Saturday, January 26, 2008

Workplace Wellness Programs: Motivating Employees to Live Healthy

A recent Wall Street Journal article--Wellness Programs May Face Legal Tests: Plans That Penalize Unhealthy Workers Could Get Tighter Rules--discusses the US Department of Labor’s decision to curtail the ability of employers to motivate workers to kick unhealthy habits by making health insurance more expensive for unhealthy workers than for their colleagues.

Workplace wellness programs--which focus on illness prevention and chronic disease management through self-maintenance--are one key ingredient for healthcare cost control. Healthier employees tend to be happier, more motivated and more focused, which benefit their employers through reduced healthcare-related expenditures, improved productivity, lowered absenteeism and fewer on-the-job accidents. While “sticks and carrots” can help convince some employees to adhere to their wellness plan and lead healthier lifestyles, it will be ineffective or even harmful for some due to powerful psychological, physiological and situational factors. These strong internal and external influences will affect the wellness market by giving credence to the legal issues in article and by stressing the judicious use of incentives and disincentives.

Even most presidential candidates agree that wellness programs are essential for controlling healthcare costs. Employer-based wellness programs have been shown to have substantial return on investment through increased productivity and reduced absenteeism, by promoting employee health & safety and organizational effectiveness, and by reducing expenses through lowered sick-care utilization. For example:
  • The Leapfrog Group reported that many of the largest U.S. employers, with 54% of them now offering some version of health coaching to employees.
  • The US Dept. of Health and Human Services reported that: (a) a Johnson and Johnson’s wellness program yielded an estimated savings of at least $1.9 million through decreased medical costs, reduced sick leave, and increased productivity; (b) city employees insured by the City of Mesa, Arizona revealed a significantly greater decrease in health care costs of employees who participated in a mobile worksite health promotion program, as opposed to employees not participating. Health care costs decreased 16%, resulting in a $3.6 savings for every dollar spent on health promotion services; and (c) the return on investment enjoyed by five large companies, as a result of their health promotion and disease prevention activities, ranged from $2.05 to $6.15 per employee.
  • The Small Business Wellness Initiative found that businesses that invest $1 in workplace wellness can often reap $3 to $5 in savings through lowered healthcare costs, decreased absenteeism and decreased workers’ compensation claims.
  • The Texas Coalition for Worksite Wellness reported that the average cost of adding prevention and wellness services to a private health insurance program is typically $50 to $85 per person. Yet, every dollar invested in worksite health promotion yields $3.50 to nearly $6 in savings through reduced absenteeism, increased productivity and decreased health care costs.
  • And a wellness program at IBM returned $3 in healthcare savings for every $1 spent on wellness.
Despite these convincing numbers, workplace wellness programs ought to be cautious in their use of rewards and punishments for motivating employees to lead healthier lifestyles. There is good reason for the Department of Labor’s recently issued regulatory guidelines rejecting the use of incentives and disincentives that make health insurance more expensive for unhealthy workers than for their colleagues. I’ve identified the following three reasons why such tactics are unrealistic and won’t work for many employees.

1. Addiction (and compulsion). As mentioned in the article, smoking (as well as drug and alcohol) addiction is due to the influence of a powerful complex of biological and psychological factors. For many people, counseling (and medications) is required, and numerous relapses are common. Instead of simply punishing smoking, those addicted ought to be rewarded initially for participating in counseling to deal with the physical and psychological causes of their addictions. For employees whose health would improve if the curtailed their use of alcoholic beverages and recreational drugs, the same strategy should be offered, assuming they are not breaking company policies.

Similarly, certain compulsions, such as the drive to persistently overeat, are driven by powerful physiological, mental and emotional influences. As with addictions, weight loss typically requires counseling, family/peer support, and even medications or other medical procedures (e.g., gastric bypass or band). Our culture makes matters worse by promoting unhealthy diets through commercials and fast-food companies selling high-carb and high-fat foods and beverages. If we’re serious about reducing obesity, our society also should focus on changing these maladaptive cultural influences.

