Fresh Faces

Anthem’s Geoffrey B. Crawford Wants To Fix Wellness Programs

The 35-year-old is a rising star in one of the country’s largest health care plans. Included in his take: ACOs hold promise, and gene therapy could break the bank.

He’s successful, handsome, and seems like a genuinely nice guy. Even his dog is cute. (He sent pictures.) So, as much as the Green Monster, (we’re talking jealousy here, not Fenway Park), might want to nudge you toward disliking Geoffrey B. Crawford, a medical director in Anthem’s office of medical policy and technology assessment, it just can’t be done.

Crawford, who has dual U.S./Canadian citizenship, lived in Jakarta, Indonesia, from ages 4 to 14 and a lot of other places growing up. They included Scotland and Calgary, Canada. His family moved around so much because his father worked in the oil and gas industry while his mother taught at international schools. The years in Indonesia were a major influence: They sparked an interest in medicine and population health “given my inevitable exposure to the gross health inequalities of a nonfunctioning health care system.” (Another young man who got there in a hurry also spent part of his childhood in Indonesia: former President Barack Obama.)

Crawford crushed it in school, graduating with distinction from McGill University, earning an MD magnum cum laude from Albany Medical College, and then topping it off with a master’s degree in epidemiology from the University of Maryland. He completed his internship in internal medicine at Stanford and residency at the University of Maryland.

So make no mistake: He’s ambitious. He also knows his limitations. “For something as complicated as health care, I don’t believe that any one person understands the system in its entirety,” Crawford says. “You have to try to see as much of that as you can while focusing on the one expertise that you’re trained in.”

He’s also capable of the pithy and insightful quote like: “Engineers have saved more lives in medicine than physicians.” When Crawford praises the work of engineers, he’s talking specifically about chlorination of the water supply, which indeed has saved millions. He is board certified in public health and general preventive medicine (population medicine), which reflects his interest in the overall health care system.

Less is more

He thinks wellness proponents should make that an example—the best wellness programs would be those in which active patient participation is least.

“If you want to keep people healthy, if you can do it in a way to engineer health, you are more likely to be successful,” Crawford says. “Growing up and later, in medical school, I discovered how complicated the health care system is and I wanted to be involved in a way that’s meaningful to me.”

Crawford became increasingly concerned about the entire health care system.

“As meaningful as it is to impact patients’ lives on a daily basis working in a clinic or daily practice, I wanted to have influence on hundreds, thousands, even millions of people and can do that through the work we do at Anthem,” says Crawford. “I get satisfaction from impacting health processes at the system level.”

That may have a lot to do with why he is now a medical policy director for Anthem, which creates medical policy for all the company’s affiliated commercial, Medicaid, and Medicare medical plans nationwide. Crawford has been at Anthem for more than six years, first in clinical analytics, where he worked to bolster member engagement in evidence-based care, and now in the office of medical policy, where he works on clinical coverage policies used to determine utilization management and formulary decision making.

Wellness “ties into the evidentiary component of my position—evaluating the scientific literature to support evidence-based medicine.”

Crawford thinks that creating a team atmosphere is one of the more important aspects of being a physician manager. “Clinicians are particular types of personalities, so they’re going to try to solve the problem that’s in front of them,” he says. “And many of the problems in health care, if not all of them, are impossible to solve as one person.”

Boost from technology

Wellness is a topic very much on Crawford’s mind. It “ties into the evidentiary component of my position—evaluating the scientific literature to support evidence-based medicine; as well, I provide clinical leadership for evaluation and implementation of preventive health service recommendations.” He appreciates the common criticism of wellness programs: They haven’t really been shown to improve health, let alone save money. “There haven’t been a lot of great studies that have shown that wellness intervention will ultimately lead to the type of health outcomes that we are looking for,” Crawford says. “Part of the problem is human nature. People think they’re healthy when they’re not feeling unwell.”

In wellness, as in the rest of health care, technology is not always the answer, in Crawford’s opinion. The person who could most benefit from IT-based solutions is probably the least plugged in. “I think those are solutions that make a lot of sense, but they’re really something that’s probably only going to be utilized by the young and healthy, or the curious.”

Still, technology could give wellness programs a boost. As an example, Crawford mentions a conceptual app that would use data about demographics, health care records, and consumer purchases to match behavior against evidence-based care. Digital reminders would tell people when they need health screenings and follow-up visits.

