Kara L. Guarini, MS

Approximately 155 million people in the United States under the age of 65 years receive employment-based health benefits.

 Most of these people spend the majority of their waking hours in the workplace but only 1 to 2 hours per year with their health care providers.

 Therefore, workplace health promotion or wellness programs have the potential to boost population health by establishing the workplace as an environment conducive to health improvement and risk reduction. Approximately two-thirds of companies offer at least 1 wellness program

; however, based on a 2004 survey, only about 7% of US employers offer comprehensive worksite health promotion programs.

Will these numbers change based on provisions in the Affordable Care Act (ACA) and culture shifts?

To learn how companies are aiding wellness efforts in the workplace, the impact of the wellness movement, and the economic rationale for moving wellness into the mainstream, 

 interviewed Ron Z. Goetzel, PhD, MA, a senior scientist and director of the Institute for Health and Productivity Studies (IHPS) at Johns Hopkins University, Bloomberg School of Public Health, and vice president of consulting and applied research at Truven Health Analytics.

Wellness is the general category—what most people call these programs. However, they are called other things. One of the more precise names for wellness is “health promotion.” Other names for these programs include employee health management and health and productivity management. These programs are called “workplace health promotion” or “wellness” because they aim to keep healthy people healthy&mdash;using tenets of primary and secondary prevention&mdash;rather than treating individuals who are already ill.

I work most often with organizations, businesses or large companies with a lot of employees (eg, Johnson & Johnson, Dow Chemical, and Prudential). My focus is helping these companies determine whether their wellness programs are improving health and impacting business metrics. When we work with these companies, our focus is on measurement and evaluation—to determine whether the company’s health (or the culture of health of that company), alongside the health of employees and their spouses, is improving as a result of the health promotion program.

An individual’s health goes hand-in-hand with a company’s health. For example, if you are working for a company and want to get healthy, but the company does not have any smoking policies, does not offer flexibility in terms of work schedules, does not offer healthy foods in cafeterias or vending machines, does not have accessible and attractive staircases, and employees are under huge pressures and exposed to a lot of stress, workers find themselves in a toxic work environment not conducive to health improvement and behavior change.

Health is not just the absence of disease. A lot of people think about it that way (ie, if I am not sick, I am healthy). A healthy person is someone who is at his or her full potential—feeling alive, with lots of energy, curious, happy most of the time, establishing positive relationships with people, and really enjoying work. We need to expand an individual’s wellness or health needs beyond the traditional view of health (ie, physical health, measurements of blood pressures and glucose levels) and include emotional health, social health, intellectual health, financial health, and spiritual health. All of these things matter and, in combination, can be placed under the broad umbrella of health. It’s a much more expansive definition of health than what most health professionals think about when they interact with people.

2. What Evidence Do We Have That a “Wellness Movement” is Underway?

A couple of indicators point in the direction of greater adoption of wellness in the workplace. People in the health promotion industry are reporting that their business is booming. There’s a lot of interest in the kinds of programs they offer.

There are also many surveys of employers conducted by such groups as the National Business Group on Health, Kaiser Family Foundation, and several consulting firms showing that employers are serious about putting in place wellness or health promotion programs. There are a few reasons for this: (1) they are truly interested; and (2) they have gotten the message that a healthy workforce is a productive and less expensive workforce.

Wellness is more than physical health (as mentioned above), and those other areas of life really have an influence on people’s productivity and performance (eg, worries about paying bills, or a mother who is sick, or being good role models for their children). If an employee can address the things that interfere with his or her work performance in a healthy way, the employee benefits as does the employer. Employers are getting it—health, broadly defined, has a positive impact on productivity and performance in the workforce.

A second important factor is that the ACA has (1) provisions mandating that clinical preventive care services are available for free, with no co-payments, coinsurance, or deductibles applied; and (2) incentive programs, whereby, employers are now encouraged to provide a workplace wellness program and also structure their insurance plans to incent employees to participate in health promotion/wellness programs and even, in some situations, achieve certain health improvement outcomes. This has brought a lot of players into this area (employers and vendors) who are interested in promoting incentive programs.

