Insights: Workplace Wellness

Dr. Ron Goetzel of Johns Hopkins and IBM Watson Health shared that, in a 2008 Kaiser Family Foundation survey of employers, the majority claimed to have some sort of workplace health promotion program. Yet, a closer look at that same collection of employers revealed that only 7% actually had a comprehensive, evidence-based program in place. While Dr. Goetzel indicated that the proportion with evidence-based programs has increased to more like 13%, the point is nonetheless painfully clear: Countless minimally impactful efforts masquerade as wellness programs, often with little or no evaluation of their efficacy. While less comprehensive efforts may still have positive effects – they may make employees happy or help attract new hires – they generally fail to achieve the intended outcomes of workplace wellness programs, including employee wellness, increased productivity, and healthcare cost savings.

However, well-constructed programs can still succeed, and they often do, because they stand on a foundation of evidence-based practices. In fact, the CDC’s review of multi-component worksite obesity prevention and control programs demonstrated that these programs have been consistently linked to increased physical activity, reductions in weight, and reductions in percentage of body fat.[i]  A systematic review conducted by the American Journal of Preventive Medicine found that workplace nutrition and physical activity programs are linked to reductions in employees’ weight and BMIs, confirming the worthwhile investment in employee health.[ii] To truly reap the benefits of wellness programs, employers must commit to a whole-hearted, evidence-based approach. Implementing one comprehensive intervention targeted at a single goal is likely to make a bigger difference than ineffectively trying to address many challenges, each with only minimal investment.

[i] Multi-Component Worksite Obesity Prevention. Centers for Disease Control and Prevention website. www.cdc.gov/policy/hst/hi5/worksite/index.html.

[ii] Anderson LA, Quinn TA, Glanz K, et al. The effectiveness of worksite nutrition and physical activity interventions for controlling employee overweight and obesity: a systematic review. Am J Prev Med 2009;37: 340 –57

The ultimate goal of workplace wellness programs isn’t just to reduce direct spending on care, but also to have employees that are healthier overall. Of course, in the long term, this should also ideally reduce direct costs, but focusing on direct costs alone overlooks some of the most substantial and easiest-to-influence ways that health affects an organization’s workforce. Health is a significant driver of indirect costs, most notably through absenteeism (lost work time) and “presenteeism” (unproductive time spent at work). For example, the American Diabetes Association estimates that diabetes alone cost the United States $245 billion in 2012, of which 28% ($69 billion) was attributed to the indirect costs of absenteeism, lost productivity, and early disability and death.[i]

Well-designed workplace health promotion programs tend to have the potential to impact both direct and indirect costs. The drivers of indirect costs, however, apply to a broader definition of health than can be captured by biometric markers or health screenings. To truly address absenteeism, and especially presenteeism or lost productivity, employers would be wise to recognize not only the physical aspects, but also the emotional, financial, intellectual, and even spiritual facets of health. By taking this comprehensive view of the overall wellness of their employees, employers have the potential to increase productivity and employee satisfaction, and even to reduce rates of employee turnover.

[i] “Statistics About Diabetes” (American Diabetes Association, March 6, 2013), http://www.diabetes.org/diabetes-basics/statistics/.

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Just like with medications, behavioral and environmental interventions also have an ideal “dose.” Falling short of the dose is likely to weaken or completely negate the impact, and overdoing such interventions, while less dangerous than overdosing medications, has the potential to be a waste of time and resources, and even something of a nuisance. For example, Dr. Michael P. O’Donnell, founder of the American Journal of Health Promotion and CEO of the Art and Science of Health Promotion Institute, explained that the optimal intervention for smoking cessation features 300 minutes of “talk therapy,” spread out over 8 sessions, and should be encouraged by a medical professional and supported by at least two other individuals. In most cases, going beyond these benchmarks yields minimal benefit while increasing costs, but undershooting them leads to a notable drop-off in success rates. Like smoking cessation, virtually all interventions have an ideal level of investment and involvement. Employers may want to consider directing their resources toward reaching the therapeutic dose on a few interventions, rather than attempting too many and coming up short on all of them.

