Ms. Dentzer has once again offered a constructive course correction with her commentary on the most recent public installment of the workplace wellness “debate” at the Population Health Continuum’s November 2015 conference. Few have done so with as much clarity and impartiality over the years, and for this she merits this note of thanks. In this instance, for those of us who have followed and at times participated in this debate but did not attend the conference, it is most appreciated.
From her summation of how return-on-investment dominated the exchange, it appears that little new transpired in terms of the debate itself. If one went to the session apprised of the previously stated positions of Lewis and colleagues and of Goetzel and colleagues and of the communications each has published in response to the other, one would likely have left with the sense that no forward movement – either in their exchange or for the debate more generally – had occurred. However, while it is presumably preferable to have not missed out on a catalytic moment, employer investment in wellness remains a domain marked by much capacity to improve the health and productivity/performance in the workplace and communities and, by extension, the value and sustainability of health care reform. Yet, it is also sorely in need of the galvanizing coherence and direction that such a moment would foster.
Toward this end, Dentzer’s post hoc wish list for reframing this and future like-minded events offers a good starting point. The questions she poses — How should employers should think about their role in promoting health when so many of those whom they would influence have been ensconced in life cycles predisposed toward ill-health well long before coming under employer coverage? If wellness programs are indeed employers’ best option for tackling their health and productivity priorities, what best practices constitute a properly designed one? And, what is the dividing line between wellness programs that constructively promote health versus those that are unduly intrusive or coercive? – serve to reorient the debate in a looking forward manner. Each speaks to challenges that will need to be well managed if wellness, per Lewis, is to be “done for employees, not to employees”.
But, this list shies away from the empirical work on program impact that has been done to date and the lessons that can be drawn from it. At the risk of belaboring the obvious, not all “looking backward” is synonymous with — or necessarily culminates in — a narrow preoccupation with return-on-investment. Moreover, to not make a broader effort to take proper stock of what has been found runs the risk of repeating mistakes that have been made or reinventing the wheel in
ways that could have been avoided. On the upside, it likewise runs the risk of remaining out of touch with what is possible, based on what has already happened on the ground.
My colleagues and I, functioning as independent observers in collaboration with company personnel, conducted a series of studies starting in 1999 on employees at Navistar, Inc., an international Fortune 500 maker of heavy transportation equipment headquartered in Lisle, IL. Our focus was the multi-faceted approach that the company evolved to measure and manage drivers of health, safety, and productivity. This workforce started the study period well above industry benchmarks in each of these domains.
Out of this body of work, which to date has produced 22 publications (12 peer-reviewed, original research papers) on topics ranging from disease burden and the impact of overtime to the use of treatment guidelines to manage costs, quality and outcomes, a striking picture of employer success has emerged – still, as far as we know, at the top end of what has been reported to date in the literature. Our longitudinal study found not only double-digit reductions from 2001 to 2009 in health care costs relative to national trend but also concurrent, sharply significant drops in lost productivity, including presenteeism, absenteeism, workers compensation and disability. These reductions ironically culminated in an excellent overall return-on-investment even though little attention was paid to the ROI for specific components along the way.
This picture, as it turns out, offers some empirically-derived grist for Dentzer’s three questions:
It provides a substantiated affirmation of employer capacity to exert a positive impact on workforce health, notwithstanding the lifespan characteristics of the individuals in the workforce. Above and beyond being peer-reviewed, not only were the results replicated by two completely separate research initiatives by independent investigators, key findings were validated by external auditors.
It lays out a realistic roadmap for achieving this success. Rather than trying to isolate specific best practices, however, this roadmap emphasizes the gestalt of proactively pursuing a quality improvement approach that prioritizes maximizing the fit between observed population health characteristics and the available resources that can be brought to bear on these characteristics — a fit that will likely have unique aspects and require customization to the circumstances at hand. This approach is further defined by being driven by evidence, oriented toward the total population, focused on primary, secondary, and tertiary prevention as well as supply and demand, sustained by “see it through” senior management commitment, and reliant on relentless, contextually-based monitoring.
It bolsters the precedent of keeping track of employee/patient experience as this approach evolves. At Navistar, surveillance indicated that satisfaction with factors pertinent to these changes remained at high levels of favorability throughout the study period. The company’s health plan and pharmaceutical arrangements continued to rate at the highest (i.e., most favorable) levels relative to comparison benchmarks. At no point did evidence emerge that was cause for concern.
In a recent invited two-part blog, Ray Fabius and I acknowledged Lewis et al for continuing to exert a clarifying presence in a field marked a history of unsubstantiated claims and suspect methods. But, we also pointed out that the above line of research exemplifies a growing body of evidence meeting the field’s highest standard that does not support their conclusion that employment-based wellness initiatives “increase rather than decrease employer spending on health care with no net health benefit”.
Going one step further, my recent letter-to-the-editor addressed Goetzel et al’s work on wellness programs. Their work has made important contributions in conceptualizing and cataloguing best practices that, for example, have much potential for figuring out why programs are not producing intended results and what remedial actions to take. This work, however, has also tamped down expectations about program impact in an apparent effort to keep them in check. Yet, despite being apparently overlooked, the above line of research frames the Navistar experience as a well-documented referent point for the wellness debate. Of course, not every wellness program by itself has or will generate such success. But prudence does not necessitate excluding what has been shown to be possible, especially when the starting point is a population with above-industry health care costs and lost productivity. On the contrary, the field would seem better served when the debate acknowledges the top end of what has been shown to work in a business setting and grapples with the roadmap that has been laid out for achieving it.
Employer successes in this realm have been recognized (cf.., the C. Everett Koop Award in affiliation with the Health Enhancement Resource Organization, and the Corporate Health Achievement Award sponsored by the American College of Occupational and Environmental Medicine). Yet, neither side of this debate nor Dentzer’s clarifying call envision or even allow for the possibility of the level of success that Navistar realized during this period.
This gives rise to a fourth question that could be added to Dentzer’s list, which arises from the maxim “begin with the end in mind”, originally crafted by Covey as one of seven habits of highly effective people but since widely adapted at the level of organizations. In this case, the end in mind is the trajectory-altering bending of the health care cost curve coupled with gains in health and productivity/performance that are sufficient to mobilize the investment and actions needed to attain these objectives. What context-appropriate steps can be taken to achieve such results? While further discussion is needed on how to define and operationalize specific numerical targets, reframing the debate to set the sights at the “top end” of what can be achieved could well help to spur the catalytic moment for the workplace wellness debate that the field needs. It is time that a success like Navistar’s be plumbed for its potential to help galvanize action in this arena.