Workplace wellness programs: Helpful or burdensome?

Workplace wellness programs seem poised for takeoff, and yet there are still many questions about whether they can truly improve patients’ health and if they will do enough to include physicians as partners, or just add to the ever-growing administrative burden.

The programs have been gaining popularity over the years, especially with large employers. An estimated half to three-quarters now offer some type of wellness program. The typical – and most common – program offers the employee a small reward – cash or otherwise – to fill out a health risk assessment survey or be screened for diabetes or high blood pressure, for instance, or to participate in a self-help or educational program. Less common are programs that offer incentives for, say, getting blood pressure to a certain target. Used even less often are penalties for failure to participate at all or to reach certain goals.

Physician groups like the American College of Physicians have seen some merit in the programs. But there are concerns about potential downsides, too, said Dr. Molly Cooke, president of the American College of Physicians (ACP). Among them: the potential for discrimination against workers who can’t meet the standards. These workers might be disadvantaged by genetics, socioeconomic status, or a medical condition, Dr. Cooke said in an interview.

Courtesy ACP

The ACP is also concerned about the carrot-and-stick philosophy being used more frequently by wellness programs. "The ACP generally prefers an approach that rewards people for being healthy as opposed to penalizing them for doing things that are unhealthy," said Dr. Cooke, who is also a professor of medicine at the University of California, San Francisco.

Dr. Reid Blackwelder, president-elect of the American Academy of Physicians, agreed. "We’d rather see employers incentivize healthy choices," he said in an interview.

"Incentives can be an effective way to motivate some employees to participate in workplace wellness programs and to begin behavior changes," said Larry Hausner, CEO of the American Diabetes Association, in a statement in July 2012. "If not implemented carefully, however, incentives can also operate as penalties – imposing financial or other burdens on employees which may be counterproductive," he said.

The ADA, along with the Health Enhancement Research Organization, American College of Occupational and Environmental Medicine, American Cancer Society, American Cancer Society Cancer Action Network (ACS CAN), and American Heart Association, issued guidelines for the programs, with the aim of protecting workers.

It’s also not clear that just offering incentives will somehow get people to change their lifestyles, said Dr. Cooke.

The programs are premised on the idea that workers aren’t sufficiently motivated, she said. But years of caring for patients who have unhealthy lifestyles have taught her that "the real issue is as simple as that they just haven’t gotten with the program yet."

Dr. Cooke said that charging patients an additional $25 or so a month for their health insurance if they don’t lose weight "may not be that powerful an additional factor for a lot of people who already recognize the complications in their lives."

Another issue: whether the physician will become an integral part of the process of improving the employee’s health. A key step would be for employers to create a connection with family physicians in the community, said Dr. Blackwelder. With wellness programs, "there’s a potential to fragment care further," he said.

The American College of Cardiology sees wellness programs as an opportunity, said Dr. Joanne Foody, chief medical expert for the ACC’s CardioSmart@Work program. "The workplace is a logical place for us to address cardiovascular disease and stroke prevention," said Dr. Foody, who is also the medical director of the Cardiovascular Wellness Service at Brigham and Women’s Hospital, Boston.

CardioSmart@Work builds on the ACC’s CardioSmart program. Started in 2008, CardioSmart offers patients and physicians tools to manage heart disease, primarily through a website. This year, the ACC partnered with INTERVENT, a Savannah, Ga.–based disease management company, to join the CardioSmart tools with INTERVENT’s work-site wellness programs. Now the ACC’s imprimatur is on programs offered to at least one major employer, and several others. CardioSmart@Work aims to eventually expand to help physicians steer patients to the wellness programs.

The Obama administration is also giving its backing to wellness programs – specifically encouraging them in the Affordable Care Act. The workplace programs have been regulated by a hodgepodge of rules from a variety of federal agencies. They must comply with federal and state laws, including the Americans with Disabilities Act of 1990 (ACA), the Genetic Information Nondiscrimination Act of 2008, and the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

In late May, the administration clarified how the programs should also comply with the ACA and with rules issued jointly by the Department of Health and Human Services, the Labor Department, and the Treasury Department. In a statement HHS said, "The final rules support workplace health promotion and prevention as a means to reduce the burden of chronic illness, improve health, and limit growth of health care costs, while ensuring that individuals are protected from unfair underwriting practices that could otherwise reduce benefits based on health status."