Wellness may be a somewhat nebulous term, but traditional medicine is always about the numbers. “We’ve developed a process at Anthem,” says Crawford. “All coverage decisions are based on evidence made by our medical policy and technology assessment committee, a majority of whom are external physicians from various specialties, practice environments, and geographic areas.”

That doesn’t necessarily lead to easy solutions. “It gets more challenging with the gene therapies that are on the horizon,” Crawford says, citing a study by the Institute for Clinical and Economic Review this year that states that the cost of gene therapies will equal the approximately $3 trillion a year that we currently spend on all health care. “There has to be a balance between affordability and care,” says Crawford. “Start with evidence and you’re in a good position to think about various solutions and strategies.”

Crawford also sees another shift on the way. “Every­body before the 20th century used to be cared for in the home,” he says. We now get care in the hospital because hospitals house the technology. But what if homes housed the technology? “We can go back to providing care in a way that makes sense, and that people enjoy, and that may end up being less costly, and utilizing technology to sort of bring back care to a human level,” Crawford says.

ACOs? While eyes in other heads may glaze over, ACOs are what excites Crawford most these days. Some details still need to be hammered out, he says, such as exactly how reimbursement should work in a pay-for-performance system. But he sees them as the nearest big chance of ushering in a new way of providing and paying for health care: “The ACO is where the data are being freely shared, where impediments are minimized, and where, as a clinician, you can hopefully see all of your hard work manifest itself in patients getting better.”

And, yes, Crawford is not spared the ubiquitous: Where do you see yourself in five years? He laughs, then responds: “In five or 10 years, I hope I’m doing exactly what I’m doing now, with more experience and more knowledge. Because there is so much to be learned.”

Frank Diamond

Humana Touts Success of Its Wellness Program

Humana says that 50,000 of its employees are ahead of schedule when it comes to achieving their wellness goals, according to a Humana progress report. The company’s wellness program, Bold Goal, set certain benchmarks it wants participating employees to reach by 2020.

Wellness Programs Focus of Lawsuit Filed by AARP Against the EEOC

Even as they’ve become more and more popular with employers, wellness programs have taken hits in recent years with naysayers arguing that the effort discriminates against some workers by leveling fines for not reaching benchmarks and also represent an invasion of privacy.



Do Diabetes Wellness Programs Work?

It depends on whom you ask. Managed Care asked two experts: “Can a wellness program help decrease the incidence of and/or lessen the severity of diabetes or prediabetes?”

No! argues Al Lewis. Lewis, a critic of the programs, is the CEO of Quizzify, a leading employee health care education company, and author of Why Nobody Believes the Numbers: Separating Fact from Fiction in Population Health Management.

Yes! rebuts Harris Allen, PhD. Allen, a defender of wellness, leads the Harris Allen Group, an independent consultancy founded in 1998 to promote stakeholder value and sustainability in health and health care.

Allen is also a senior lecturer on health care leadership at Brown University.

Wellness Programs Will Not and Cannot Prevent Diabetes

Al Lewis

Conventional workplace wellness has not worked, by any measure. Partly, that’s because only a small percentage of people who quit smoking or lose weight succeed in the long term even when they are self-motivated. And employers cajoling employees is the opposite of self-motivation. Also, employers spend surprisingly little money on hospital admissions related to conditions that wellness programs are designed to address, compounding the poor economics of medicalizing the workplace.

Prediabetes risk factor reduction is the poster child for the failure of workplace wellness. It specifically has failed in three instances where success would have seemed most likely: a health insurance company spending $500 per employee, a wellness vendor itself, and an award-winning wellness program.

Al Lewis

Al Lewis

Aetna’s experience

Take the first instance. Aetna thought workplace wellness could prevent diabetes and prediabetes. To that end, it launched a program for 500 of its own employees in October 2013. In practice, however, Aetna’s study group didn’t outperform its control group, despite Aetna spending an industry-leading $500 per participant fee, as outlined in a December 2015 study published in the Journal of Environmental and Occupational Medicine.

