Until corporate wellness programs demonstrate ROI, many companies have to consider whether there are other ways to improve the health of their employees and the country.
The backlash against corporate wellness programs has reached a crescendo with lawsuits by the Equal Opportunity Employment Commission on behalf of workers who feel coerced to complete health risk assessment programs as a condition of receiving healthcare insurance.
The backlash has been long simmering, and in the summer of 2013 came to a boil in central Pennsylvania when Penn State University professors and staff successfully revolted against a proposal to require physical exams and health risk assessment and impose a $100 per month premium surcharge for opting out.
It was a victory for avuncular art and law professors in State College -- and also for Al Lewis and Vik Khanna, independent consultants who are trying to expose what they see as a counterproductive wellness industry run amok.
After a decade of promotion, mixed evidence
Khanna, who lives near St. Louis, started his career as a managed care analyst. In the early 2000s he started wondering if the nascent employer wellness industry "might actually be able to do everything the managed care industry says it's going to do," including "actually lowering healthcare costs and making anybody better."
Pretty quickly, he came to the conclusion that wellness was "just as ineffective, unlikable and wasteful."
A few years ago, he met Lewis, a Boston-based corporate consultant and lawyer, and they started a partnership trying to convince employers to rethink their own wellness programs and spending. They dedicated 165 pages to criticising wellness in a book called Surviving Workplace Wellness With Your Dignity, Finances and (Major) Organs Intact, and started discussing the issues with companies and in the influential pages of the Harvard Business Review.
They contend that the major claims of wellness vendors -- that risk assessments, weight loss programs, financial rewards and penalties improve individuals' health and their employers' bottom line -- "can not be supported."
While wellness programs may prevent a few heart attacks here and make companies feel like they're improving health, Lewis and Khanna argue that it is hard to justify the $10 billion wellness industry as it currently exists. They suggest that any savings employers are promised or see are more likely to be a result of the high deductible health plans so many companies have adopted in the last decade.
To some extent, their arguments are vindicated by recent research.
"Although there may be other valid reasons, beyond lowering costs, to institute workplace wellness programs, we found little evidence that such programs can easily save costs through health improvement without being discriminatory," concluded one 2013 Health Affairs study of the existing literature. "Our evidence suggests that savings to employers may come from cost shifting."
Another study in the same issue of Health Affairs honed in on a hospital system's wellness program and found that although it was associated with fewer hospitalizations, "it did not save money for the employer in the short-term."
In the long-term?
Previous research projected a bright future. A 2009 Health Affairs study led by Harvard health economist Kate Baicker examined 32 previous studies of workplace wellness programs, and was titled "Workplace Wellness Programs Can Generate Savings." The ROI calculated across those studies was $3.27 in medical costs and $2.73 in absenteeism for every dollar spent on wellness programs.
But, amid criticism from Khanna, Lewis and others about the methodology and original studies of that research, Baicker has since equivocated and come to the conclusion that wellness' ROI is probably positive but still uncertain -- in the long-term.
"It could be that when all the full set of evidence comes in it will have huge returns on investment, and the billions we're spending on it are completely warranted," Baicker told National Public Radio last year. But for now, "there are very few studies that have reliable data on both the costs and the benefits."
Ron Goetzel, the director of Johns Hopkins' Institute for Health and Productivity Studies and a VP at Truven Health Analytics, is one of the oldest proponents of wellness programs -- and he's a target of Khanna and Lewis as one of wellness hypers.
Goetzel, though, is more conservative these days. A lot of higher ROI claims "are not credible," he said. Good programs should be able to have an ROI in the range of $1.50 to $3 for every dollar spent over three to five years.
The original incentive-based wellness program he helped design at Johnson & Johnson in 1995 is largely still is place and has been a success, Goetzel said. It features a $500 annual discount of premiums for a biometric screening and participation in an intervention program for chronic conditions that can be changed, like diabetes.
Culture, environment and choice
Beyond the economics, Khanna and Lewis are skeptics of clinical prevention, the idea that asymptomatic adults need annual primary care visits or diabetes screenings. There, too, some research is in their favor, suggesting that mass screenings does not save many lives, with few a exceptions.
"We're big proponents of primordial prevention," said Khanna, who like Lewis is aging actively, without the kind of protruding belly so many middle age men and baby boomers carry around.
"Stay physically active, eat a high quality diet, don't smoke, drink modestly and buckle your seat belt," Khanna advised. "Those are the things we wish employers would focus on, creating environments and cultures to empower people to do those things to keep people out of the doctor's office."
The typical wellness program tends to have a myopic focus on health risk assessments and primary care visits, and often do not address factors that may lead to poor health -- like stressful commutes and the ubiquity of processed food.
There is a consensus that lifestyle choices contribute significantly to the national disease burden, and that Americans need to be more active and eat healthier.
Since employers spend more than half a trillion dollars on healthcare and in the 40-hour work week consume a third of an individual's non-sleeping hours, they are in a unique position to improve not only healthcare delivery but also the factors outside of healthcare that contribute to health.
America's transportation system, for one, can be wasteful, inefficient and harmful, much like its healthcare system. A study in the Journal of Preventive Medicine following 4,200 Texans found that those with longer commutes also had higher blood pressure, bigger waistlines, higher metabolic risks, and lower levels of cardiovascular fitness. In the Gallup-Healthways Well-Being Index, American workers with lengthy commutes are more likely to report a range of adverse physical and emotional conditions.
Would people eat healthier if companies had fresh food available? Would more people bike to work if bike lanes and paths were available or public transit was not so terrible? Would employees be more productive, healthier and happier if they could work from home more often?
Those are the kinds of questions on the minds of skeptics like Khanna and Lewis, proponents like Goetzel, public health researchers and progressive employers. The hypothesis is that businesses and local governments can help make it easier to be healthy, and thus aid more people in becoming healthy.
"There is a paradigm shift" taking place in corporate culture and health benefits, said LuAnn Heinen, a vice president at the National Business Group on Health. "It's a transformation going on from wellness to well-being."
It's a challenge or in some places a demand on companies. "What are you offering to reduce stress and have a positive community impact?" Heinen asked.
On that front, companies are experimenting with and even embracing new ideas -- from telecommuting, in jobs where it can be done, to active transportation and mass transit incentives in jobs where physical presence is required, to company gardens, standing desks and walking meetings.
In Madison, Wisconsin, a city committee is considering adopting a new program to reimburse government employees for giving up their parking spots and biking, walking or taking a bus to work.
On the midcoast of Maine, Jackson Laboratories provides busing for employees who live in surrounding communities 20, 30 or 40 miles away and don't want to or can't drive. (Jackson Labs also has multi-layered wellness program that includes traditional HRA-cost-discount features and incentives for healthy eating.)
And in the insurance industry, at a time of increasing competition and cost pressure, companies like Aetna and Prudential see telecommuting as a benefit for employees and a way to save money -- in fact, for both employee and employer, time is money, including time not spent commuting. The average American spends almost an hour commuting to work round trip.
At Prudential, more than three-quarters work from home some of the time. Since Mark Bertolini became CEO of Aetna in 2009, the company has expanded its telecommuting policy to offer the arrangement full-time to much of its workforce.
Employees from division managers to case managers can work from home if the nature of their job allows it and they meet performance standards. Today, some 40 percent of the company is based at home full-time, which according to Bertolini saves about $80 million annually in reduced real estate costs and helps keep voluntary employee turnover to just 3 percent.