Health-contingent workplace wellness, the two-time darling of federal legislation codified in both the Health Insurance Portability and Affordability Act (HIPAA) and the Affordable Care Act (ACA), is now plagued by doubts about effectiveness and validity that are inexorably grinding away its legitimacy. This puts employers, particularly large employers who have committed to it so vocally and visibly, in an awkward spot. In the style of politicians nervously trying to change the terms of debate, wellness advocates are now walking back the assertions that have undergirded their entire construct for more than a decade. While some business leaders are apparently either unwilling or unable to back away from this self-inflicted wound, staying the present course is neither inevitable nor required. A course correction might actually prove quite liberating, especially for leaders of smaller and mid-sized businesses who must scratch their heads wondering how they’re supposed to reproduce a big-company style workplace wellness program or even why they should, given the dearth of data on effectiveness.
As a case in point, we offer GE, an iconic American multinational with 305,000 employees, $147BN in revenues, and $16.1BN in earnings worldwide in 2012. The company offers its employees a much-lauded wellness program, saluted by the National Business Group on Health (NBGH) in a fawning 2009 case study. GE’s wellness program has several things to recommend it:
- A top line focus on environmental change
- An emphasis on strong and consistent positive health messaging to employees
- The “Health By The Numbers” strategy that asks employees to commit to essential behavior changes (don’t smoke, eat more produce, walk more, and maintain a healthy body mass index [BMI]; there is wisdom in these choices, as they are the baseline activities for good health)
Beyond these obviously beneficial wellness program components, the GE wellness program veers off into a compendium of wellness convention, with encouragement for employees to take HRAs and get screenings, in particular, mammography, colonoscopy, cholesterol, and blood pressure. Some of the affection for diagnostics springs, of course, from GE’s corporate commitment to health care, which includes selling a broad variety of diagnostic devices to medical care providers who must, in turn, induce demand in order to pay for their contribution to GE Healthcare’s $18.2BN revenue stream.
As far as is discernible from publicly available documents, the wellness program targets GE worksites with over 100 employees, and GE claims in the NBGH case report that over 90% of employees worldwide participate. Beyond these data, however, it is remarkably difficult to understand what results GE gets and at what cost. The only publicly available insight on expense comes from GE wellness leader Rachel Becker in an essay published online by EHS Journal, in which she reports $100,000 per site as the wellness startup cost. Extrapolating this figure to GE’s more than 600 global worksites produces a wellness capitalization expense of about $60M, which presumably does not include annual wellness program operating costs. This might be why GE makes absolutely no mention of the cost or results of its wellness program in either its annual report or its 10K filing, although the NBGH quotes GE as saying the implementation was “inexpensive”. Even though $60M is equal to only 0.38% of GE’s 2012 earnings, it nonetheless might seem an untidy sum to skeptical shareholders.
Even more interesting is that there are no data on the program home page, in GE’s DataViz, or in the 10k or annual report on the wellness program’s ability to attenuate medical care spending or modify employee risk measures. GE does not break out medical care spending for current employees as a line item anywhere. GE does report, however, that it spent $500M on retiree health benefits in 2013, a figure it expects will increase to $600M in 2013. Ironically, the wellness program apparently is not foisted upon retirees. The only outcomes metrics explicitly cited in public GE documents and presentations have to do with participation rates, not actual changes in the prevalence of risk factors or the incidence of wellness-sensitive events in any group of GE employees.
If we were rogue GE shareholders, we would send these messages to Jeff Immelt and colleagues, as well as businesses of any size considering a wellness program.
- Stick with lifestyle and behavior strategies that cost little, impact everyone, and send strong consistent messages through participatory wellness:
- Remove sugar-sweetened beverages and calorie-dense, nutrient-poor foods (i.e., pizza, candy, fried foods, etc.) from all vending and food services, or price them so expensively that their purchase by employees is cost-prohibitive. Then, subsidize the purchase of healthier foods. Condition the bonuses of executives in charge of food services on how much produce and non-caloric beverages they sell to employees.
- Develop catering guidelines that govern all corporate events (on-site or off), from the smallest lunch to the most lavish buffet, and extoll the fact that they are based on a credible, palatable, and broadly acceptable healthy eating template, the DASH diet. Contract only with local vendors who can deliver DASH diet-consistent foods. In a similar vein, establish meal reimbursement guidelines for executives who travel. No more alcohol-soaked dinners and no fast food.
- Give every GE employee 30 minutes per day for exercise, before, during, or after work. Allow people who are the most unfit or overweight get more time from a time bank to which their more highly fit colleagues can contribute hours that they don’t need.
- Create internal environments that are immersed in health messaging: no candy bowls or plates of donuts lying around; art, murals, and signage that are health-driven; an avatar with daily exercise and nutrition messages that appears onscreen every day the first time an employee logs on.
- Provide every employee with a $0.99 measuring tape and instructions on how to measure their waist line. In addition to embossing the tape with the GE logo, include the formula for calculating a waist to height ratio; the ideal ratio is 0.5, meaning that the closer you come to being as wide as you are tall (1.0), the less healthy you will be and the more you and the company will spend on medical care.
- Expand the no smoking ban to make it a “if you smoke, you don’t get hired” ban. Make Nicorette freely available in GE work sites. Then, tell everyone who smokes that they have three years to become smoke free, or…find another place to work. Back it up with random nicotine testing.
- Ditch the screening strategy and hold your administrative services organization (most likely a major managed care plan) and contracted medical care providers responsible for ensuring that GE employees are up to date with consensus, evidence-based, age- and gender-specific immunizations and screenings. Beyond that, stop promoting screenings. Let clinicians diagnose and treat, not wellness vendors.
