Wednesday, March 11, 2015

Does Worksite Wellness Work? A Critical Look at the "Wellness Incentives In the Workplace" Article

A waste of money and
a basis for discrimination?
The answer to the "Does Worksite Wellness Work?" question depends on your frame of reference.

If you read this 2010 review by Baicker, Cutler and Song, you'll see that there are 32 peer-reviewed published studies from work settings that a) transparently described the intervention and b) used a valid parallel control group - persons who did not receive the intervention - as a comparison. When interventions like these were deployed, impressive reductions in medical costs and absenteeism like these were achieved in the intervention groups, compared to the groups that did not receive the wellness programs.

If you read this just-published 2015 review by Jill Horwitz, Brenna Kelly and John DiNardo, you'll see that it's possible to use a "conceptual framework" to completely trash the notion that worksite wellness programs offer any benefit.  Oh, and by the way, they also result in discrimination.

How is that you ask?

This framework asks:

1) Do employees with chronic conditions or health risks spend more?  The authors' answer is that most studies for most conditions indicate the answer is yes.

2) Do financial incentives change behavior? The authors' answer, based on a review of the literature, is that obese persons tend to gain weight and many persons who quit tobacco relapse.  The impact on high blood pressure and lipids is less certain.

3) Do health improvements lead to employer savings? The authors' brief three paragraph answer, based on two references (here and here), is "uncertain," "depends" and "erroneously assuming."

The authors also

a) point to the abundant literature that questions the relationship between "process" and "intermediate" outcomes (blood glucose testing or control in persons with diabetes mellitus) versus long-term outcomes (like mortality - an example is here),

b) note that aggressive treatment can lead to unintended consequences (an example is here), and

c) suggest that wellness programs disproportionately benefit persons from higher socioeconomic classes who suffer from less disease. It's frankly difficult for the Disease Management Care Blog to follow the authors' logic, but as it understands it, anything that benefits one segment of a population is a zero-sum loss for the remaining segment.

The DMCB's two-fold take:

1) The 2010 review examines state-of-the-art clinical trial data, while the 2015 "conceptual framework" interprets the underlying published literature and finds it wanting.  According to the framework authors, the value of any counseling is ultimately unproven.

Big deal. The DMCB would like to point out that a similarly conducted review of primary care (where there are no randomized control clinical trials), Medicare (a social experiment if there ever was one) and parachutes (to combat "gravitational challenges") could also conclude that there's no proof.

Bottom line: Lack of proof for a benefit is not the same as proof that there is a lack of any benefit.  What's more, the business persons that run worksite wellness programs know that evidence based medicine is necessary, but not sufficient.  They don't demand proof, they use reasonable assurance.  The 58% of large employers that are offering worksite wellness are using seasoned logic in a world of conflicting data.  Good for them.

2) The Homer Simpson-inspired DMCB doesn't quite "get" the framework's socioeconomic argument.  If persons from lower socioeconomic classes have a higher burden of obesity, diabetes, high cholesterol levels and poor fitness, anything that offers increased access to a higher level of care is not only good policy but a proportionately noble thing.

What's more, if worksite wellness results in no economic benefit and doesn't shift costs in any direction, how does that result in any discrimination?

While economic incentives in a zero sum game can be problematic, the DMCB believes that Horwitz, Kelly and DiNardo's logic is overlawyered worksite nihilism run amok. Their ultimate unspoken conclusion is that when it comes to employees, all should be treated to the same level of neglect.

Image from Wikipedia

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