Mayo’s news release describes the study design: “All [100] participants were given a goal of losing 4 pounds per month up to a predetermined goal weight. Participants were weighed monthly for one year… Participants in the incentive groups who met their goals received $20 per month, while those who failed to meet their targets paid $20 each month into a bonus pool. Participants in both incentive groups who completed the study were eligible to win the pool by lottery.”

Study subjects were Mayo Clinic employees. 62% of the incentivized participants completed the program, compared to only 26% of the unincentivized participants.  Participants receiving incentives lost an average of 9.08 pounds, compared with 2.34 pounds for those not receiving incentives.

This is a small study, but it sure paints a rosy picture of incentives. It will be interesting to learn the details from tomorrow’s presentation.

Will the presentation acknowledge that, while it seems inevitable that overweight people are more likely to stick with a program and achieve weight loss goals if they’re paid to do so, previous research has demonstrated the potential undermining effect of lifestyle incentives. As a result of the undermining effect, incentivized weight loss participants may be more likely to regain weight after the cash stops rolling in.

And we can only hope that, when the Mayo study is publicized more broadly, its pitchmen appropriately disclose that the study’s lead author is the scientific advisor and reportedly a stock holder of GymPact, the mobile app that promises to “incentivize your exercise.”

Related articles

• Cash can bribe dieters to lose weight, study says (todayhealth.today.com)
• Cash Incentives Help People Lose Weight, Researchers Find – Bloomberg (bloomberg.com)
• Money talks when it comes to losing weight, Mayo Clinic study finds (eurekalert.org)
• Bribing people to lose weight works, says study (cbsnews.com)
• Cash can bribe dieters to lose weight, study finds (reporternews.com)
• What’s Stronger than Willpower for Weight Loss? Cold, Hard Cash (healthland.time.com)

As American managers puzzle over how to help employees “thrive” at work, Japan struggles at the other end of the spectrum — how to keep employees from working themselves to death. Karoshi, literally translated as “death from overwork,” is an officially recognized cause-of-death in Japan. In the United States, one of the few countries where employees work more paid hours than Japanese employees, we commonly think of karoshi as someone else’s problem. But is it?

Karoshi is a well known phenomenon in Japan, where victims commonly work 14-hour days, seven-day weeks and die at an early age. Some karoshi victims have been known to work 80 straight days and more than 100 hours of overtime for months at a time. This brutal regimen is rooted in a culture that reveres hard work and self-sacrifice, as well as a 1980′s economic boom that drove demands for productivity, followed by a grueling economic recession that led to deep-seated job insecurity ever since. A 2004 International Labour Organization survey revealed that more than six million Japanese were working an average of more than 60 hours per week.

The first documented case of karoshi occurred in 1969, reportedly when a 29-year-old married man working in the shipping department of Japan’s largest newspaper died suddenly of stroke while at work. The Workers Compensation Bureau of Japan’s Ministry of Labor eventually deemed shift work and overwork as the causes of the death. Five years later, the man’s family received compensation.

In subsequent years, karoshi became an increasingly known phenomenon in Japan, predominantly among white collar workers known as “salary men.” The direct medical causes of karoshi were usually heart attack and stroke. A variation of the phenomenon is karo jisatsu, suicide due to overwork. (Suicide is believed to be underreported due to its stigma in Japanese culture, but in 2009 Japan’s national police agency estimated that 10,000 suicides, of the total 30,000 occurrences in Japan that year, were related to work.)

Tetsunojo Uehata, the medical authority who coined the term, defined karoshi as a “condition in which psychologically unsound work processes are allowed to continue in a way that disrupts the worker’s normal life rhythms, leading to a buildup of fatigue in the body and accompanied by a worsening of preexistent high blood pressure and a hardening of the arteries, finally resulting in a fatal breakdown.” More specifically, karoshi is linked to crushing workloads, relentless hours, absence of work/life balance, and silent suffering with no outlet to express dissatisfaction and no influence over work conditions.