Then, there are the wellness vendors themselves. One, Vitality, couldn’t reduce the weight of its own employees. At least that was an honest admission. Now, examine the industry’s allegedly most successful program by visiting the website that I write for, www.theysaidwhat.net, and search for Navistar. Navistar originally claimed an industry-leading 400-to-1 ROI. Then their ROI inexplicably plummeted to 40-to-1 before equally inexplicably bouncing back to 400-to-1. Questioning that accounting would put you in good company: While Navistar was “doing wellness,” it was also “doing fraud.” The Dow Jones dropped them and the stock exchange delisted them. They also wrote off $4 billion in fake shareholder equity, fired successive CFOs, and sued their auditor.

Next, consider McKesson. As described in Employee Benefit News, McKesson’s program won the 2015 C. Everett Koop National Health Award. Yet BMI and glucose increased. If an award-winning company can’t reduce employee diabetes risk factors, who can?

Losses and more losses

Even the hypothetical scenario presented by the Health Enhancement Research Organization and Population Health Alliance to justify wellness (“Program Measurement and Evaluation Guide: Core Metrics for Employee Health Management”) actually shows losses—a vendor charging $18 per employee per year to save only $12 in claims. Substituting your own program fees for that hypothetical $18 could even increase those losses. And note their caution that utilization declines only in wellness-sensitive hospital admissions. They freely admit other medical claims increase, but they don’t count those increases against the $12 in gross savings.

If wellness worked in practice, there would have been a steady and dramatic reduction in admissions related to heart disease, diabetes, and other cardiometabolic problems paralleling this century’s explosion of wellness programs. Instead, the admission rate for the commercially insured population (largely exposed to wellness) has flatlined on an absolute basis. On a relative basis, the exposed population has slightly underperformed the remainder of the population that has no exposure to workplace wellness. In other words, wellness-sensitive admissions haven’t declined faster than admissions as a whole.

Workplace Wellness and Diabetes: An Approach Coming of Age

Harris Allen

Some 86 million Americans with prediabetes progress toward diabetes at a rate of 5% to 10% per year. The CDC Diabetes Prevention Program (DPP), a randomized clinical trial based on the NIH-funded Diabetes Prevention Program, has shown that this rate can be reduced significantly by a structured lifestyle intervention focusing on physical exercise and diet and by prophylactic metformin treatment.

Subsequent work has paved the way for deployment of the DPP and like-minded inter­ventions in work settings. For instance, in an initial test, researchers at Brigham Young University demonstrated that the DPP can be successfully implemented in the workplace.

Harris Allen

Harris Allen

Moreover, to mitigate the structural difficulties of implementing large-scale lifestyle enhancement programs and concerns about metformin side effects, University of Michigan researchers have developed risk-stratification models. Likewise, a 12-month worksite-based education program can significantly improve diabetes knowledge and self-efficacy, even in a workforce with well-controlled diabetes, as demonstrated in a 2015 study published in Population Health Management.

The Validation Institute, which has been critical of workplace wellness programs, recently publicized a claims-based audit of prepublished data on diabetes that documents workplace wellness effectiveness. Among the institute’s “validated organizations” is US Preventive Medicine (USPM), a leading wellness services provider. The institute’s website cites USPM’s “sustained … reduction(s) in wellness-sensitive medical events” across several major diseases—including diabetes—that “significantly outpaced the much smaller national decline in these events.” While the institute’s website does not furnish the details—in sharp contrast to that provided on other similar entities’s websites like the Koop Award program—this development helps to dispel the notion that workplace wellness is incapable of sustained reductions in diabetes burden.

Not all studies of workplace programs have yielded positive results. Consider a randomized controlled trial of three self-management interventions for employees with diabetes. The results, published in Population Health Management in 2012, show that at one year, neither use of a personal digital assistant handheld device, participation in a six-week chronic disease self-management program, nor the two combined, led to greater reductions in lost productivity costs than the usual care arm.

What accounts for the uneven results? One explanation is scope. Compare the information-imparting focus of self-management interventions with the information → knowledge → activation → sustainment progression that USPM promotes with its integrated suite of “high tech, high touch” population health services.

Clearly, all that passes today for workplace wellness is not geared for success. Kaiser’s Employer Health Benefit Survey reports that while 74% of firms offering health benefits in 2014 included wellness programs, there is variation in the services they provide. The Rand Corporation reports that only 12.9% of wellness programs can be characterized as comprehensive.

The question is not whether workplace wellness can exert an impact—it can—but how best to design a program so it will. Researchers at HealthPartners Institute have identified five elements defining comprehensiveness: health education, supportive physical and social environments, program integration into the organization’s structure, linkages to related programs, and worksite screening programs. Comprehensiveness, however, is just one of nine dimensions in their framework. Their premise is that the more that interventions advance on all these dimensions, the better the chances of success.

