What Does the RAND Report on Workplace Wellness Programs Really Say?

Speculation was running rampant on the web and the blogosphere about the bad news that the Rand Report was going to be for the industry.

Only problem was: Those who were talking hadn´t read it. And those who had read it were not talking.

But here it is. Please, read the COMPLETE Final Report, from RAND Corp, on Workplace Wellness Programs Study.

And what did we find after a good read? Apparently, the old adage is true: Reading is fundamental.

May we quote?

“In an analysis of the CCA database, when comparing wellness program participants to statistically matched nonparticipants, we find statistically significant and clinically meaningful improvements in exercise frequency, smoking behavior, and weight control, but not cholesterol control. Those improvements are sustainable over an observation period of four years, and our simulation analyses point to cumulative effects with ongoing program participation.” Page XVII, for the inquisitive minds. This point is of critical importance as it speaks to the importance of workplace wellness programs to help contain the epidemic of lifestyle-related diseases in the U.S. (RAND report, p. xxvi)

Then, there is this other morsel of wisdom:

“The published literature, the results presented here, and our case studies corroborate the finding of positive effects of worksite wellness programs on health-related behavior and health risks among program participants.” Page XVIII

Please, CCA will issue a more complete analysis and responses to any of your questions and inquiries, now that we actually know what we are discussing… You know, we are sticklers for full picture, well-informed statements.

But we want to give our readers a nice preview of some of the most relevant points of the report. And, unlike others, we are actually giving you chapter and verse…and a link to the actual report, so you can make sure we are quoting correctly.

  • Programs with a weight management component can be credited with a positive impact on weight over time. Results show a differential change of about 1 pound per year sustained for the current year of participation and two years thereafter, in a population of 104,920 employees. (RAND report, p. 48) Compared to this: the average adult gains between 5 and 15 lbs. per year after age 40.
  • Cholesterol improved for participants and nonparticipants alike. (RAND report, p. 52) Increased use in statins among the full population can partly explain the lack of program effect.
  • Even with a small sample size (N=746), smoking cessation programs were found to have a significant sustainable effect for 1-2 years after the year of participation. “One year of program participation decreases the smoking rate of participating smokers by nearly 30% in the first year compared to nonparticipating smokers.” (RAND report, pp. 45-46)
    • Program participation is associated with a trend toward lower health care costs, while those changes are not statistically significant. Over a five year span, the cumulative simulated effect of wellness program participation on total health care costs per health plan member per month shows a curve that flattens for participants and continues on an upward trajectory for nonparticipants. This lower cost trend is driven by reduction in hospital inpatient cost of approximately $40 per member per month. (RAND report, pp. 56-57)
  • Corresponding to these cost reduction trends are declines in inpatient admissions and emergency department visits, compared with an increase or slight decrease for the nonparticipant comparison group. (RAND report, p. 57)
  • While the report’s estimates of wellness program effects on health care cost are lower than results reported in the literature, the RAND research sought to isolate the effect of lifestyle management interventions as opposed to the effect of an employer’s overall approach to health and wellness. (RAND report, p. xxvi) Even with a program that is cost neutral, positive impact on health risk, i.e. healthier employees, is a good result without added cost.

Read the Final Report, from RAND Corp, on Workplace Wellness Programs Study

View the presentation of Wellness Program Study Final Briefing

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Just Released: Final Rule on Incentives for Nondiscriminatory Wellness Programs in Group Health Plans

After a long wait, on May 29, the agencies released the final rule on Incentives for Nondiscriminatory Wellness Programs in Group Health Plans is a must read and essential for all population health and wellness industry stakeholders.

The rule was issued by the Internal Revenue Service, Department of the Treasury; Employee Benefits Security Administration, Department of Labor; Centers for Medicare & Medicaid Services, Department of Health and Human Services.

Victoria Shapiro, Care Continuum Alliance Government Affairs Director wanted to share our initial impression review of the rule´s impact for CCA members and the industry as a whole.

In its formal comments on the proposed version of this rule, CCA asked HHS to:

  • Maintain flexibility in the core features of a “reasonably designed” wellness program.
  • Allow for program innovation to create new evidence on wellness strategies for specific populations.

