More on Penn State's Wellness Woes and The Evolving Science of Evaluating Health Promotion Program Outcomes: There Is No Gold Standard

Aside from keeping up to date with work buddies, the Disease Management Care Blog doesn't really use LinkedIn all that much. But when "Support our Penn State Colleagues in their Fight to Prevent Coercive Junk-Science Wellness Programs" postings began to appear in a Discussions board, the DMCB couldn't resist. It rose in support of its alma mater (College of Medicine, '77) faster than a med-mal attorney can calculate a contingency fee.

 As noted in this prior DMCB posting, Penn State University launched a rather routine health promotion program that prompted some nasty and very public teaching faculty resentment. Calls for "civil disobedience" and sinister references to "eugenics" made the DMCB wonder how much of the reported push-back was mainstream employee opinion vs. mainstream media's biased reporting. That distinction didn't stop the LinkedIn board from running a mostly one-sided dialogue on the matter.

So, undeterred by the unfairness of so many vs. just one, the contrarian DMCB naturally jumped right in.  Among the issues raised:

The RAND Study on wellness casts doubts on the merits of employer sponsored wellness programs:

Actually, RAND found employer-sponsored programs lead to statistically significant increases in exercise levels as well as reductions in tobacco abuse and body weight.  To the disappointment of wellness vendors everywhere, however, these programs did not lead to statistically significant reductions in health insurance claims expense.  The ever-optimistic DMCB points out that that means that these health improvements occurred without an increase in health care costs.

While cost neutrality alone is good news, the DMCB also believes that an emerging generation of wellness programs will do a far better job of identifying persons with 1) actionable risk and 2) who are willing to take action.  By husbanding wellness resources for subpopulations where it will have the greatest "bang," program costs will go down and claims savings will achieve statistical significance.

The author of the widely quoted Health Affairs paper on the merits of employer sponsored wellness programs has back-pedaled away ("too early to tell") from her study's original conclusions.

Actually, the original Health Affairs paper said that the finding of a $3.27 return on every dollar spent is subject to:

 "(f)urther study.... to elucidate the time path of return on investment.... The assumption of a linear trend in savings from the beginning to the end of program evaluation may not reflect the reality of behavior change within organizations."

The point is that nuanced and calibrated conservatism is typical of excellent peer-reviewed research and, taken in context, the authors are being quite consistent in-print and on-air.  Academics will always say more research is needed.  Skeptics will over read that.

There are powerful arguments against the common wisdom that "wellness saves money," suggesting that the health promotion industry has been intentionally ripping employers off.

Actually, when it comes to wellness outcomes, there is no agreement on "the" measurement "gold standard." Without any consensus on which assessment approach (for e.g., this vs. this) is truly "better," only one thing is certain: much like the Betamax vs. VHS wars, the future owner of "the" standard stands to reap a consultant's bonanza. Until we declare a winner, assessing the truth will be a messy mix of triangulating on means, medians, confidence intervals, imperfect reference controls, suspect generalizability, human judgment, moving targets and evolving interventions.

What about [insert name of wellness program here] that is an obvious sham?

There have been women who have had mammograms with missed cancer, victims of car crashes who have died despite seat belts and times when the DMCB did something really dumb despite the advice of the DMCB spouse.  That doesn't mean mammogram, seat belts or advice are worthless.  The plural of anecdotes is not data.

Coda: By the way, the statistically significant "value of  0.05" is more of a consensus than a gold standard.  Why is a 5% chance that an observed result is not the result of randomness wiser than a 6% chance or a 4% chance?

Penn State's Wellness Woes: Seven Lessons Learned About Launching a Worksite Employer-Based Health Promotion Program

Penn State's mascot goes on the
prowl for a good wellness program

Listen to this NPR report and it's easy to conclude that another employer-based health promotion program has gone amok. Reporter Jeff Brady implies rising health care costs have led Penn State University to force its employees into an intrusive wellness initiative, pitting David-like faculty members against the Goliath-Administration.

