Health and Wellness: The Shift from Managing Illness to Promoting Health

Originally published as Issue Brief No. 121 by the Center for Studying Health System Change (HSC), June 2008. HSC was a nonpartisan policy research organization funded principally by the Robert Wood Johnson Foundation.

Health and Wellness: The Shift from Managing Illness to Promoting Health

Despite a widely acknowledged lack of evidence that workplace wellness programs produced a clear financial return on investment, health plan initiatives to promote health and wellness had become commonplace across the country, according to findings from the Center for Studying Health System Change's 2007 site visits to 12 nationally representative metropolitan communities. Much of the impetus came from employers -- primarily large employers -- that were embedding wellness activities into benefit designs placing greater responsibility on employees for health care decisions and costs. Health plans offered a broad menu of health and wellness services, from traditional worksite health fairs and educational seminars to behavior modification programs such as weight management and smoking cessation, to online tools including health risk assessments. Engaging employees in these activities proved difficult, however, since participation was usually voluntary and privacy concerns created resistance. More employers and plans were turning to financial incentives to boost participation rates.

Wellness as Part of a Broader Consumerism Strategy

Fueled in part by heightened awareness of the nation's growing obesity crisis, health and wellness initiatives were now standard across all 12 communities HSC studied. Much of the momentum came from employers looking for long-term strategies to address rising costs while supporting their broader effort to give employees more responsibility for health care decisions and spending. As one Phoenix health plan executive explained, overall health was not improving even as consumer demand for health care continued to grow, and employers wanted to engage their workers differently.

Wellness programs also offered health plans a way to reposition themselves with employers and enrollees. Rather than being viewed solely as claims processors and cost managers, plans could present themselves as partners in improving employee health outcomes. Employers hoped that wellness activities would reduce absenteeism, improve productivity, and prevent the kind of costly medical events associated with chronic conditions like asthma, diabetes, and hypertension. The American Hospital Association estimated that those three conditions alone generated 164 million days of absenteeism each year, costing employers $30 billion.

Plans Build Capacity and Compete on Wellness

Health plans were increasingly building, acquiring, or enhancing capabilities to deliver wellness services, in part because they had been losing business to non-health-plan vendors in this space. Plans across the 12 communities were packaging, branding, and marketing wellness activities as a way to differentiate themselves. Often these programs were positioned as a key component of a comprehensive approach to care management, and plans emphasized the value of integrating wellness activities with other care management efforts that drew on their claims data.

Range of Activities

Wellness activities were premised on the idea that healthier people use fewer medical resources and are more productive at work. These programs targeted enrollees regardless of current health status and aimed to encourage healthy behaviors and lifestyle changes. They went beyond disease screening (such as mammograms and colonoscopies) and differed from disease management and case management interventions, which apply after a diagnosis. While many of the specific activities were not new, what had changed was their intensity and the heightened awareness driving them. In addition to worksite health fairs, seminars, and screenings, plans focused on providing access to behavior modification programs for weight management, smoking cessation, and fitness. One of the most notable developments was the growing use of online health risk assessments -- questionnaires collecting information on personal and family medical history, current diagnoses, lifestyle behaviors, and preventive care use.

Enrollee Engagement and Incentives

Engaging enrollees remained the central challenge, since participation was typically voluntary. Most respondents across the 12 communities believed some form of incentive was necessary -- not just to get people involved initially, but to motivate them to actually improve their health. Incentives varied widely in size and design, from small cash payments for completing a health risk assessment to gift cards, gym membership discounts, and reimbursement for programs like Weight Watchers. Consumer-directed health plans (CDHPs) often incorporated larger incentives: one Indianapolis plan deposited up to $100 in enrollees' health spending accounts for completing a health risk assessment, an additional $100 for signing up for personal health coaching, and another $250 for finishing a weight loss or smoking cessation program.

Most plans relied on incentives rather than penalties to encourage participation, but the discussion was beginning to shift toward tying incentives to results rather than participation alone. UnitedHealthcare, for example, offered a product where employees could reduce their plan deductible through verified absence of smoking and meeting objectives for body-mass index, blood pressure, and cholesterol levels. Privacy concerns presented another barrier: nearly half of employees surveyed by the Employee Benefit Research Institute believed that employers offering wellness programs were intruding on worker privacy.

Investment Payoff and Implications

The credibility of health and wellness activities as mechanisms to improve health and control costs ultimately depended on evidence demonstrating their clinical and financial effectiveness, as well as consumers' acceptance and validation of their legitimacy. Most employers and plans acknowledged that robust evidence of return on investment was lacking, and many were investing in wellness based on intuition and competitive pressure rather than hard data. The long-term viability of the wellness movement hinged on whether these programs could produce measurable improvements in health outcomes and meaningful reductions in health care spending -- a question that remained open as of 2008.

Sources and Further Reading

Draper, Debra A., Ann Tynan, and Jon B. Christianson, Issue Brief No. 121, Center for Studying Health System Change, June 2008. | HSC Community Tracking Study site visits, 12 metropolitan communities, 2007. | American Hospital Association report on absenteeism costs from chronic diseases. | Employee Benefit Research Institute and Mathew Greenwald and Associates, 2007 Health Confidence Survey.