The ACA also set aside $10 million from the Prevention and Public Health Fund for the Centers for Disease Control and Prevention to work with small and mid-sized employers to develop wellness programs. The CDC announced in June that 104 employers had voluntarily chosen to participate in the National Healthy Worksite Program.

Do they improve health or cut costs?

Wellness programs have been envisioned as a way to get employees interested in being engaged in their own health care, but they also are seen as a way to reduce health costs. The evidence so far suggests the programs have done more to improve health than to cut costs, but the database is fairly thin – despite the growing adoption of the programs.

A recent survey of 800 large and mid-sized employers by Aon Hewitt found that 83% said they offered an incentive – the vast majority, a reward – for participating in basic programs such as completing a health risk survey or biometric screening.

Another study by the RAND Corporation, conducted for the Department of Health and Human Services and issued in late May, found that at least half of employers with more than 50 workers offer a wellness program.

Employee participation was underwhelming, though. Less than half of workers participated in even the most basic screenings, and only 7%-21% took part in programs designed to help them lose weight or lower their blood pressure, for instance.

The literature is mixed on whether wellness programs cut costs or save employers money. The RAND researchers reported that a review of randomized controlled trials found significant cost decreases, ranging from $11 to $626 per year per employee. More than half of the employers surveyed believed that their programs saved money, and an even greater number thought they reduced absenteeism and increased productivity. Interestingly, however, according to the report, "less than half of the employers reported regularly evaluating their wellness programs, and only 2 percent provided actual savings estimates."

The RAND group concluded that wellness programs were successful when it came to diet, exercise, smoking, and alcohol use, but that there was "limited evidence for effects on absenteeism and mental health." Even so, the authors said their findings should be viewed with caution because most of the studies they looked at were not particularly rigorous.

A study published in Health Affairs in 2010 found medical cost savings of $3.27 for every dollar spent on wellness programs, and that absentee day costs dropped by about $2.73 for every dollar spent. The authors concluded that "the wider adoption of such programs could prove beneficial for budgets as well as health."

A more recent article by Jill R. Horwitz, a professor at the University of California, Los Angeles, School of Law, suggests that wellness programs create savings by essentially shifting costs onto employees – and are discriminatory, to boot. "The most vulnerable employees – those from lower socioeconomic strata with the most health risks – probably bear greater costs that in effect subsidize their healthier colleagues," Ms. Horwitz and her colleagues wrote. The study was funded by University of Michigan Law School Cook Fund.

The laws governing wellness programs allow employers to give employees a discount for meeting health goals of up to 30% of the premium. For quitting tobacco, the discount can go as high as 50%. Employers can also penalize workers by the same amounts.

Most surveys have shown that, for now, employers are giving discounts, not levying penalties. That could change. According to the Aon Hewitt survey, within the next few years 58% of employers plan to "impose consequences" on workers.

What’s in it for you?

Ostensibly, workplace wellness programs can assist physicians in helping patients to make lifestyle changes. But there’s also the possibility that the programs can increase the paperwork without any real improvement in patient outcomes.

In comments to HHS, the Labor department, and the Treasury department in January, ACP’s immediate past president, David Bronson, wrote that the organization was "concerned that plans may impose an undue administrative burden on physicians and their staffs."

The rules issued in late May did not clarify what might be reasonably expected from doctors.

At a minimum, physicians will likely be asked to sign off on health risk assessment forms for patients. Dr. Cooke said she’s noticed an uptick in patients asking for that, whereas 3 or 4 years ago she’d never encountered such a request. For now, it’s "not hugely onerous," but as requests have increased, "I began to wonder where this would go next," she said.

The regulations for programs that ask employees to participate in education programs or smoking cessation programs, or to meet particular health outcomes, may end up steering more patients to their doctors’ offices. That’s because employers are required to provide "a reasonable alternative standard." For so-called participatory programs, the alternative has to be provided for workers for whom "it is either unreasonably difficult due to a medical condition to meet the otherwise applicable standard, or for whom it is medically inadvisable to attempt to satisfy the otherwise applicable standard."

