A RAND Report on “Workplace Wellness” Is Quietly Buried for Five Months—Why?
Health Beat, 6/5/13
By Maggie Mahar
Did you know that in the U.S. “Workplace Wellness” has become a $6 billion industry? That’s how much employers pay vendors who sell workplace wellness programs designed to encourage employees to lose weight, lower their cholesterol, or stop smoking..
Today, firms lay out an average of $521 per employee per year on ‘wellness incentives’ such as gift cards for employees who shed pounds. That is more than double the $260 they spent in 2009 according to a recent survey by Fidelity Investments and the National Business Group on Health.
At first blush, this sounds like progress: Enlightened employers are doing their best to encourage employees to take care of themselves. There is just one catch: we have no hard evidence that these programs either improve health or lower health care bills.
Even Bruce Elliott, manager of compensation and benefits at the Society for Human Resource Management, the largest professional organization that represents benefits managers, is concerned. As employers chase Wellness, “the one things that does worry me is the utter lack of metrics and really, the utter lack of thought” Elliott recently told Bloomberg News, pointing to the “herd mentality” that seems to have overtaken the idea of “workplace wellness.”
A Rand Report Appears Briefly Online—and Disappears
Two weeks ago, Reuters broke a story about a RAND report on Wellness programs that was supposed to come out last winter. The report was mandated by the Affordable Care Act, and RAND delivered the analysis to the U.S. Department of Labor and the Department of Health and Human Services last fall.
According to Reuters’ reporter Sharon Begley, “Two sources close to the report expected it to be released publicly this past winter.” She added that “Reuters read the report when it was briefly posted online by RAND before being taken down because the federal agencies were not ready to release it, said a third source with knowledge of the analysis.”
RAND had collected information about wellness programs from about 600 businesses with at least 50 employees and analyzed medical claims collected by the Care Continuum Alliance, a trade association for the health and wellness industry.
Reuters revealed that the results were disappointing: “The programs that try to get employees to become healthier and reduce medical costs have only a modest effect. Those findings run contrary to claims by the mostly small firms that sell workplace wellness to companies ranging from corporate titans to mom-and-pop operations.”
Perhaps it should come as no surprise that just as most studies that “prove” the benefits of new drugs and medical devices are overseen by the companies that peddle the products, “most employers leave the calculations showing that Wellness programs reduce medical costs to the companies that sell them the programs, or to consultants, opening the door to creative accounting.
“Tom Emerick, president of Emerick Consulting and former vice president of global benefits at WalMart is one of those skeptics. He told Reuters: “Many of the vendors reporting savings are making it up.’”
RAND Report Surfaces
At the very end of May, the RAND Report was finally made public.
The “Preface” attempts to put a cheerful spin in the results: “our case studies corroborate the finding of positive effects of worksite wellness programs on health-related behavior and health risks among participants.”
But if you actually read the 199-page study, it confirms what Reuters had reported about “modest effects.”
- Dubious savings: “We estimate the average annual [savings] to be $157, but the change is not statistically significant.”
- “We do not detect statistically significant decreases in cost and use of emergency department and hospital care” as a result of the programs.
- “Wellness participation was not associated with significant reductions in total cholesterol levels.”
- Minimal Weight Loss: Over a period of four years employees who participated in weight loss programs lost an average an average of 1 pound a year for 3 years, and three-tenths of a pound in the fourth year. Over those four years, presumably many lost more than one pound, gained it back, then lost it again.
- We know that “yo-yo” weight gain and weight loss is not good for anyone’s health.
We also know that ninety-five percent of obese patients who remain in medically supervised treatment regain whatever pounds they lose. Physicians don’t know why. They have not been able to figure out how to help these patients because medical science has not yet sliced through the tangle of genetic, metabolic, social, psychological and environmental factors that cause obesity.
– “There is some evidence that smoking cessation programs have positive effects on reducing or stopping smoking in the short term.” But RAND noted that while “peer-reviewed” medical research “indicates that financial incentives may attract individuals to enroll or participate in smoking cessation programs and increase initial quit rates, but generally they do not achieve long-term behavior change. (Cahill and Perera, 2011; Osilla et al., 2012)
– RAND concluded that “while incentives to participate in wellness programs can reduce weight and smoking rates and increase exercise “the size of these effects is small and unlikely to be clinically meaningful
When Corporations “Play Doctor”
Reuters added that some experts not involved with the new report say even the modest benefits RAND found need qualification.
“The strongest predictor of whether someone will lose weight or stop smoking is how motivated they are,” said Al Lewis, founder and president of the Disease Management Purchasing Consortium International, which helps self-insured employers and state programs reduce healthcare costs. “Since the programs are usually voluntary, the most motivated employees sign up. That makes it impossible to credit the programs with success in smoking cessation or weight loss rather than the employees’ motivation.”
Companies risk putting workers through unnecessary screenings and invite excess treatment that can be both costly and harmful, Lewis adds. A former consultant to health plans and employers who used to preach the benefits of wellness and disease management. Lewis became one of their most prolific critics after he says he realized the hoped-for savings never materialized.
