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Wellness Programs: Paternalism-Based, Impersonal Medicine

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In recent years, many corporations, universities, and medical centers have initiated wellness programs for their employees. The presumption is that such programs will improve average employee health, thereby decreasing medical costs and saving money for the company or organization in the long run. These programs often involve financial incentives of varying magnitudes to encourage employees to submit to particular medical screening tests and to adopt or increase particular activities related to exercise, diet, or other aspects of personal behavior or even attitude.

Research from the RAND Corporation and separately from the California Health Benefits Review Program on the effectiveness of those portions of wellness programs focused on improving the health status of employees who have existing medical conditions or on maintaining the health status of employees who are currently free of major medical conditions suggest that the effectiveness of these programs on average is modest to minimal depending on the endpoint of interest. Typical endpoints are the number of smokers, average weight over time, diet quality, and incidence of hypertension. According to the RAND investigators, programs intended to assist employees in managing already diagnosed chronic diseases are somewhat more effective.

There is a chance that for a subset of individuals who have not been routinely engaged in healthful practices, the financial incentives and incessant reminders to exercise more, eat foods deemed to be health-promoting, reduce stress, and interact with others as a way of increasing social support might lead to benefit. However, for individuals who were already pursuing health-preserving or health-promoting practices, the constant admonitions to eat particular foods or perform particular exercises for a specified week may bring limited to no gains in health and serve as an irritating nuisance.

In addition, the incessant nagging can be perceived as both intrusive and condescending. The operative assumption on the part of the wellness program bureaucrats contacting me appears to be that all employees are completely ignorant of how to maintain health. This implicit message is particularly galling when the wellness program is being offered to employees, including physicians, nurses, and other health-oriented professionals at a medical center, who may know as much or more as the program designers about the actual effects of the practices being aggressively promoted.

It is also unclear how much money is saved by wellness programs. Even if the average wellness program saves money, it is likely that any such cost savings will vary widely with the nature of the program, the efficiency of the program management, and the sizes of the relevant workforces.

But there are much more frustrating, consequential, and problematic features with these programs:

• Wellness programs often evaluate employees solely on what actions they claim to have taken and for any specific activity only over a limited time interval, such as a specific week. The program managers may completely ignore longer-term commitments to exercise, diet, or other health-sustaining behavioral patterns.

• The focus of wellness program incentives is often solely on purported activities and not on measurable results. If for whatever reason you cannot or choose not to modify your behavior to fit the prescribed and rewarded behavior, you are financially "penalized" even if your ongoing behaviors were as or more conducive to health. Consequently, wellness programs can, however inadvertently, exhibit a substantial lack of fairness.

• The designers of wellness programs appear to be unaware of the limitations of self-reporting. Among these limitations are: 1) erroneous recall or assessment of activity or consumption of recommended foods and 2) frank cheating.

For example, I have seen an employee, while seated in a conference, dangling two pedometers (of the type dispensed by the wellness program contractor and presumably belonging to the employee and partner) and gently swinging and clanking them together to "simulate" walking. While I have no way to estimate the scale of such subversion, the possibility that it is non-trivial cannot be dismissed without investigation.

• In some instances, wellness programs run the risk of causing harm to some participants through incentivizing generally healthful behaviors that may be manifestly unhealthful for these particular individuals. In my own case, certain metabolic proclivities make some otherwise healthful foods potentially harmful. This particular metabolic tendency is reasonably common and illustrative of many other individualized health-related constraints. When the wellness program aggressively promotes the consumption of these foods, some individuals with metabolisms like mine may be knowingly or unknowingly putting themselves at risk in pursuit of the financial incentives. Others, who are aware of the associated risks and choose to ignore the advice offered by the wellness program, will be unable to receive the financial benefits given to others even if overall they are just as careful in managing their diets.

The overall point is not that wellness programs are necessarily harmful or without value. However, as currently designed and implemented such programs can be of minimal or even negative value in improving the health and general well-being of at least some employees. Alternatively, corporations and organizations could implement programs that, where appropriate, take account of medically relevant individual differences and treat employees as adults with some knowledge of healthful habits and health maintenance. There is a strong chance that such programs, both more sensitive to relevant evidence and more personalized could prove more effective than the currently blighted schemes.