In 1994, the government’s Institute of Economics estimated the number of karoshi deaths at around 1,000 or 5 percent of all deaths from cerebrovascular and cardiovascular disease in the 25 to 59 age group.

Some researchers have drawn a connection between the Japanese prevalence of karoshi and the nation’s commitment to lean production, the efficiency-above-all else approach to manufacturing that ultimately helped spawn the Lean Six Sigma approach that has taken American industry, especially healthcare, by storm.

One of the most notorious cases of karoshi occurred in 2002, when Kenichi Uchino, a 30-year-old manager of quality control at Toyota, collapsed dead at 4am — at work — having perservered more than 80 hours of overtime each month for the previous six months. Toyota and the Japanese government refused to compensate Uchino’s family, arguing that much of the overtime was voluntary and unpaid. Japanese courts didn’t buy it, and the family was compensated by both the government and Toyota. (Compensation for karoshi has been reported to frequently be the equivalent of $20,000 per year and up to $1 million dollars in punitive damages). The case led to systematic reform — new government regulations limiting overtime and promoting work-life balance, and corporate reforms, as well.

According to an insightful article by British journalist Emma Holmqvist

In response to mounting pressure, many Japanese companies are now making an effort to establish a better work-life balance… Toyota has upped its game, and has attempted to limit overtime to 360 hours a year, which amounts to about 30 hours monthly. Meanwhile, some companies run recorded announcements to urge their staff to go home or take a break at certain times, while firms such as Nissan have introduced telecommuting to ease the burden of employees with children. Taking the overtime issue more seriously still, a string of large corporations have begun operating with days strictly prohibiting overtime, requiring staff to leave the office promptly at 5:30pm.

But the extent to which these changes have influenced rates of karoshi is unclear. Widespread reports suggest that Japanese workers continue to work exorbitant overtime hours — off the books (“cloaked overtime” or furoshiki). And cases of overwork leading to non-disabling illness and to neglected health are not tracked. Indeed, the nature of the culture is that even true cases of karoshi, for which victims’ families can be compensated, are not likely to be reported. Some have speculated that the reigning issue has shifted — from prevalent work-related stroke and heart attack to a greater prevalence of work-related suicide.

Does karoshi exist in the United States, one of the few industrialized nations where employees work more reported hours than Japanese employees (though it’s believed that the Japanese tip the scales with cloaked overtime)? Some writers have drawn comparisons, such as Matthew Reiss writing on American Karoshi in the New Internationalist, and a Bostinno.com post called Karoshi: How Chronic Long Hours May Kill, And How Startup Life May Point to the Future.

American culture differs from Japan’s. In the United States, individualism reigns supreme. And the U.S. tradition of organized labor and workplace regulation reflects a different attitude toward the employee/employer relationship. Perhaps the difference in Japanese and American approaches to karoshi can best be illustrated with this observation: Whereas Japan has been criticized for sweeping karoshi under the rug, the U.S. has given karoshi little attention beyond one company’s development and the subsequent popularization of the video game “Karoshi: Suicide Salaryman.”

When it comes to employment and health, are Americans having strokes and heart attacks — or committing suicide — after suffering in silence under crushing workloads?  Or is something else at work? We’ll get to that in an upcoming post.

Related articles

• What’s the point in working yourself to death? (japantimes.co.jp)
• When is an hour at work not a work hour? (japantimes.co.jp)
• Could Japan’s Latest Buzz Word Get You Sued? Lawyer Weighs In (en.rocketnews24.com)

Where did this 10,000-step goal come from? What are the alternatives? And what’s been shown to work? Pedometer programs are reasonably effective, but solving these mysteries may lead to even greater effectiveness and may even influence how we think about goal-setting and self-tracking.

Back in the 1960s, a Japanese pedometer manufacturer dubbed one of its products manpo-kei, which translates to “ten thousand steps meter.” There was no known reason  the company settled on 10,000 for its product name, but shortly thereafter, Japanese researchers did determine that habitually active walkers typically accumulate something in the neighborhood of 10,000 steps per day.