A third factor is the idea of the Cadillac tax (ie, under a provision in the ACA, beginning in 2018, if the aggregate cost of employer-sponsored health coverage provided to an employee exceeds a certain amount, which is revised annually, the excess is subject to a 40% excise tax).

 Up until this point, this had not been the case; employers could offer as much health insurance as they wanted at whatever cost they wished, and they and their employees were not taxed for that benefit—in fact, the provision of health benefits was classified as a business expense. Now, the ACA says employers can only do that up to a certain limit and then they are going to pay a tax on the excess benefits they offer. Employers are now seriously thinking about how they can lower costs, and one way to do that is to have a healthier workforce, supported by a good health promotion program.

3. What is the Economic Rationale for Adopting Wellness into the Mainstream?

There are 4 categories of outcomes from well-designed and effective programs. The first is health outcomes (the most important). How can health be improved? People need to be more physically active, eat a nutritious diet, manage their biometric measures (eg, blood pressure, cholesterol, blood glucose, and weight), stop smoking, do a better job at managing stress, get help for depression, not drink too much alcohol, not use drugs, and get enough sleep. These are all behaviors that are modifiable. It is possible to get a population to exercise more and eat healthy within a fairly short period of time; studies demonstrate that population health can be improved within a year. Getting people to change their behaviors and improve health is the first category of outcomes. The second bucket is risk reduction for disease. Modifiable risks can be monitored, as well as the incidence of certain diseases such as diabetes, cancer, and heart disease. These are affected when people start exercising regularly, eating well, losing weight, stopping smoking, and managing their biometric values (however, it may take 5 to 10 years to see a reduction in the incidence and prevalence of disease).

The third category is cost. The goal here is to reduce the rate of increase in health care costs by implementing health promotion programs so rates go down or remain stable. Studies demonstrate that it is possible to bend the cost curve on health care expenditures by achieving reductions in utilization, most notably hospitalizations and emergency department visits.

Sometimes there are more preventive care visits, and also reductions in the number of prescriptions that people need to take to stay healthy. There are opportunities for positive returns on investments (ie, you get money back for the money you invest), generally over a 3- to 5-year time period. There are cases where money can be saved, but the more important metric is cost-effectiveness (ie, for individuals with a medical condition such as diabetes, selecting the treatment that costs the least while offering the same outcome as more expensive options).

The fourth category of outcomes is called humanistic, also referred to as the value on investment. It includes things such as morale of the workforce, attraction and retention of talent, the company’s reputation, and the company’s adherence to corporate social responsibility principles. These items are harder to measure, monetize, and quantify than some other more direct measures, such as health care costs. However, we should be paying a lot more attention to these set of outcomes rather than just focusing on cost cutting.

4. What Types of Providers Engage in Wellness-Supporting Activities?

All providers, including pharmacists, nurses, health educators, and dietitians, can play an important role in supporting health improvement in the general population. Cross-training is needed across specialties (eg, behavioral health/social health for depression, medical health for heart disease) so the basic principles and approaches can be shared by all providers and patients can be directed to individual specialists.

5. Is There an Economic Rationale From a Provider Standpoint for Wellness Programs? 

There is, and it has been spurred by the ACA, where quality and outcomes will hopefully overtake volume as metrics for revenue. Up until recently, the more providers did (eg, procedures), the more they got paid; that’s what drove revenue for hospitals, providers, pharmacists, etc. However, there is now a shift in the direction of quality of care and outcomes, which is especially relevant to accountable care organizations and patient-centered medical homes, where the negotiations with health plans are directed at keeping people healthy and care is sometimes paid for on a per eligible basis, rather than for the amount of medical treatment provided. There is an important shift happening today where providers are beginning to be reimbursed for keeping people healthy and out of the hospital, not for delivering a lot of services. This will also impact pharmacists, as they will be paid for the health of the population as opposed to the number of prescriptions filled.