For outcomes-based programs, an alternative "must be provided to all individuals who do not meet the initial standard, to ensure that the program is reasonably designed to improve health and is not a subterfuge for underwriting or reducing benefits based on health status," according to the rules.

The rules say that an individual’s personal physician is the arbiter of what’s medically appropriate – and of coming up with a reasonable alternative that will allow the employee to be eligible for the incentive program.

Dr. Blackwelder said it’s important for physicians to be involved. For instance, he said, "For some diabetics, getting their hemoglobin A_1c to a normal level might not be the best thing." Only a doctor could make that determination, he said.

Finally, there are concerns that incentives might not be enough to get people to change their lifestyle.

Ms. Horowitz and her colleagues said that "evidence is sparse that financial incentives induce behavior that improves health." They said it was not surprising, given that "powerful personal, social, and financial incentives to be healthy, nonsmoking, and thin already exist." Even so, "people often fail at efforts to lose weight and stop smoking."

Dr. Cooke agrees, noting that "from the practicing clinician’s side, it’s not news to someone who smokes or weighs twice as much as they should that they’re doing something unhealthy." She added, "I haven’t spoken to a significantly overweight person who hasn’t tried to lose weight."

In the meantime, wellness programs are expected to continue to grow – despite no clear evidence that they accomplish their stated goals of improving health and cutting costs.

Dr. Cooke said she hoped that employers look at what works and what doesn’t "before they just hand money hand over fist to programs to produce a result that we’re all interested in."

aault@frontlinemedcom.com

On Twitter @aliciaault

Workplace wellness programs seem poised for takeoff, and yet there are still many questions about whether they can truly improve patients’ health and if they will do enough to include physicians as partners, or just add to the ever-growing administrative burden.

The programs have been gaining popularity over the years, especially with large employers. An estimated half to three-quarters now offer some type of wellness program. The typical – and most common – program offers the employee a small reward – cash or otherwise – to fill out a health risk assessment survey or be screened for diabetes or high blood pressure, for instance, or to participate in a self-help or educational program. Less common are programs that offer incentives for, say, getting blood pressure to a certain target. Used even less often are penalties for failure to participate at all or to reach certain goals.

Physician groups like the American College of Physicians have seen some merit in the programs. But there are concerns about potential downsides, too, said Dr. Molly Cooke, president of the American College of Physicians (ACP). Among them: the potential for discrimination against workers who can’t meet the standards. These workers might be disadvantaged by genetics, socioeconomic status, or a medical condition, Dr. Cooke said in an interview.

Courtesy ACP

The ACP is also concerned about the carrot-and-stick philosophy being used more frequently by wellness programs. "The ACP generally prefers an approach that rewards people for being healthy as opposed to penalizing them for doing things that are unhealthy," said Dr. Cooke, who is also a professor of medicine at the University of California, San Francisco.

Dr. Reid Blackwelder, president-elect of the American Academy of Physicians, agreed. "We’d rather see employers incentivize healthy choices," he said in an interview.

"Incentives can be an effective way to motivate some employees to participate in workplace wellness programs and to begin behavior changes," said Larry Hausner, CEO of the American Diabetes Association, in a statement in July 2012. "If not implemented carefully, however, incentives can also operate as penalties – imposing financial or other burdens on employees which may be counterproductive," he said.

The ADA, along with the Health Enhancement Research Organization, American College of Occupational and Environmental Medicine, American Cancer Society, American Cancer Society Cancer Action Network (ACS CAN), and American Heart Association, issued guidelines for the programs, with the aim of protecting workers.

It’s also not clear that just offering incentives will somehow get people to change their lifestyles, said Dr. Cooke.

The programs are premised on the idea that workers aren’t sufficiently motivated, she said. But years of caring for patients who have unhealthy lifestyles have taught her that "the real issue is as simple as that they just haven’t gotten with the program yet."

Dr. Cooke said that charging patients an additional $25 or so a month for their health insurance if they don’t lose weight "may not be that powerful an additional factor for a lot of people who already recognize the complications in their lives."

Another issue: whether the physician will become an integral part of the process of improving the employee’s health. A key step would be for employers to create a connection with family physicians in the community, said Dr. Blackwelder. With wellness programs, "there’s a potential to fragment care further," he said.