2. Hopelessness/Helplessness, Depression, and Denial. Some people lack the optimism and confidence to change their unhealthy lifestyles. Feelings and perceptions of hopelessness and helplessness are part of their personalities, which have been created by their personal experiences, attitudes and emotions. People who don’t believe they can succeed are not motivated to change, of course. Likewise, lonely or depressed people aren’t going to change their lifestyles in order to extend their lives because the prospect of living longer in chronic emotional pain isn’t very motivating. And when confronted with the knowledge that their health risks can kill them, many people tend to deny it because the idea is just too emotionally painful to acknowledge. So, threat of death isn’t a powerful motivator for many. In fact, the odds are nine to one that a person will fail to make substantial lifestyle changes, even if facing probable death!

Compelling discoveries in the fields of cognitive science, linguistics and neuroscience, however, are helping us understand how “reframing” the issue is essential. For example, people are more motivated to change if they can have a vision of “joy of living” rather than a “fear of dying,” since joy is a more powerful motivator than fear. This kind of reframing changes the mental structures that shape one’s view of the world, and it typically requires psychological counseling (individual and/or group). It may take months of counseling to the break through the thoughts and feelings that block one’s motivation to change. [Reference]

Sticks and carrots alone will not motivate these people to change; and some sticks may even lead to denial. Instead, they must first believe they can succeed in making the necessary changes in their lives and they must have a mental framework in which the prospect of a longer life brings them joy. Their initial incentives, therefore, ought to be focused on getting them involved in the counseling they need.

3. Time and Money (Resource) Constraints. Many employees have work, family and other demands that consume their time and make lifestyle change difficult. What they need is help with time management and developing wellness plans that take their busy schedules into account. Some have serious money problems, which prevent them from buying more healthy foods, a gym membership, prescribed medications, diagnostic tests, etc. s Sticks and carrots will be useless until these time and financial issues are resolved.

In conclusion, using incentives and disincentives fails to motivate many employees to live healthier lives. Wellness programs, therefore, ought to focus on providing the risk assessment, feedback and counseling necessary to deal with the emotional, attitudinal and resource blocks that prevent employees from making positive changes. Rewarding these people for participating in such counseling make sense, but punishing them for failing to improve their health is foolish and worthy of criticism by the Labor Dept. Not until these employees have attained a more positive psychological/emotional state will they be motivated to change. Only then does is make sense to reward them for achieving biologic benchmarks (e.g., weight, cholesterol levels, blood pressure, etc.) and behavioral goals (e.g., diet, exercise, non-smoking, reduced alcohol consumption, medication compliance, etc.).

In my next post, I discuss how a "whole-person integrated care" model addresses the particular needs of people with different personalities and levels of motivation.

Saturday, January 12, 2008

Can our government be trusted to run a universal healthcare system?

I've been involved in several discussions about the Analysis of the Candidates’ Healthcare Proposals web site I published last week (and have updated since then). Much of the debate centers on mandates and trust of our government to run a nation-wide universal healthcare system.

One reader had this to say:
Within the current system, the mandated "Medicare drug plan" appears to be heavily weighted to benefit the pharmaceutical manufacturing & distribution industry. Please give me your thoughts or analysis on the recognition of the candidates in what certainly appears to be an industry with very powerful influence in government. My personal assessment/feeling leans toward a more competitive market with as few government controls as possible. However I do feel government has a needed and viable role in the healthcare of our citizens.
I responded as follows:
I haven't analyzed who benefits most from the Medicare drug plan, but based on my understanding of our current healthcare system, I have little doubt that powerful lobbies influence policy. For example, a 2004 study on healthcare lobbyists [here’s the link] found that, of the of 1192 organizations were involved in healthcare lobbying, pharmaceutical companies spend more money lobbying Congress than other health care organization. Other top lobbyists are medical device manufacturers, insurance companies and healthcare provider organizations. In 2000, healthcare lobbying expenditures totaled $237 million, which was more than the lobbying expenditures of every other industry, including agriculture, communications and defense.