Since then, evidence has shown that it takes approximately 3,000 steps over and above the average steps taken by typical sedentary people to meet the standard recommendation for physical activity — namely, getting at least 30 minutes of moderate-intensity activity each day. Anything less than 5,000 steps a day is considered sedentary. So a daily recommendation for physical activity — 3,000 steps over and above a baseline of 5,000 — would be 8,000 steps.

The Institutes of Medicine, however, advises that 60 minutes of daily activity is necessary to maintain a healthy weight. This would be equivalent to 6,000 steps, which, when added to the baseline 5,000, means participants should accumulate 11,000 or so steps per day to prevent weight gain.

This establishes that 8,000 to 11,000 steps, a guideline subject to individual variation, is equivalent to the minimum amount of physical activity people should get to maintain good health.  The question remains: How do you motivate sedentary employees to achieve this level?

An alternate to the 10,000-steps-per-day goal has been popularized by one of the first widescale pedometer programs, America On the Move, founded by obesity researchers James Hill and John Peters. AOM encourages participants to wear their pedometers for three days prior to the program, then to set a goal 2,000 steps above their average for these three days. When they achieve this goal, they can set a goal 2,000 steps higher. It’s individualized and incremental.

But research has not shown individualized, incremental step goals to be more effective.

One randomized, controlled study compared participants who had 10,000-step goals to participants who had individualized goals. It found that, although previously sedentary participants rarely reached their goal of 10,000 steps per day, they increased their steps as much as those with the more modest, individualized goal.

Referring to this study, the authors of a 2007 meta-analysis concluded, “Given the relatively similar increases in physical activity among those pedometer users given the 10,000-step goal and users given other goals, we conclude that the relative benefits of setting different goals remains unclear.”

The specific goal didn’t make a difference. What about people who didn’t have any goal whatsoever? The authors of the meta-analysis reported:

“Pedometer users who were given a goal, whether the 10,000-step goal or an alternative personalized step goal, significantly increased their physical activity over baseline, whereas pedometer users who were not given a goal did not increase their physical activity.”

In 2011, Catrine Tudor-Locke and a team of distinguished researchers, in their comprehensive scientific review, “How Many Steps/Day Are Enough? for Adults,” added:

“…It may be premature to make firm conclusions about the efficacy, effectiveness, or appropriateness of any specific step-based goal in terms of behaviour change…Regardless of the number of steps per day, effective programs, informed by the best research on critical moderators and mediators of behaviour change (i.e., what works best for whom under what conditions and at what cost) remain implicitly necessary in terms of increasing individual and population levels of ambulatory activity.”

In the end, it may not be the ambitiousness of the goal, but the existence of the goal — any goal — and a behaviorally sound program, that make the difference.

The significance of this conclusion may go beyond employee pedometer programs. For example: with all the talk these days about the quantified self movement — and people strapping on accelerometers, body sensors, and all sorts of biometric devices — we should not assume that tracking organically leads to improved behavior.

We all know that goals don’t amount to much without measurement. Now we also know that measurement — in this case, step tracking — may not amount to much without goals.

Myths about Obesity

Some of the myths — beliefs commonly and fervently held (and perpetuated by both journalists and scientists), despite evidence to the contrary — include things like:

• Realistic goals are important for obesity treatment.
• Gradually losing weight is better than rapid weight loss.
• Assessing the stage-of-change or diet readiness is important in helping patients seeking weight-loss treatment.
• Being breastfed protects against future obesity.

Presumptions about Obesity

Some of the presumptions — beliefs commonly held in the absence of supporting evidence — identified in the article include:

• Snacking leads to weight gain.
• Regularly eating breakfast helps prevent obesity. 
• Eating more fruits and vegetables encourages weight loss.
• Yo-yo dieting leads to increased mortality rates.
• Obesity is affected by the “built environment,” things like bike paths and parks.

