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Do wellness initiatives actually save health care dollars?

March 28, 2013

I think this is a very appropriate question that needs to be asked, especially in light of the recent decision by CVS Caremark to demand that their employees show up to a doctor for an annual WebMD Wellness Review and submit to tests for blood sugar, blood pressure, cholesterol and body mass and body weight or pay a penalty in the form of a $50 a month raise in their insurance premium. (Sign the petition here!)

But do wellness programs really save companies money?

Safeway has had a wellness initiative in place since January 1, 2009. To date “Safeway has not been able to show yet that its wellness focused approach to reducing health care costs is actually working.”

The program sounds similar to what CVS has planned:

Safeway is giving non-union administrative employees up to $800 in rebates on health insurance premiums. The program, called Healthy Measures, rewards employees for remaining within limits on four common medical risk factors — smoking, obesity, blood pressure and cholesterol.

This isn’t as bad as what CVS is planning — at least Safeway isn’t penalizing employees by raising their premiums if they don’t “conform” to the medical community’s idea of what constitutes “health.” I will concede that smoking, high blood pressure, and high cholesterol can lead to adverse health consequences (as far as I’m concerned, the jury is still out on whether or not “obesity” is as big a risk factor as the medical establishment would have us believe). Considering that there still isn’t a sustainable way to change one’s weight permanently, I highly doubt that Safeway’s employees will be able to stay within limits on weight for very long.

Seventy percent of health-care costs are linked to behavior such as smoking, eating too much of the wrong things and not getting enough exercise, says Safeway Senior Vice President Ken Shachmut.

Safeway is following a policy of “health re-engineering.” The company’s goal is to give individuals more control of their health dollars and to focus more on prevention than on treatment.

In addition to the Health Measures program, Safeway offers employees many ways to get and stay healthy. Wellness measures include:

  • A state-of-the-art fitness center near Safeway’s Pleasanton headquarters.
  • Free lunch at the company cafeteria for every eight visits to the gym.
  • Subsidized cafeteria, which offers lots of vegetarian fare.
  • Portion size, calorie count, cholesterol and fiber count posted for all prepared meals in the cafeteria.

These are all good ideas that can lead to improved metabolic health for employees that take advantage of them, but they may not lead to weight loss, and penalizing an employee who does all of the above, but doesn’t lose weight, rather negates the idea behind the whole program: improving employee health and thereby lowering medical costs.

According to this article in MedPage Today, these wellness initiatives can’t show whether they reduce medical costs or not.

It is not uncommon for employers these days to make adjustments to copayments and deductibles, based on employee engagement. But the reality is that most employers seldom have the means to measure the cause and effect relationships. They’ve heard anecdotes, alleged success stories, but have not been given data that truly link the impact of their incentives on medical outcomes. [emphasis mine]

That’s because it is very complicated to bring together all of the necessary data for an employer to be able to measure whether a certain wellness program has truly had an impact on medical outcomes.

Take the case of Safeway, for instance. There have been many reports about Safeway’s success in reducing the trend of health inflation, but when one looks under the covers, the company has many programs in place, none of which are integrated. In addition, there has yet to be published any substantial data to support the notion that their programs have reduced the incidents of chronic disease or utilization of services.

There are many employers who will make investments in onsite clinics, wellness screenings, fitness devices, and spend enormous amounts of money on these initiatives. Without adequate measurement of how engaged a consumer really is, both at home and at work, and accurately linking this data back to clinical outcomes, any claims of success at cost reduction are guess work.

If these companies don’t know that the programs they’re initiating are actually going to work, why aren’t they doing the necessary work to integrate the program participation with actual outcomes? Do they not want to know that these initiatives may not be working as well as they were told they would? Would they rather just go with the flow, keep believing the propaganda that “thin = healthy, fat = unhealthy” and penalize anyone who doesn’t fit their cookie-cutter mold?

Whatever happened to basing decisions on evidence? Why don’t they implement the program on a small scale and test to see if it actually works before rolling it out for full implementation? Why do people and corporations think that just because something sounds like a good idea, they will implement it without testing it, without seeing if it really works?

While these programs may improve employee health, they can’t prevent heart disease, hypertension, or type 2 diabetes (all of which have genetic determinants). They can find the people who have these diseases, they can catch the diseases early, they can help an employee implement changes to diet and exercise in order to help manage them, but they can’t prevent them, only postpone them in most cases. And this detection and treatment costs money.

Without a way to track an employee’s health before the program started, how it changed (if it changed) while on the program, and correlate those numbers with the amount of healthcare used during both stages, there is no way to know how well these programs work. Not to mention that whoever is going to do the tracking/correlation would have to have some way of knowing that the employees being tracked were actually being consistent with their diet and exercise habits, as well whatever medical treatment might have been prescribed. There goes your privacy right out the window — things that should be between you and your doctor are now the business of your employer, your insurance company, and whoever is tracking all the information gathered in order to see if the program really works, all in the name of “reducing health care costs,” without knowing if that reduction will really happen.

Whether you’re talking about Safeway or CVS, these programs are punitive in nature, a carrot-and-stick approach to mandating “health” — something that isn’t a moral imperative for anyone.


5 Comments leave one →
  1. March 28, 2013 5:08 pm

    Great job, Vesta44, reporting on these discriminatory practices—and kudos for calling into question the underlying, insupportable, pseudo-scientific assumptions and biases (including sizeism and fat stigma) on which corporations (e.g. CVS and Safeway) attempt to justify intrusive programs that have very little to do with “improved” employee health outcomes and have MUCH to do with effectively manipulating public impressions and managing (distorting) public relations messages about their *concerned*, altruistic, employee-centered corporate priorities.