The American College of Cardiology sees wellness programs as an opportunity, said Dr. Joanne Foody, chief medical expert for the ACC’s CardioSmart@Work program. "The workplace is a logical place for us to address cardiovascular disease and stroke prevention," said Dr. Foody, who is also the medical director of the Cardiovascular Wellness Service at Brigham and Women’s Hospital, Boston.

CardioSmart@Work builds on the ACC’s CardioSmart program. Started in 2008, CardioSmart offers patients and physicians tools to manage heart disease, primarily through a website. This year, the ACC partnered with INTERVENT, a Savannah, Ga.–based disease management company, to join the CardioSmart tools with INTERVENT’s work-site wellness programs. Now the ACC’s imprimatur is on programs offered to at least one major employer, and several others. CardioSmart@Work aims to eventually expand to help physicians steer patients to the wellness programs.

The Obama administration is also giving its backing to wellness programs – specifically encouraging them in the Affordable Care Act. The workplace programs have been regulated by a hodgepodge of rules from a variety of federal agencies. They must comply with federal and state laws, including the Americans with Disabilities Act of 1990 (ACA), the Genetic Information Nondiscrimination Act of 2008, and the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

In late May, the administration clarified how the programs should also comply with the ACA and with rules issued jointly by the Department of Health and Human Services, the Labor Department, and the Treasury Department. In a statement HHS said, "The final rules support workplace health promotion and prevention as a means to reduce the burden of chronic illness, improve health, and limit growth of health care costs, while ensuring that individuals are protected from unfair underwriting practices that could otherwise reduce benefits based on health status."

The ACA also set aside $10 million from the Prevention and Public Health Fund for the Centers for Disease Control and Prevention to work with small and mid-sized employers to develop wellness programs. The CDC announced in June that 104 employers had voluntarily chosen to participate in the National Healthy Worksite Program.

Do they improve health or cut costs?

Wellness programs have been envisioned as a way to get employees interested in being engaged in their own health care, but they also are seen as a way to reduce health costs. The evidence so far suggests the programs have done more to improve health than to cut costs, but the database is fairly thin – despite the growing adoption of the programs.

A recent survey of 800 large and mid-sized employers by Aon Hewitt found that 83% said they offered an incentive – the vast majority, a reward – for participating in basic programs such as completing a health risk survey or biometric screening.

Another study by the RAND Corporation, conducted for the Department of Health and Human Services and issued in late May, found that at least half of employers with more than 50 workers offer a wellness program.

Employee participation was underwhelming, though. Less than half of workers participated in even the most basic screenings, and only 7%-21% took part in programs designed to help them lose weight or lower their blood pressure, for instance.

The literature is mixed on whether wellness programs cut costs or save employers money. The RAND researchers reported that a review of randomized controlled trials found significant cost decreases, ranging from $11 to $626 per year per employee. More than half of the employers surveyed believed that their programs saved money, and an even greater number thought they reduced absenteeism and increased productivity. Interestingly, however, according to the report, "less than half of the employers reported regularly evaluating their wellness programs, and only 2 percent provided actual savings estimates."

The RAND group concluded that wellness programs were successful when it came to diet, exercise, smoking, and alcohol use, but that there was "limited evidence for effects on absenteeism and mental health." Even so, the authors said their findings should be viewed with caution because most of the studies they looked at were not particularly rigorous.

A study published in Health Affairs in 2010 found medical cost savings of $3.27 for every dollar spent on wellness programs, and that absentee day costs dropped by about $2.73 for every dollar spent. The authors concluded that "the wider adoption of such programs could prove beneficial for budgets as well as health."

A more recent article by Jill R. Horwitz, a professor at the University of California, Los Angeles, School of Law, suggests that wellness programs create savings by essentially shifting costs onto employees – and are discriminatory, to boot. "The most vulnerable employees – those from lower socioeconomic strata with the most health risks – probably bear greater costs that in effect subsidize their healthier colleagues," Ms. Horwitz and her colleagues wrote. The study was funded by University of Michigan Law School Cook Fund.

The laws governing wellness programs allow employers to give employees a discount for meeting health goals of up to 30% of the premium. For quitting tobacco, the discount can go as high as 50%. Employers can also penalize workers by the same amounts.

Most surveys have shown that, for now, employers are giving discounts, not levying penalties. That could change. According to the Aon Hewitt survey, within the next few years 58% of employers plan to "impose consequences" on workers.

