Wellness Programs Aren’t Working. Three Ideas That Could Help.

You’d be forgiven if, after reading last month’s Health Affairs, you came to the conclusion that all manner of wellness programs simply will not work; in it, a spate of articles documented myriad failures to make patients healthier, save money, or both.

Which is a shame, because – let’s face it – we need wellness programs to work and, in theory, they should. So I’d rather we figure out how to make wellness work. It seems that a combination of behavioral economics, technology, and networking theory provide a framework for creating, implementing, and sustaining programs to do just that.

Let’s define what we’re talking about. “Wellness program” is an umbrella term for a wide variety of initiatives – from paying for smoking cessation, to smartphone apps to track how much you walk or how well you comply with your plan of care, and everything in between. The term is almost too broad to be useful, but let’s go with it for now.

When we say “Wellness programs don’t work,” the word work does a lot of, well, work. If a wellness program makes people healthier but doesn’t save lives, is it “working”? What if it saves money but doesn’t make people healthier?

To be thorough and appropriately critical, let’s go with the following definition:  a wellness program “works” if it improves the health of a population and reduces health care costs for that population. Full stop.

Unsurprisingly, this high bar doesn’t leave room for a lot of success. One of the Health Affairs studies found a 12% reduction in hospitalizations and a $22.20 per member per month decrease in inpatient health claims cost – but also a $19 per member per month increase in non-inpatient claims costs (which doesn’t include the wellness program costs, which were substantial). Clearly, it’s a good thing that patients are spending less time and money in hospitals – something we should celebrate! – but without the resulting decrease in costs, this doesn’t  fit our definition of “working.”

Another found that Florida’s, Idaho’s, and West Virginia’s wellness incentive programs for Medicaid members were unsuccessful at engaging the population. Two shocking stats from the study: of Florida’s entire Medicaid population, from early 2006 to July 2011, “only two enrollees earned credits for participating in a smoking cessation program…” and “only two enrollees earned credits for participation in an exercise program.” These programs utterly failed to engage their patient populations in a meaningful way.

So, what’s going on? Are all wellness programs doomed to fail?

Maybe, but I am much more bullish on their prospects. First, let’s concede that “wellness program” is an overly-broad umbrella term that includes everything from “Hey employee, here’s $20, go join a gym” to the most sophisticated, targeted interventions; the failure of one wellness program says little-to-nothing about whether another program will succeed. It’s also instructive to remember that many of these studies started in 2005, which, in technological terms, was a lifetime ago (need proof? Check this out)—and there are reasons to believe that technology may be a missing link in making wellness work.

What else may help us crack the code? Drawing on behavioral economics and networking theory, the following components hold promise:

Turn Wellness Into a Game: Provide Feedback Instantly. A recent Wall Street Journal article discussed popular consumer items like the Jawbone UP and Nike FuelBand – essentially, tricked-out pedometers. It’s a bit fawning, but cites a JAMA study in which people with pedometers took an average of 2,491 more steps per day (almost an extra half hour of walking). Make walking a game, and people walk more.

This result also gels with what Daniel Kahneman and other behavioral economists have shown: hyperbolic discounting – our tendency to value immediate incentives more than future incentives – is a significant cognitive bias. We’re primed to care about now before we care about later; we’re biased to the present. Taking advantage of this bias in the form of instant feedback, as in the immediate reward of knowing how many steps you’ve just taken, can be a mechanism towards making wellness work. This is, more or less, why many believe gamification holds such promise.

Take Advantage of Automated Hovering.  It’d be creepy if your doctor or nurse practitioner spent all day, every day, with you, clipboard in hand. With devices like Asthmapolis (an asthma inhaler add-on that connects with your smartphone via Bluetooth to track your inhaler use), he or she doesn’t have to; if you use your inhaler frequently – a sign that your disease isn’t well-controlled and that you’re at high-risk for a run-in with your local Emergency Department – your physician automatically gets a warning, no physical hovering necessary.

