The long awaited federally-mandated RAND Corporation report on workplace wellness programs is finally out, after months of anticipation. Despite an odd now-you-see-it/now-you-don’t release, both wellness proponents and critics anxiously awaited the report’s public deliverance.
Like many documents emanating from the political cauldron, the RAND report has elements in it to please both camps, although proponents will have to reach deep into the document for snippets of hope built around simulations, models, and what they term “convenience” samples of employers predisposed to support health-contingent workplace wellness programs.
For critics of health-contingent workplace wellness programs, the conclusion is much more straightforward: even using prejudicial data sources and lacking a critique of the quality of the evidence, the impact of workplace wellness on the actual health of employees and the corporate medical care cost burden, is, generously stated, negligible.
This is not worth $6BN a year, which is the purported size of the US market for health-contingent workplace wellness programs (“purported” because like everything else in wellness, the size of the industry itself is totally opaque). There are clearly better ways to spend these funds; at the very least, it must be possible to get the same dismal results for far less money and with vastly less complexity.
With the push of the Affordable Care Act, the drive to implement health-contingent workplace wellness programs is accelerating. The RAND report, rather than contributing propellant, ought to give responsible business leaders pause as they consider whether to step up the pressure (i.e., increase incentives and penalties) for employees to participate in these highly intrusive, clinically dubious, spendthrift programs that yield health in RAND’s hypothetical world of models and simulations, but perhaps not so much, as RAND notes, in a more earthbound reality.
The lesson for executive leaders is that the nearly hagiographic employer belief in the value of health-contingent wellness is completely undone by the fact that RAND says virtually no employer (2% of their sample) measures program impacts and, as we have written previously, it doesn’t look like any employer, benefits consulting firm, or vendor actually knows how to do so.
The RAND report has two other insurmountable shortcomings. The first is its reliance on the conventional wellness literature rather than giving that literature its long overdue and deserved outing as deficient. Unlike reports from the Cochrane Collaboration, which are particularly insightful for their unvarnished assessments of the quality of the available evidence (if the evidence is poor, it is impossible to draw credible conclusions, and the product of simulations is not evidence), RAND politely, with politics in mind, tolerates the wellness literature’s surfeit of design errors (though a careful reader can sense the authors’ discomfiture).
For example, using people as their own controls and measuring the progress of participants versus against non-participants (thus ignoring the effect of motivation) should have proven disqualifying. Instead, RAND takes a philosophical middle ground, lamenting that the literature is inadequate, but relying upon it nonetheless, because doing otherwise would really have left them almost nothing to write about.
The second insurmountable deficiency is the necessary and unavoidable reliance on a database of large employers with a predisposition to support workplace wellness. It is insufficient to draw data from employers who’ve committed deeply to health-contingent workplace wellness and contribute their data to an industry trade association.
Though impractical if not impossible, it would have been insightful to draw data from employers that are not involved in the industry trade association, know why employers choose not to commit to wellness, why some employers may have dropped their wellness programs, and, critically, why virtually no one expends the time, money, or energy to quantify programmatic impacts. These concerns are wholly unaccounted for.
Of the five case study employers, two — accounting for fully 82% of the employees in the five organizations — are government agencies. No industry sector has gone all-in for wellness the way that government has.
In sum, these issues go to the heart of credibility. They bring to mind the critique of published literature by John Ioannidis of Tufts and the University of Ioannina, who argues essentially that many reported results are simply a restatement of prevailing biases and are shaped by financial and other influences.
The RAND report has not settled the debate over the value and credibility of health-contingent workplace wellness programs. RAND is not itself to blame for its inconclusive treatise; they had no choice but to throw the lifelines of simulations and models to an industry that should otherwise collapse under the weight of its own fecklessness and mendacity. Yet, the industry’s addiction to sophistry rages on unabated, as is evident in this flier, which one of us recently received from wellness vendor.
The RAND report should, however, make people question how the document – and many others like it – helps to meet the political ends of administration leaders who demanded and paid for it. It was not coincidental that the RAND report and the government’s rules on wellness programs were released contemporaneously.
The RAND fig leaf will encourage political supporters of health-contingent wellness to say that their approach is “evidence-based”. We believe, however, that a more sober reading of the report will leave many more people wondering not only about the meaning of the word “evidence,” but about whether, if after more than a decade of hyperbolic bluster it is not possible to demonstrate the salubrious value of health-contingent wellness programs, just how much more time and money will it take?
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. He is also the Wellness Editor-At-Large for THCB.
Al Lewis is the author of Why Nobody Believes the Numbers, co-author of Cracking Health Costs: How to Cut Your Company’s Health Costs and Provide Employees Better Care, and president of the Disease Management Purchasing Consortium.