What’s in it for you?

Ostensibly, workplace wellness programs can assist physicians in helping patients to make lifestyle changes. But there’s also the possibility that the programs can increase the paperwork without any real improvement in patient outcomes.

In comments to HHS, the Labor department, and the Treasury department in January, ACP’s immediate past president, David Bronson, wrote that the organization was "concerned that plans may impose an undue administrative burden on physicians and their staffs."

The rules issued in late May did not clarify what might be reasonably expected from doctors.

At a minimum, physicians will likely be asked to sign off on health risk assessment forms for patients. Dr. Cooke said she’s noticed an uptick in patients asking for that, whereas 3 or 4 years ago she’d never encountered such a request. For now, it’s "not hugely onerous," but as requests have increased, "I began to wonder where this would go next," she said.

The regulations for programs that ask employees to participate in education programs or smoking cessation programs, or to meet particular health outcomes, may end up steering more patients to their doctors’ offices. That’s because employers are required to provide "a reasonable alternative standard." For so-called participatory programs, the alternative has to be provided for workers for whom "it is either unreasonably difficult due to a medical condition to meet the otherwise applicable standard, or for whom it is medically inadvisable to attempt to satisfy the otherwise applicable standard."

For outcomes-based programs, an alternative "must be provided to all individuals who do not meet the initial standard, to ensure that the program is reasonably designed to improve health and is not a subterfuge for underwriting or reducing benefits based on health status," according to the rules.

The rules say that an individual’s personal physician is the arbiter of what’s medically appropriate – and of coming up with a reasonable alternative that will allow the employee to be eligible for the incentive program.

Dr. Blackwelder said it’s important for physicians to be involved. For instance, he said, "For some diabetics, getting their hemoglobin A_1c to a normal level might not be the best thing." Only a doctor could make that determination, he said.

Finally, there are concerns that incentives might not be enough to get people to change their lifestyle.

Ms. Horowitz and her colleagues said that "evidence is sparse that financial incentives induce behavior that improves health." They said it was not surprising, given that "powerful personal, social, and financial incentives to be healthy, nonsmoking, and thin already exist." Even so, "people often fail at efforts to lose weight and stop smoking."

Dr. Cooke agrees, noting that "from the practicing clinician’s side, it’s not news to someone who smokes or weighs twice as much as they should that they’re doing something unhealthy." She added, "I haven’t spoken to a significantly overweight person who hasn’t tried to lose weight."

In the meantime, wellness programs are expected to continue to grow – despite no clear evidence that they accomplish their stated goals of improving health and cutting costs.

Dr. Cooke said she hoped that employers look at what works and what doesn’t "before they just hand money hand over fist to programs to produce a result that we’re all interested in."

aault@frontlinemedcom.com

On Twitter @aliciaault

Workplace wellness programs seem poised for takeoff, and yet there are still many questions about whether they can truly improve patients’ health and if they will do enough to include physicians as partners, or just add to the ever-growing administrative burden.

The programs have been gaining popularity over the years, especially with large employers. An estimated half to three-quarters now offer some type of wellness program. The typical – and most common – program offers the employee a small reward – cash or otherwise – to fill out a health risk assessment survey or be screened for diabetes or high blood pressure, for instance, or to participate in a self-help or educational program. Less common are programs that offer incentives for, say, getting blood pressure to a certain target. Used even less often are penalties for failure to participate at all or to reach certain goals.

Physician groups like the American College of Physicians have seen some merit in the programs. But there are concerns about potential downsides, too, said Dr. Molly Cooke, president of the American College of Physicians (ACP). Among them: the potential for discrimination against workers who can’t meet the standards. These workers might be disadvantaged by genetics, socioeconomic status, or a medical condition, Dr. Cooke said in an interview.

Courtesy ACP

The ACP is also concerned about the carrot-and-stick philosophy being used more frequently by wellness programs. "The ACP generally prefers an approach that rewards people for being healthy as opposed to penalizing them for doing things that are unhealthy," said Dr. Cooke, who is also a professor of medicine at the University of California, San Francisco.

Dr. Reid Blackwelder, president-elect of the American Academy of Physicians, agreed. "We’d rather see employers incentivize healthy choices," he said in an interview.

