Will wellness ever really catch on? – The State of Health Care in America

Will wellness ever really catch on? – The State of Health Care in America – Industry Overview

Catherine Caruthers

Despite abundant proof that it saves money and lives, prevention takes a back seat to disease treatment. Some visionary employers, however, are working hard to change all that.

In the areas of disease prevention and health promotion–vaguely defined as “wellness”–the United States is wracked with contradictions. We know what’s good for us, but we do the opposite. “Light” food products and their ubiquitous promotion keep pace with the ever-growing number of fast-food restaurants that cater to the fat-loving palate. The exercise video business booms, while personal fitness equipment gathers dust and our collective waistline steadily expands. Smoking cessation? We thought we had that one licked. But studies point to a rising number of teenage smokers and a leveling off of the decline in adult smokers. All in all, our hearts and minds are in the right place, but our mouths and muscles still are not listening.

“As a society, we have the right attitude, but we don’t have the right commitment,” says John Pinney, president of Pinney Associates, a consulting firm based in Bethesda, Md., and a member of the steering committee for the Center for the Advancement of Health. In 1994, Pinney’s firm helped compile a 440-page report entitled Health Promotion & Disease Prevention Programs: Rx for the 1990s? The answer to the title question, according to Pinney, was and continues to be, “not yet.” Although several disparate groups are tackling wellness with single-minded purpose, experts say the main ingredient for real success is sorely lacking.

“We are still whacking away at prevention with a somewhat unfocused approach,” Pinney explains. “We’ve got disease management going on, we’ve got corporate wellness programs and we’ve got some good work being done by managed care, which is also giving a lot of lip service to prevention. But there’s not a really integrated national focus.”

Integrated is the key word, for there is no lack of initiatives designed to get Americans to choose healthier lifestyles, and employers are among the leading players. In its 1992 National Survey of Worksite Health Promotion Activities, the U.S. Department of Health and Human Services found that of the 1,507 private and public concerns surveyed, 52 percent offered health risk assessments, 42 percent offered physical activity and fitness programs and 40 percent offered information or activities designed to help employees stop smoking.

Because it commands so much of the average person’s time and attention, the workplace is a good place to start, but support for good health behavior needs to continue when the employee heads out the door, says Carson Beadle, managing director of William M. Mercer Inc., the New York City-based benefits consulting firm.

“Rather than have something that is just work-oriented or just community-oriented or just done through your HMO,” explains Beadle, who is also president of The Health Project, a White House-endorsed consortium of business, health and government leaders, “it would be best if employers, community resources and health care providers worked together. That way, there’s a kind of mutual reinforcement and a much greater likelihood of success in changing habits sooner.”

Orchestrated efforts like the ones Beadle describes are rare today, partly because the health care system hasn’t shifted from a treatment to a prevention model. To promote that shift, The Health Project sponsors the annual C. Everett Koop Awards for outstanding employee wellness programs. The Koop awards go to programs that can demonstrate actual cost savings from improving the health behavior (and, it naturally follows, the health) of their people. Receipt of the award comes with one requirement: Winners must be willing to share the details of their programs for free with anyone who asks for them. “Our goal has been to spread the idea of health promotion and disease prevention Johnny Appleseed-style across the country,” Beadle says:

What programs work?

The Health Project and similar organizations have shown that wellness programs pay off–if they’re done right. A company can’t just sponsor a cholesterol screening every now and then or a build a gymnasium that nobody uses. The companies that win Koop awards demonstrate innovation in the fight to win people over to wellness.

Take Union Pacific Railroad. With health care costs per employee approaching $6,000 annually, the company searched for ways to reach its 28,000 mostly mobile, unionized blue-collar workers. Carson Beadle outlines the challenge: “Picture engineers riding in that engine, sitting for hours on end and then stopping for a big dinner of chicken fried steak. And they’re driving your train. They’re not the kind of guys who are likely to be moved by this wishy-washy health promotion stuff.”

So Union Pacific came up with a comprehensive wellness program that features rolling fitness centers that travel with workers who lay track and burly role models who espouse exercise and good eating habits to co-workers. “They had a wrestler-type who was one of the gang,” Beadle says, “and he bought into health promotion and became the role model. The others thought, ‘Oh, okay, if he can do it, I can do it.'” Nine years later, their self-care program has netted $1.26 million in savings, and initiatives to reduce cholesterol intake and blood pressure have produced a benefit-cost ratio of 1.57 to 1.00.

Successful wellness programs share a few other commonalties besides innovation. Those that work are well-defined, well-promoted throughout the organization, bought into at the highest level of management and adequately funded. Definition is important because employers’ needs vary. At First National Bank of Chicago, for example, wellness program planners found that the leading area of claims for their primarily young, female workforce was in reproductive services. “Women, many of whom already had children at home, were not taking the time to go to the doctor, and they didn’t have transportation. So the company made sure they got both,” Beadle says. As a result, the rate of low birth weight babies fell to less than half the national average of 7 percent, and the bank saved an average $2,393 per case.

Promoting a program is the next step. Wellness initiatives that no one knows about are bound to fail, no matter how well thought out they are. At corporate headquarters of Marriott International Inc., in Washington, D.C., the 3,800 employees have a hard time not knowing about wellness initiatives. The measures include heart-healthy cafeteria food; signs next to elevators asking, “Why Not Take the Stairs Today?”; and regular classes, publicized in a monthly newsletter, on such topics as low-fat cooking and medical self-care. In addition, Marriott gently but regularly prods employees to work on risks detected during periodic health-risk appraisals. Payoffs have included a risk reduction rate of 57 percent for blood pressure and a 2.5 to 1 return on investment for a maternity education program.

