0 Does Worksite Wellness Work A Critical Look at the Wellness Incentives In the Workplace Article

A waste of money and
a basis for discrimination?

The answer to the "Does Worksite Wellness Work?" question depends on your frame of erence.

If you read this 2010 review by Baicker, Cutler and Song, youll see that there are 32 peer-reviewed published studies from work settings that a) transparently described the intervention and b) used a valid parallel control group - persons who did not receive the intervention - as a comparison. When interventions like these were deployed, impressive reductions in medical costs and absenteeism like these were achieved in the intervention groups, compared to the groups that did not receive the wellness programs.

If you read this just-published 2013 review by Jill Horwitz, Brenna Kelly and John DiNardo, youll see that its possible to use a "conceptual framework" to completely trash the notion that worksite wellness programs offer any benefit.  Oh, and by the way, they also result in discrimination.

How is that you ask?

This framework asks:

1) Do employees with chronic conditions or health risks spend more?  The authors answer is that most studies for most conditions indicate the answer is yes.

2) Do financial incentives change behavior? The authors answer, based on a review of the literature, is that obese persons tend to gain weight and many persons who quit tobacco relapse.  The impact on high blood pressure and lipids is less certain.

3) Do health improvements lead to employer savings? The authors brief three paragraph answer, based on two erences (here and here), is "uncertain," "depends" and "erroneously assuming."

The authors also

a) point to the abundant literature that questions the relationship between "process" and "intermediate" outcomes (blood glucose testing or control in persons with diabetes mellitus) versus long-term outcomes (like mortality - an example is here),

b) note that aggressive treatment can lead to unintended consequences (an example is here), and

c) suggest that wellness programs disproportionately benefit persons from higher socioeconomic classes who suffer from less disease. Its frankly difficult for the Disease Management Care Blog to follow the authors logic, but as it understands it, anything that benefits one segment of a population is a zero-sum loss for the remaining segment.

The DMCBs two-fold take:

1) The 2010 review examines state-of-the-art clinical trial data, while the 2013 "conceptual framework" interprets the underlying published literature and finds it wanting.  According to the framework authors, the value of any counseling is ultimately unproven.

Big deal. The DMCB would like to point out that a similarly conducted review of primary care (where there are no randomized control clinical trials), Medicare (a social experiment if there ever was one) and parachutes (to combat "gravitational challenges") could also conclude that theres no proof.

Bottom line: Lack of proof for a benefit is not the same as proof that there is a lack of any benefit.  Whats more, the business persons that run worksite wellness programs know that evidence based medicine is necessary, but not sufficient.  They dont demand proof, they use reasonable assurance.  The 58% of large employers that are offering worksite wellness are using seasoned logic in a world of conflicting data.  Good for them.

2) The Homer Simpson-inspired DMCB doesnt quite "get" the frameworks socioeconomic argument.  If persons from lower socioeconomic classes have a higher burden of obesity, diabetes, high cholesterol levels and poor fitness, anything that offers increased access to a higher level of care is not only good policy but a proportionately noble thing.

Whats more, if worksite wellness results in no economic benefit and doesnt shift costs in any direction, how does that result in any discrimination?

While economic incentives in a zero sum game can be problematic, the DMCB believes that Horwitz, Kelly and DiNardos logic is overlawyered worksite nihilism run amok. Their ultimate unspoken conclusion is that when it comes to employees, all should be treated to the same level of neglect.

Image from Wikipedia

0 Big Data and the Coming New Value Proposition for Disease Care and Wellness Management Providers

Disease Management Care Blog readers know that the its latest interest is "Big Data." While the researcher-DMCB has played in the sandbox of some insurance claims data sets, the idea of combining and combing through multiple terrabytes of clinical and public data remains a topic of endless fascination. It knows its not alone.

So, it was only a matter of time until one of the major clinical journals published an article on the topic. JAMA has stepped forward, and not a moment too soon.

Its "must reading" for the disease and care management provider community.

Drs. Murdoch and Detsky point out that Big Data offers four value propositions:

1. Observational correlations may generate insights that cannot be found using standard research approaches. Scanning text for key words in electronic record systems involving hundreds of thousands of patients may find associations or trigger early warnings faster, quicker and cheaper than any formal scientific protocol or clinical trial.

2. Those insights, especially since they can be tailored to fit the circumstances of an otherwise unique patient, can be used to guide diagnosis or treatment. Physician judgement cannot be replaced, but if Big Data points out that there were other patients with a similar pattern of illness who responded best to one treatment versus another, patient outcomes could improve.

3. A Big Data approach to genomics can correlate genetic information with outcomes and further guide therapy. While the DMCB still wonders if "genomics," outside some narrow anecdotes, will always remain the science of the future, Big Data may turn out to be the key to finally unlocking its potential.

4. Since Big Data, by its very nature, can combine clinical information to other personal data (the foods youve bought or your driving history), Big Data will necessarily tilt toward the patient-consumer and away from the health care system. Not only does permission for access lie with the patient, but the insights will be less about sickness and more about wellness.

The authors do a good job of pointing out that there are plenty of challenges. Most doctors dont get it, privacy laws could be over-interpreted or enforced, it remains to be seen who will pay for it and Big Data is still in its infancy.  The DMCB also points out that while Medicare has just discovered that alternative research innovations are possible, Big Data promises to eclipse those approaches (like traditional time series analysis, propensity matching), again making CMS a day late and another dollar over budget.

The implications for the care management and population health community are considerable. The industry has amassed years of intellectual capital in the science of predictive modeling and Big Data is its next step. Many care management vendors have multiple clinical partners and already have access to terrabytes of data involving millions of persons. Not only is the math and the informatics well within reach, they also "get" the tilt toward wellness and consumer empowerment. Last but not least, if anyone can monetize a value proposition like this and turn insights into revenue (or "shared savings"), these nimble vendors can.

A DMCB prediction: while academics will write about Big Data in scientific journals, the care management industry will be doing it.  In fact, they probably already are.

Two particularly good quotes to use to impress your CEO and stymie your competitors:

"Data has gone from use to riches."

and

Economic theory describes the quantitative conversion of 3 kinds of inputs (capital, labor, and raw materials) into outputs (goods and services)...The current revolution in data management makes it clear that a fourth kind of input, information, will become just as important as these other inputs in the future of many industries.