What can wellness architects and service providers learn from this imbroglio?

Here's the facts:

Penn State provides health benefits to over 45,000 employees and dependents. It's self-insured (administered by Highmark), which means the University, not some remote insurer, is on the hook for any unanticipated health care costs. 

Those costs have led to a whopping $217 million health care budget for 2013-2014 and a long term $3 billion pension liability. In response to the threat of budgetary "crowd out," the University made some important changes to the insurance benefit that included a high deductible option and value-based benefits.

It also hatched a health promotion initiative. It checked in with the Faculty Benefits Committee in the early spring of 2013 and then used the summer to unveil a "comprehensive wellness-focused strategy."  This included the "Take Care of Your Health" program that packaged biometric screening (some labs, weight blood pressure), an on-line WebMD wellness survey and preventive health exam. Failure to complete that screening, survey and exam will result in a $100 per month payroll deduction in 2014.

The plan didn't sit well with everyone. Faculty members Matthew Woessner fretted about privacy and penned a "call for action and civil resistance," Barry Ickes doubted the economics and Larry Backer invoked eugenics, human dignity and sinister profit-motives.  Brian Curran used the Change.Org website to post an anti-wellness petition for "employees, alumni and friends" that has reached 2000 signatories.  Naturally, wellness gadflies Vik Khanna and Al Lewis were unable to resist and used The Health Care Blog to pile on any wellness program with the temerity to not use their consulting services.

The Disease Management Care Blog speculates on lessons learned......

While worksite wellness programs have a reputation for increasing employee morale, it stands to reason for that any stressed organization (and here's why that may be true here), it runs both ways: low employee morale can hinder acceptance of a wellness program. The faculty backlash may be as much of a symptom as a problem.

Lesson: Health promotion programs should tread lightly in times of organization turmoil.  This is no time for "big bang" multidimensional interventions, especially if they involve a $100 per month penalty.

There is good evidence that employer-sponsored wellness programs save money, but it's unlikely that any health promotion will be enough to tame a $217 million budget.  To Penn State's credit, they simultaneously made some health insurance benefit changes, but that's been lost in this controversy.

Lesson: If you're fighting high health care cost trends, don't let the positive return on investment (ROI) from health promotion take the lead. It won't work that well, and employees will think this about reducing your costs, not about increasing their well-being.

Similar on-line WebMD wellness assessments for Pittsburgh city employees and the Mennonite Church have gone without any substantial privacy concerns.

Lesson: If there are two employee groups with a special talent for indignant paranoiac outrage over any employer-sponsored health initiative, it's medical providers and university faculty. There are plenty of reasons, but the DMCB suspects both are victims of the decades-long twin cultures of 1) autonomy and 2) abundance in health care and higher education.  Stopping by a Faculty Benefits Committee is not enough to secure buy-in.

Interestingly, Penn State's College of Medicine has a long standing agreement with Highmark that includes the joint development of evidence-based health, wellness and prevention programs.  Unless that's been cancelled, the medical science faculty's silence is deafening.

Lesson: Search for and engage employee subgroups that can be your allies in launching a health promotion initiative. Their advocacy may really help.

There are wellness service providers like this and this with established records of performance that can successfully reconcile employee and employer needs.

Lesson: There's nothing wrong with preferring to "build" over "buy," but only if both options are carefully considered at the outset.  External wellness providers are often subject to financial performance and recruitment standards. If the petition gains traction, the latter would sure come in handy here.

Critics of wellness programs in general and this one in particular say that they lead to unnecessary testing.

Lesson: The science is still evolving, but here is one answer to that criticism: it's not wellness per se but our society's love of technology.  Wellness programs can use initiatives like Choosing Wisely to develop even better programs.

As a self-insured entity, Penn State technically already has access to all the employees' insurance and claims information.  The WebMD privacy concern is silly.

Lesson: Now would not be a good time for Penn State's administration to point that out.

 

Image from Wikipedia