    Mostly, these programs use powerful corporate strategies and advocacy to marshall socioeconomic support for healthism.

    “Healthism” as defined by Jan Henderson (“The Health Culture”):

    “Healthism is the idea that a correct lifestyle is the key to avoiding disease and that each individual is personally responsible for his or her health (the environment and other corporate externalities be damned)…[even though] modifying behavior has less influence on overall health than genetics, social status, economic inequality, and environmental degradation. Understandably, that’s not a message that is welcomed — and it’s not just those with a financial interest in the status quo who oppose it. With so much uncertainty in the world today, ordinary citizens prefer to hold the comforting belief that their health is something they can control.”

    In other words, corporate programs such as these (and many others) are part of a much larger cultural movement seeking to dominate health discourses and thus to socially control the distorted ways in which people conceptualize “health”. These “wellness programs”, for instance, 1) keep framing “health” issues as problems for individual to solve, 2) continue analyzing health/medical outcomes in relation to personal responsibility, 3) maintain media/corporate/institutional focus on “risk prevention” as a “natural” byproduct of lifestyle choices, 4) divert attention away from social determinants of health and corresponding health disparities (such as unemployment, low pay, unsafe housing, inadequate transportation, racism, fat stigma and discrimination, food insecurity, bullying and violence in schools and neighborhoods, widespread socioeconomic uncertainties, environmental toxins in air and water, and so forth.)

    When Individuals cannot control these social determinants of health—their resulting health inequities leave them feeling helpless, scared or powerless in response—and therefore these worried people tend to grab hold of the loudest and most convincing messages they keep hearing everywhere—from morning talk shows to magazine articles to daytime medical expert panels, etc—the repeated, uncomplicated messages which assure us that each one of us, as an individual, can CHOOSE to take personal responsibility for our health, each of us can make a huge difference in improving our own personal health outcomes by making a simple commitment to follow a basic, healthy lifestyle.

    Maybe we NEED to believe that our personal choices, that our behaviors and efforts will have much GREATER impacts on our health outcomes—and will result in much greater health improvements compared to any “vague” or dubious influences which might arise from “social factors” or determinants.”

    This self-deceiving, yet strong individualist belief—(in the power of the individual to battle and conquer his own health adversity with enough commitment, effort, faith, self-esteem, planning, dedication and learning)—may be the only belief left on which to cling for hope, when jobs become scarce, when savings have dwindled, when housing consists of living in one’s car, when all that’s left is his commitment to daily walking in a decent pair of shoes, the shoes reassure him, again, his lifestyle holds the key to his health and longevity. Thus, the fate of his future health remains in his own chosen lifestyle—in his decision to walk or run.

    • March 29, 2013 10:50 am

      All of these estimates come with a caveat, which are present in that first study, and which vesta mentioned in her piece:

      Some empirical studies attempt to estimate the return on investment for employer wellness programs more systematically, but shortcomings in this literature leave the question unresolved.16 In particular, most studies lack an adequate comparison or control group, and are thus not able to account for possible unobserved variables or alternative pathways that might be responsible for observed differences in costs between wellness program participants and nonparticipants (rather than those differences’ being attributable to the wellness program itself). This leaves open the possibility of selection bias—for example, if the healthiest employees were most likely to enroll in voluntary wellness programs, a comparison of participants and nonparticipants might suggest that the programs are improving health more than they really are.

      Low response rates, inexact case-control matching, and potential publication bias (studies finding high returns may be more likely to be published) also call into question the evidence of high returns. In addition, Sean Nicholson and colleagues show that common methods used by employers to calculate costs and benefits of health-related investments might not reflect the true impact of these programs.17 These shortcomings mean that even the limited evidence available might not be robust or generalizable.

      That first study is a meta-analysis, so it probably includes most of the other studies you cited. Although it overall shows a nice return on investment, they include both controlled and non-controlled studies:

      Studies with random assignment to treatment and control groups or with carefully matched comparison groups are perhaps the most persuasive. In a typical randomized study, employees were randomly assigned to the program and control group, or in several cases to different intensities of the wellness program. In matched comparison studies, the comparison group typically comprises age- and sex-matched nonparticipants from the same employer identified through a retrospective review of participation.

      And when you look at the table comparing the cost savings, as divided by study type, you’ll notice that most of the studies found only slight improvements in cost savings. The following are a comparison of the nine studies (the last three use the same control and different experimental groups) and the rate at which healthcare costs rose or fell at followup (T is the treatment group, C is the control group):

      T = 1.9
      C = 2.4

      T = 0.8
      C = 0.9

      T = 1.2
      C = 1.4

      T = 2.7
      C = 4.9

      T = 0.8
      C = 1.1

      T = 1.3
      C = 1.4

      T = 0.9
      C = 0.9

      T = 0.6
      C = 0.9

      T = 0.7
      C = 0.9

      Only two of the studies show a truly significant difference in costs. I would like to dig deeper and see what these studies actually look like, but the link to the table that outlines those studies is broken. But this raises more questions, in my mind, than it answers. And finally, there are significant limitations to the study, which you can read for yourself. But this is hardly a ringing endorsement for cost savings.


  2. Lauren C. permalink
    March 30, 2013 1:07 am


  3. April 9, 2013 3:54 pm

    Awesome post! Great analysis that should be made mandatory reading for the heads of these and other companies!

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