Gut Check is a periodic look at health claims made by studies, newsmakers, or conventional wisdom. We ask: Should you believe this?
The Claim: Workplace wellness programs improve employees’ health and reduce the incidence of preventable disease.
The Backstory: These employer-based programs typically combine health questionnaires; biometric screenings for disease risk factors such as cholesterol and blood pressure; incentives such as gym memberships; smoking cessation help; and sometimes a “healthy workplace culture” (no junk food in vending machines or the cafeteria). The programs have become hugely popular in corporate America. According to a 2015 survey of 1,997 firms by the Kaiser Family Foundation, 49 percent of companies with fewer than 200 employees offer wellness programs; 81 percent of larger ones do.
The programs’ chief goal is to improve employees’ health. (Another is to control employers’ medical spending, but whether the programs do that is so controversial that STAT will leave that to another day.) The programs encourage and, often, incentivize healthy behaviors (follow dietary guidelines, be physically active, don’t smoke) and identify risk factors for serious disease. But while workplace wellness programs have been around for more than 20 years, there is a startling lack of rigorous evidence that they achieve their stated goals.
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“For a lot of things companies do, it’s all about being evidence-based,” said Karen Pollitz, a health care analyst at Kaiser. “But with workplace wellness programs, it’s faith-based: A telling finding from our survey is that most employers who offer wellness programs don’t collect data on whether they work.”
First Take: That data vacuum has been filled largely by wellness vendors themselves, whose $8 billion in annual revenue depends on customers (employers) believing their claims.
Vendors’ “research,” however, has made so many elementary mistakes as to inspire voluminous criticism. For instance, one vendor reported weight changes only for those participating in the wellness program, not for non-participants. Without a comparison group, before-and-after measures for participants can’t show that any changes were the result of the program rather than of random variation or something outside work. Another common ploy is to exclude from analyses employees who regained weight they lost, instead counting only participants who succeeded, said Al Lewis, a wellness program watchdog and president of Disease Management Purchasing Consortium International, a consulting company that advises employers on benefits programs.
Another vendor reported that “the average employee who lost weight” lost 12 pounds, without disclosing what percentage of employees lost weight. That’s like saying the average employee who got a raise got 5 percent but omitting the inconvenient fact that 99 percent got no raise at all. Analyses also routinely omit employees who drop out of a weight-loss or smoking-cessation program. It isn’t unusual for analyses to claim that if 100 workers began a program and 80 dropped out, the 10 who quit smoking mean the program had a success rate of 50 percent (10/20) rather than 10 percent (10/100). The wellness industry’s “modus operandi is to report only successes and not failures,” Lewis and colleagues wrote last year in the American Journal of Managed Care.
Comparing employees who choose to participate in wellness programs to those who don’t, as both vendors and many outside researchers do, can also be misleading. Such studies cannot show whether any health improvements in the first group are due to the programs or to the fact that participants are likely more motivated. Motivation is a crucial factor in whether someone loses weight or quits smoking.
Despite vendors’ and wellness supporters’ habit of stacking the deck methodologically, a 2010 review of scores of published studies found tiny if any benefits on many measures (an increase of fruit and vegetable consumption of 0.14 serving per day, for instance, or about one bite of banana) and little consistency on other measures. It concluded that any reported benefits “were small or modest in size and came from simple before-and-after studies that were susceptible to several potential sources of bias.”
These flaws in wellness studies have come under the microscope because the rosy claims are at odds with more objective research. A 2013 study by RAND is considered “the most comprehensive and authoritative,” said Kaiser’s Pollitz. “They didn’t have an axe to grind.” It found that program participants lost about 1 pound over the first three years, on average, compared to non-participants; by the fourth year, that edge had shrunk to about one-quarter pound. The programs seemed to help smokers quit, though the 73 percent of would-be quitters who were still smoking in the year after their wellness program had risen to 83 percent two years later. RAND found no effect on cholesterol reduction.
Second Take: The wellness debate has become bitterly polarized, so STAT sought common ground between one of the programs’ staunchest defenders, Ron Goetzel of Truven Health Analytics, and their harshest critic, Lewis.
There is some agreement, including on the industry’s shaky research methodology. In a 2014 paper, Goetzel and his colleagues wrote that it’s hard to get an accurate view of the programs’ effects because “many unsuccessful programs are not reported.”
It’s nevertheless clear that programs’ quality and effectiveness varies wildly: “There is a group of about 100 employers whose programs have really smart ingredients” and follow best practices, Goetzel said. “But thousands of other [employers] still don’t do wellness right” and “are not getting good health outcomes.”
He recommends employers create a “culture of health” — provide bike racks, cyclist showers, and standing desks; form lunchtime walking clubs; stock vending machines and the cafeteria with healthy (maybe free) choices; make tobacco-cessation courses and medications free. Be wary of programs based on “pry, poke, and punish” — questionnaires, mandatory screenings, higher insurance costs for not participating. And while employees often welcome financial incentives to participate, such bribery doesn’t work in the long run, according to a study this week.
Offering his own olive branch, Lewis holds out Florida-based wellness vendor US Preventive Medicine as an exception to his criticism. Based on an analysis of insurance claims, he said, USPM reduced the incidence of asthma, cardiac events, chronic obstructive pulmonary disease, congestive heart failure, and diabetes among its customers. “The numbers add up and [disease] events definitely declined,” said Lewis. USPM put together “all of the items” that go into best practices, he said, including individualized health coaching and high employee participation.
Asserting that workplace wellness programs cannot improve employees’ health is a step too far. And just because the programs overall have not lived up to their hype doesn’t mean they all fall short. “Workplace wellness programs are like snowflakes,” Kaiser’s Pollitz said. “If you’ve seen one, you’ve seen one.”
The Takeaway: Workplace wellness programs have the potential to improve health but vanishingly few have done so.