Facts about Obesity

The study authors also listed nine facts about obesity, some of which included:

• Meal replacements offer an effective means of battling obesity.
• Pharmaceuticals can effectively promote weight reduction.
• Bariatric surgery can be an effective treatment for obesity.

The Food and Drug Industries…and Obesity

I’m glad the authors have prompted a discussion about obesity facts vs. fiction, though I question a few of their categorizations — such as those for breakfast and meal replacements. I’m also glad that journals like NEJM require authors to disclose financial ties relevant to their research. The following is a list of some of the organizations to which at least one of this study’s 20 authors had financial ties. Prepare to scroll. And draw your own conclusions.

• Global Dairy Platform
• Kraft Foods
• Knowledge Institute for Beer
• McDonald’s Global Advisory Council
• Arena Pharmaceuticals
• Basic Research
• Novo Nordisk
• Pathway Genomics
• Jenny Craig
• Vivus
• Global Dairy Platform
• Danish Brewers Association
• GlaxoSmithKline
• Danish Dairy Association
• International Dairy Foundation
• European Dairy Foundation
• AstraZeneca
• Mobile Fitness
• Coca-Cola Foundation
• General Mills Bell Institute of Health and Nutrition
• Jenny Craig
• International Life Sciences Institute of North America
• Arena Pharmaceuticals
• Pfizer
• National Cattlemen’s Association
• Mead Johnson Nutrition
• Frontiers Foundation
• Orexigen Therapeutics
• Jason Pharmaceuticals
• Almond Board of California
• United Soybean Board
• Northarvest Bean Growers Association
• Aetna Foundation
• McNeil Nutritionals
• Coca-Cola
• PepsiCo
• Red Bull
• World Sugar Research Organisation
• Archer Daniels Midland
• Mars
• Eli Lilly and Company
• Merck

[My own disclosure: Because I was unable to get to a library before work this morning, I have not yet had an opportunity to read the full NEJM article. NEJM, creator of the infamous Ingelfinger Rule, never ceases to amaze with its ability to harness information. (If NEJM was the CIA, the film Zero, Dark, Thirty never could have been made.) For those of us who do not subscribe to NEJM, it can be difficult to get the full low-down on this week's obesity article. The abstract provides few specifics and no context, and many of the more credible news releases focus on the myths and disregard the "facts" identified by the authors. (Hence, at this early stage, only the myths -- and none of the facts -- are grabbing headlines.) A respectable summary of the NEJM article can be found on medpagetoday.com. An article on today.com has some critical balance, once you get through the ridiculous sex talk. I based most of my comments above on the NEJM abstract, a news story from the University of Alabama at Birmingham (where several of the authors are based), and numerous news reports.]

Specifically, the Trust report states, “prevention is the most effective, common-sense way to improve health and reduce health care costs in the United States.”

If the Trust is making news with its preventive approach to reducing health care costs, why is the focus of the ensuing media buzz to “think again” about whether the construct works?

When I first skimmed the Reuters article, then skimmed the full 100-page Trust report, I thought it was a simple case of a news service getting the story wrong — reporting the exact opposite of what the report was saying about preventive care reducing health care costs. Upon closer review, I understood that Reuters sought balance in its story by seeking objective viewpoints from health economists, most of whom say preventive procedures — while essential for good health — do not (with only a few exceptions) reduce health care costs, contrary to the Trust’s proposals.

The Trust report is informative reading for anyone interested in public health and wellness. The Reuters article is also a must-read for insights into the economics of preventive health care.

Of course, I’m a diehard believer in evidence-based preventive care, though I’m skeptical about many of the cost-saving claims commonly attached to it. In the end, I think the health economists in the Reuters article are correct that most preventive health procedures, while essential for well-being of individuals and society, do not save money. But, somewhere in the Trust report, there may also be truth that broad focus on prevention and on environments that support healthy lifestyles — creating a national culture of health — may be important pieces of the health care cost control puzzle. (I don’t, however, believe savings will be realized within four years. As I’ve previously written, we need to think in terms of a timeframe 20 years or longer for solutions to chronic risks and preventable diseases, and to see impact on costs).