"Incentives can be an effective way to motivate some employees to participate in workplace wellness programs and to begin behavior changes," said Larry Hausner, CEO of the American Diabetes Association, in a statement in July 2012. "If not implemented carefully, however, incentives can also operate as penalties – imposing financial or other burdens on employees which may be counterproductive," he said.

The ADA, along with the Health Enhancement Research Organization, American College of Occupational and Environmental Medicine, American Cancer Society, American Cancer Society Cancer Action Network (ACS CAN), and American Heart Association, issued guidelines for the programs, with the aim of protecting workers.

It’s also not clear that just offering incentives will somehow get people to change their lifestyles, said Dr. Cooke.

The programs are premised on the idea that workers aren’t sufficiently motivated, she said. But years of caring for patients who have unhealthy lifestyles have taught her that "the real issue is as simple as that they just haven’t gotten with the program yet."

Dr. Cooke said that charging patients an additional $25 or so a month for their health insurance if they don’t lose weight "may not be that powerful an additional factor for a lot of people who already recognize the complications in their lives."

Another issue: whether the physician will become an integral part of the process of improving the employee’s health. A key step would be for employers to create a connection with family physicians in the community, said Dr. Blackwelder. With wellness programs, "there’s a potential to fragment care further," he said.

The American College of Cardiology sees wellness programs as an opportunity, said Dr. Joanne Foody, chief medical expert for the ACC’s CardioSmart@Work program. "The workplace is a logical place for us to address cardiovascular disease and stroke prevention," said Dr. Foody, who is also the medical director of the Cardiovascular Wellness Service at Brigham and Women’s Hospital, Boston.

CardioSmart@Work builds on the ACC’s CardioSmart program. Started in 2008, CardioSmart offers patients and physicians tools to manage heart disease, primarily through a website. This year, the ACC partnered with INTERVENT, a Savannah, Ga.–based disease management company, to join the CardioSmart tools with INTERVENT’s work-site wellness programs. Now the ACC’s imprimatur is on programs offered to at least one major employer, and several others. CardioSmart@Work aims to eventually expand to help physicians steer patients to the wellness programs.

The Obama administration is also giving its backing to wellness programs – specifically encouraging them in the Affordable Care Act. The workplace programs have been regulated by a hodgepodge of rules from a variety of federal agencies. They must comply with federal and state laws, including the Americans with Disabilities Act of 1990 (ACA), the Genetic Information Nondiscrimination Act of 2008, and the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

In late May, the administration clarified how the programs should also comply with the ACA and with rules issued jointly by the Department of Health and Human Services, the Labor Department, and the Treasury Department. In a statement HHS said, "The final rules support workplace health promotion and prevention as a means to reduce the burden of chronic illness, improve health, and limit growth of health care costs, while ensuring that individuals are protected from unfair underwriting practices that could otherwise reduce benefits based on health status."

The ACA also set aside $10 million from the Prevention and Public Health Fund for the Centers for Disease Control and Prevention to work with small and mid-sized employers to develop wellness programs. The CDC announced in June that 104 employers had voluntarily chosen to participate in the National Healthy Worksite Program.

Do they improve health or cut costs?

Wellness programs have been envisioned as a way to get employees interested in being engaged in their own health care, but they also are seen as a way to reduce health costs. The evidence so far suggests the programs have done more to improve health than to cut costs, but the database is fairly thin – despite the growing adoption of the programs.

A recent survey of 800 large and mid-sized employers by Aon Hewitt found that 83% said they offered an incentive – the vast majority, a reward – for participating in basic programs such as completing a health risk survey or biometric screening.

Another study by the RAND Corporation, conducted for the Department of Health and Human Services and issued in late May, found that at least half of employers with more than 50 workers offer a wellness program.

Employee participation was underwhelming, though. Less than half of workers participated in even the most basic screenings, and only 7%-21% took part in programs designed to help them lose weight or lower their blood pressure, for instance.

The literature is mixed on whether wellness programs cut costs or save employers money. The RAND researchers reported that a review of randomized controlled trials found significant cost decreases, ranging from $11 to $626 per year per employee. More than half of the employers surveyed believed that their programs saved money, and an even greater number thought they reduced absenteeism and increased productivity. Interestingly, however, according to the report, "less than half of the employers reported regularly evaluating their wellness programs, and only 2 percent provided actual savings estimates."