Ultimately the will to make the investments that move the needle is key. Evidence-based workplace health promotion and disease management programs continue to present opportunities for employers to reduce the incidence and severity of diabetes. Elsewhere I have argued that the workplace wellness successes of leading employers offer much grist for providers, payers, and other stakeholders as the latter grapple with their own value/sustainability challenges. These gains on diabetes further attest that it is very much in our collective best interest to promote well-executed workplace wellness.

Plan Watch

Wellness Debate Irrelevant For Insurers Eyeing the Market

Despite last year’s fiasco at Penn State and growing concern about the effectiveness of such programs, employers are still believers

Reports about wellness programs have occupied this space many times. Why shouldn’t they? Employers demand, insurers supply.

Jaan Sidorov, MD, a consultant, former health plan medical director, and member of our editorial advisory board, says, “It’s a no-brainer.” He adds, “Employers and their employees want them. Laypersons believe that wellness programs, thanks to prevention and health promotion, should translate into lower premiums.”

Yet thanks in part to last year’s fiasco at Penn State, the benefits of wellness have been questioned. Writing in the Los Angeles Times (http://tinyurl.com/op-ed-wellness), Rahul K. Parikh, MD, asked, “Do such programs have the intended effect of healthier employees and lower health-care costs? As more businesses embrace health incentives, these questions are becoming more urgent.”

Does it work?

There’s no doubt where Al Lewis stands. Lewis, the founder of the Disease Management Purchasing Consortium, says that if wellness programs were so popular with employees, then the penalties and incentives would not have doubled in the last four years.

“Wellness programs are so worthless that employers basically have to force their employees to lose money if they don’t participate,” says Al Lewis, founder of the Disease Management Purchasing Consortium.

“People have to be paid to do wellness,” says Lewis. “If something is valuable, people will pay you to do it. For example, I’m talking to you on an iPhone. Apple did not pay me to take the iPhone off their hands; I paid Apple. Wellness programs are so worthless that employers basically have to force their employees to lose money if they don’t participate.”

Further, Lewis contends, there’s no evidence that wellness programs work — that they actually improve outcomes. He cites a study in 2009 in Health Affairs co-written by Katherine Baicker, PhD, a professor of health economics in the department of health policy and management at the Harvard School of Public Health (http://tinyurl.com/sBaicker-article).

“In the top-tier journals, there’s been only one. Ever. One ever. That supported wellness,” Lewis says. Baicker’s article says that wellness can generate an ROI of 3.27:1. Lewis, who says he has a lot of respect for Baicker, also mentions that she “walked it back” on the NPR show Marketplace last year.

“She goes on Marketplace and says, ‘It’s too early to tell; we have to keep experimenting.’”

Baicker basically corroborates this, telling Managed Care that the “Health Affairs article includes many caveats, but of course such academic nuances are rarely reported in the popular press. Whenever I am interviewed, I try to reintroduce those cautions alongside the main results of the paper — so my comments on Marketplace mirror what we said in the paper itself.”

What she said: First, there are clearly limitations in the broader generalization of these findings. Second, the companies implementing these programs are probably those with the highest expected returns. Third, it is difficult to gauge the extent of publication bias, with programs seeing high return on investment most likely to be written about and studies with significant findings of positive returns most likely to be published. Fourth, almost all of the studies were implemented by large employers, which are more likely than others to have the resources and economies of scale necessary both to implement and to achieve broad savings through employee wellness programs.

Lewis argues that the only ones who believe in wellness programs are those who get to sell them. “There’s wellness that’s done to employees, and there’s wellness that’s done for employees. The Penn State program was clearly done to employees. Is it something that people like intuitively, or is it something people have to be forced into? They were definitely forced into it.”

No one objects to someone losing weight, stopping smoking, or exercising more. But Lewis believes that you can’t pay people to do those things.

It is especially difficult to lose weight. He calls the connection between weight and health a loose correlation.

“Most of those comorbidities don’t happen until you’re over 65,” says Lewis. “Even if they do happen when you’re under 65 — like diabetes — the actual complications and the facts that are going to cause the money to go up are over 65. So as an employer, if you’re seeking out cases of very early stage pre-diabetes, you’re simply going to create costs for yourself.”