The final rule expressly used this language and granted both of these requests. CCA is also cited in the language of the final rule:

“Currently, insufficient broad-based evidence makes it difficult to definitively assess the impact of workplace wellness on health outcomes and cost; however, available evidence suggests that wellness programs may have some effect on improving health outcomes. The RAND Corporation’s analysis of the Care Continuum Alliance (CCA) database found statistically significant and clinically meaningful improvements in exercise frequency, smoking behavior, and weight control between wellness program participants and non-participants.”

The Departments anticipate that future sub-regulatory guidance may be needed to further clarify portions of this final rule, and will issue such guidance as necessary.

Some Key Points about the Final Rule

  • Clarifies the scope of HIPAA and the Affordable Care Act rules governing wellness programs.
  • Outlines criteria for “an affirmative defense that can be used by plans and issuers” in a claim regarding compliance with HIPAA provisions.
  • Offers detailed steps a plan or issuer can take to ensure wellness programs are reasonably designed and also what constitutes a “reasonable alternative standard”.

Last Thought

The language of the rule reads:

“These final regulations continue to provide plans and issuers flexibility and encourage innovation.”

Final rule on Incentives for Nondiscriminatory Wellness Programs in Group Health Plans

CCA Comments and Recommendations to EEOC on Wellness Programs and Incentives

May 23, 2013

The Honorable Jacqueline Berrien, Chair

The Honorable Constance Barker, Commissioner

The Honorable Chai Feldblum, Commissioner

The Honorable Victoria Lipnic, Commissioner

The Honorable Jenny Yang, Commissioner

The Honorable P. David Lopez, General Counsel

U.S. Equal Employment Opportunity Commission

Re: Wellness Programs and Incentives

Dear Sir or Madam,

The Care Continuum Alliance (CCA) welcomes this opportunity to comment on the discussion at the May 8th EEOC public meeting on “Wellness Programs Under Federal EEOC Laws” in Washington, D.C. We are a non-profit association of almost 200 companies. CCA convenes all stakeholders in the population health management industry. Our members design and provide services, programs and tools to better coordinate care for all patients along the continuum, from the healthy to those with chronic conditions. Through advocacy, research and education, we advance strategies that increase quality in the health care system while reducing costs.

CCA appreciates your thoughtful consideration and careful attention to the value of worksite wellness programs and incentives. We observed in your meeting that a significant portion of the discussion revolved around the “voluntary” aspect of workplace wellness programs. Jointly-issued 2006 final regulations on Nondiscrimination and Wellness Programs by the Department of Labor, Department of the Treasury and Department of Health and Human Services expressly identify the five-prong Health Information Portability and Accountability Act (HIPAA) standard as the appropriate metric for evaluating the “voluntary” aspect of worksite wellness programs.[1] The EEOC also referenced this standard in its 2008 final rule, acknowledging that Title II of the Genetic Information Nondiscrimination Act allows covered entities to offer incentives for participating in wellness programs.[2] 

The HIPAA five-prong test states that wellness programs offering rewards based on achieving a particular health status are voluntary if: (1) the reward does not exceed 30 percent of the cost of the individual’s health coverage or 50 percent in relation to tobacco; (2) the program is reasonably designed to promote health or prevent disease; (3) individuals have the opportunity to qualify for the reward at least once annually; (4) the reward is available to all similarly situated individuals; and (5) disclosure of a reasonable alternative standard if the terms of the program are described.[3],[4] Please also note the useful Wellness Program Analysis and Checklist provided by the Department of Labor to clarify application of the existing HIPAA standard.[5]

CCA supports this HIPAA standard as the appropriate metric. We encourage the EEOC to adopt this standard and issue such guidance to employers. This will alleviate confusion and concern regarding the possibility of additional regulatory hurdles for worksite wellness programs.[6] Confusion often leads employers to simply withdraw or abstain from offering even well-designed evidence-based wellness and incentive programs. The HIPAA standard aligns with CCA’s and the EEOC’s shared goal of promoting and improving health, while prohibiting discrimination in an employee’s eligibility or ability to participate in wellness programs.[7] Furthermore, applying the standard to worksite wellness programs offers compelling advantages over forging new compliance requirements. Using this standard in the context of worksite wellness programs would be a natural extension from its current application with group health plans, ensuring consistent and streamlined regulatory requirements around wellness programs in the health industry. Also, many employers with well-received and successfully implemented wellness programs currently use the five-prong HIPAA standard. This indicates that the standard operates as a strong functional basis for future EEOC guidance.

