It depends on whom you ask. Managed Care asked two experts: “Can a wellness program help decrease the incidence of and/or lessen the severity of diabetes or prediabetes?”
No! argues Al Lewis. Lewis, a critic of the programs, is the CEO of Quizzify, a leading employee health care education company, and author of Why Nobody Believes the Numbers: Separating Fact from Fiction in Population Health Management.
Yes! rebuts Harris Allen, PhD. Allen, a defender of wellness, leads the Harris Allen Group, an independent consultancy founded in 1998 to promote stakeholder value and sustainability in health and health care.
Allen is also a senior lecturer on health care leadership at Brown University.
Wellness Programs Will Not and Cannot Prevent Diabetes
Conventional workplace wellness has not worked, by any measure. Partly, that’s because only a small percentage of people who quit smoking or lose weight succeed in the long term even when they are self-motivated. And employers cajoling employees is the opposite of self-motivation. Also, employers spend surprisingly little money on hospital admissions related to conditions that wellness programs are designed to address, compounding the poor economics of medicalizing the workplace.
Prediabetes risk factor reduction is the poster child for the failure of workplace wellness. It specifically has failed in three instances where success would have seemed most likely: a health insurance company spending $500 per employee, a wellness vendor itself, and an award-winning wellness program.
Take the first instance. Aetna thought workplace wellness could prevent diabetes and prediabetes. To that end, it launched a program for 500 of its own employees in October 2013. In practice, however, Aetna’s study group didn’t outperform its control group, despite Aetna spending an industry-leading $500 per participant fee, as outlined in a December 2015 study published in the Journal of Environmental and Occupational Medicine.
Then, there are the wellness vendors themselves. One, Vitality, couldn’t reduce the weight of its own employees. At least that was an honest admission. Now, examine the industry’s allegedly most successful program by visiting the website that I write for, www.theysaidwhat.net, and search for Navistar. Navistar originally claimed an industry-leading 400-to-1 ROI. Then their ROI inexplicably plummeted to 40-to-1 before equally inexplicably bouncing back to 400-to-1. Questioning that accounting would put you in good company: While Navistar was “doing wellness,” it was also “doing fraud.” The Dow Jones dropped them and the stock exchange delisted them. They also wrote off $4 billion in fake shareholder equity, fired successive CFOs, and sued their auditor.
Next, consider McKesson. As described in Employee Benefit News, McKesson’s program won the 2015 C. Everett Koop National Health Award. Yet BMI and glucose increased. If an award-winning company can’t reduce employee diabetes risk factors, who can?
Losses and more losses
Even the hypothetical scenario presented by the Health Enhancement Research Organization and Population Health Alliance to justify wellness (“Program Measurement and Evaluation Guide: Core Metrics for Employee Health Management”) actually shows losses—a vendor charging $18 per employee per year to save only $12 in claims. Substituting your own program fees for that hypothetical $18 could even increase those losses. And note their caution that utilization declines only in wellness-sensitive hospital admissions. They freely admit other medical claims increase, but they don’t count those increases against the $12 in gross savings.
If wellness worked in practice, there would have been a steady and dramatic reduction in admissions related to heart disease, diabetes, and other cardiometabolic problems paralleling this century’s explosion of wellness programs. Instead, the admission rate for the commercially insured population (largely exposed to wellness) has flatlined on an absolute basis. On a relative basis, the exposed population has slightly underperformed the remainder of the population that has no exposure to workplace wellness. In other words, wellness-sensitive admissions haven’t declined faster than admissions as a whole.
Workplace Wellness and Diabetes: An Approach Coming of Age
Some 86 million Americans with prediabetes progress toward diabetes at a rate of 5% to 10% per year. The CDC Diabetes Prevention Program (DPP), a randomized clinical trial based on the NIH-funded Diabetes Prevention Program, has shown that this rate can be reduced significantly by a structured lifestyle intervention focusing on physical exercise and diet and by prophylactic metformin treatment.
Subsequent work has paved the way for deployment of the DPP and like-minded interventions in work settings. For instance, in an initial test, researchers at Brigham Young University demonstrated that the DPP can be successfully implemented in the workplace.
Moreover, to mitigate the structural difficulties of implementing large-scale lifestyle enhancement programs and concerns about metformin side effects, University of Michigan researchers have developed risk-stratification models. Likewise, a 12-month worksite-based education program can significantly improve diabetes knowledge and self-efficacy, even in a workforce with well-controlled diabetes, as demonstrated in a 2015 study published in Population Health Management.
The Validation Institute, which has been critical of workplace wellness programs, recently publicized a claims-based audit of prepublished data on diabetes that documents workplace wellness effectiveness. Among the institute’s “validated organizations” is US Preventive Medicine (USPM), a leading wellness services provider. The institute’s website cites USPM’s “sustained … reduction(s) in wellness-sensitive medical events” across several major diseases—including diabetes—that “significantly outpaced the much smaller national decline in these events.” While the institute’s website does not furnish the details—in sharp contrast to that provided on other similar entities’s websites like the Koop Award program—this development helps to dispel the notion that workplace wellness is incapable of sustained reductions in diabetes burden.
Not all studies of workplace programs have yielded positive results. Consider a randomized controlled trial of three self-management interventions for employees with diabetes. The results, published in Population Health Management in 2012, show that at one year, neither use of a personal digital assistant handheld device, participation in a six-week chronic disease self-management program, nor the two combined, led to greater reductions in lost productivity costs than the usual care arm.
What accounts for the uneven results? One explanation is scope. Compare the information-imparting focus of self-management interventions with the information → knowledge → activation → sustainment progression that USPM promotes with its integrated suite of “high tech, high touch” population health services.
Clearly, all that passes today for workplace wellness is not geared for success. Kaiser’s Employer Health Benefit Survey reports that while 74% of firms offering health benefits in 2014 included wellness programs, there is variation in the services they provide. The Rand Corporation reports that only 12.9% of wellness programs can be characterized as comprehensive.
The question is not whether workplace wellness can exert an impact—it can—but how best to design a program so it will. Researchers at HealthPartners Institute have identified five elements defining comprehensiveness: health education, supportive physical and social environments, program integration into the organization’s structure, linkages to related programs, and worksite screening programs. Comprehensiveness, however, is just one of nine dimensions in their framework. Their premise is that the more that interventions advance on all these dimensions, the better the chances of success.
Ultimately the will to make the investments that move the needle is key. Evidence-based workplace health promotion and disease management programs continue to present opportunities for employers to reduce the incidence and severity of diabetes. Elsewhere I have argued that the workplace wellness successes of leading employers offer much grist for providers, payers, and other stakeholders as the latter grapple with their own value/sustainability challenges. These gains on diabetes further attest that it is very much in our collective best interest to promote well-executed workplace wellness.