“WELLNESS OR ELSE” is Dead! Well...Not Quite

I just watched the recent online webinar by wellness vendor Bravo on the forthcoming changes to the EEOC regulations. This presentation can serve as a tutorial for the serious problems the industry has had since the passage of the now discredited Safeway Amendment to The Affordable Care Act, so aggressively lobbied for by the wellness industry and just as aggressively lobbied against by major health and prevention organizations in the country.

Because of the opportunity for education on numerous issues, my colleague Al Lewis and I have decided to split the discussion. His comments can be found here and specifically address the EEOC concerns, the failure of Bravo’s program to save money, the ignorance of clinical guidelines, and how they put their finger on the scale when it comes to outcomes measurement.

My comments will focus on the following four concerns:

• Misunderstanding of the meaning of the word “voluntary”
• Confusion around the research on incentives and health behavior change
• Misinterpretation of the meaning of “successful” weight loss
• “Stuckness” to a mean-spirited, 20th century approach to employee wellness

1) The so-called “safe harbor” provided by the Safeway Amendment permits companies to fine their employees 30% of their total health insurance premium for not participating in wellness programs, as long as they are voluntary. The webinar discussion about whether this is effective, reasonable or coercive ignores the real issue. The word “voluntary” is clearly defined and its meaning is universally understood in our culture:

• Dictionary.com -- done, made, brought about, undertaken, etc., of one's own accord or by free choice
• Merriam Webster -- done or given because you want to and not because you are forced to: done or given by choice

So, if you find yourself scratching your head when the EEOC or Bravo or anyone else suggest that programs can require participation, compel employees to hand over medical information from screenings and health risk assessments and punish them if they don’t comply, as long as the programs are voluntary - you are not alone! This is precisely why we refer to this approach to employee health as “wellness or else.”

For those who remember George Orwell’s Animal Farm, this misrepresentation of the meaning of “voluntary” is eerily reminiscent of Napoleon’s decree that, in addition to an already 60-hour work week, the other animals would be asked to work on Sunday afternoons and that:

2) Despite the conclusive research around the lack of efficacy of incentives for changing health behaviors and saving on health care costs, there are numerous claims in this piece to the contrary, particularly in relation to this “wellness or else” approach to driving health behavior change. Apparently, the conclusions of our leading behavioral economists in this regard were somehow missed.

According to these experts there was never was any research evidence supporting the use of incentives in the form of differential insurance premiums to drive behavior change or lower health insurance costs. As the authors put it in The New England Journal of Medicine:

“Although it may seem obvious that charging higher premiums for smoking (body mass index, cholesterol, or blood pressure) would encourage people to modify their habits to lower their premiums, evidence that differential premiums change health-related behavior is scant. Indeed, we’re unaware of any insurance data that convincingly demonstrate such effects.”

At Minute 32:00, the webinar continues to ignore decades of research on the consequences engendered by these types of approaches to promote sustainable change, saying:

“You should reward what you want to achieve. So, saying we want to reward you for signing up, you’re gonna get a lot of people to sign up. If you say we are going to reward you for a 5% improvement, you’re gonna get 5% improvement far more often than when you don’t reward that.”

Unfortunately, the research is clear that these kinds of incentivized approaches, while they may increase short term participation, are also likely to promote lying, cheating, and blunted creativity and intrinsic motivation – hardly a desirable recipe for wellness at the workplace.

Perhaps the most valid point in the webinar comes at Minute 31:58 when the presenter says in regard to his conclusions about incentives: “I see a lot of minds blowing up right now for that statement.” For those of us who are familiar with the research, this was certainly the case, although probably not for the reasons implied.

3) There are also claims about how weight loss programs with “the right incentives” can get people to lose weight. While people do lose weight in almost all weight loss programs, the research over the past 5 or 6 decades is crystal clear that the vast majority of “losers” end up gaining their weight back.

Nevertheless, at Minute 31:54 of the webinar this graphic was shown as support for the efficacy of incentives for weight loss.

The discussion about how many more people will participate or lose weight with a substantial incentive not only ignores the research on the efficacy of incentives, but is at best a moot point, since again, according to the nation’s leading behavioral economists, there is no evidence that incentivized weight losers maintain their weight losses any better than non-incentivized ones.