We are providing you with a current literature review and case studies that demonstrate advancements in worksite wellness programs. The literature shows that incentives can facilitate behavior change to increase patient engagement in wellness programs. It also positively indicates that appropriate incentive and wellness program design can produce cost savings for employers. Finally, the literature reinforces that the value of incentives in wellness programs extends beyond direct healthcare cost savings. As one component of an organizational culture of health, incentives in wellness programs can produce additional positive outcomes such as workforce productivity. 

We are also including a joint consensus paper by the Health Enhancement Research Organization, the American College of Occupational and Environmental Medicine, the American Cancer Society and American Cancer Society Cancer Action Network, the American Diabetes Association, and the American Heart Association entitled, “Guidance for a Reasonably Designed, Employer-Sponsored Wellness Program Using Outcomes-Based incentives”. This paper offers valuable insights on wellness program and incentives design for your consideration. It outlines elements of a reasonably designed wellness program and provides guidance on devising reasonable alternative standards.[8] The paper notes that incentives in wellness programs should be designed with flexibility to incent meaningful progress toward health goals and not just ideal targets.[9] It also advises employers to incorporate options that allow employees to earn any given incentive in multiple ways, promoting behavior change through individual choice.[10]

CCA looks forward to continuing this dialogue and would be glad to serve as a resource. Please feel free to contact us with thoughts or questions.

Thank you,

Frederic S. Goldstein

Interim Executive Director

Care continuum Alliance

Victoria Shapiro

Director of Government Affairs

Care Continuum Alliance

Read CCA Submitted Comments to EEOC on Wellness Programs under Federal EEOC Laws, May 23, 2013

Read JOEM Joint Consensus Statement article on Workplace Wellness Programs and use of Incentives


[1] 45 CFR Part 146 §146.121(f)(2)(i)-(v), Department of the Treasury, Department of Labor, Department of Health and Human Services, Nondiscrimination and Wellness Programs in Health Coverage in the Group Market, Federal Register vol. 71 No. 239 (Dec. 2006): 75052.

[2] 29 CFR Part 1635, Equal Employment Opportunity Commission, Regulations Under the Genetic Information Nondiscrimination Act of 2008, Federal Register vol. 75 No. 216 (Nov. 2010):68923 n.13.

[3] 45 CFR Part 146 §146.121(f)(2)(i)-(v) at 75052.

[4] §1201, Patient Protection and Affordable Care Act, H.R. 3590 (2010).

[5] Employee Benefits Security Administration, U.S. Department of Labor, Wellness Program Analysis, Field Assistance Bulletin No. 2008-02 (Feb. 2008) 1-5.

[6] 45 CFR Part 146 §146.121(f)(2)(i)-(v) at 75052.

[7] Id.

[8] Health Enhancement Research Organization, the American College of Occupational and Environmental Medicine, the American Cancer Society and American Cancer Society Cancer Action Network, the American Diabetes Association, and the American Heart Association, Guidance for a Reasonably Designed, Employer-Sponsored Wellness Program Using Outcomes-Based Incentives, Journal of Occupational and Environmental Medicine, Vol. 54 (July 2012).

[9] Id. at 894

[10] Id.

 

Beacon Community: Population Health Industry Innovators Hold Key to HIT Transformation

Attention, population health management innovators, you may have answers in your toolbox to health information technology problems that are plaguing communities around the nation, as they look to transform their HIT infrastructure.

A group of organizations that are part of the Beacon Community Cooperative Agreement Program participated at a Public Meeting Day on Wednesday, May 22. They shared their experiences lessons learned, and pointed to existing opportunities for health care stakeholders to engage.

The HHS office of the National Coordinator for Health IT (ONC) provided $250 million in funding through the American Recovery and Reinvestment Act of 2009 over three years (2010-2013) to 17 select Beacon Communities throughout the US for local improvement.

We thought CCA members and population health management stakeholders would be well served by a quick recap of this insightful discussion.  