Difficult to gauge

Parikh, in his Los Angeles Times article, said, “A number of recent studies have cast doubt on both the cost savings and the sustainability of some employee wellness programs.”

One such study, Parikh wrote, showed that fewer employees were hospitalized. Money saved, right? Well, no. Those savings were offset by more visits to the doctor and use of prescription drugs.

For health insurers, though, this debate is academic. Randel K. Johnson, the senior vice president for labor, immigration, and employee benefits at the U.S. Chamber of Commerce, wrote an op-ed last April in The Hill with the telling headline, “The Truth About Workplace Programs: Everybody Wins” (http://tinyurl.com/Johnson-article).

“In identifying impending and current chronic disease and illnesses, these programs offer another way to advance our country’s health care evolving approach beyond simply treating diseases and caring for the sick to improving health and maintaining wellness. These wellness programs give people tools to identify their risk factors, improve their health, modify unhealthy behavior, and stay well both in the workplace and at home.”

We circle back to Sidorov’s point: Employers want wellness programs. He also argues that they are not as ineffectual as Lewis and others think.

“I think insurers have internal numbers that have not been made public that do show a beneficial impact on utilization,” says Sidorov. “What’s more, even if there isn’t that much of a return on investment, it’s what the market wants, and that alone qualifies as a classic loss-leader.

“In addition, health plans with a reputation for strong wellness programs may benefit from stickiness with consumers who are baseline healthy and dilute the risk pool. Last but not least, health plans are, whether they like it or not, in the public spotlight and, from a brand as well as public policy perspective, need to be perceived as part of the solution.”

It comes down to execution, Sidorov believes. Penn State shows how things can go wrong, but is not an indictment of wellness programs. “I have some opinions about Penn State — charging more for nonparticipation, a school in turmoil, ultimately meritless but hot-button concerns over privacy, suspicious faculty, effective communications from a few alarmed professors, a rather ham-fisted administrative response, and the distractions that come from a national spotlight. These have more to do with execution than merit.”

Frank Diamond
News & Commentary

Wellness Benefits Not in the Mind

Wellness is as wellness does, to coin a phrase that probably can’t stand on its own but means in this instance that workers get out of a program what they put into it.

So much for the obvious. What’s new in a study in the American Journal of Health Promotion is that the positive effects of wellness programs on mental health are negligible at best.

That study, “Is Usage of a Wellness Center Associated With Improved Quality of Life?”, says that “a wellness center can improve physical health and has limited or no effect on maintaining mental health.”

Researchers at the Mayo Clinic measured quality of life (QOL) for about 1,100 members of a wellness center from September 2008 through December 2009.

Even for those who used the centers the most and got the most physical benefit as a result, the mental health benefits were practically non-existent, and they actually declined for those who used the centers the least, from 51.4% to 34.5%.

The authors have some suggestions.

“The benefits of physical activity are well established, but perhaps to fully affect mental QOL, wellness centers need to offer a wide range of strategies for spirituality, stress reduction, sleep, social support, relationships, career advancement, and financial planning.”

Managed Care Outlook

Large employers agree on rewarding healthy behavior

Large employers plan to continue offering health coverage to workers, according to the 18th annual Towers Watson/National Business Group on Health Employer Survey, but the struggle to minimize costs continues. This year, the survey looks at how this challenge is taken up by employers that, of the 583 respondents, “are in the top tier of respondents whose costs have increased over four years at a much lower rate than the … median.”

Companies that have controlled health costs well now plan to …
Examine health care benefits, employee subsidies, and out-of-pocket costs in a “total rewards” framework 39%
Manage company subsidy as part of a “total rewards” budget rather than a separate health plan budget 30%
Increase employee contributions in tiers, with dependent coverage at higher rate than single coverage 24%
Structure employee contributions based on employees taking specific actions 23%
Adopt new payment methodologies that hold providers accountable for the cost of episodes of care, replacing fee for service 22%
Offer telemedicine for professional consultations 22%
Fund account-based health plans in accord with wellness or health management behavior 22%
Offer specialty provider networks 20%
Track outcomes quantitatively from all vendors 20%
Contract directly with physicians, hospitals, and/or ACOs 18%
Provide access to a private or corporate health exchange 18%

“The actions of our best performers may well provide a playbook that others can follow to achieve their goals,” the study says. “This is especially true for those whose strategies and tactics have led to less-than-desirable financial and health results.”

