When Idaho’s Boise School District receives the workplace wellness industry’s highest award Wednesday at a celebration in Atlanta, it is expected to be applauded for helping its 3,000-plus employees and their families improve their health and reduce their risk of illness.
It is “an exemplary program,” said Dr. James Fries, an emeritus professor of medicine at Stanford University and member of The Health Project, an industry-sponsored group that makes the annual award. Program participants, he said in an announcement this month, “showed improvements in health behavior,” helping Boise save money on medical costs.
Data collected by the company that sold Boise the wellness program and trumpeted the “Koop Award,” however, cast doubt on that claim. More key measures of health deteriorated than improved. Self-reported quality of health got worse. And health care costs jumped around in a way that suggests any changes were due at least in part to random fluctuations and possibly employee turnover, not any benefits of the wellness program.
The award “represents a troubling new precedent, a precedent that threatens the credibility of the entire industry,” said longtime wellness industry skeptic Al Lewis, CEO of employee health care literacy company Quizzify. “This is the first time a vendor’s data actually showed that a wellness program has gone over the bright red line of harming employees, and raises questions about how effective workplace wellness programs are when the industry’s top award goes to one like this.”
This would not be the first time the Koop Award, named for the late US Surgeon General Dr. C. Everett Koop, stirred controversy. Employees in the wellness program that won in 2015, for instance, collectively achieved a lower reduction in smoking than the national average. More gained weight than lost, more raised their total cholesterol level than lowered it, and more had higher blood glucose levels after participating in the wellness program than before.
Such cases reinforce a growing recognition among experts that wellness programs — which constitute an $8 billion a year industry — “don’t lead to any visible results,” Stanford’s Emma Seppala recently wrote in Harvard Business Review. “At best, these initiatives are nothing more than lip service or PR. But at worst, they actually cause more stress.”
Companies that sell the programs to employers reject that charge, at least when it comes to their own efforts. “I agree that there is some real crap out there being sold under the guise of wellness,” said Dr. Steven Aldana, CEO of WellSteps, the Salt Lake City-based company that sold the program to the Boise schools and collected data on its effects.
But WellSteps is different, he said — so much so that the company guarantees employers will save more in health care costs after three years than the program costs them.
The Health Project cited Boise’s use of apps for mobile devices and gains in exercise, fruit and vegetable consumption, days of quality sleep, tobacco and alcohol use, and in mental health-related outcomes.
Aldana questioned the motivation of critics like Lewis. “Some people are just interested in picking fights, not looking at the data,” he said.
In the Boise schools, according to data from WellSteps, self-rated quality of health fell from an average 7.96 (on a scale of 1 to 10) at baseline to 7.88 after one year of the program. The average ticked up after two years to 7.92. That left participants’ health slightly worse off, in their own estimation, than before the program began.
More objective measures are less clear. WellSteps reported changes in standard measures such as BMI, blood pressure, and cholesterol levels after one year. All of those bounce around, so the significance of just two measurements at the start and end of the study period is limited. But that aside, the numbers did not show much benefit from the wellness program.
The average BMI of the 903 people who started out with a normal weight rose 0.2 BMI units. That of the 738 overweight people rose 0.1. The average BMI of the 683 obese participants decreased 0.3. That works out to a gain of 254 BMI units across the groups compared to a loss of 204 BMI units.
Similarly, there was an overall increase in systolic blood pressure (the first number). Average cholesterol levels rose for the 1,434 people who started with normal levels but fell for the 907 people whose levels were borderline or put them at high risk of heart disease or stroke.
Kellie Wirth, a Boise wellness consultant who was involved in the district’s program before it hired Wellsteps, called the biometric data “indeed disappointing.” Concerns about whether they show a meaningful improvement in participants’ health from the wellness program “are valid,” she told STAT.
Even the apparent benefit in the dangerously high groups for both cholesterol and blood pressure is in doubt. People naturally migrate into and out of different categories of health risk, health care delivery researcher Dee Eddington showed in years of research at the University of Michigan. Nearly half of people in a high-risk group will move to a lower-risk category on their own, absent any program (workplace or otherwise) nudging them to do so.
“It’s regression to the mean,” said Michael Lavine, professor of statistics at the University of Massachusetts Amherst who examined the WellSteps data at STAT’s request. “It happens without any outside intervention.”
Aldana acknowledges that. “In just one year, many employees will move from one [risk] group to the other,” he explained, “even though they did not participate in any wellness programs or any intervention whatsoever.” That movement, he continued, “reflects changes in health risks that occur naturally,” making it possible that some high-risk people become low risk “even though your program didn’t do anything.”
One hint that that might be true comes from the behavior changes that participants reported. They ate an average 0.16 more fruit servings and 0.11 more vegetables servings per day after two years in the wellness program, and exercised three more minutes per day. That seems too small to cause even the benefits WellSteps claims, but “even one more bite of a banana” and a few more minutes of activity “are meaningful changes in behavior,” Aldana said.
The components of the wellness program that WellSteps sold the Boise schools are fairly standard. They include a questionnaire-based health risk assessment, a biometric screening (basic things such as blood work, height, weight, and blood pressure), activity reports, and a smoking-cessation program.
Participation, which came with financial inducements such as lower copays for doctor visits, was voluntary, and only 66 percent of employees signed on in the program’s first year, 2011. Participation rose to 81 percent in 2014 as financial incentives increased — often a sign that employees are signing up not because they like the program but for the reductions in monthly insurance premiums and deductibles.
When critics say the program caused harm, they mean not only the drop in self-reported health and the overall worsening of systolic blood pressure, cholesterol, and BMI. They also point to the annual screening the program requires regardless of someone’s health care needs and whether medical guidelines say such screening is recommended.
Aldana acknowledged that annual screening of “an entire employee population” is not recommended and “always [has costs] greater than any possible savings that might come from reduced chronic disease incidence or premature death.” For many people, especially those with normal readings, blood glucose can safely be tested every three years, cholesterol every five years, and blood pressure every other year.
But although WellSteps advised the Boise school district against annual screenings, Aldana said, “there is a limit to what an outside wellness vendor can do.”
The school district did not respond to STAT’s questions about its wellness program.
While more frequent screenings might seem benign, they can flag as problems conditions that aren’t. Sandy Wargo, 57, a retired counselor and assistant principal, considers herself healthy and active and loves the Boise wellness program (which is open to retirees), especially the informational packets about chain restaurant menus and the team competitions that encourage exercise.
But an annual screening determined that her HDL cholesterol was too low; it was “starred” as something she should follow up with her doctor. Wargo did. “She told me it’s so frustrating that they starred this because my total cholesterol was 98” — very low, she said. But the cookie-cutter approach might, in the hands of another doctor, have led to Wargo’s being prescribed drugs unnecessarily.
It may be that The Health Project did not have anything better to honor with the Koop Award. It received only seven applications. With some 70 percent of large employers offering a workplace wellness program, that means the reviewers selected from a minuscule percentage of them.
In the past, said Ron Goetzel, president and CEO of The Health Project, the organization has received as many as 21 applications for the award, but the application process, including the requirement that wellness programs submit statistics and rigorous data analysis, has become so strict that fewer programs want to go through the process.
“We’re not looking for perfection” in wellness programs that apply for the Koop, he said in response to critics. “We would look askance at an application that said everything went exactly right.”