsidize any of the higher health-care costs incurred by employees who do not meet the standards.
This is reprehensible on a number of levels. Perhaps most importantly, it contradicts one of the primary goals of the Affordable Care Act which is to erase the burden of pre-existing conditions. And it is precisely why major health organizations in this country including the American Cancer Society, The American Heart Association and the American Diabetes Association opposed the inclusion of the Safeway Amendment. As they put it:
“Based on the evidence to date regarding the impact of financial incentives on behavior, we believe the potential to discriminate against persons with chronic conditions – like heart disease, cancer, and diabetes – far outweigh any potential benefits to improving wellness.”
A 2013 review article in the prestigious journal Health Affairs agreed with what is more likely to be the reality behind these approaches:
“We found little evidence that such programs can easily save costs through health improvement without being discriminatory. Our evidence suggests that savings to employers may come from cost shifting, with the most vulnerable employees—those from lower socioeconomic strata with the most health risks—probably bearing greater costs that in effect subsidize their healthier colleagues.”
Even the Prevention Institute, an organization that normally enthusiastically promotes all things preventative opposed the amendment saying:
“We also have a pretty good idea of what doesn’t work, and heading the list are strategies that tie individual employees’ share of health insurance premiums to health-related behaviors and/or meeting benchmarks.”
More recently, Dr. Soeren Mattke, Managing Director of RAND Health Advisory Services and one of the most respected researchers in the world in this space summed up the evidence with regard to the impact of these interventions.
“In my mind, exposing the most vulnerable employees to that level of pressure would be sound policy if, and only if, workplace wellness programs were powerful enough to reverse years of deeply engrained behaviors. Yet our data show that they are not even attracting more than a quarter of employees and have a modest impact on those who participate. That is why I believe it is time to start rethinking workplace wellness, and come up with models that are both fairer and more effective.”
And Then There Are the Incentives
Finally, it would be almost criminal to leave a commentary on this mishmash of outdated, mean-spirited proposals without addressing the complete myopia regarding the past 3 decades of research related to the impact of incentives (rewards and punishments). This remarkably conclusive and consistent research tells us that the kinds of incentives being recommended here not only fail to promote sustained change but in fact engender many negative consequences; including lying, cheating, taking shortcuts, and decreased creativity and intrinsic motivation.
In a referenced work in the editorial that completely ignores this research; the author goes into great detail about all the ways incentives can be used to coerce people into doing all manner of behaviors. Amazingly, way back in 1998 after considerable, vigorous discussions with me on the subject, he concluded in his own Journal, The Art of Health Promotion 1998;2(3):8):
“The combination of theory and empirical results tells us that we should use incentives to increase participation, not to change health behaviors.”
Of course people are entitled to change their minds, but since nothing in the literature around the use of incentives has changed since that time, other than that we have scores of additional studies that all reach precisely the same conclusions, it is again sad that the suggested recommendations here would take us backwards rather than forwards.
Take Home – Please!
So, where do we go from here? As you review the recommendations in this editorial, I entreat health professionals to ask themselves:
“Do I really want to subject my fellow human beings to these types of interventions and consequences”?
And for business leaders to ask themselves:
“Are these outcomes and consequences what I really want for my employees and my organization?”
I sincerely believe and hope that in both cases the answers to these questions will be a resounding no!
PS – for vendors who feel these critiques are unwarranted and want to challenge their validity, you are invited to do so here. The more public discussion we have about these important issues, the better for our industry and for the people and organizations that we serve.