The RAND group concluded that wellness programs were successful when it came to diet, exercise, smoking, and alcohol use, but that there was "limited evidence for effects on absenteeism and mental health." Even so, the authors said their findings should be viewed with caution because most of the studies they looked at were not particularly rigorous.

A study published in Health Affairs in 2010 found medical cost savings of $3.27 for every dollar spent on wellness programs, and that absentee day costs dropped by about $2.73 for every dollar spent. The authors concluded that "the wider adoption of such programs could prove beneficial for budgets as well as health."

A more recent article by Jill R. Horwitz, a professor at the University of California, Los Angeles, School of Law, suggests that wellness programs create savings by essentially shifting costs onto employees – and are discriminatory, to boot. "The most vulnerable employees – those from lower socioeconomic strata with the most health risks – probably bear greater costs that in effect subsidize their healthier colleagues," Ms. Horwitz and her colleagues wrote. The study was funded by University of Michigan Law School Cook Fund.

The laws governing wellness programs allow employers to give employees a discount for meeting health goals of up to 30% of the premium. For quitting tobacco, the discount can go as high as 50%. Employers can also penalize workers by the same amounts.

Most surveys have shown that, for now, employers are giving discounts, not levying penalties. That could change. According to the Aon Hewitt survey, within the next few years 58% of employers plan to "impose consequences" on workers.

What’s in it for you?

Ostensibly, workplace wellness programs can assist physicians in helping patients to make lifestyle changes. But there’s also the possibility that the programs can increase the paperwork without any real improvement in patient outcomes.

In comments to HHS, the Labor department, and the Treasury department in January, ACP’s immediate past president, David Bronson, wrote that the organization was "concerned that plans may impose an undue administrative burden on physicians and their staffs."

The rules issued in late May did not clarify what might be reasonably expected from doctors.

At a minimum, physicians will likely be asked to sign off on health risk assessment forms for patients. Dr. Cooke said she’s noticed an uptick in patients asking for that, whereas 3 or 4 years ago she’d never encountered such a request. For now, it’s "not hugely onerous," but as requests have increased, "I began to wonder where this would go next," she said.

The regulations for programs that ask employees to participate in education programs or smoking cessation programs, or to meet particular health outcomes, may end up steering more patients to their doctors’ offices. That’s because employers are required to provide "a reasonable alternative standard." For so-called participatory programs, the alternative has to be provided for workers for whom "it is either unreasonably difficult due to a medical condition to meet the otherwise applicable standard, or for whom it is medically inadvisable to attempt to satisfy the otherwise applicable standard."

For outcomes-based programs, an alternative "must be provided to all individuals who do not meet the initial standard, to ensure that the program is reasonably designed to improve health and is not a subterfuge for underwriting or reducing benefits based on health status," according to the rules.

The rules say that an individual’s personal physician is the arbiter of what’s medically appropriate – and of coming up with a reasonable alternative that will allow the employee to be eligible for the incentive program.

Dr. Blackwelder said it’s important for physicians to be involved. For instance, he said, "For some diabetics, getting their hemoglobin A_1c to a normal level might not be the best thing." Only a doctor could make that determination, he said.

Finally, there are concerns that incentives might not be enough to get people to change their lifestyle.

Ms. Horowitz and her colleagues said that "evidence is sparse that financial incentives induce behavior that improves health." They said it was not surprising, given that "powerful personal, social, and financial incentives to be healthy, nonsmoking, and thin already exist." Even so, "people often fail at efforts to lose weight and stop smoking."

Dr. Cooke agrees, noting that "from the practicing clinician’s side, it’s not news to someone who smokes or weighs twice as much as they should that they’re doing something unhealthy." She added, "I haven’t spoken to a significantly overweight person who hasn’t tried to lose weight."

In the meantime, wellness programs are expected to continue to grow – despite no clear evidence that they accomplish their stated goals of improving health and cutting costs.

Dr. Cooke said she hoped that employers look at what works and what doesn’t "before they just hand money hand over fist to programs to produce a result that we’re all interested in."

aault@frontlinemedcom.com

On Twitter @aliciaault