- Lose the HRA. If you really must survey your employees about something, randomly sample them about their health-related quality of life using valid instruments: the SF-12 for adults and the parent-completed SF-10 for children.
- Stop kidding yourselves and your employees about what it takes to improve health-related quality of life: great personal responsibility and effort within a facilitative environment and an inordinate amount of patience by management. Instead of making hollow statements about the financial impact of wellness, call it what it is: a fixed cost of doing business.
GE’s half-a-loaf approach to wellness is a warning flag to every business considering a wellness program as a result of federal encouragement. If a Fortune 10 company, with effectively no resource constraints, cannot produce believable data on wellness program costs or effectiveness – or worse, chooses not to produce data because their diagnostics business depends on showing returns from diagnostic activities – what exactly does that mean? Aside from winning wellness industry accolades, which is like being in a child’s sports league where everyone finishes first and gets a trophy, despite the huge investment that they’ve made, GE cannot say definitively that its wellness strategy has brought any good things to life.
Vik Khanna is a St. Louis-based independent health consultant with extensive experience in managed care and wellness. An iconoclast to the core, he is the author of the Khanna On Health Blog.
Al Lewis is the author of Why Nobody Believes the Numbers, co-author of Cracking Health Costs, co-author of forthcoming How to Cut Your Company’s Health Costs and Provide Employees Better Care, and president of the Disease Management Purchasing Consortium.
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I think refusing to hire smokers is not something I’d be willing to do. Smoking over-indexes among disadvantaged populations; such policies are discriminatory in their impact. I do like the idea of subsidizing healthier choices and making less healthy choices expensive. I would add the step of banning chip, cookies and similar foods from vending machines. No soda or other sweetened beverages either.
Mitch: thanks for your comment. The number of companies that tout wellness but simply don’t get the importance of altering their environments is very disappointing. It’s one of the most important measures of how the wellness movement is lip service more than it is anything else. Last year, I did a review of, and strategic plan for, the food services operation of a Fortune 500 company, which had both a wellness program and vending machines with items such as animal crackers, gummy candies, and various jerky treats labeled as “healthy choices” by the vending company. It never struck anyone as odd.
Thank you to everyone for these first-person and professional comments. Usually Vik and I post on wellness sites, and get scathing responses from people who look at wellness from the viewpoint of either true believers or vendors/consultants. (This is thankfully not the case on the Corporate Wellness Intelligence linkedin group.) Part of the business model of the wellness “ignorati” is to disbelieve all facts. This is not because they are stupid. Quite the contrary, they are smart enough to know that facts are their worst nightmare.
For a non-athletic person like me, anything to do with sports and exercise, other than walking, has always come hard. I have to force myself to do it. It’s a slog. It’s not fun. Most fruits and vegetables I just don’t like and wouldn’t eat them if you paid me though there are a few that I do like and do eat. On the plus side, I never smoked, don’t drink and maintain a normal weight but heart disease runs in my family. I had a CBAG in 1999 and needed a DES in 2005.
So, what I really want to know from the medical profession is the MINIMUM I need to do in terms of exercise to capture most of the health benefits. Though wellness programs are well intentioned, companies should not expect them to reduce their healthcare costs nor should the overall healthcare system.
Barry: thanks for your comment. Your observation about company expectations is right on point, as these programs have been wildly oversold and now that they are meeting meaningful resistance, all of a sudden no one wants to talk about the claims of success.
As for your clinical situation, I empathize, and I have a suggestion. I suggest that you sit with your cardiologist to establish the parameters of exercise that would be suitable for you (frequency, duration, intensity, type). Your physician should be able to express this to you in METs or metabolic equivalents (this reference document from the CDC is a good tool: http://www.cdc.gov/nccdphp/dnpa/physical/pdf/PA_Intensity_table_2_1.pdf). Finally, I encourage you to share and discuss this paper with your doctor (http://www.cdc.gov/nccdphp/dnpa/physical/pdf/PA_Intensity_table_2_1.pdf). It is an editorial on the impact of improving fitness in people who’ve completed cardiac rehab, which may track with your experience. The results are dramatic, with mortality reductions of 20% to 30% with each incremental increase in fitness. Good luck to you.
Sorry…in my earlier note, the second link was wrong. Here is the correct one for the editorial:
To Mr. Flansbaum: the lack of visibility may not equate with negative ROI, but it does raise questions about validity and transparency in the finances of a public corporation that cheerleads on this issue. Any evidence of any kind of effectiveness would be helpful. The suggestion we made may not do any more than what GE has tried but they would do so at much lower cost and far less intrusively, and they are more closely tied to the process of culture change. That’s beneficial in its own right.
To Mr. Schmidt: you have hit a key point. People must want to pursue better health. Employers should do only what is necessary to facilitate that voluntary effort, rather than secure half-hearted and costly participation from people who really don’t give a flip.
While often well intentioned, it seems as though wellness programs are hard to implement with fidelity unless the employees actually want to be healthy. I worked at a place once that offered an incentive for biking to work. Well one person we worked with would ride the bus (with his bike in tow), get off about a block from work, and then ride up on his bike as though he’d been pumping pedals for the last 3 miles. Clearly this was an effort to encourage employees to stay fit, while also cutting down on pollution, but there’s always going to be someone who breaks the rules, which would make gathering reliable data that much harder.
This is hilarious, thanks for sharing.
–GE does not make the data available. Do you feel 100% certain lack of visibility equals negative ROI?
–Why do you assume the menu of suggestions you list will do any more than the current GE approach? To my eye, aside from being well meaning, they have just a great a chance of failing for the same reasons society fails. People go home, live their lives, and engage in their usual routines–with all the distractions that got us here initially. You will have success with 5-10% of employees, but no company wide home runs.