Workplace wellness programs have been touted as a powerful tool that can make employees healthier and more productive while reducing health care spending, but the results of a new Harvard study suggest such interventions yield unimpressive results in the short term.
The findings, published April 16 in JAMA, raise questions about the effectiveness of these programs offered by 80 percent of large U.S. employers via an $8 billion workplace wellness industry.
The analysis, the first peer-reviewed, large-scale, multisite randomized controlled trial of a workplace wellness program, shows that people who worked at sites offering the program exhibited notably higher rates of some healthy behaviors, but no significant differences in other behaviors compared to the control group. Employees working at sites offering the program did not have better clinical measures of health such as body mass index, blood pressure or cholesterol after 18 months, nor did they exhibit lower absenteeism, better job performance or lower health care use or spending.
"Our findings show that health behaviors can respond to a workplace wellness program, but they also temper expectations of realizing large returns on investment in the short term," said study author Zirui Song, assistant professor of health care policy and medicine in the Department of Health Care Policy at the Blavatnik Institute at Harvard Medical School.
an assistant professor of health care policy in the Blavatnik Institute at Harvard Medical School and an internal medicine physician at Massachusetts General Hospital.
Song and study co-author Katherine Baicker, who was on faculty at Harvard at the time of the work reported in the study and now dean of the University of Chicago Harris School of Public Policy, said the ultimate goal of the team's analysis is to provide scientific evidence to inform policy and ensure that decisions and investments are based on rigorous science instead of on studies that point to links and associations or on assumptions.
"We wanted to explore the causal effects of workplace wellness programs using the rigorous methods of an experimental design in order to help policymakers and employers make informed decisions about investing in wellness," Song said.
What worked
Worksites offering a wellness program had an 8.3 percentage point higher rate of employees who reported engaging in regular exercise and a 13.6 percentage point higher rate of employees who reported actively managing their weight, compared to those working at sites where a program wasn't offered.
What didn't work
The program had no significant effects on other outcomes including 27 self-reported health and behavioral measures such as employees' overall health, sleep quality and food choices; 10 clinical markers of health; 38 measures tracking spending and utilization for doctor's visits, medical tests, procedures and prescription drugs; and three employment outcomes--absenteeism, job tenure and job performance.
The rationale behind the workplace wellness movement
The motivation for employer-based wellness programs is straightforward. If employers can help workers cut back on alcohol consumption, quit smoking or increase exercise, the idea goes, workers' health will improve, generating savings on health care costs, lowering the number of sick days people take and improving the overall well-being and productivity of the workforce.
In addition to private investment in workplace wellness program, the Affordable Care Act allocated public funding for wellness programs. In the broader context of health system reform, wellness programs are part of a suite of ideas that encourage preventive medicine, coordinated care and wellness education as ways to keep people healthy and reduce medical costs.
Past research has suggested workplace wellness programs might be a good investment. In 2010, Song, Baicker and David Cutler, the Otto Eckstein Professor of Applied Economics at Harvard, published a meta-analysis of prior research on wellness programs that found a roughly three to one return on investment for such interventions. However, as the authors noted in that meta-analysis, much of the prior literature was limited by the lack of a robust control group, leaving open the possibility that estimates could be biased by confounding factors, and by limited sites, sample sizes and outcome measures.
The experiment
To help improve the evidence on wellness programs, Song and Baicker decided to implement a large-scale controlled experiment. To eliminate the unwanted effects of self-selection and other biases inherent in nonrandomized studies, Song and Baicker randomized wellness program offerings across different worksites and tracked outcomes among all workers.
"In assessing the potential benefits of a workplace wellness program, it's essential to separate out confounding factors. The firms that choose to have a program may have employees who are already more health-conscious than those at firms without a program. And the employees who choose to participate may have different health profiles than those that don't," Baicker said. "Our study lets us isolate the effect of the program itself from those confounding factors."
The researchers partnered with BJ's Wholesale Clubs to offer new wellness programs in randomly selected sites, which they then compared to the control sites. This allowed the researchers to capture the effects that the program might have in changing workplace culture as well as individual behavior.
Among 160 eligible worksites across the Eastern United States, the wellness program was implemented at 20 randomly selected sites with a total of 4,037 employees--the test group. The remaining 140 sites and a total of 28,936 employees represented the control, or comparison, group. The wellness program comprised eight modules on topics such as nutrition, physical activity and stress reduction implemented by registered dietitians and administered by Wellness Workdays, a commercial operator of such services to corporate customers. The 18-month evaluation ran from January 2015 through June 2016. Administrative medical claims and employment data were gathered through June 2016; data from surveys and biometrics were collected from July through August 2016.
The new study findings complement the results of a recent well-designed randomized controlled trial conducted at the University of Illinois, where individuals (rather than entire worksites) were randomized into a wellness program or a control group, Song said. The working paper on the Illinois workplace wellness study is available at the National Bureau of Economic Research.
What next?
Song said that experimental evaluations in the field of wellness promotion are still relatively uncommon. While this study provides important insights about some kinds of programs currently in use, many questions remain about the best ways to improve population health, he said. One line of questioning directly related to the JAMA study is whether 18 months is enough time to see an impact from a program like this, or whether the kinds of changes in healthy behaviors the program produced take longer to yield measurable health benefits.
"As we grow to understand how best to encourage healthy behavior, it may be that workplace wellness programs will play an important role in improving health and lowering the cost of health care," Song said. "For now, however, we should remain cautious about our expectations from such interventions. Rigorous research to measure the effects of such programs can help make sure we're spending society's health and wellness dollars in the most effective way."
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The research was supported by the National Institute on Aging (R01 AG050329; P30 AG012810 through the National Bureau of Economic Research), the Robert Wood Johnson Foundation (grant no. 72611), and Abdul Latif Jameel Poverty Action Lab (J-PAL) North America. BJ's Wholesale Club provided in-kind logistical and personnel support for fielding the wellness program. Song has no conflicts of interest to disclose. Baicker serves on the board of directors of Eli Lilly and on the Congressional Budget Office's Panel of Health Advisers.
Journal
JAMA