One thing the most successful companies are doing is “integrating their contribution strategy with their health management and wellness activities. Many more companies are tying their wellness incentive strategy to their [account-based health plan] contributions.”

More employers are not just taking the workers’ word for it regarding whether they’re making necessary lifestyle adjustments.

“More recently, companies have been expanding biometric outcomes to include achievement of specific body mass index levels and target cholesterol levels. Today, 16 percent of companies align their rewards/penalties with specific biometric targets (other than tobacco use), and another 31 percent are considering this strategy for 2014.”

Wellness incentives to expand; requirements to be tougher

2011 2012 2013 2014
Use financial rewards for people who participate in health management programs/activities 54% 61% 62% 81%
Use penalties for people not completing requirements of health management programs/activities 19% 20% 18% 36%
Require employees to complete a health risk appraisal and/or a biometric screening to be eligible for financial incentives 35% 42% 54% 75%
Require employees to validate participation in healthy lifestyle activities to receive a reward or avoid a penalty (e.g., proof of fitness center use or engagement with a primary nurse case manager) _ 23% 33% 59%
Reward or penalize based on tobacco use 30% 35% 42% 62%
Reward or penalize based on biometric outcomes such as achievement of weight control or target cholesterol levels 12% 10% 16% 47%
Apply rewards or penalties and/or requirements under health management programs/activities to employees and spouses alike 19% 23% 31% 59%

Source: “Reshaping Health Care: Best Performers Leading the Way,” Towers Watson/National Business Group on Health, March 2013

Plan Watch

Kaiser Permanente Goes All Out To Provide Access to Wellness

The insurer studies exactly what works and why in studying two programs that battle diabetes

Usually studies stir interest when they’re finished, not when they’re started. That’s not the case with Kaiser Permanente Northern California Division’s plan to review two recently launched diabetes programs. Employers have historically been behind wellness efforts, but Kaiser’s endeavors indicate that more insurer-based programs may be on the way.

“If our studies show that wellness coaching has a positive impact on health and wellness outcomes, then an important question will be, ‘How can we get members who might most benefit from these programs to engage with them?’” says Julie Schmittdiel, PhD, a research scientist at the Kaiser Permanente Northern California Division of Research. “So testing different methods of outreach to see what works best will be an important way to address a key question for employers and health plans.”

Julie Schmittdiel, PhD

“Our wellness efforts have been proven effective in a number of rigorous evaluations,” says Julie Schmittdiel, PhD, a research scientist at the Kaiser Permanente Northern California Division of Research.

Schmittdiel is the lead author of an article in the January Preventing Chronic Disease, a publication by the Centers for Disease Control & Prevention. (“Health-Plan and Employer-Based Wellness Programs to Reduce Diabetes Risk: The Kaiser Permanente Northern California NEXT-D Study,” https://www.cdc.gov/pcd/issues/2013/12_0146.htm. NEXT-D stands for Natural Experiments in Translation for Diabetes.) That article outlines how she and her team plan to study two of Kaiser Permanente’s antidiabetes efforts.

“The two [programs] described in our article are both still in process,” says Schmittdiel.

Active role

Her article says that health plans and providers are starting to offer wellness programs, often health education and lifestyle programs.

That insurers undertake this effort is a relatively new development. Al Lewis, founder and president of the Disease Management Purchasing Consortium, points out that “The first health plan to put wellness in a request-for-proposals for outsourced services was Carefirst in 2006.” Carefirst is a Blues plan in Maryland.

One of the programs measured by Schmittdiel uses telephone coaching and motivational interviewing to encourage lifestyle changes. The other targets women with gestational diabetes mellitus, offering postpartum glucose screening and diabetes prevention education.

“Gestational diabetes is one of the biggest risk factors for developing type 2 diabetes in young women,” says Schmittdiel. “Two to 10 percent of pregnant women will develop gestational diabetes, and women with gestational diabetes are seven times more likely to develop type II diabetes later. Reducing this risk is a critical women’s health issue and diabetes prevention issue.”

Three phases

She adds that she hopes to publish the results of the coaching and gestational diabetes projects this year.

Schmittdiel divides her effort into three phases, the first two focusing on about 1,400 beneficiaries who participated in the insurer’s wellness coaching program from January through August 2011.

