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Beyond Paternalism

August 2014 Vol 7, No 5 - Editorial
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Most readers of American Health & Drug Benefits are leaders across the spectrum of the healthcare industry. We proudly represent nearly every stakeholder, including consumers, payers, providers, pharmaceutical executives, and others. As leaders in healthcare, there are important questions we must consider, such as “Are your employees healthy?” and “Why should you care about their health?” Let’s get past the idea of paternalism and examine the potentially controversial topics of employee wellness and productivity.

Recently, 2 major national groups collaborated to create a critically important report that helps to frame this issue. On March 24, 2014, the Health Enhancement Research Organization (HERO) and the Population Health Alliance (PHA) announced the release of their joint report entitled “Program Measurement and Evaluation Guide: Core Metrics for Employee Health Management.”1

HERO, a nonprofit corporation established in 1996 that is based in Edina, MN, is “dedicated to the creation and dissemination of employee health management research, education, policy, strategy and leadership” ( The PHA is a global trade association of the population health industry with 80 members who represent stakeholders from across the delivery spectrum. PHA’s mission is “to advance the principles of population health improvement, so they become pillars of our healthcare system” (

The Program Measurement and Evaluation Guide was the result of a collaborative effort initiated by the 2 organizations in 2011. It included participation from 40 organizations representing many segments of our industry, including employers, health plans, academic research centers, and various certification agencies. The executive summary listed the following 7 essential measures for the success of employee wellness programs.2

  1. Financial outcomes. The report notes that employee wellness programs deliver direct monetized claims savings and a monetized impact of wellness on hospital claims and health outcomes rather than a classic return on investment (ROI).

    In my view, this is probably the most controversial aspect of the report. The value of an employee health management program should be measured in terms of savings realized (eg, monies not spent because of a prevented hospitalization or a prevented visit to the emergency department). ROI calculations are not transparent, and some employee health management “programs have also claimed implausible levels of ROI.”2 Kudos to HERO and PHA for making the distinction between reduction in expenses and ROI—these are not synonymous concepts. Moving forward, specific financial metrics that may be appropriate include items such as long-term versus non–long-term spending comparisons, participant versus nonparticipant cross comparisons, and comparison with matched controls in a nonexposed population.

  2. Health impact. This area attempts to measure the impact of employee wellness programs on the overall health and well-being of specific, targeted populations. After an extensive review of the literature in this arena, the authors of the report note that all aspects of health (eg, physical health, mental and emotional health, healthy behaviors, and current health status) should be included in any initial set of measures.

    Again, I am very supportive of the authors in this respect, because they specifically observe that measures that are available in the public domain are preferred over measures that are proprietary and therefore have additional costs for use.

  3. Participation. This, too, is controversial. The report notes that there is no industry standard that directly links the number of contacts for every time period with an employee and the outcome of the employees’ efforts to improve their personal health and wellness. Simply put, we do not know how many nurse calls, in-person visits, e-mail reminders, and text messages it takes to change behavior.

    This is the first time, I believe, that these 2 major national organizations have frankly noted the lack of clear connectivity between the number and type of contact with individual employees and the specific health outcomes. This is a courageous step. As a result, “even if being non-prescriptive, there are too many variables to recommend a specific threshold, or even a range, for the number of contacts constituting participation.”2 We still have a lot of work to do regarding how we should connect with employees.

  4. Employee satisfaction. This is relatively straightforward and noncontroversial. There are many specific domains that one could consider, including overall satisfaction; satisfaction with the scope, convenience, individual patient experience; and reporting of the program.

  5. Organizational support. This is probably the core challenge. Without senior leadership support that is visible and consistent throughout the organization, any attempt, in my view, to improve employee wellness is doomed to fail. The authors of the report essentially concur and call for top-down organizational support for these kinds of efforts.

  6. Productivity and performance of employee health management systems. The authors noted the key challenge that the purchasers of these programs need to get beyond the “singular focus on health care costs” and demand “focus on the effects of…work outcomes, such as attendance, performance and turnover. These measures are more readily linked to operations measures that typically matter to business leaders.”2 The report notes the spectrum that includes concepts such as time away from work because of health (eg, unscheduled absences, short- and long-term disability) all the way to productivity loss while at work.

    Time away from work and productivity loss while at work are important concepts in the human resources arena.

  7. Value on investment (VOI). As opposed to ROI, “VOI better reflects the broader savings potential of wellness programs and provides a framework for constructing a VOI analysis.”1 You may ask, what is the difference between ROI and VOI? “First, the VOI framework uses the conventions of cost-effectiveness analysis (CEA). A CEA expresses its results in terms of the costs per unit of outcome. The numerator therefore represents the cost component and the denominator the outcome (this is the opposite of an ROI ratio). CEA analytic techniques can be abstruse, but the central idea is quite simple and straightforward: how to get the most for the money.”2

I applaud the use of the VOI framework rather than the classic ROI analysis. It is consistent with excellent work being done in the area of health economics and outcomes research.

In summary, this critically important report (and the publicly available guide for easy-to-use metrics that may be implemented at your organization) represents an important step in the right direction to getting us beyond corporate paternalism and giving us clearer measures for implementing effective employee health management programs. Leaders in every sector represented by our readership have an obligation to promote the health and wellness of their employees. Now we have a framework and a platform for rigorous discussion of the implementation and measurement of the outcomes of these programs. As always, I am interested in your views, and you can reach me via e-mail at This email address is being protected from spambots. You need JavaScript enabled to view it..


  1. Health Enhancement Research Organization, Population Health Alliance. HERO and Population Health Alliance collaborate on employer guidance for measuring employee health management outcomes. Press release. March 24, 2014. Accessed July 15, 2014.
  2. Health Enhancement Research Organization, Population Health Alliance. Program measurement and evaluation guide: core metrics for employee health management. Executive summary. July 1, 2014. July 15, 2014.
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