One point that may especially be of interest to employee wellness managers: The Trust report includes this lofty recommendation: “Provide workplace wellness programs to all American workers.” In its explanation of “Why Workplace Wellness Programs Matter,” the Trust emphasizes, ”For every wellness dollar spent, studies have found, medical costs fall by about $3.27…”

In fact, studies have only purported to find medical costs falling by $3.27 for every dollar spent, but closer analysis reveals the evidence does not support this conclusion.

The Trust can’t be expected to deconstruct the minutiae of every study it cites, but where it wasn’t able to  scrutinize study findings, it should have at least stuck to common sense rather than perpetuating myths. If the full report depends on shaky science, the Trust should not be surprised to find its public communications effort backfiring — prompting people who otherwise would never have questioned the cost savings of preventive care, finally, to “think again.”

The first pedometer illustrations were done in the 15th century by Leonardo da Vinci.

With all the chatter these days about whiz-bang innovations in employee wellness — mobile apps, body sensors, social media, and such — overshadowed is the lowly pedometer program. But why? I’d venture to guess that most employers running robust wellness programs, and even smaller employers just getting started, are offering some sort of pedometer-based program.

What are we to make of these programs, in which employees — usually in teams —  wear a pedometer for several weeks and record the total number of steps they take each day? Are they little more than the minor league of more hi-tech solutions?

Given my penchant for evidence-based approaches, you may assume I’d balk at pedometer programs. Not so.

The great challenge of implementing evidence-based employee wellness solutions is that there aren’t many of them. After reviewing the evidence, we frequently have to go with where it is strongest – even if it’s not very strong – as we factor in what’s most feasible and the best fit for our purposes. The “best fit” analysis may include employees’ needs, employees’ wants, resource availability, occupational factors (Do employees have internet access? Are they working on a manufacturing line? Are they in vehicles all day? What’s their educational level?), our organization’s goals and, of course, cultural fit.

I categorize pedometer programs as low-resource/modest-impact. As such, I believe they have a place in many, if not most, employee wellness programs, certainly compared to many of the high-resource/low-impact programs that we’ve grown so fond of.

Here are some things we know:

• Evidence is mixed regarding the effectiveness of pedometer programs. A limited meta-analyses of programs conducted in various settings — published in the Journal of the American Medical Association (JAMA) — found “significant increases in physical activity and significant decreases in body mass index and blood pressure.” (A 2012 Finnish study concluded that a pedometer intervention ”was able to affect only modestly some of the outcomes of walking,” but acknowledged, “The intervention seemed safe, inexpensive and highly adoptable in worksite setting.”)
• Pedometers can be crude instruments. Their accuracy depends on the quality of the unit. It can vary based on participant age, weight, and walking speed. But, generally, they are sufficiently accurate to be effective in promoting physical activity.
• Employees enjoy pedometer programs, and team-based challenges using pedometers may help foster camaraderie and a culture of health at the workplace.

Pedometer programs are affordable, scalable, well received by participants, and work about as well as anything else.

One of the more interesting, unresolved questions, about pedometer programs has to do with the goal — number of steps — recommended to participants. Employee wellness programs commonly implore participants to strive for 10,000 steps a day. Is this based on evidence? Does it work as a motivational strategy?

The question of pedometer programs’ “step goal” goes to the heart of our understanding of motivation and behavior change. We’ll get to some answers in my next blog post.

♦♦♦♦♦

Much to my surprise, these little devices were shown to increase physical activity by just over 2,000 steps, or about 1 mile of walking, per day.

– Dena Bravada, MD, lead researcher of a Stanford meta-analysis

The most optimistic thing I can say about employee wellness return-on-investment (ROI) is that it may be possible. But, as I illustrated in my previous post, it’s certainly not common or likely. The question is: Does this matter?