Phase 1 is a survey of patient satisfaction, and their reasons for using the wellness coaching program, self-reported changes in healthy behaviors, and patient engagement. The coaching program looks at healthy eating, physical activity, stress management, smoking cessation, and weight control.

Phase 2 involves observing control groups at different times both before and after the intervention to assess the effect of wellness coaching on levels of BMI, systolic blood pressure, and low-density lipoprotein cholesterol levels.

If researchers determine that the coaching has helped, then phase 3 will compare the effectiveness of three outreach methods (letters, interactive voice–response telephone messages, and secure e-mail) on about 30,000 patients with prediabetes.


The reviews have not all been positive. The health care blogger Vik Khanna, MHS, for instance, sees little that is really new in Kaiser Permanente’s efforts.

Khanna is a consultant whose background includes a stint at the Johns Hopkins University Bloomberg School of Hygiene and Public Health. He is admittedly a hard man to please when it comes to wellness programs.

On his Web site, he notes that he at one time designed corporate wellness programs for both large and small companies.

“These experiences have proven both enlightening and discouraging,” Khanna writes. “Notably, my experience has taught me that the corporate wellness industry, now valued at about $6 billion, really is just a fiction. For all the claims made by industry vendors, there are few data points about programmatic success that can withstand even modest scrutiny. Hence, my philosophical shift from industry acolyte to industry heretic. The corporate wellness industry isn’t saving anyone a dime.”

What wellness should not be

Khanna calls Kaiser Permanente’s effort a “perfect example of what wellness should not be.... This is just managed care all dressed up to seem like something bright, shiny, and new. The study participants are obese (i.e., at least one risk factor and probably multiple ones have already emerged) and were given one-on-one coaching. In other words, they were treated with a conventional medical model. And there is almost zero chance of ever returning these people to a state of risk-free good health.”

Lewis, while not commenting on Kaiser’s efforts specifically, also has some doubts. The entire wellness industry, he says, is “made up.”

Schmittdiel responds that “while wellness programs have their detractors, that has not been the experience at Kaiser Permanente. Our wellness efforts have been proven effective in a number of rigorous evaluations. The current study seeks to quantify what is working with our diabetes prevention programs so that we can provide improved access to them for our members.”


Schmittdiel adds that the studies are particularly timely in an age of health reform that emphasizes accountable care organizations and patient-centered medical homes.

“We believe that these changes in the U.S. health care system will continue to place a strong emphasis on efforts to improve the level of care integration and also emphasize accountability for prevention and wellness,” she says.

Besides, employers like wellness programs and want to understand the best approaches, and are also looking for programs that get workers to participate in programs that will improve their health.

Frank Diamond
News & Commentary

Employers told to measure wellness ROI

Companies that make the effort to find out what they are saving with their wellness programs are often pleasantly surprised, says a study by the International Foundation of Employee Benefit Plans. The IFEBP, a not-for-profit group that studies benefit plans, surveyed 447 member organizations, finding that about 1 in 5 analyzes ROI and of them, 4 in 5 achieve positive results. A significant number show a savings of $3 for every $1 spent.

“Attaching plan design incentives to participation was the most frequently cited reason” given by responding organizations for achieving positive ROI. The largest differences in participation rates between companies that offer program participation incentives and those that do not occur with health screenings (33 vs. 57 percent) and health risk assessments (33 vs. 55 percent).

Effect of incentives on average participation rate

Source: “A Closer Look: Wellness ROI,” International Foundation of Employee Benefit Plans

News & Commentary

Biometrics now part of wellness mix

“What do you want from me? Blood?” So goes the oft-thought but rarely voiced employee complaint. Well, more employers have actually begun taking employee blood to integrate biometric information into wellness programs by measuring such things as cholesterol and body mass index.“ Nine percent of large firms that ask employees to complete a health risk assessment (HRA) report that employees are rewarded or penalized financially based on whether they meet specified biometric outcomes, such as meeting a target body mass index or cholesterol level,” says a study by the Kaiser Family Foundation and the Health Research & Educational Trust. (Smoking cessation is not one of the targets.)

In addition, 11 percent of large companies (200 or more employees) say that they require an employee at risk to complete a wellness program to avoid a financial penalty such as higher premium contribution or more cost-sharing.

Some large companies offer rewards or slap penalties based on wellness

Source: The Kaiser Family Foundation, and the Health Research & Educational Trust