Q&A about the Rand Report on Workplace Wellness (Part I)
What Employers Must Know
The RAND Corp Workplace Wellness Programs Study, presented to Congress, brought about much needed discussion and questions about the state of workplace wellness programs, their outcomes, and their long term role in the transformation of our health care system and the attainment of a better health status for all in our Nation. Questions abound on the report, its methodology and its findings. CCA received and studied many of those questions and, on Wednesday June 19, convened a group of researchers and experts to go over the methodology, data and conclusions of the RAND Workplace Wellness Programs Study with the authors.
Soeren Mattke and Hangsheng Liu, senior scientists at RAND, answered the questions received and the follow up clarifications posed by those on the call. The following is a summary of that long and in depth conversation.
Read Q&A about the Rand Report on Workplace Wellness (Part II)
The RAND Corp Workplace Wellness Programs Study, presented to Congress, brought about much needed discussion and questions about the state of workplace wellness programs, their outcomes, and their long term role on the transformation of health care and the attainment of a better health status for all in our Nation.
Did anything surprise you?
I was surprised that the cost curve did not reach statistical significance, due to random noise in the model. Another surprise…high-powered incentives tied to health outcomes are much less common than the literature would have us think. Nine percent of employers use health contingent incentives and use them in modest amounts. Public debate is ahead of the actual state of the field.
Did the study look at all at components – online, in-person counseling, content, classes, support, communications, etc.?
No. The limited time and funding prohibited that level of granularity. Our wish list for future research includes amount of exposure, level of interventions, and level of exposure.
Among the nonparticipants who also receive the benefits of health promotion, a. Is there a motivation selection bias or in fact could the nonparticipants be receiving benefits? b. Could savings, therefore, be underestimated?
a. Yes, there is still the possibility of some bias because it was not a randomized, controlled trial. The difference-in-difference method is powerful in observing those, but we can’t rule out unobservable differences between participants and nonparticipants. It is possible that some nonparticipants were exposed to health promotion activities (e.g., better food offerings, exercise messaging) at the worksite but didn’t participate in personalized counseling program and would not be picked up by the analysis.
b. These estimates, given the research design used, reflect the marginal impact of a lifestyle management component. Changes in environment would impact both participants and nonparticipants, and we would have no way of comparing to other employers to get to that effect.
How does the report affect the current position of wellness in the market? For example, do you feel it does anything to temper the “rosy” expectations that came from earlier meta-analyses? Will the current data in the report help us to better manage more realistic expectations around workplace wellness?
Some past numbers were too rosy. Look at what wellness programs are doing. It is not unrealistic that cost neutrality is a positive result because these programs are intervening in a workforce population that is not sick. These programs are a preventive effort to avoid future healthcare costs, so if we can get to cost neutrality and better health this is a good result for the industry and the programs.
Given the fact that some of these presentations are somewhat old now, a. What’s your thought about some of the newer strategies/approaches to wellness program engagement, including outcomes-based interventions? b. Were there sufficient data to look specifically at the outcomes-based programs for their impact on healthcare costs?
a. These types of programs remain rare, so there is not enough good data for meaningful statistical assessment.
b. No, there was not enough data and no employers tied to outcomes. A fine line exists between shifting risk and cost to more vulnerable employees and dependents and making employees feel compelled to take advantage of the programs offered. More research and more data are needed to find the right balance between appropriate risk sharing and inappropriate cost shifting.
a. What value do you think there’d be in formulating a clearly established list of wellness-sensitive conditions, so that outcomes can be more specifically studied? b. What about process measures – the outcomes of wellness on use of preventive care services, disease-specific preventive care, and medication adherence?
a. Hard question. In essence, we know many conditions are sensitive to health behaviors. The former surgeon general attributes 75% of healthcare costs to behavior. Many cancers, and potentially asthma and COPD, can be tied to obesity. We must find a way to quantify the strength of relationship in order to call it “wellness sensitive.” To begin to unpack the “black box,” we should define conditions and look more closely at what can be done for a quicker response versus what can be expected to happen later in the process.
b. The more clinical outcomes are better tied to disease management, the better, because that is the intervention strongly tied to medication adherence. There would be value in looking at the use of preventive services, either through employer screenings or healthcare providers, but really only those recommended by USPSTF.
I saw a tweet that approximately says, “…see? Wellness doesn’t work.” I would assume, seeing your presentations, that you would not make such a strong statement. Comment?
Workplace wellness involves complex interventions, and success will always depend on the particular intervention within the particular context and the particular measures of outcomes used. From what we see here, there is clear evidence for a qualitative and meaningful effect on health risks, but no strong evidence for savings of healthcare costs. Here we see a roughly cost neutral intervention that achieves a gain in health risk reduction.
a. What costs were or were not included in the cost analysis? b. Were there any assessments of costs directly related to the interventions versus costs unrelated to interventions?
a. We included medical and prescription drug costs. We did not have data on work loss, workers comp, disability, etc.
b. We did not analyze whether changes in healthcare utilization were for wellness sensitive conditions. Rather, this was a high level look at overall costs without attempting to attribute at a more granular level. We did, however, take out years in which an employee was pregnant or participating in a case management program for high cost, high-risk conditions.
Can you comment on suggestions for future research?
Future research should seek to get more granular with related versus unrelated costs. Another area to consider is different type of outcomes, like productivity and other work-related impacts. A larger sample size may show significant effect on cost, so more employers in the database and a longer time series may indicate at what difference the curves converge and reach statistical significance. Also, we need to begin to unpack the black box. We can’t assume that all programs are effective or all programs are ineffective, and we need to understand the distinctions, i.e. how do employer (e.g., culture, support) and employee (e.g., health literacy, age, gender, ethnicity) characteristics drive changes so that targeting interventions becomes more effective.
Read Q&A about the Rand Report on Workplace Wellness (Part II)