Underlying the arguments of many ROI stalwarts is the belief that ROI is the only reason employers would conduct a wellness program.  But there are other, better reasons to conduct wellness programs. For example:

• Some analyses have shown that good employee wellness programs are associated with increased employee motivation, engagement, retention, attendance and productivity. Some of this data is soft, but that’s because we spend most of our time and energy focusing on the wrong metrics: health care costs.
• We need more people in our society to be more engaged in healthier lifestyles — not simply to control health care costs, but because health is by definition good for us as individuals and as a society. Employers have a role in supporting this effort, just as many employers see themselves as having a role in other social causes. This requires a broad, long-range outlook.

Defense of ROI myths is often predicated on another myth — namely, that employers only spend on things that deliver a positive ROI. Ask an employer what the ROI is of their Employee Assistance Program, their community service program, their diversity program, or even their training program. You’ll be hard pressed to find an employer who knows or cares, for example, about the ROI of their EAP. This is because EAPs have not made the mistake we wellness managers have made — justifying our existence based solely on ROI.

Employers, indeed, constantly incur expenses that do not deliver a measurable ROI. Next time you drive onto the campus of a large company, and you see the facilities staff planting daffodils or repairing the fountain, ask them what the ROI is, or ask their boss what the ROI is for the millions of dollars he/she spends on maintaining a comfortable workplace for employees.

Large employers with robust wellness programs typically spend on their wellness programs approximately 2% of their overall medical expenses (according to a 2012 survey by the National Business Group on Health and Fidelity Investments). So, if we spend, say, $100 million on health care, and $2 million on wellness, why are we wasting our time and our organization’s resources worrying about the ROI of wellness? What about the other $98 million? Think of what a self-funded employer spends on unnecessary back surgery, unnecessary knee surgery, unnecessary caesarians, unnecessary screenings like PSAs (and the resulting unnecessary treatment costs). unnecessary emergency room visits, and medications like Viagra. What a misdirection of resources to get all worked up about the ROI of the relatively piddling wellness expense.

Sometimes, when I cast doubt on ROI, colleagues say to me, “You’re a wellness manager, and you don’t believe in wellness?!” The question strikes me as cynical. I believe that a company with the will and the resources is well-served by promoting the health of its employees in a positive way. I believe that doing so is likely to have benefits for the business, but that generally wellness may be better viewed as an expense rather than an investment, or we should focus on value-of-investment rather than return-on-investment.

Those who think I don’t believe… they are the true non-believers. They have not even conceived of any reason to promote employee health other than the short-sighted and misguided goal of ROI. My hope is that we wellness managers unclench our grip on our ROI goals, so that we can focus on the real work of helping people get healthier.

Due to budget limitations, the state of Oregon in 2008 was unable to fund Medicaid for its entire uninsured population, and took the novel approach of selecting recipients using a lottery system. Based on the lottery results, the state offered Medicaid enrollment randomly to 10,000 low income, uninsured Oregonians out of 90,000 lottery entrants. This randomization process allowed Harvard health economist Katherine Baicker  et al to conduct a randomized, controlled study design to compare Medicaid recipients to the uninsured non-recipients. Drawing on data from hospital discharge records, credit reports, mortality records, and extensive mail surveys, Baicker and her team found that Medicaid recipients, as many would expect, used more health care than non-recipients and had significantly higher rates of self-reported health and well-being. They also had fewer financial crises and less likelihood of negative screenings for depression.

The findings may seem to go without saying. But Medicaid critics historically have argued that Medicaid recipients experience reduced access to care and worse health outcomes. The Oregon study represented the first opportunity to study the issue using rigorous research design. Details of the study, including findings published in peer-reviewed journals, are available on the Oregon Health Study’s website.