The top themes of the meeting can be summarized as follows:

  • Population Health Management Services Are Essential To Transformation
  • Payment Reform Policies Must Be Addressed To Incorporate and Encourage Health Technology Innovations
  • Organizations Need A Robust Data Sharing and Communications Infrastructure
  • Technology Tools that Solve Community and Primary Care Level Challenges Are Paramount
  • Organizations Need To Adopt Continuous Measurement And Program Evaluation To Create Learning Opportunities And Drive Value

As you can see, these are all areas where CCA members excel and have resources to offer to help communities transform their health technology infrastructures.

The panelists provided very timely advice to the Beacon Communities.

Carol Beasley, Vice President of Business Development at the Institute for Healthcare Improvement:

Share your stories and experience.

Consolidate lessons to generate the next layer of innovation.

Dr. Asaf Bitton, Division of General Medicine, Brigham and Women’s Hospital, Harvard Medical School Center for Primary Care:

Relationships and governance structures are an important foundation.

Keep focusing on the big tough issues because they are the critical dynamics of practice transformation.

Be ready to spring to new opportunities.

Susan Dentzer, Senior Policy Advisor at the Robert Wood Johnson Foundation, and On-Air Analyst on Health Policy, PBS NewsHour: 

For communities looking to transform, state innovation grants will be big receptor sites for new opportunities. 

Dr. Mark McClellan, Director of the Engelberg Center for Health Care Reform, Senior Fellow, Economic Studies, Leonard D Schaeffer Chair in Health Policy Studies, Brookings Institution:

Distill the specific areas where communities can start.

The Beacon leanings can be foundations that are relevant for communities elsewhere.

We will get to a day where data moves with patients. Share key information needed by patients and providers in other communities that can be provided reliably and confidently.

 

A Must Read: Article on Population Health and Health Care Consumerism

The latest issue of the Health Care Consumerism Outlook 2013 includes an article by members of the Care Continuum Alliance’s team discussing how population health management and health care consumerism have a symbiotic relationship.

HCCS-13Outlook-cvr4in

The Future for Population Health Relies on Three Key Consumer-Centric Features: Health Data, Care Coordination, and mHealth” is an excellent read, if we may say so ourselves.

Consumerism and its impact on health often move faster than the health care industry. At CCA we have worked to keep pace with this market movement and respond appropriately. In 2013 our research and advocacy priorities, which are driven by our members through their participation in our Quality and Research committees, focus on the understanding of how incentives work, not merely to move consumers into wellness programs, but to engage them in community wellness, that is, incentives that inspire the consumer to transcend the health of self to move into a community health mindset.

Improving the health of populations starts by building a healthy shield around one individual consumer at a time. CCA’s population health framework, an outcome of our committees’ work puts the consumer at its very center.  We use the term consumer, not patient, because the health continuum encompasses services beyond those of “health care” and being a “patient” to include wellness and prevention, and the engagement of the individual. Lifestyle issues such as exercise and diet have been one of the initial foci of consumerism as it entered the health care space.

Read the article the full article, “The Future for Population Health Relies on Three Key Consumer-Centric Features: Health Data, Care Coordination, and mHealth”, on the magazine HealthCare Consumerism Outlook 2013.

Action Alert: Attend EEOC Meeting to Discuss Wellness Programs, Federal Law

The Wednesday May 8 meeting of the Equal Employment Opportunity Commission (EEOC) will be a discussion on wellness programs and federal law. It is open to the public and CCA members are strongly encouraged to attend and make their voices heard.

CCA Government Affairs Director will be at the meeting, and will report back, but the input of many informed voices is required to influence the discussion.

The panelists will discuss the federal law treatment of wellness programs. It will devote particular attention to the ways in which the Americans with Disabilities Act, the Genetic Information Nondiscrimination Act and other laws the EEOC enforces “may be implicated by these programs,” according to an EEOC statement.

Among the panelists will be Christopher Kuczynski, Acting Associate Legal Counsel, EEOC, who has also agreed to participate on a Washington Representatives meeting with CCA members on May 23, in Washington DC. Make sure you RSVP.

Read the announcement and full list of panelists here.

More information can be found here.

What: EEOC Meeting on Wellness Programs

Who: Equal Employment Opportunity Commission

Where: Commission Meeting Room

First Floor

EEOC Office Building

131 “M” Street, NE

Washington, D.C. 20507

When: Wednesday, May 8, 2013, 9:00 A.M. Eastern Time

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