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The latest Kaiser Family Foundation survey on employer sponsored health insurance focused on the fact that growth in premiums in 2013 was as low as it has ever been in the 16 years of the survey. And that's awesome. Health insurance premiums have been rising more quickly than we'd like for a long time. But buried in the details of the report were some interesting insights into how employers think about controlling health care costs. One example is that they're very fond of workplace wellness programs. This is surprising, because while such programs sound great, research shows they rarely work as advertised. Watch and learn!

This episode is adapted from Aaron's and Austin's NYT piece on the topic. References can be found in the links there:

John Green -- Executive Producer
Stan Muller -- Director, Producer
Aaron Carroll -- Writer
Mark Olsen -- Graphics
Aaron: Every year, the Kaiser Family Foundation puts out a survey on employer sponsored health insurance in the United States.  Most news coverage of the most recent survey seemed on the fact that growth in premiums in 2013 was as low as it's ever been in the 16 years of the survey.  And that's awesome.  Health insurance premiums have been rising more quickly than we'd like for a long time.  But buried in the details of the report were some interesting insights to how employers think about controlling healthcare costs.  One example is that they're very fond of workplace wellness programs.  This is surprising, because while such programs sound great, research shows they rarely work as advertised.

Wellness programs are the topic of this week's Healthcare Triage.

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Wellness programs aim to encourage workers to be more healthy.  Many use financial incentives to motivate workers to monitor and improve their health, sometimes through lifestyle modification programs, aimed at lowering cholesterol or blood pressure, for instance.  Some programs offer a carrot, like discounts on health insurance, to employees who complete Health Risk Assessments.  Others use a stick, penalizing poor performance or charging people more for smoking or having a high Body Mass Index, for example.

Wellness programs are very popular among employers.  An analysis by the RAND Corporation found that half of all organizations with 50 or more employees have them.  The new survey by the Kaiser Family Foundation found that 36% of firms with more than 200 workers, and 18% of firms overall use financial incentives tied to health objectives like weight loss and smoking cessation.  Even more large firms, 51% of those with 200 workers or more, offer incentives for employees to complete Health Risk Assessments intended to identify health issues.  Medium to large employers in the United States spent an average of $521 per employee on wellness programs last year, double the amount they spent five years ago, according to a February report by Fidelity Investments and the National Business Group on Health.  The programs are generally not offered directly by insurance companies, but instead by specialist firms that tell employers they will reduce spending on employees' care by encouraging the employees to take better care of their health.  

Wellness programs have grown into a $6,000,000,000 industry, because employers believe this.  In fact, asked which programs are most effective at reducing cost, more firms picked wellness programs than any other approach.  The Kaiser survey found that 71% of all firms think such programs are very or somewhat effective compared with only 47% for greater employee cost sharing and 33% for tighter networks of doctors.  

What research exists on wellness programs doesn't support this optimism.  This is, in part, because most studies of wellness programs are of poor quality, using weak methods that suggest that wellness programs are associated with lower spending but don't prove causation.  Or they consider only short-term effects that aren't likely to be sustained.  Many such studies are written by the wellness industry itself.  A meta analysis published in the journal Health-Affairs in 2010 reported that wellness programs had a pretty impressive return on investment.  Medical costs fell by about $3.27 for every $1 spent, and absenteeism costs fell by about $2.73 for every $1 spent.  But many of the studies they examined were older and used less rigorous study designs.

More rigorous studies, including a more recent systematic review published in 2012 in the American Journal of Managed Care, tend to find that wellness programs don't save money, and, with few exceptions, do not appreciably improve health.  This is often because additional health screenings built into the programs encourage overuse of unnecessary care, pushing spending higher without improving health.  However, this doesn't mean that employers aren't right, in a way.  Wellness programs can achieve cost savings, for employers, by shifting higher costs of care onto workers. In particular, workers who don't meet the demands and goals of wellness programs end up paying more, whether by not participating at all or by failing to meet benchmarks like a reduction in Body Mass Index.  

Financial incentives to get healthier sometimes simply become financial penalties on workers who resist participation or who aren't as fit.  Some believe this can be a form of discrimination.  The Affordable Care Act encourages this approach.  It raises the legal limit on penalties that employers can charge for health-contingent wellness programs to 30% of total premium cost.  Employers can also charge tobacco users up to 50% more in premiums.  Needless to say, this strikes some people as unfair and has led to objections by workers at some organizations as well as lawsuits.  

Another way that wellness programs can help employers is by putting a more palatable loss on other changes in health coverage.  For instance, workers might complain if a company tried to reduce costs through higher cost-sharing, or narrower networks, that limit doctor and hospital choice.  But if these are quietly phased in at the same time as a wellness program that's marketed as helping people become healthier, a company might be able to achieve those cost-reductions with less grumbling.  

At least one study has shown that a wellness program can achieve long-term savings.   In 2003, PepsiCo introduced what was to become its Healthy Living program.  This program included lifestyle management, such as weight, nutrition, and stress management, along with smoking cessation and fitness, along with disease management components, such as targeting participants with asthma, coronary heart disease, atrial fibrillation, heart failure, stroke, hyperlipidemia, low back pain, and other issues.  A study published in the journal Heath Affairs examined the outcomes of the program seven years after implementation, the longest such study of a wellness program to date.  The researchers found that participation in the PepsiCo program was associated with lower healthcare costs, but only after the third year, and all from the disease management components of the program.  

This suggests that wellness programs that target specific diseases that may drive employer costs could achieve savings, though perhaps only after several years.  When more broadly implemented, and focused on lifestyle management, as many wellness programs are, savings may not materialize and certainly not in the short-term.  Employers may misunderstand the research, if they think that just any wellness program, by itself, is the surest route to reducing overall healthcare spending.  That just isn't the case.  It may be true that if designed well, some programs can save money for both the employer and employees in the long run, but not by focusing on lifestyle changes.  Programs that merely do that may cut employer cost, but only by shifting them onto employees.  If firms wish to count that as a victory in the battle against healthcare costs, they can do so, but they're employees may look at it differently.

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