When Do Workplace Wellness Incentives Cease to be Voluntary?

This is a recent NPR clip about the current state of workplace wellness. It’s a pretty good summary of the current state of affairs so I wanted to post it. The transcript of the audio is below. 

Most medium to large employers offer some sort of wellness program for their workers. That can range from health screenings, to weight loss, and smoking cessation programs. Many employees like these options, and employers like that they can help hold down health insurance cost. But, there are legal questions about how far employers can go to encourage participation. NPR’s Yuki Noguchi has the story.  

Yuki Noguchi: Scott’s Miracle Grow makes products for the care and health of lawns. The Marysville, Ohio company says it wants to nurture its 8,000 employees the same way.

Jim King: It’s very much of a family culture here.

Yuki Noguchi: Jim King is a spokesman for the Scott’s company, which offers discounted prescriptions, annual health screenings, and some free medical care. In states where it’s legal, it refuses to hire people who smoke.

Jim King: We’ve been screening for tobacco use for about a decade. We no longer employ tobacco users.

Yuki Noguchi: That provision landed the company in court several years ago. A new hire failed a urine test for nicotine, lost his job offer, and sued the company arguing it was meddling in private affairs in order to drive down costs. He lost on appeal in 2012. About 80% of Scott’s employees submit to health screenings, and those who make unhealthy choices pay more for health insurance. King says Scott’s wellness policy attracted outside scrutiny, but employees embrace it.

Jim King: Once people understood what the program actually was, they recognized that it wasn’t anything like Big Brother at all. In fact, what we were doing was providing them tools.

Yuki Noguchi: Participation in the wellness program at Scott’s is not mandatory. In fact, under the law, such programs must be voluntary. But, regulators are now trying to define what voluntary means. Some hospitals require their workers get flu shots, which is controversial among those who can’t or don’t want to get vaccines. Beyond that, there are questions about money. For example, is a big financial penalty for non-participation too coercive? What about incentives for completing health screenings? Nico Pronk is Chief Science Officer at HealthPartners, a hospital system. He researches the effectiveness of wellness programs and says their design matters. He says incentives can work, but you have to be careful not to overdo it.

Nico Pronk: Once the incentives amounts go over a certain threshold, it may become a little bit more coercive.

Yuki Noguchi: Last year, the Equal Employment Opportunity Commission sued several companies, alleging their policies were too heavy handed. They argued those companies required health screenings or made non-participants bear the full cost of health insurance. Christopher Krysinksi is Associate Legal Counsel at the EEOC. He notes that, in a separate proceeding, the Commission is considering regulations to define what companies are allowed to do to encourage participation in wellness programs.

Christopher Krysinski: Limited incentives are permissible as long as the maximum incentive for participating doesn’t exceed 30% of the total cost of coverage.

Yuki Noguchi: Krysinski says employers must make sure that programs comply with many laws, including health and genetic information privacy, the Affordable Care Act, and the Americans with Disabilities Act. Employers can’t use a worker’s health against them.

Christopher Krysinski: There are opportunities for discrimination. This information that’s collected as part of a wellness program can’t crossover to anyone who deals with making employment decisions.

Yuki Noguchi: Business groups say they are striking a balance between encouraging participation and protecting the choice of their workers. Brian Marcotte is President and CEO of National Business Group on Health, a policy group representing large employers. He says most health care costs are lifestyle related and employers want to reduce costs. But, that’s not the only calculation companies are making.

Brian Marcotte:    At the end of the day, employers want healthy, productive, engaged, resilient employees in the most competitive workforce possible. And investments in health and well-being are part of that equation.

Yuki Noguchi: Nancy Hammer is Government Affair’s Counsel for the Society for Human Resource Management. She says employers want to draw in, not compel workers.

Nancy Hammer:   Health care and wellness is an employee benefit. So, you got to do something that is attractive to your employees.

Yuki Noguchi: No one benefits, she says, if no one uses the programs. Yuki Noguchi, NPR News, Washington.