Most incentives provide extrinsic motivation – they push you to reach a goal with the offer of a reward when you get there. The transaction generally ends here. But extrinsic motivations tend not to stick, because they don’t change people’s habits and more personal (intrinsic) motivations and goals. In other words, an incentive like a monetary reward for weight loss will be effective in getting people to lose weight in the short term, but is generally ineffective in sustaining that weight loss or changing eating habits in the long term. Obesity, prediabetes, and diabetes are chronic, even life-long challenges that require follow-up and sustained commitment to care.

While incentives generally aren’t sufficient to keep people engaged long-term, however, they shouldn’t be written off altogether. In fact, as Dr. Michael P. O’Donnell reminded us, extrinsic motivators are quite effective at getting people’s attention in the first place. Intrinsic motivation, by contrast, drives long-term change but takes time to build, as do habits. Intrinsic motivators are slow-uptake, high-retention while extrinsic motivators tend to be fast-uptake, low-retention; and a well-designed wellness program should incorporate both.

It’s important to have elements that encourage that initial engagement because a health promotion program can only be as good as its ability to get people involved in the first place. This means that, in addition to those incentives that reward employees for behaviors (rather than outcomes), employers should also consider incentives that can attract participation. But the actual value of health promotion programs results from everything that comes after employees get involved. If employers invest all their resources in getting people to show up, with no subsequent emphasis on supporting and encouraging their sustained engagement, they are unlikely to see positive results. It is critical that employers don’t just create excitement upfront; the excitement needs to be justified by a program that aligns with the initial motivation and a workplace culture that supports and reinforces the behaviors that the wellness program encourages.

While incentives are best for providing extrinsic motivation, it is worth asking whether or not they can influence the intrinsic drivers of sustained change. The answer appears to be a resounding “maybe.” First, it depends on the type of incentive. Most employers favor monetary incentives – a bonus, for example, or a reduction in the share of coverage costs paid by the employee. However, while money can certainly serve as a powerful motivator, it tends to function extrinsically. Given this, the other things that might function as additional rewards should be evaluated, such as positive recognition among peers or supervisors, charitable contributions in place of monetary prizes, and more.

Arguably more important is the question of what the incentives reward. The impulse is often to reward people for reaching desirable benchmarks, such as a target BMI or cholesterol. But again, the transactional form of “reach a benchmark, get a reward” (or for that matter, “miss a benchmark, get punished”) fails to address long-term, intrinsic motivations. Dr. Goetzel recommends, instead of rewarding outcomes, reward behaviors. The best incentives – “smart incentives,” as he calls them – aim to reward people for habits that stick long term, not for changes in the short term. Even if outcomes determine healthcare costs (or savings), healthy behaviors, and not just biometric benchmarks, should be the goal.

Many people with whom we spoke emphasized that buy-in from the leaders in any organization is essential to establishing a culture that supports and reinforces an effective wellness program. Part of this comes from direct culture-setting; leaders need to “walk the talk” on workplace wellness to establish a health culture as the norm in any organization. In a more practical sense, leadership buy-in is also often the key to securing the necessary resources to create and sustain a comprehensive program. In large organizations, this works best when buy-in comes from multiple departments or areas, as this reinforces the culture in a broad way and creates many stakeholders in the program’s success.

What is true for virtually all health interventions holds particularly true for workplace wellness programs – the environment in which the intervention occurs directly affects its success. A nutritional education and weight loss program, for example, probably won’t do well in an organization where the cafeteria doesn’t offer, prominently display, and promote healthy options. That being said, many of the most important environmental factors are not so simple as having fruits and vegetables on display.

After all, the reason that environment is so crucial in health promotion is that a person’s environment determines how convenient, safe, and straightforward it is to practice any particular behavior. Does the healthy option require more or less work than an unhealthy alternative? Is it likely to be encouraged or discouraged based on what you see other people doing around you?

Workplaces can be particularly challenging to create an environment where people can default to healthy choices. Jobs that involve extended periods of time sitting at a desk or in meetings, for example, can strongly discourage physical activity, not simply for practical reasons but also for more culture-driven reasons – disruptions from the normal sedentary habits of the workday can be discouraged as unproductive or wasted time. In this way, employers can undermine their own health interventions by discouraging, through culture, the very behaviors that they aim to encourage in their health promotion efforts

Given that a significant proportion of adults spend substantial amounts of time at work, workplaces are a logical place to focus health promotion resources. However, the best programs motivate employees to engage in healthy behaviors not only at work but also throughout their day-to-day lives outside of work. For example, many employers offer the opportunity for family involvement in their programs, whether through extending various resources and benefits like fitness classes, offering technological support to spouses of employees, or even including families in company challenges and competitions. By allowing for shared opportunities in this way, employers create social support and reinforcement for healthy behaviors.