“You have to identify and medicate tons and tons of people to prevent one or two from getting sick,” he told Business Week. Corporate HR departments are “playing doctor. They’re doing things they don’t really know how to do.”
For example, appetite suppressants have a minimal effect in helping obese patients according to Dr. Robert Lustig of the Division of Pediatric Endocrinology at the University of California, San Francisco. “These medications become less and less effective after just 4 months,” Lustig explains. This is not because of a lack of compliance on the part of the patient, but rather due to leptin resistance, which persists even in the face of pharmacotherapy. When appetite suppressants foil one set of receptors, another mechanism kicks in, and hunger returns.”
Other Studies Support the RAND Report
If the RAND study were the only research suggesting that Wellness in the Workplace is being hyped, I wouldn’t be so quick to suggest that we’re looking at another huge instance of “Money-Driven Medicine”
But Reuters reports that the studies are piling up: “ This year researchers at the University of California conducted an analysis of dozens of existing studies of workplace wellness programs at the behest of the California state senate. Based on gold-standard studies, similar to those that evaluate a new drug, participating in work-based wellness programs does not lower blood pressure, blood sugar or cholesterol and rarely leads to weight loss, said Janet Coffman, a health policy expert at the University of California, San Francisco, Institute for Health Policy Studies.
“Even in studies that found statistically significant weight loss, it was not always sustained,” she added.
“Similarly,” Begley writes, “after years in which vendors and others claimed that the programs return $3, $9 and more for every $1 invested, rigorous studies have found the opposite, providing more support for Rand’s findin
Earlier this year, a study published in Health Affairs examined the effectiveness of a program put in place by BJC HealthCare, a hospital system based in St. Louis, Missouri, that tied employees’ eligibility to participate in the system’s most generous health plan with participation in a wellness program. intervention, which began in 2005, was associated with a 41 percent decrease, relative to a comparison group, in hospitalizations for conditions targeted by the wellness program but with no significant decrease in other hospitalizations. That was the good news.
But in the end economist Gautam Gowrisankaran of the University of Arizona and colleagues found that “employees who participated in the wellness program were hospitalized less often for illnesses such as heart disease and diabetes. But their overall spending did not decrease.” The program “did not save money for the employer.”
The main reasons, said Gowrisankaran, were that employees who fill out company surveys assessing their health risks (“what is your blood pressure?”) or get health screenings at company-sponsored health fairs (“you better see a doctor about that”) led to more office visits and medication use. In-patient costs fell $22 per employee per month, on average, but other costs rose $19. The program cost $500,000 per year.
But did employees benefit? The authors conclude that it is hard to say: “ “It has often proved difficult to find sustained changes in health behavior in response to financial incentives.”
Money may not motivate people as much as many assume. As noted, a patient must want to improve his health. But education can help. The authors write: “It may be that the screening process” that was part of the program, and the health pledge led to better self-management, increased health literacy, and better medical care among beneficiaries already being treated for targeted conditions.”
On the other hand, we cannot rule out the possibility that, as Lewis suggests, some employees will be over-diagnosed, over-medicated and over-treated. This is of particular concern when patients are told that they should lower their cholesterol to the levels that pharmaceutical companies tell us are healthy. Few employers understand the risks that statins pose for many patients.
Long-term Wellness Programs Might Help . . . . But –Why I Have Reservatioins about Workplace Programs
That said, Gowrisankaran et. al. write that “institutional support for the program may have also spurred a “culture of health.” It is also possible that simply asking employees to record biometric information may have spurred changes in behavior. . . . For these reasons, expanding wellness incentives may be in the interest of both employers and employees.
Finally, this was only a two-year study. Future research may show that over the long term, workplace wellness programs can save money.
But I continue to have reservations about employers “playing doctor.” Even with the best of intentions, they often don’t know what physicians know. For instance, for truly obese patients, dieting is not likely to help. Even if they are compliant, they will regain the weight. To be healthy, it is far more important that they exercise, even if they don’t shed pounds. How many employers would reward a patient for exercising, even if he continued to gain weight?
In addition, employers often do not understand the metrics that they are using. BMI (body mass index) can be over-used as a measure of whether someone needs to lose weight. As noted there is much controversy over what constitutes a healthy cholesterol level and whether “bad cholesterol” actually causes fatal heart attacks and strokes or whether it is simply a “marker.”
Third-party “vendors” or “consultants” who sell these programs are, quite naturally, focused on profits. That goal may conflict with disclosing to employers how difficult it is –even for physicians — to help patients lose weight, cut back on excessive alchohol consumption, or lower their blood pressure. If vendors disclosed that the evidence that workplace wellness reduces health care spending is at best, thin, they would have few customers. Thus, they have ever incentive to exaggerate results.
These are reasons why I would rather see ‘workplace programs” replaced by public health programs—run by nutritionists, physical therapists, and physicians who specialize in helping patients with additions.
Finally, as the post below suggests, when employers begin using financial carrots and sticks to motivate employees to become healthier, this is a very real danger that they will wind up discriminating against sick employees who, through no fault of their own, physically are not able to meet the employer’s goals. In the worst-case-scenario, a “wellness program” becomes a way to shift costs to sick employees while creating a culture of “blame and shame.”