Support from the top

Another requirement for success is the support of the entire management, especially those at the top. As a cautionary tale, Beadle points to the demise of the program at Southern California Edison, a 1994 Koop award winner. “They had a great program, and then when a new CEO came in, the program disappeared,” he says.

Contrast that with Townsend Engineering Co., in Des Moines, Iowa, where President Ted Townsend regularly addresses health promotion in company meetings with his 157 employees. An excerpt from a company meeting: “Personal fitness must be elevated in importance in daily priority to the same level as eating and sleeping. It is imperative that I make myself dear. It is not our jobs that are at stake, it is our lives!”

The company, which designs, manufactures and sells food processing equipment, is designated a Well Workplace, Gold Level, by the Wellness Council of America (WellCOA), a membership-based organization that scrutinizes program data submitted by members and awards achievement in wellness. Townsend’s commitment to preventive health paid off in 1992, when there were only two hospital admissions with possible lifestyle connections.

When the groundwork has been done, the company must come up with ways to provide services at a reasonable cost. The County of San Mateo, Calif., a 1994 Koop honorable mention, is promoting the wellness of its 4,200 employees with the help of its three health plans–Aetna, Blue Shield of California (both Koop winners) and Kaiser Permanente.

“We require that they offer their programs not exclusively to their own members, but to any interested county employee,” says Paul Hackleman, benefits manager for the county. San Mateo County also participates in the Corporate Health Program sponsored by Stanford University’s Center for Research in Disease Prevention. This partnership benefits all concerned: Stanford gets subjects for its studies, the County of San Mateo employees get expert health care at reduced costs and the County of San Mateo–as well as the rest of the world–gets the benefit of data from the studies.

The County of San Mateo is also a member of the Healthtrac program, offered by Integrated Health Sciences. Healthtrac, another Koop award recipient (1994), conducts regular programs that focus on self-care with the goal of reducing demand for health services. The county has had particular success with Seniortrac, which targets retirees. In a study involving 59,000 active participants, the California Public Employees Retirement System reported a return on investment of 4 to 1–cost savings amounting to $4 million–as a result of Seniortrac.

Shortcomings and controversies

Employer-sponsored programs are becoming more popular for large companies, but according to John Pinney, they reach only about 15 percent of Americans. Smaller companies often rely on HMOs or other health plans to provide preventive medicine. With notable exceptions, though, many providers are still mired in the disease treatment model.

“Purchasers have got to recognize that most managed care plans are in the business of making money. They’re not willing to offer services unless their clients demand them,” Pinney says. “I think it’s appropriate for purchasers to expect more. I think that managed care as it exists now doesn’t just eliminate unnecessary procedures–it also limits the contact individuals have with the health care system. And people who are at high risk of developing chronic diseases shouldn’t be left alone.”

Most existing programs have also overlooked employee dependents, a population sorely in need of attention. When the next generation brings its increasing obesity and poor health habits to the workforce, it may undo hard-won wellness advances. In the end, however, young and old alike may have no choice but to change risky behavior if they want a place in the workforce–and therein lies a controversy.

Some employers are also implementing more drastic methods of bettering their workers’ health odds. For example, the City of Dubuque, Iowa, is in the process of passing a measure that, in effect, prohibits smoking among city employees. “So what will get that cigarette-smoking, sofa-sitting kid to stop being a nicotine addict and a couch potato? One factor might be livelihood,” says William Hembree, director of the Health Research Institute in Walnut Creek, Calif. “If you can’t get a job, all of a:sudden you might be willing to change some of your behavior. It’s not an issue of justice. It’s an issue of sound business practice.”

Whether the American public will accept this approach remains to be seen. Is it right to target people who have increased health risks that may result from inherited conditions such as diabetes? Another area of controversy is the use of incentives for good health habits and disincentives for poor ones. A 1995 Hewitt Associates employer survey showed that 37 percent used financial incentives or disincentives in their benefit plans, up from 18 percent two years before. (For the four-year trend, see chart, page 56.) Typical incentives included cash payments or reduced premiums for smoking cessation and weight loss. Disincentives included charging smokers higher premiums or lowering medical benefit payouts for injuries resulting from alcohol use. Behavior experts generally disapprove of this kind of slap-on-the-hand approach, citing the potential for defiance. (See chart on this page for analysis of the health behaviors employers target most often.)

But as Hembree points out, people with low-risk lifestyles may feel penalized by the current system. These employees need only observe co-workers who make repeated, costly lifestyle-related health claims to conclude that, over time, unhealthy employees are receiving a good deal more of the company’s money. “We have a system that incorrectly rewards wrong health behaviors and does not reward good health behaviors. I fully expect all of that to change. But it takes time,” Hembree says.

It will also take adequate investment in health promotion. Until the culture at large changes its thinking about health and disease, though, the benefits of prevention will be confined to the handful of employers committed to making it work.

GETTING TOUGH ON WELLNESS

Between 1993 and 1995, the precentage of major employers using wellness incentives and disincentives more than doubled.

% of employers

1992 14%

1993 18%

1994 35%

1995 37%

COPYRIGHT 1996 A Thomson Healthcare Company

COPYRIGHT 2004 Gale Group