This supports your implication that our government can’t be trusted to do the right thing for the masses due to the influence of special interests.

At the same time, these data imply that these special interest groups--i.e., those making money from the current system--will not likely start delivering high-value to the consumer/patient on their own since greater cost-effectiveness for the consumer/patient eats into their profits under our current broken healthcare system (see this link for more about the need for a greater value).

So, I agree that more sensible competition is one part of the solution, and I agree there must be government mandates if we are to have quality improvement, cost control and good care for all. But it’s debatable as to the kind of government influence is needed (e.g., what types of mandates) and what can be done to hold politicians accountable to the people/consumers/citizens?

Personally, I’d like to see our government provide funding and management for all the reasonable quality improvement and cost control strategies presented in the candidate comparison web site. I’d like this to be done in the most effective and efficient way possible, with all government agencies involved being closely watched and scrutinized by an independent oversight organization whose allegiance is to the consumer.

One question is whether a single-payer system, which is run completely by the government as in other countries, would be better than a system in which private insurers compete with a government run universal healthcare program. As discussed in the candidate comparison web site, the main arguments against a single-payer system can be disputed. CMS does run Medicare and Medicaid after all, which is a single-payer system.
The issue of trust in our government, however, remains unresolved. I suggest that these be the healthcare-related issue we focus on.

Thursday, January 03, 2008

Analysis of the Candidates’ Healthcare Proposals

After analyzing the details of each Presidential candidate’s healthcare proposal, it appears that a person is likely to select a proposal based on one’s:
  • Current health insurance plan
  • Level of wealth
  • Priority for assuring good healthcare for all.
Combining these three factors results in eighteen groups of voters--each with particular wants and needs--who would prefer different candidates' proposals based on these factors.

Here is a link to the Analysis of the Candidates’ healthcare Proposals web site. It presents a systematic detailed comparative analysis of each candidate's healthcare proposal based on the wants and needs of the 18 voter groups. The analysis resulted in the following conclusions:
  • The candidates most concerned with improving the quality and controlling the costs (i.e., increasing the value) of healthcare are: Clinton, Edwards, Kucinich, Obama, Richardson and McCain.
  • Voters who want good care for all are willing to do what it takes—including paying increased taxes, etc.—to support a publically-funded UHS. Candidates who want a Federal Employees Health Benefits Program UHS (FEHBP-UHS) and want to keep private insurance as an option are: Biden, Clinton, Dodd, Edwards, Obama and Richardson. Only Kucinich proposes a government-run Single Payer UHS (SP-UHS). Choosing between these two options is discussed on the web site.

    • If an FEHBP-UHS is desired, then Clinton and Edwards are the best choices because they also more focused on increasing care value, with Obama and Richardson coming in second.
    • If an SP-UHS is desired, then Kucinich is the only choice. Note that his plan (HR 676) is also the most detailed (has the greatest specificity), which means it may be the most credible.
  • On the other hand, any Republican is a suitable choice for voters who (a) are not concerned about the care others receive (they aren’t interested in good care for all) and (b) are confident they will always have excellent insurance, or can afford to pay for the care they need out-of-pocket if they lack adequate insurance. Choosing between Republican candidates would likely be based on their strategies for:

    • Minimizing taxes and reducing personal health-related expenses
    • Increasing healthcare value (cost-effectiveness), in which case McCain is probably the best choice since he proposes the most strategies of all Republicans for improving quality and controlling costs (as well as being the only Republican addressing the health need of veterans through the VA).
    Note, however, that there are significant gaps in every candidate’s proposal. It would be useful to know how what it would require to (a) evaluate all the quality improvement and cost control strategies described in this document and to (b) implement the effective ones efficiently.
    All these and other related issues are examined on the web site, including issues concerning healthcare quality improvement, cost control, financing new publicly funded universal healthcare systems, subsidies, mandates, tax changes, and more.

    I welcome your comments.