In an interview, Baicker acknowledged that better health came at a cost. “”We found that gaining access to Medicaid increased health care use — and that was preventive care, doctor’s office visits, but also hospitalizations,” she said.

Employee wellness enthusiasts, who tend to view better health and return-on-investment as somehow inextricably linked, may well wonder whether the Oregon study demonstrated an ROI for Medicaid. While acknowledging that the better access and better care associated with Medicaid (compared to the uninsured population) may someday lead to a positive ROI, Baicker didn’t take the bait.

“I would argue against measuring the success of a health insurance expansion by whether or not it saves money. We don’t say for food stamps, ‘Food stamps — they save money!’ We say, ‘Food stamps — they give people food.’  And that’s the purpose. Health insurance? It gives people access to health care, and that improves their health. That’s the purpose. The right metric shouldn’t be ‘Does it save money?’ the right metric should be, ‘Is however much it costs warranted by the benefits it generates?’”

In addition to being a professor of economics at Harvard School of Public Health, Baicker serves on the Congressional Budget Office’s Panel of Health Advisers and previously served on George W. Bush’s Council of Ecnomic Advisers.

So, why is any of this important to employee wellness professionals?

• The health of employees is inextricably linked to the health of the community. Your employees and their loved ones come from the community and live in the community. Employers must attend to the health of the community, and community health professionals must attend to the health of the workplace.
• Baicker’s reluctance to focus on Medicaid ROI may be instructional for employee wellness managers (though no one would argue that employers — more than federal and state governments — are not only expected to focus on financial returns, but have a responsibility to do so). Should we focus on VOI (value-on-investment) more than ROI?
• Of greatest interest to wellness professionals: Perhaps in recognition that employers, unlike the government, are driven to generate ROI, Baicker in 2010 published a landmark study of employee wellness ROI in Health Affairs (a journal on which she also serves as Editorial Board member).

In an upcoming post, we’ll take a closer look at Baicker’s employee wellness ROI study. The study is often cited as if it offered the final say on employee wellness. But a closer look leads to unexpected findings.

But some of the survey respondents’ comments — as well as much of the employee wellness literature — reveals that employers are evaluating HRAs with a narrow lens.

Employers question whether HRAs improve health. It’s the wrong metric.

There may be some employees whose health has benefited based on some feedback they got on an HRA, but not enough to warrant the investment you are making in the HRA (that investment includes your organization’s money; your time; and, perhaps most importantly, your participants’ time, energy, and goodwill). But don’t listen to me. Your employees will also tell you that your HRA doesn’t make much difference to their health. That’s why some employers pay employees up to $500 just to complete an HRA.You wouldn’t have to pay employees to complete a simple form if they actually saw any value in it to begin with.

This series of blog posts about HRAs, a branch off the series about the ShapeUp survey, has deconstructed HRAs with an eye toward better understanding their value or lack of value. Here are the cliff notes:

• The conventional framework of employee wellness programs is predicated on the principle that improvements in the health risk profile of a population can lead to reductions in healthcare costs and improved employee productivity.
• HRAs are techniques or processes of gathering information to develop health profiles, using the profiles to estimate future risks of adverse health outcomes.
• HRAs are dependent on self-reported data, which is valid for effective use in population health management intervention, although it’s value at the individual level is questionable.
• Importing clinical screening values — such as blood pressure and cholesterol — to an HRA does not add much validity to the HRA on an individual basis, but, like the self-reported data, should be sufficient to measure the health risk of a population.
• HRAs may help steer individual’s towards more intensive programs based on the position of the individual in the strata of the population’s health risk and predicted health care costs.

These findings point to the same thing: Health risk assessment is a population health tool. HRAs’ primary utility is in helping employers identify the health risks that deserve the most attention in order to achieve positive health and financial outcomes. The same tool can then be used to measure a program’s success in shifting the health risk of the population. The HRA can also be used to project the financial impact of shifting the population’s health risk.