This is only one example of what Professor Kevin Volpp has termed “automated hovering” – essentially, passive data collection via available technology. As sensor costs fall and smartphone adoption rises, automatic, passive monitoring will become an increasingly important tool to improve the health of a population.

Emphasize Social Connection. The pedometer article cited above ends with this quote: “It’s like a videogame. I have such a competitive personality, so I’m going to beat these people today.” Which gets at a fundamental truth: we are social animals, and our motivations are inextricably linked to our interactions with others. Nicholas Christakis and James Fowler showed that health behaviors can be contagious; as someone who runs and works out regularly, I improve the chance that my friends – and, interestingly, their friends, even if I don’t know them – become marginally healthier.

Connecting with others to get healthy and stay healthy is as easy now as logging onto a social network. at the vanguard of this trend are companies like CafeWellKeas, andRedBrick – social networks to get healthy and stay healthy. The challenge, as ever, is to make these networks as addicting as Facebook, so that patients stay interested and engaged in their health.

To be sure, it’s not immediately clear that a wellness program that included all of those components would work, in our sense – while they can all scale considerably, they aren’t cheap to start. And it’s pretty easy to be unhealthy, or to forget to take your medication. But, if I had my wellness druthers, that’s where I would start to make wellness work.

Mike Miesen is a healthcare consultant and recent graduate of the University of Wisconsin-Madison. He is currently on loan to the Ugandan Ministry of Health (via NGO), leading a project to reduce maternal mortality. You can follow him on Twitter @MikeMiesen and at Project Millennial, where this post first appeared.

29 replies »

  1. Ironic isn’t it? And both ‘wellness’ and ‘electronic medical records’ are highly reliant on….engagement. Funny how that works when you don’t accurately factor in endusers or ‘consumers’ in the processes one is imposing and figure how to reasonably engage them.

  2. I got to this late – but just wanted to say the social contagion work of Fowler (at least with respect to obesity) which I believe is what was referenced in the initial post has been completely discredited. For those who want the more detailed math of the issues you can easily google it – But using math that every health professional should have learned a long time ago – it was so obvious from the start that it was nonsense – Claiming causality from observational data as they did is just slightly above 8th grade math in terms of a no-no. And anyone who read their original article would no what nonsense it was from that standpoint alone – In addition, their proposed solution – which was to have people lose weight in groups – would be completely laughable if it wasn’t so ridiculous – let’;s see what could we call this novel solution – weight together? weight-viewers – what about weight watchers? yep – that’s the ticket!. People bought this nonsense line, hook and sinker – because it was published in a major medical journal – and peer-reviewed no less – Jon

  3. I friend of mine has joined a wellness clinic in the south. There business model is to stress wellness. The patient load is reduced and the frequency of visits are increased. The theory is that if the patients are guided to stay healthy. The system will save money. This model does appear to be working. Although I don’t have any data, this company is thriving.

  4. Fair enough.

    I think that getting people/patients to be healthier is a worthwhile goal in and of itself.

    The question is: “How much money (if any) will we save by doing it?”

  5. Legacyflyer, To clarify, I agree with Gowrisankaran et al. that doing things like getting health assessments, taking medications, and visiting the doctor may spur increases in health. I do not claim to know whether the employees in that study have gotten healthier or not or how long it might take for these changes to lead to measurable improvements in health.

    Convincing my skeptical mind that something has no impact is hard to do, because as the saying goes, “an absence of evidence is not evidence of absence.”

  6. Bernadette,

    So you are interpreting a decrease in hospitalization with an offsetting increase in prescription costs as an improvement in health?

    Is there any other data to support your belief that people are getting more healthy? Are people missing less time from work for illness, are they avoiding disability?

    A skeptic (like me) might say that these wellness programs have no benefit to an employer because they don’t save any money.

  7. Legacyflyer, I interpreted the decline in hospital spending for the targeted conditions as a positive change, because that it is an indicator that people were less likely to have serious medical problems from those conditions. I interpreted the increases in spending on health screenings, needed medications, and doctor visits for targeted conditions as positive changes, because these are indicators that people are treating their illnesses, which research suggests leads to better health and cost savings.