Traditional health care providers (eg, doctors, nurses) usually don’t have the time and expertise to provide health education, coaching, and counseling. They need to recognize that there are professionals who specialize in behavioral change and know methods and techniques that work to help people improve their health. To keep people healthy, especially individuals who are at high risk for disease, providers are advised to bring health coaches into their teams who can counsel patients about healthy living—the importance of physical activity, good diet, not smoking, managing weight, dealing with stress, and focusing on health, not disease.

Additionally, health care clinics/centers within pharmacies such as CVS, Walgreens, and Walmart present a great opportunity to converge health education with treatment. [DM to add link to 

6. What Is the Single Most Important Policy Implementation That Would Support the Proliferation of Wellness?

By and large, the biggest causes of disease and disability in this country are cardiovascular disease and cancer, which are mainly due to tobacco use and poor diet. There have been a lot of policy changes to limit tobacco use. Reports of the Surgeon General from the 1960s, and later marketing prohibitions, higher taxation, and changes in policies and norms at companies and restaurants, have led to tremendous reductions in traditional tobacco use.

 There are probably a dozen or more things that could be done to bring tobacco use down to zero in this country, most notably, increasing taxes on cigarettes and restricting marketing of the product.

The area of obesity is more difficult, because everyone needs to eat (unlike tobacco use; not everyone needs to smoke). There are, however, a number of policies that can be implemented. First, marketing of food needs to be more regulated (eg, banning advertising of sugary cereal to kids on Saturday morning) and there should be taxation of unhealthy foods that provide very little dietary nutrition. There are ways of creating indices for what is considered “good” and “bad”—healthy and unhealthy&mdash;food. Beyond that, it’s certainly hard. Labeling has a role. Moreover, work by Brian Wansink at Cornell University (http://dyson.cornell.edu/people/brian-wansink/) has demonstrated that behavioral economics can be put in place to nudge people in the direction of healthier eating (eg, people will buy more fruits and vegetables if that section is larger in a grocery store).

For more information, go to The Community Guide (www.thecommunityguide.org), which includes all Community Preventive Services Task Force findings and provides evidence-based recommendations for what can be done, from a policy standpoint, to improve health.

				The IHPS has partnered with the Robert Wood Johnson Foundation in an initiative called Promoting Healthy Workplaces (http://bit.ly/1JswMih) to educate corporate executives about the benefits of workplace health promotion programs and help them implement effective and evidence-based programs at their workplaces.

				The Centers for Disease Control and Prevention is working to establish a clearing house of information (a knowledge center about best practices). There will be technical assistance provided and a lot more practical information for employers to use if they want to implement these programs.

				The Transamerica Center for Health Studies is launching a website, www.transamericacenterforhealthstudies.org, that gives very specific guidance for employers who want to implement evidence-based health promotion programs.

		Fronstin P. Sources of health insurance and characteristics of the uninsured: analysis of the March 2011 current population survey. 

		Goetzel R. Structuring legal, ethical, and workplace health incentives: a reply to Horwitz, Kelly, and DiNardo. 

 blog. April 23, 2013. http://healthaffairs.org/blog/2013/04/23/structuring-legal-ethical-and-practical-workplace-health-incentives-a-reply-to-horwitz-kelly-and-dinardo/. Accessed September 18, 2015.

 website. May 16, 2013. http://healthaffairs.org/healthpolicybriefs/brief_pdfs/healthpolicybrief_93.pdf. Accessed September 18, 2015.

		Linnan L, Bowling M, Childress J, et al. Results of the 2004 National Worksite Health Promotion Survey. 

. 2008;98(8):1503-1509. doi: 10.2105/AJPH.2006.100313.

		Affordable Care Act Tax Provisions. Internal Revenue Service website. http://www.irs.gov/Affordable-Care-Act/Affordable-Care-Act-Tax-Provisions. Accessed October 4, 2015.

		Goetzel RZ, Henke RM, Tabrizi M, et al. Do workplace health promotion (wellness) programs work? 

. 2014;56(9): 927-934. doi: 10.1097/JOM.0000000000000276.

		US Department of Health and Human Services. The health consequences of smoking—50 years of progress: a report of the Surgeon General. www.surgeongeneral.gov/library/reports/50-years-of-progress/fact-sheet.html. Accessed October 4, 2015.