Unfortunately, employers have been using HRAs, a population health measurement instrument, as a behavioral intervention. No wonder you are disappointed! Be honest with yourself and with your employees: The HRA is for you — a potentially useful tool in the administration of your program. It’s not an employee benefit, and your employees know it.

Part of the reason employers have mistaken HRAs with a full-fledged health intervention is that vendors have marketed them as such. As a measurement tool, you should reassess whether your HRA is worth what you are paying.

But don’t rush to throw the baby out with the bath water. If you decide that your HRA’s capacity to measure risk in your employee population justifies its use, your next step is to reconsider whether you truly need to have all your program participants complete an HRA every year. Your vendor doesn’t want to hear it, but you may be able to realize the measurement potential of your HRA more cost effectively by having a sample of your employee population complete it every two or three years.

I’m not making a case for or against health risk assessments, just encouraging you to make a well informed and critical decision. What do you want your HRA to do? What does your HRA do? Is your organization getting its money’s worth?

Technology Assessment: HRA (click to access the pdf)

One of the most rigorous and most recent analyses, Health Risk Assessment: Technology Report, conducted by McMaster University Evidence-based Practice Center for Agency for the Healthcare Research and Quality, examined 118 studies of health outcomes associated with HRAs. The report concluded:

Many HRA programs demonstrated improvements on intermediate health outcomes such as blood pressure, cholesterol, physical activity, or fat intake. However, only one article considered hard health outcomes (i.e., freedom from any of the following after 24-month followup: death, myocardial infarction, stroke, Class II-IV angina, or severe asymptomatic ischemia ). Also, followup periods were often shorter than 24 months. Therefore, we were unable to assess whether HRA programs produced health benefits over the medium to long term.

A previous, similarly comprehensive, review was conducted by Rand Corporation. Rand’s study endeavored to evaluate the effectiveness of HRAs for Medicare populations, but in order to do that their study focused on the evidence of HRAs’ effectiveness in any setting, especially worksites. Rand’s conclusions foreshadowed the AHRQ study, stating, “Interventions that combine HRA feedback with health promotion programs are most likely to show beneficial effects… It is not known if these effects persist over the long term.” But Rand also examined cost-effectiveness — importantly for corporate wellness programs — and added:

RAND: Evidence Report and Recommendations: HRAs and Medicare (click to access the pdf)

Current literature is insufficient to accurately estimate the cost effectiveness of programs using HRA. Limited evidence suggests that a carefully designed program that uses a systematic approach to implement HRA and subsequent disease prevention/health promotion interventions has the potential to be cost-beneficial. Considerable effort is needed to optimize program design, implementation, and evaluation.

Yet another study, conducted by the Task Force on Community Preventive Services and published in the American Journal of Preventive Medicinein 2010, suggested more positive outcomes for HRAs, but still with qualifications. The study concluded that HRAs with feedback “has utility as a gateway intervention to a broader worksite health promotion program that includes health education lasting at least one hour or being repeated multiple times during one year….Results of this review suggest that this intervention may be more effective for some outcomes (e.g., smoking behavior or cholesterol) than for others (e.g., change in body composition).”

Task Force report: The Assessment of Health Risks with Feedback (click to access the pdf)

(These three reviews, in addition to trying to measure the value of HRAs, also provide comprehensive background information about HRAs — their history, their intended purpose, their modes of delivery, their strengths and weaknesses. If you haven’t studied HRA methodology, I strongly recommend that you read at least one of these reviews. As I mentioned in a previous post, many managers responsible for HRA implementation haven’t had an opportunity to learn what an HRA really is — how it’s supposed to work or what it’s supposed to achieve. Any of these three reviews will provide much-needed context. The AHQR review is the best place to start.)

Each of these reviews suggests that there is or may be some potential for HRAs in evoking positive health outcomes for individuals, but none of them are a ringing endorsement. In an upcoming post, I’ll offer my own opinion on why employers may want to hang in there with their HRAs.

[This is one in a series of posts about health risk and health risk appraisals.]