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.