Wellness Programs: The Role of the Pharmacist 

The percentage of US companies sponsoring some version of a wellness program has increased annually for the past 5 years and now stands at about 80% of large and mid-size employers.

 New opportunities for health care professionals have emerged as a result of this trend, and many pharmacists have been able to create successful workplace practice models in support of these programs.

Other than sharing the common purpose of promoting employee health, employer-sponsored wellness programs vary widely in scope, component elements, emphasis, and any number of other descriptors. Elements commonly include programs for individual risk assessment, health education, and promotion of healthier behaviors. Some employers extend additional support and intervention programs for those most at risk.

Some specific examples of employer-sponsored wellness programming include:

		Biometric screenings and health risk questionnaires—May include follow-up feedback, risk-related counseling, or individual intervention programs. Aggregated data from these screenings and questionnaires can be useful to employers when designing and refining programming to improve alignment with overall population risk and needs.

		Healthy lifestyle promotion—May include smoking cessation programs and policies, voluntary weight loss programs/competitions, healthier snacks and food choices at the work site, walking trails, exercise facilities, gym memberships, nutritional counseling.

		Disease management—May be more passive, such as making information or counseling available through a website or telephonically, or more intensive, such as face-to-face personal health coaching or case management.

Many employers hold annual health fairs to educate employees and promote awareness of programs and supportive resources available to them. Health screenings and vaccination campaigns are often integrated into these events.

Pharmacists have become involved in nearly all aspects of wellness programs for many employers. Assisting with biometric screenings, health risk management counseling, smoking cessation programs, employee vaccinations, educational programs, and health fairs have all been avenues whereby pharmacists have established initial relationships with employers. Chronic disease management/health coaching programs and medication therapy management (MTM) for targeted plan members are also becoming more prevalent. With their education and training, pharmacists are ideally suited to provide deeper and more regular engagement with employees and management.

Efforts undertaken by the American Pharmacists Association (APhA) Foundation over a decade ago helped to establish many initial opportunities for pharmacists in health coaching roles. The APhA Foundation set out to build on the success of the Asheville Project by encouraging and connecting employers with pharmacists across the country to work together in propagating the model. Projects such as the “Diabetes Ten City Challenge”

 and a number of more local ventures were facilitated by the foundation and served to demonstrate both the value and feasibility of scaling pharmacist—employer partnerships as an effective and innovative option for managing costs through improved employee health.

For a number of pharmacists and the networks that emerged to facilitate access to employer work sites, initial contributions primarily involved health coaching for conditions such as diabetes, asthma, and cardiovascular disease. Pharmacists in this role collaborate with participants and their doctors to evaluate and tailor drug therapy and identify, prioritize, and address other relevant health issues on a personal, individualized basis.

Articles

Workplace Wellness: Promoting a Culture That Benefits Companies and Employees

A component of health care as critical as pharmacy calls for direct engagement.

Accountable care organizations (ACOs) are groups of physicians, hospitals, and other health care providers that join together to take responsibility for the cost and quality of patient outcomes.

 ACOs and other new payments models do not, however, include the costs of pharmacy services in the total cost of care.

Pharmacists have the opportunity to make a tremendous impact on outcomes and efficiency, especially in chronic disease management. Pharmacy services in communities have greatly expanded in recent years to include medication therapy management, comprehensive medication reviews, immunizations, and medical education and counseling, and community pharmacies have developed strategies to participate in ACOs. However, ACOs currently lack direct incentives for community pharmacy participation.

The American Pharmacists Association continues to push for inclusion of the Medicare Part D prescription plan benefit into ACOs and other integrated care delivery models.2 Unfortunately, pharmacists are not recognized by Medicare with “provider status,” which has limited their opportunities for reimbursement for the services they deliver to patients. Additional barriers, such as health information technology (HIT) and electronic health record (EHR) access, have stifled the effective integration of community pharmacy into ACOs. Recent developments highlight setbacks and advances affecting the future role of community pharmacy participation in ACOs. In late 2014, Walgreens (the first retail pharmacy to establish ACO relationships) ended 2 of its 3 ACO contracts, citing barriers to exchanging information, challenges related to physician engagement, and poor financial returns.

