“The way I see it, if you want the rainbow, you gotta put up with the rain.”– Dolly Parton
Sometimes, helpful perspective can be found in the most unexpected places. Ms. Parton may be better known for her achievements in country music, but her maxim also applies to certain aspects of the public dialogue on workplace wellness that have become a recurrent feature..
An example is a thread that has its roots in a blog invited two-part response counter-response (i.e., see the comments at the end of Part II) exchange between Al Lewis (aka whynobodybeliev) and myself that began November, 2014. The resumption of this exchange was initiated with my comments on a 12/4/15 post on this blog page from Ms. Dentzer, who noted the focus on return on investment that dominated the “debate” between Goetzel and Lewis on workplace wellness at the PHA Forum 2015. Her post offered some questions for positioning future like-minded events in more looking forward ways. My 12/19/15 post, also on this page, offered a supplement to her formulation by urging wellness program implementers to also take stock of the empirical work that has been done to date on program impact. Indeed, it urged implementers to consider (re-) setting their sights toward the top end of what has been shown to be possible and referenced the success that Navistar achieved during the 1999-2009 period as a model. This, in turn, prompted another sharply worded response from Mr. Lewis, expressed in terms that were not only reminiscent of his counter-response noted above but have also come to typify much of his published commentary in this area, even on work that has met the test of peer-review.
In a bit of irony, as the momentum for re-shaping workplace wellness continues to grow, Mr. Lewis’s comments and the way they are expressed provide an opportunity for moving the dialogue – and the field – forward. Herein, Ms. Parton’s maxim offers a helpful analogy. On one hand, her “rainbow” offers a pithy way of framing what can be seen as the end-goal of this growing momentum: the fully maximized potential of workplace wellness to improve health, recoup lost productivity, and rein in health care costs. On the other, the “rain” in her words of wisdom seems a good fit for the “scorched earth” rhetoric characterizing Mr. Lewis’s comments.Constructively addressing the challenge embedded in this “rain”, if you will, affords a pathway for making new headway to this “rainbow.”
Our Work & the Workplace Wellness-Financial Performance Link
First, the line of research that has led to now 24 (counting my 12/19/15 post and this post) publications that have either directly accessed the Navistar database or commented on its findings has focused on the company’s approach toward health and productivity/performance per se. While this has enabled a framework for measuring, managing, and discussing this approach specifically, it has not afforded the same for the company’s overall corporate performance and profitability. Our work has never been positioned to tackle these larger issues, nor have claims ever been made to this effect. Mr. Lewis’s insinuation that it should now be answerable to such considerations is tantamount to equating apples and oranges.
In a coincidental development that is itself indicative of the field’s growing momentum, other just-published research has taken the next step of linking workplace wellness to organizational financial performance. Three studies in the January issue of the Journal of Occupational and Environmental Medicine have compared the stock market price performance of portfolios of companies having award-winning wellness programs with the S&P 500 Index. Although using similar statistical methods, these studies involved differing groups of companies and differing time periods, and used different metrics. Yet, each found that its selected portfolio out performed the index by rates ranging from 7 to 16% per year.
As even these other authors point out, though, each of these high performing companies likely excelled on a wide range of best practices above and beyond their focus on wellness programs,yet none of the studies attempted controls to isolate the effects of wellness programs from these other best practices. As it stands, the extent to which these other best practices and well-implemented wellness programs co-occur has yet to be systematically examined.
This new evidence thus establishes a strong association between well-implemented wellness programs and superior organizational financial performance, but it has yet to make a causal connection between the two. The former may well be a necessary but not sufficient condition for the latter. As a corollary, well-implemented wellness programs may serve to mitigate the effects of other business practices – however less than “best” they may be — and lessen what would otherwise be worse organizational financial performance. This too merits testing.
The “Rain”: Is It Warranted?
Second, as mentioned previously, nearly a year ago an invited two-part blog which I co-authored acknowledged Lewis and his colleagues for helping to usher in a new and needed scrutiny of employment-based wellness programs. Such scrutiny, however, was not part of the picture when it came time to summarize the work of my group’s work with Navistar. This summary included calculations of the return-on-investment achieved with the company’s extraordinary progress toward a workplace culture of health during the 1999-2009 period.
Preliminary estimates of this ROI – for which I take full responsibility despite some issues which arose during the pre-publication phase that were out of my control — were indeed circulated and eventually restated in light of subsequent,internally acquired information. It is the re-stated version of these estimates, however, that appears in the summary and the latter provides the only detailed account of the calculations that has been published. External scrutiny played no role.