The bottom line is employers benefit from investing in wellness and minimizing incurred losses due to employee illness and related loss of productivity. One study, which modeled returns on investments for workplace obesity interventions, estimated that a 5% weight loss would result in a reduction of total annual costs, including medical costs and costs of absenteeism, of $90 per person, demonstrating that workplace wellness is not only beneficial to employees, but employers too!^[i] Studies have also suggested that worksite health promotions interventions can improve workplace productivity, which suggests the cost-effectiveness of such programs.^[ii] Last, employers need to invest in their employees with chronic conditions, and it is actually cost-effective for them to do so. A 2014 RAND study estimated that the total return on investment for workplace wellness programs was $1.50 – or a return of $1.50 for every dollar the employer invested in workplace wellness.^[iii]It is important to note that the majority of these returns were driven by investments from disease management programs. While the workplace wellness programs evaluated only invested 13% of total workplace wellness funds towards disease management programs (87% on lifestyle management programs), those investments had significantly higher returns of $3.80. In other words, there was a return of $3.80 for every dollar employer’s invested in disease management programs, savings that were driven primarily by reduced healthcare costs, and secondarily by reduced absenteeism and increased productivity. ^[iv] These findings should encourage employers to invest in their employees who have chronic conditions like diabetes, prediabetes, and obesity.

^{[i] {Citation}}

^[ii] Jensen, J.D., Can worksite nutritional interventions improve productivity and firm profitability? A literature review. Perspectives in Public Health, 2011. 131(4): p. 184-192.

^[iii] Soeren Mattke et al., “Do Workplace Wellness Programs Save Employers Money?,” 2014.

^[iv] Do Workplace Wellness Programs Save Employers Money? Santa Monica, CA: RAND Corporation; 2014.

www.rand.org/content/dam/rand/pubs/research_briefs/RB9700/RB9744/RAND_RB9744.pdf.

The following are 20 questions that we have assembled as a tool for considering how your workplace encourages and supports health. These are meant to provide “big picture” considerations of some of the most important facets of health promotion, rather than specific ideas for programs. For more specific and detailed health assessment tools, we encourage you to explore the CDC’s Worksite Health Scorecard and HERO Health’s Well-Being Best Practices Scorecard.

Program Design and Assessment

1. Does your worksite have a health promotion program? If so, who does it cover?

2. How does your company/organization fund health promotion? Does it have an annual health promotion budget set aside?

3. How does your company/organization assess your health promotion efforts? Do you measure behaviors in addition to healthcare costs and biometric markers or outcomes?

4. What aspects of your program are modeled after evidence-based best practices? Does this include consideration of the “therapeutic dose” of initiatives? Does it allow for referral to therapy and higher levels of medical care?

5. Are programs offered to all employees, or specifically to those who meet certain criteria or risk levels?

Holistic Wellness

1. Do your employees have sufficient income and sufficient time to practice healthy behaviors?

2. What measures are in place to address mental and emotional health, including stress?

3. What elements of your program allow your employees to engage in healthy behaviors outside of work? Does this involve their families?

4. What programs does your worksite have to support people living with chronic conditions?

5. How does your wellness program incorporate chronic disease prevention?

Employee Engagement

1. How do you involve employees and their priorities in the design of your wellness program?

2. How do you engage your employees in your wellness program? What kind of incentives do you offer for participation? What reasons are there to engage beyond incentives?

3. If you offer incentives, do they reward behaviors, outcomes, biometric markers, or something else?

4. What group or communal activities are available to employees?

5. What is the central message of your wellness program? Who does it most benefit, and how is this communicated?

Healthy Culture, Healthy Environment

1. What is the central message of your wellness program? Who does it most benefit, and how is this communicated?

2. How are healthy choices made more convenient at your workplace?

3. How do aspects of the physical environment of your workplace reinforce or contradict wellness messaging?

4. How many different departments of your organization are invested in encouraging wellness? Is it seen as a benefit, or as an organizational value?

5. How do leaders in your company/organization communicate, encourage, and model a message of wellness?