 Developments this year, however, signal encouraging changes: Washington and Oregon now join California in establishing provider status laws for pharmacists that permit them to receive payment or reimbursement for their services.

Will these changes foster more integration of community pharmacies in ACOs or will they still struggle to find their role in the ACO environment? To answer some of these questions and identify additional barriers, 

 interviewed John Friend, founder and managing member of Value Stream Partners LLC in Tucson, Arizona.

Q: How can community pharmacy provide value to an ACO?

Pharmacists and patients have a unique relationship, and the connectivity and frequency of good contact distinguishes community pharmacy from other care providers. For integrated care, you want to look for points of access that are reliable and trusted. When considering the more central issues of adherence or impact on the care of complex patients or those with multiple chronic conditions, pharmacists play a very direct role in clinical management.

In many ACOs, the degree of collaboration and integration between providers is still a struggle. There are many types of people who participate in the provision of care that are not frequently identified. In ACOs, there was a lot of focus on primary care as the central character, but every party needs to be integrated in care delivery. Pharmacy represents a significant advantage over other care sites because the costs are very reasonable.

Q: What are the value points, and why is community pharmacy uniquely positioned to provide that value?

 As you launch an ACO, it is difficult to know the patient population. Getting to know your patients allows you to do 2 things: (1) care for them, and (2) count on them as reliable in your ACO (on the financial side). Community pharmacy provides the ability to know patients as close to home as possible. The pharmacists are aware of their patients’ real issues and concerns, some of which enter the clinical domain (eg, an unsafe environment or caregivers who are disengaged). Patients spend a lot of time in their pharmacies, and they may be closer to home than their physician offices. Moreover, patients may have a stronger relationship with their pharmacists than their primary care physician. The value of time that patients can get with pharmacists uniquely positions community pharmacy as an important player in the provision of care.

Q: Why are community pharmacies still hesitant to participate in ACOs? 

 The role of pharmacy is unclear. If Medicare Part D was included from the beginning, it would be different. The impact of pharmacy, however, is as strong, so it really doesn’t matter. The first vision of an ACO centered on transformation of the primary care setting. As a result, attention to pharmacy and other sites was secondary. Some pharmacy services were considered when ACOs were initially designed, and those who pressed the role of pharmacy suggested “mobile care teams.”

Recent success of this concept was evidenced by a program launched by Community Care of North Carolina. Because it used community-wide resourcing and provided value in the broader community, it made for a rational investment. However, when I was initially designing ACOs and being approached with services with similar attributes, they couldn’t afford to do it (they were struggling with the “normal” investments of an ACO). The idea of a mobile care team with a pharmacist at a very high price point was something that many ACOs could not weave into their business plan. That maybe drew a distance, and the ACO reaction was, “Maybe we can’t afford to engage pharmacy” at this time, and they focused on primary care. There was perhaps a little bit of cost overload (and what was being suggested for mobile care teams may have been excessive as opposed to what community pharmacy can do every day in their pharmacy to make an impact).

Also, community pharmacy feels as though they haven’t really been encouraged to participate in ACOs. They should more aggressively seek integration into the care design and acknowledgement as critical care providers in the ACO population. If pharmacy makes a compelling argument for integration in care redesign activities of the ACO, they become central to the solution and from that point, rules of participation in the business plan will become clearer.

Q: What do you think was the reasoning behind Walgreens’ decision to leave 2 out of 3 ACOs this year? 

There were probably several factors. The one they remained in was a high-cost setting. The Centers for Medicare & Medicaid Services has tried hard to create a model that wouldn’t penalize efficient markets, but the balance isn’t perfect. Largely, it was probably a market-specific decision or it could have come down to the partners (which were minorities to the primary care providers). The silos we created within ACOs really haven’t gone away, although we hope they are in the process of changing. In this market, there was probably a high level of patient movement, so you didn’t know your panel well and it becomes hard to manage (hence why inclusion of pharmacy is important). That could play into the decision on whether to continue with an ACO in a market. Some markets are more conducive to ACOs than others.

