Large, randomized study shows mixed results, highlighting challenges of programs
Are wellness programs really worth the investment? It’s a broad question for a broad issue, but one study has found the gains might not be as hoped. And that could have a lot to do with the objectives of such a program.
“If employers were implementing these programs in the hopes that they would save money over the first year or two, we don’t find any evidence to support that. If they were implementing these programs in the hopes of improving employee health behaviours and providing a benefit that employees value, we do find evidence to support it,” said Katherine Baicker, co-author of the study and adjunct professor of health policy and economics in the Department of Health Policy and Management at the Harvard T.H. Chan School of Public Health in Boston.
The issue of wellness and return on investment (ROI) is complex, said Farrell Cahill, post-doctoral fellow at Medisys Health Group and Horizon Occupational Health Solutions in St. John’s.
“A lot of the papers that come out saying that wellness is of no use means just that that wellness approach… wasn’t specific enough, wasn’t tailored enough,” he said. “We need to really, really understand that we can’t just create a standardized or generic wellness program. Maybe we can look at what are the minimum components — physical activity, nutrition, stress reduction, all of those are important — but to just assume that they’re going to change the KPI (key performance indicators), they’re going to help with an ROI, they’re going to make a reduction in health, and they’re going to have people get healthier — you don’t even know how many people participate.”
The randomized trial involved 32,974 employees at a large U.S. warehouse retail company, with randomly selected treatment worksites and control worksites that received no wellness programming. The 2016 program comprised eight modules focused on nutrition, physical activity, stress reduction, and related topics implemented by registered dietitians.
The study looked at self-reported health and behaviours through surveys, while clinical measures of health were done through screenings. It also looked at health-care spending and utilization, and employment outcomes from administrative data.
After 18 months, the rates for two self-reported outcomes were higher in the intervention group than in the control group: engaging in regular exercise (69.8 per cent versus 61.9 per cent) and actively managing weight (69.2 per cent versus 54.7 per cent).
However, the program had no significant effects in other areas: health outcomes and behaviours (including health, sleep quality and food choices), clinical markers of health (including cholesterol, blood pressure and body mass index), medical and pharmaceutical spending and utilization measures, and employment outcomes (absenteeism, job tenure and job performance).
“We were not able to detect any improvements in health outcomes, like blood pressure or obesity. Nor in health-care spending, we didn’t see any statistically significant reduction… nor improvements in employment outcomes, like reductions in the number of absentee days or increases in tenure at the workplace,” said Baicker.
“It’s possible that those effects would manifest after a longer time period, and we’ve continued to study this population.”
For employers keen to jump on the wellness bandwagon, these results may give them pause, said Zirui Song, co-author and assistant professor of health-care policy and medicine at Harvard Medical School.
“It encourages them to ask the question: ‘Do we know what the return on investment on our investment will be? Do we have evidence of what the effects of the program we are about to purchase are?’” he said. “These results ought to provide some caution that perhaps in the short run, the changes and the outcomes that they desire may not be realized as easily as they may have hoped.”
It can really depend on the employer’s objectives, said Song.
“If an employer values behaviour change, for example, without necessarily the need to have a return on investment in health-care spending in the short run, then these results might be encouraging. Whereas an employer who values savings on health-care costs beyond other potential outcomes may find these results less encouraging.”
But there are many different types and designs of wellness programs, he said.
“(This study is) certainly not a final verdict on wellness programs that might be more targeted towards a specific subpopulation or disease condition or outcome... they could certainly lead to different results when they are designed differently and vary in intensity and implementation.”
It is hard to know what wellness programs are really accomplishing without a randomized controlled trial like this, said Baicker.
“The type of person who volunteers to participate in a wellness program may look different — in lots of ways — from the type of person who chooses not to participate. For example, if you just looked at a company that offers a wellness program, and saw the health of people who participated in, say, the free gym membership compared to people who didn’t, and found that the people who participated in the free gym membership are more physically fit, it would be tempting to say, ‘Look, the wellness program increased physical fitness,’” she said.
“But the type of person who’s more likely to take up your offer of a free gym membership is probably the type of person who was more interested in exercising in the first place, and might have been going to the gym anyway. And so a lot of prior studies of the return on investment were forced to compare participants to non-participants, and get that potentially biased conclusion.”
One of the problems with wellness programs is that no one bothers to measure adherence, because most people who fill out surveys are early adopters and already physically fit, said Cahill.
“We’re not after them, we’re not trying to move the needle with them — they’re already healthy. We’re trying to find a way to see if we can get everybody to participate. And we should be more worried about the fact that we’re getting below 90 or 95 per cent participation than being happy with 30 per cent participation.”
Tips for employers
Employers need to be clear on what the goal of the program is, said Baicker.
“Is the goal to save money by reducing health-care spending and reducing absenteeism? Or is the goal to offer a benefit that employees value? Those would lead to very different conclusions.”
Employers also have to be patient, according to Cahill.
“There has to be a realistic approach of what the culture will adopt… you have to take baby steps, if you will, to try to understand what you actually need. You have to try to find a way to customize your wellness to acceptable components that you think will actually help you, and then try to increase more and more of it as it becomes more applicable to your workforce, and the more you understand it.”
If, for example, there’s a problem around ergonomics, then that’s a place to start, he said.
“We’re going to look at those workers that are experiencing those types of injuries and build wellness specifically around that to reduce the injuries, to reduce the cost that’s actually coming out of your pocket. And then we’ll have made a shift where wellness will be useful, it will help prevent injuries, and will help to be able to mitigate the injuries that are taking place,” said Cahill.
“If it’s specific in that way, wellness works. But if wellness is going to be something that you’re just going to try to sell a large company, and the company is basically buying it because they think, ‘Well, it’s good,’ you’re going to destroy what wellness really can be.”
The program needs to factor in the work environment, said Cahill. “People who work in the offshore oil and gas industry cannot be treated the same way as people that work in a warehouse, or people who work for companies like Tim Hortons… they all have to be treated specifically based on their occupation.”
Connecting with participants is also key. The wellness program used in the study had a lot of outreach, said Baicker, including emails, physical posters and on-site registered dietitians. The latter is an important component in having great people employees can talk with, she said.
“There was a nice in-person component that I think was probably very important to encouraging participation and helping implement the programming.”
Having people on site is critical, said Cahill.
“One-on-one is the best approach… there’s a more meaningful interaction going on. And they’re able to make sure that they’re getting help rather than trying to read the material.”
And if that’s not possible, a virtual portal can help in having human beings to coach and support employees, he said.
“If we can virtually communicate with them, we get a lot further than me giving them a website to maybe look at.”