The reality of more than half a centuries’ worth of research was summed up clearly in a recent article in the Centers for Disease Control’s journal, Preventing Chronic Disease.

“Sustained weight loss of greater than 5% of body weight is rare.” 

And although there is certainly money to be made claiming otherwise and continuing to promote these initiatives, as Dr. Dee Edington put it almost a decade and a half ago, when it comes to the financial benefits of such programs for employees or their organizations: 

“Weight loss money is money down the toilet.”

4) Perhaps the most troubling part of the presentation concerns the sentiments towards employees. At one point, the discussion turns to the Net Promoter Scores for wellness programs. The Net Promoter Score (NPS) is an alternative to traditional customer satisfaction research that is used by more than two thirds of Fortune 1000 companies. The NPS is calculated based on responses to a single question as follows:

“How likely is it you would recommend our company/product/service to a friend or colleague?”

As is clear from the graphic below, the average Net Promoter Scores for wellness (on the right) are lower than for any other measured industry (on the left).

 How bad are the scores for wellness? Positive scores are considered to be good and scores of 50 or above are considered to be excellent. As the red arrow on the right side of the graphic demonstrates, the average score for the wellness industry in North America is considerably lower than that of any of the industry scores on the left, meaning that participants are highly unlikely to recommend their programs to others.

As a response to this disconcerting data, instead of suggesting that wellness may need to reexamine its approaches, the webinar cites an example of a company whose NPS demonstrated that their employees really didn’t like their wellness program. At Minute 40:27 of the presentation we are told the company should not be concerned and provided the following analogy:

“This is like saying your kid doesn’t like school if you ask me. It doesn’t mean you should say ok sweetie you don’t need to go to school if you don’t like it. We know they might not like getting out of bed at 7 in the morning and heading back to school, but we’ve got a responsibility to help them get educated. So, let me just throw that in there as a quick little two cents, that if you are looking for a program that everybody loves on a survey, its probably not going to require them to lose weight, but if you have a program that helps them lose weight, motivates them, incentivizes them to lose weight and its well-designed, they will lose weight and they will reduce risk and your company will benefit. And usually they’ll thank you at some point. But don’t look for them to say they love their wellness program, if its really focused on risk reduction.”

First, this paragraph can help us to reinforce the importance of grounding what we do in the wellness industry in the existing research because:

• It is not the case that programs that “motivate” and “incentivize” people to lose weight result in sustained weight loss for any but the very few.
• Incentives (punishments and rewards) rarely result in sustained behavior change and are likely to engender significant iatrogenic consequences.
• Employees are overwhelmingly not “thankful” for their wellness programs.

Additionally, this demeaning approach to employee wellness harkens back to Frederick Taylor’s Scientific Management of the early 20th century, which conceptualized and treated workers as basically cogs in a machine with little need for self-management or autonomy.

“Each man must give up his own particular way of doing things, adapt his methods to the many new standards and grow accustomed to receiving and obeying instructions, covering details large and small, which in the past had been left to individual judgment. The workmen are to do as they are told.”

Unfortunately, this kind of harsh, authoritarian view of employees is not uncommon in the wellness space. Infantilizing employees and/or treating them like cogs in a machine is an approach that is antithetical to our current understanding of the critical importance of worker autonomy in today’s rapidly evolving business landscape.

It is all but impossible to imagine any self-aware, forward thinking leader who would accept this kind of portrayal of the employees they serve – and just as hard to imagine any employee striving to do their best for such a leader.

Take Home

We know only too well how difficult it is to retire old paradigms, and the “wellness or else” experiment is no exception. While some in the industry continue to promote these initiatives despite the research, the good news is that more and more companies and wellness vendors alike are realizing that this approach is not helpful and potentially harmful to both employees and their organizations.

So, while proclamations about the death of “wellness or else” may still be a bit premature – we are getting there! - take care - Dr. Jon

For professionals in business and wellness who are looking to find more humanistic ways of improving the employee experience, we invite you to a unique, upcoming conference in Minneapolis in November – FUSION 2.0 – INSPIRING HUMANITY AT THE WORKPLACE – where you will encounter passionate, progressive leaders from business and wellness demonstrating how they are improving the employee experience by putting people first.

And where you will not encounter promotion of "wellness or else," incentives, weight loss programs, medicalizing the workplace, or any other initiatives that threaten the ability of employees to bring their best selves to work and home each day.