Q: With states starting to move toward recognizing pharmacists as providers, is this a much-needed first step toward pharmacies participating in ACOs or is there more work that needs to be done?

A regulatory designation is not critical, but can only help. Many physicians and physician delivery networks believe they are better suited to do some services (eg, medication reconciliation). Failure to integrate and build the professional dialogue among all caregivers is more of an issue than a regulatory designation.

There is currently a reassessment of the practice limitations and regulatory constraints on some providers, and whether the same level of limitation/oversight is detrimental and needs to be relaxed. If pharmacist designation as providers expands the scope of license, the greater scope will be very beneficial when integrated into an ACO environment. It will also make pharmacy a more significant and upfront consideration.

Q: If the cost of pharmacy services were included in the total cost of care, would it encourage ACO participation? 

Yes, but only because if pharmacy services were included, they would be targeted. Because they are not included, they are very effective interventions that have a huge impact on the cost of care and the associated risk. You could spend more in pharmacy and make someone highly adherent to therapy and the cost of increase in pharmacy spend is not a risk to the ACO today, but the benefit of doing so has a very large impact on cost in others settings (eg, emergency department visits due to unmanaged diabetes).

Better management through pharmacy services is very beneficial to ACOs. Strangely, the lack of inclusion of Part D is an incredible opportunity for ACOs to focus on solutions without a lot of risk (ie, it is predominately a reward environment). Had costs initially been considered, ACOs would be more inclined to engage with pharmacy partners. Participation in an ACO model bends your business plan. For example, in a primary care office, you’re going to have to do more with the same amount of resources.

Q: Beyond payment, HIT and EHR access, and provider status, are there additional barriers to effective integration of pharmacists in ACOs? 

 There are other barriers that aren’t talked about much that are even more meaningful. The original premise of ACOs was that patients have a very consistent orbit around their chosen primary care provider. However, patients move around and are getting care from a variety of places, and ACOs’ reach didn’t cover the spectrum. One of the largest obstacles when designing ACOs is the methodology of patient assignment and the ability to use a few more incentives for patients to seek care from ACO-integrated providers. Risk is substantially more difficult when you can’t identify your patient population. That is probably the single largest problem within the ACO movement.

Failure to know the population makes it very difficult to consider taking on the risk of a transient population. ACOs were meant as transitional phases to get to risk-bearing programs. In the marketplace, there is a divide between those who believe they can manage things well and are looking forward to it in next-generation business models and many who think there’s a lack of stability in the program and structure and they prefer to defer risk as long as they can.

ACOs need to move to a risk environment. To do that, they need to solve the problem that may keep pharmacy on the sidelines and improve panel identification. ACOs need to create an incentive model that is strong enough to incent all the various participants in the value stream.

		Summers L, de Lisle K, Ness DL, Kennedy LB, Muhlestein D. The impact of accountable care: how accountable care impacts the way consumers receive care. Leavitt Partners website. http://leavittpartners.com/wp-content/uploads/2015/05/Impact-of-Accountable-Care_Consumers-05.2015.pdf. Published May 2015. Accessed July 5, 2015.

		Yap D. Community pharmacy to CMS: integrate pharmacists’ services into ACOs. American Pharmacists Association website. www.pharmacist.com/community-pharmacy-cms-integrate-pharmacists-services-acos. Published July 1, 2014. Accessed July 5, 2015.

		Jeffery SM. Walgreens severs ties with ACOs. Pharmacy Times website. www.pharmacytimes.com/publications/directions-in-pharmacy/2015/march2015/Walgreens-Severs-Ties-with-ACOs. Published March 24, 2015. Accessed July 5, 2015.

		Bonner L. Pharmacist provider status now law in Oregon. American Pharmacist Association website. www.pharmacist.com/pharmacist-provider-status-now-law-oregon. Published June 18, 2015. Updated June 19, 2015. Accessed July 5, 2015.

Pharmacists have the opportunity to make a tremendous impact on outcomes and efficiency, especially in chronic disease management. 