  8. Of course lobbyist have a huge amount of blame/influence for what happens. Lobbyists are doing what they are paid to do. They are like flies on sh*t. They will always be there.

    The problem (and I don’t have a good solution) is what influence they have on public policy. Or put differently, which legislators/politicians are letting lobbyists “buy them”.

    Saying “the lobbyists made me do it” is a cop out.

  9. Bernadette,

    If: “the wellness program reduced hospital costs and increased prescription costs”

    Then why does it: “…suggests that the program led to positive economic effects”

    To me an increase in one area that was balanced by a decrease in another shows no effect.

    Am I missing something? Was the increase in prescription cost significantly less than the decrease in hospitalization?

  10. hmm… how do you explain Barnes’ off-the-charts admit rates and wellness-sensitive event rates during the baseline year? Would you say that the minor positive impact from that study is generalizable to employers with more typical admit rates and wellness-sensitive event rates?

    How do you explain that virtually every wellness vendor that has reported ROI has transparently lied? http://blogs.hbr.org/cs/2013/03/do_wellness_programs_really_sa.html

  11. Thank you Christine. I would like to add, although the title of the Gowrisankaran et al. paper draws attention to the lack of overall savings in employer health care spending within two years, the overall findings are positive. Benefits for employees included increased completion of health risk assessments, increased doctor visits and use of medication, and fewer hospitalizations for targeted conditions. The authors note that the program may spur increases in employee health and productivity. The Commonwealth Fund gives a nice summary http://www.commonwealthfund.org/Publications/In-the-Literature/2013/Mar/Hospital-Systems-Wellness-Program.aspx .

    Some questions that may be important for future research are the longer-term effects for employer health program costs and the economic effects for employers beyond health care spending (e.g., are there any payroll savings associated with reduced sick days, less absenteeism, increased productivity, or reduced turnover due to employees being healthier?).

  12. As a wellness subject matter expert with a healthcare and wellness consulting background, I support Bernadette’s recommendation that outcomes need to be considered to realize the true impact of wellness.

    Companies are making sizable investments in wellness. An outcomes based wellness program that measures the health and financial impact in the population is the only way to identify a solid return and true risk migration.

    The blog suggests that technology works (gaming, social media) when combined with instant gratification. Which is correct- it works to get members engaged initially- however, varoious engagement tools, staggered rewards, and outcomes based actuarial tracking is also necessary for long term success. In my experience, there is only one outcomes based wellness program in the marketplace that brilliantly ties all the key components together- technology, gaming, social media, challenges, instant gratification, incentives, continuous engagement tools, behavioral economics, clinical science and a large seamless network. This is exactly the type of program US and Global companies need to have in place as we tackle the complex issues surrounding public health and wellness.

  13. Bernadette, if you look hard at that study you’ll see Barnes is a major outlier, a great place to do wellness. Their admits/1000 are 50% higher than average and (if you assume that 25% of their employees/dependents are >45 and 90% of wellness events happen in that age) the average Barnes employee >45 goes to the hospital every twelve years with a wellness-sensitive medical event.

    If they can’t save money no one can

  14. Mike, As an evaluation researcher, I completely agree with your points about the problems with looking at “wellness programs” as a single intervention that can be measured with a single measure. Notably, within the 2-year window of Gowrisankaran et al.’s study, the wellness program reduced hospital costs and increased prescription costs. This suggests that the program led to positive economic effects that could be expected to result in longer-term savings, as start-up implementation costs are reduced and the benefits of increased treatment are realized. A noted limitation of the study was that it “could not disentangle the roles of the different program components.” This suggests that future research should use methods that can explain what processes increase chances of success and that look at the outcomes over time to understand the true effects of various program designs and strategies.

  15. In one of my jobs, I got to know the employees in a big box store in state A. There were a number of overweight people. A wellness program was implemented and a weight loss program was part of that program. The visible results among the women were dramatic, among the men not so much.