As recounted and cited in the summary, what can be reasonably asserted is that the empirical basis for evaluating the savings embedded in these estimates was as robust as any that has been reported to date in the peer-reviewed literature. Recall that the Navistar workforce started out the study period with health, productivity and safety characteristics that were considerably worse than industry benchmarks. Recall also that ROI calculations pitted it against the general population, which averaged year-on-year increases in direct costs of roughly 10% throughout the study period. Adapting the same methodology under analogous circumstances, it could well be that one or more of companies in the above three selected portfolios would be found to report similar excellent returns. In the end, readers will have to judge whether the savings we have reported provide a plausible representation of what is possible with workplace wellness, or whether the“rain” conveyed in Mr. Lewis’s comments is warranted.
Also worthy of consideration, though, is the question, just how constructive is the rhetoric with which these comments have been rendered? There is and always should be room for civilly expressed disagreement in the field. If, however, the assumptions are that (1) we who work therein are all striving to promote the best interests of employees and employers and to help maximize their capacity to meet their current and future challenges in health and health care and (2) our respective efforts toward this end are best furthered when our work is shared, discussed and evaluated openly and with respect in both peer-reviewed and non peer-reviewed forums, then is there room for the ad hominem contempt and dismissal conveyed in Mr. Lewis’s rhetoric? Are the best interests of the field and the collective enterprise in which we are all joined advanced? Again, readers will have to judge, but just to be clear, I for one think not.
Reaching the “Rainbow”: Where are we?
Finally, for those open to viewing the Navistar experience in terms of its galvanizing potential, what are the essential features of this “rainbow” that sets it apart from the efforts that are now or will soon be underway at many companies to promote wellness in the workplace? My Dec. 19th post alluded to a road map with some guiding principles that emerged from the Navistar experience: orient toward the entire workforce; be driven by evidence; maximize the fit between the observed health characteristics of this population and the available resources that can be brought to bear; focus on primary, secondary, and tertiary prevention as well as supply and demand; cultivate sustained senior management commitment;and rely on relentless monitoring, not only of utilization and costs but also of outcomes and patient/consumer experiences.
Yet, while workplace wellness has seen substantial growth – spurred by enhanced incentive provisions under the Affordable Care Act, the Employer Health Benefit Survey reports that 74% of all firms offering health benefits in 2014 offered wellness programs — there is much variation in the services these programs are providing and in their use of financial incentives. RAND has differentiated three types of services— health risk screening, lifestyle management, and disease management — and reports that only 13% of wellness programs can be characterized as comprehensive, offering extensive services in all three areas. This latter figure, alone, suggests that these programs in many cases are likely to be static, stand-alone primary prevention programs, whose implementation is being accompanied by short-term time horizons, limited management commitment, and other features that are inconsistent with what the Navistar experience suggests will be needed to achieve “rainbow”-like results.
The approach that came to fruition at Navistar was an integrated whole, consisting of a wide array of interdependent components spanning management and measurement that worked together synergistically. The evolution process took some five years before it flattened the cost curve to the point that the latter could first be linked to a cost increase that was below national trend and another several years before the magnitude of its impact could fully register. It was informed and shaped by complementary internally and externally directed monitoring mechanisms that routinely examined and reported on both direct and indirect costs and their drivers as well as patient/consumer experiences over time.These and other features that comprised the approach, ranging from a novel musculoskeletal disability management program to evidence-based benefit design, have been written about extensively elsewhere.
In our dynamic field, recent developments have included further refinement in the definition and operationalization of“cultures of health” in the workplace. Among the most notable is a new book by Edington and Pitts on re-orienting workplace culture toward the promotion of positive health and the well-being through the cultivation of shared values among both employees and management. This is work on which Lewis, I am delighted to acknowledge, has provided a positive review.
On some key dimensions — total workforce focus, senior management/work force buy-in, and the cultivation of behavior change, to mention some examples — the Navistar experience during 1999-2009 would seem to have achieved an initial if approximate incarnation of this vision. Both in terms of the results achieved and the road map that evolved to get there, it remains a top-end model of success that other employers can access to inform, shape and guide their efforts to improve health and productivity/performance while bringing health care costs under control.
Dr. Allen is principal of the Harris Allen Group, LLC (www.harrisallengroup.com). He first-authored a paper selected by the American College of Occupational & Environmental Medicine for its 2015 Kammer Merit in Authorship Award.