If Wellness Programs Work so Well, Why Isn’t Everybody Convinced?

Given my success as a marketer, getting one to buy something they might not (know they) need or that they might consider a luxury is second nature. When it comes to wellness programs, much has already been written about companies advertising the positive return on wellness – different numbers are consistently tossed around: from a ROI estimate of about $3 for every dollar spent to humbler claims of $1.65 saved for every dollar invested (Naydeck et al., 2008). Until recently, these research findings were generously and unquestionably provided to clients to make them feel confident about their investment in workplace wellness (by using quantifiable data that substantiated the managers’ decisions to invest in the program).

Researcher and participant bias

An undeniable concern of wellness program assessments is that they are often performed by the consultants who advocate them. Therefore, if a particular program is evaluated as ineffective, this could lead to the loss of a client or a job (Lewis & Khanna, 2013).

Another bias has to do with the selection of research participants: employees who opt-in to workplace wellness willingly are generally a group of volunteers who are already motivated to engage. The control group, on the other hand, is usually comprised of disproportionate amount of people who decided not to take part in the program, so in comparison, this group could be considered less motivated to improve their health (Lewis & Khanna, 2013). Since motivation is the key factor when it comes to changing health-related behaviors, having a group of motivated people compared to a group of (potentially) non-motivated people becomes highly questionable in terms of research validity, and certainly a methodological limitation.

Those who shout the loudest are not necessarily in the biggest trouble

A recent critique of workplace wellness programs has been that they provide for employees who do not really need them and who would likely lead a healthy lifestyle with or without these initiatives. People who might be at higher risk (smokers, the obese) are less likely to be drawn in – instead merely serving as a control group that positions the program as viable.

However, non-participants are more than just a methodological glitch. They also embody the industry’s challenge to engage people who could arguably benefit most from health promotion – if only we could sway them to participate in the programs wholeheartedly and continuously.

Why doesn’t more of the workforce participate?

Critics of workplace wellness such as Lewis and Khanna (2013) argue if wellness programs do so much in terms of health improvement and save both employers and employees’ money, how come not everybody is jumping onboard?

Barb Hendrickson (2013) explored some of the reasons employees choose not to participate in sponsored wellness programs. The explanations ranged from not being interested in improving health (ex. smokers usually know that smoking is bad for them) to not trusting the company’s intentions regarding the handling of their health data.

More often than not, workers opt-out due to their established believes (about health, the company, the management’s motivations, etc.) and/or because deeply rooted behaviors take more than a health questionnaire and a health club membership to alter.

The twofold question

How do we make the non-participants participate?

Workplace wellness providers often focus their efforts on those who are willing to participate. This is likely because strategies to engage those who lack motivation are more difficult to execute. Arguably, engaged participants are prone to change their risky behavior with or without the extra support and are internally motivated to do so anyway. It is the not so eager ones who are often exposed to higher health risks and could benefit most from good health initiatives.  

How do we build a stronger evidence-base for wellness programs?

When conducting studies, it is possible to employ a somewhat less biased participant selection, as demonstrated by Naydeck and colleagues (2008). In their study, participants and non-participants were carefully matched on a variety of factors that are known to contribute to health cost such as gender, age, total medical expenditure for one year, evidence of heart disease and diabetes, and scores on the Charlson Comorbidity Index (which predicts mortality, stroke, the presence of some health conditions, and the length of hospital stay).

Through research and civil discourse, these two questions can get answered. As we continue to get a better understanding of participants’ motivation – one of the key factors for success in improving health – we in the field need to ensure we consult other disciplines such as behavioral psychology, social psychology, environmental engineering, nutrition, and also employ novel/less conventional methods of assessments that can capture this complex phenomenon.  Furthermore, the concept of cultivating a culture of wellness within organizations needs to be further explored. Otherwise, wellness programs will remain primarily activity-based and participation rates in the long-term will remain flat.