    I later worked at a different store in state B in a different part of the country. Same program. Based on employee conversations, much lower participation. No visible impact.

    Was all the impact in the first six months, and by working the stores sequentially, did I miss the impact? Or, is some other factor playing a big role?

  16. It sounds like there are some folks on this comment stream who, having shown up the day the fifth-grade teacher covered arithmetic, realize that wellness outcomes are totally made up. I would invite you to join our linkedin group Corporate Wellness Intelligence, for the wellness industry’s grownups in the room. It’s invitation-only and we do not allow the wellness ignorati to join.

    You might also enjoy my book Why Nobody Believes the Numbers, a hilarious smackdown of this wellness drivel.

  17. The foundations of Obamacare are cracked. First, it was his delusion that HIT was going to reduce costs and improve outcomes. Now, it is that the wellness programs had sham recommendations. Next, you will see that the patient portal and data acquisition by patients will be an expensive meaningfully useless feature.

    It will cost 3 trillion dollars to wire the medical care of the US, and that coes not include maintenance. How many lifesaving meds could be purchased for that?

    Wellness programs are farces and HIT is sham sham sham…no beef all grizzle.

  18. Not sure what you mean. “Too many things depend on doing things wrong – especially when it comes to (this) government”

    Are you suggesting that the government is sabotaging its own efforts?

    Usually, the simpler explanation (poor planning, poor execution) is more likely than the conspiracy theory.

  19. “So far, neither seems to have lives up to expectations.”

    Assuming they were done correctly? Too many incomes depend on doing things wrong – especially when it comes to (this) government.

  20. d.d.

    Good point, I hate it when an analogy fails 😉

    I think you understand my point though. Health Care reform is built on a number of pillars, including “wellness” and “electronic records”. So far, neither seems to have lives up to expectations.

  21. This. Until we get rid of our poisoned, corporate food supply, we are wasting our time.

  22. Just for fun, I will point out that the (Leaning) Tower of Pisa was started in 1173, and was already tilting noticeably when the 2nd floor was completed in 1178. Construction of the rest of it spread over 300 years. It stands iconically to this day. (Source Wikipedia.)

  23. I can completely agree with ‘making parts of wellness a game’. Take for example dieting. One tactic is to not clear away empty plates so that you can see the remains of what you’ve eaten. Because you can see a plate with some remains on it you know you’ve eaten, this in turn will make most weight conscious people or at least those thinking about their diet stop over eating.

  24. Some things sound so good that – well who could argue.

    “Lets set up ‘Wellness Programs’ to improve people’s health. Keeping people healthy will save money.”

    “Lets transition to Electronic Medical Records. Having digital records will save money and improve health.”

    Except they don’t. These two pillars of Health Care Reform seem to be as structurally sound as the leaning tower of Pisa.

  25. “We can continue to strive for healthier workforces, or we can say it’s not worth the effort.”

    What effort? Trying to fight the forces of the industrial processed food industry is impossible. It would be easier to throw up our hands and just tax salt, sugar, fat then let everyone just gorge away.

  26. Well, these ideas can’t be any worse than what companies are doing now, which is to say, egged on by their consultants, throwing massive amounts of money at vendors who almost invariably lie about their outcomes for the simple reason that it’s not possible to reduce wellness-sensitive medical events by enough to overcome the cost of the programs.

    You are suggesting programs which cost very little. Since none of these programs accomplish anything, it’s a terrific improvement to spend very little on accomplishing nothing than to spend a lot with the same outcome.

  27. Good points. Wellness programs are for companies who want their employees to be healthy rather than unhealthy. That’s the need and the desire. It’s also the challenge. The focus should be on continuing to identify and improve the most promising, effective, cost efficient, and engaging components of wellness, and on developing widely accepted standards of measuring value (taking into account different reasons for an organization to have wellness as a priority).

    We can continue to strive for healthier workforces, or we can say it’s not worth the effort. My belief is that competitive companies will take employee health seriously.