Approximately 155 million people in the United States under the age of 65 years receive employment-based health benefits.1 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.2 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 program3; however, based on a 2004 survey, only about 7% of US employers offer comprehensive worksite health promotion programs.4 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, Directions in Pharmacy 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.
 
1. What is Wellness?
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—using tenets of primary and secondary prevention—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).5 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.6
 
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 Contemporary Clinic once finalized.]
 
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.7 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—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.
 
Resources on Wellness Programs
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.

References
  1. Fronstin P. Sources of health insurance and characteristics of the uninsured: analysis of the March 2011 current population survey. EBRI Issue Brief. 2001;363:1-35.
  2. Goetzel R. Structuring legal, ethical, and workplace health incentives: a reply to Horwitz, Kelly, and DiNardo. Health Affairs 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.
  3. Workplace wellness programs. Health Affairs website. May 16, 2013. http://healthaffairs.org/healthpolicybriefs/brief_pdfs/healthpolicybrief_93.pdf. Accessed September 18, 2015.
  4. Linnan L, Bowling M, Childress J, et al. Results of the 2004 National Worksite Health Promotion Survey. Am J Public Health. 2008;98(8):1503-1509. doi: 10.2105/AJPH.2006.100313.
  5. 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.
  6. Goetzel RZ, Henke RM, Tabrizi M, et al. Do workplace health promotion (wellness) programs work? J Occup Environ Med. 2014;56(9): 927-934. doi: 10.1097/JOM.0000000000000276.
  7. 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.
Sidebar

Wellness Programs: The Role of the Pharmacist
Larry Long

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.1 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”2 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.

Programming typically emphasizes:
  • Optimization of drug therapy, including promotion of adherence
  • Assessment and improvement of participant knowledge and self-care skills
  • Communication and coordination with participant’s medical provider(s)
  • Establishment of personal goals relevant to health risk priorities
  • Providing motivation and support for achievement of goals and healthier lifestyles
  • Care coordination/communication—identification and management of “care gaps”
  • Addressing relevant considerations such as nutrition, exercise, and lifestyle improvements, as appropriate

Once programming was established, many pharmacists and networks discovered additional opportunities to contribute to, and even shape, employers’ broader wellness initiatives. The Illinois Pharmacist Network, Piedmont Pharmaceutical Care Network of North Carolina, Linking Pharmacists to Improved Health Outcomes in Pennsylvania, the Maryland P3 group, the Pittsburgh Business Group on Health, and My Pharmacist Connection of Arizona are among the organizations that have been able to create additional offerings in support of wellness and expand beyond the initial opportunities for coaching specific conditions.

Health risk assessment, biometric screening, vaccination, care transition support, and assistance with population health analytics, risk segmentation, and targeted risk reduction programming are some examples of the more evolved services now offered. Many have expanded their original disease-specific coaching programs to include support and intervention not necessarily related to specific conditions.

Some have customized adherence and MTM programs for employers, as have Mirixa, OutcomesMTM, and MMS of Minnesota. Case management for specialty pharmaceuticals is also being offered as part of employer services by some groups.

As the percentage of US employers who provide wellness programs increases, opportunities for health care professionals, such as pharmacists, continue to emerge to support successful collaboration within these programs. With pharmacists involved in nearly all aspects of wellness programs, participants are afforded a deeper understanding of their health, thus increasing the chance for positive patient outcomes.


Larry Long is president and managing partner, Medication Management, LLC, and its affiliate company, Piedmont Pharmaceutical Care Network. Both companies provide clinical risk and cost management services to a variety of organizations. Medication Management provides consulting and clinical support for individual medical practices and networks, while Piedmont Pharmaceutical Care Network customers are primarily employers with self-funded health plans. He earned his BS in pharmacy from the University of North Carolina at Chapel Hill. 


References
1. Society for Human Resource Management. 2015 Employee Benefits: An Overview of Benefits Offerings in the US. Alexandria, VA: Society for Human Resource Management; 2015. www.shrm.org/Research/SurveyFindings/Articles/Documents/2015-Employee-Benefits.pdf. Published June 2015.
2. Fera T, Bluml BM, Ellis WM. Diabetes Ten City Challenge: final economic and clinical results. J Am Pharm Assoc (2003). 2009;49(3):383-391. doi: 10.1331/JAPhA.2009.09015.