The Affordable Care Act includes provisions intended to encourage workplace health promotion and prevention as a means to reduce the burden of chronic illness, improve health, and slow the growth of health care costs. One provision of the Public Health Service Act (Section 2705(m)(1)), as amended by the Affordable Care Act, directs that the Secretary of the Department of Health and Human Services (HHS), in consultation with the Secretaries of the Treasury and Labor, gather relevant information from employers who provide employees with access to wellness programs, including state and federal agencies, and submit a report to the appropriate committees of Congress concerning:
(1) the effectiveness of wellness programs;
(2) the impact of such wellness programs on the access to care and affordability of coverage for participants and non-participants of such programs;
(3) the impact of premium-based and cost-sharing incentives on participant behavior and the role of such programs in changing behavior; and
(4) the effectiveness of different types of rewards.
At the request of HHS, the Department of Labor (DOL) contracted with the RAND Corporation to help to prepare this report to fulfill this provision of the Affordable Care Act. This study consists of four parts: a) a literature review, b) a national representative employer survey, c) analysis of an existing industry-wide database (Care Continuum Alliance or CCA database) to which wellness providers contribute data anonymously, and d) five case studies. The Workplace Wellness Programs Study Final Report is attached.
A wellness program is defined in section 2705(j)(1)(A) of the Public Health Service Act, as amended by the Affordable Care Act, as a program offered by an employer designed to promote health or prevent disease. Certain types of wellness programs offered through employment-based group health plan coverage must meet standards the Affordable Care Act sets forth. More broadly, there is a wide array of workplace wellness programs which include employment-based activities or employer-sponsored benefits aimed to promote health-related behaviors (primary prevention or health promotion) and disease management (secondary prevention). Wellness programs may include a combination of data collection on employee health risks with population-based strategies and individually-focused interventions to reduce those risks. Programs may be part of a group health plan or offered outside of that context. They may range from narrow offerings, such as free gym memberships, to comprehensive counseling and lifestyle management interventions.
The burden of chronic disease is growing in the United States as rising rates of obesity and physical inactivity are leading to more diabetes and cardiovascular disease. Particularly worrisome is that the onset of chronic conditions such as obesity and hypertension is shifting to younger age cohorts, who are still participating in the labor market. This shift increases the economic burden of chronic disease, as illness-related loss of productivity is added to the cost of medical care. To counter this trend, employers are adopting health promotion and disease prevention strategies, taking advantage of their access to employees at an age where interventions directed at healthy behaviors can still change the trajectory of employees’ long-term health. These strategies range from changes to the working environment, such as providing healthy food options in the cafeteria, to comprehensive interventions that support employees in adopting and sustaining healthy lifestyles.
According to the employer survey conducted for this study, approximately half of U.S. employers with 50 or more employees offer wellness promotion initiatives. Larger employers are more likely to offer programs than smaller employers and larger employers offer a greater variety of options. Seventy-five percent of employees in organizations with 50 or more employees work for employers offering wellness programs. Programs often include a combination of wellness screening activities to identify health risks and interventions to reduce risks and promote healthy lifestyles. Wellness benefits can be offered by employers directly to all employees or through group health plans to plan members. According to the survey, less than half of employees (46 percent) in those organizations with a wellness program undergo clinical screening and/or complete a Health Risk Assessment (HRA), and fewer participate in interventions (ranging from 7 to 21 percent). Focus group participants indicate that poor accessibility of wellness activities due to rigid work schedules and wait times limit access to wellness benefits.
Effectiveness of wellness programs
A review of the scientific literature evaluating the impact of workplace wellness programs on health-related behavior and medical cost outcomes found, consistent with previous reviews, evidence for positive effects on diet, exercise, smoking, alcohol use, physiologic markers and healthcare costs, but limited evidence for effects on absenteeism and mental health. It was not clear from the literature whether program intensity was positively correlated with impact. Positive results found in the literature review studies should be interpreted with caution as many of these programs were not evaluated with a rigorous approach, and published results tend to focus on larger employers and therefore may not be representative of the experience of a typical U.S. employer. A RAND analysis of the CCA database, when comparing wellness program participants to statistically matched non-participants, found statistically significant and clinically meaningful improvements in exercise frequency, smoking behavior, and weight control, but not in cholesterol control.
Impact of such wellness programs on the access to care and affordability of coverage for participants and non-participants of such programs
Most employers who offer workplace wellness programs regard them as a viable strategy to contain health care costs. A review of the literature identified randomized controlled trials that found workplace wellness programs did result in significant decreases in healthcare costs, including a savings in medical costs ranging from $11 to $626 per year. The employer survey found that 60 percent of employers offering a wellness program stated that their programs reduced healthcare costs, and around four-fifths reported that they decreased absenteeism and increased productivity. But less than half of the employers reported regularly evaluating their wellness programs and only 2 percent provided actual savings estimates. Analysis of the CCA database was inconclusive as point estimates suggest that participation in a wellness program may lower healthcare costs and decrease utilization, but differences between participants and non-participants were not statistically significant.
Wellness programs can also provide direct access to care through on-site vaccination activities or health or occupational clinics. Of those employers offering a wellness program, 76 percent offered on-site vaccinations. Over 40 percent of employers, regardless of whether they offer a wellness program, reported having an Employee Assistance Program (EAP), which provides access to counseling and assistance for personal issues, and over 24 percent an occupational health service. About five percent of employers nationally maintain an on-site clinic.
Impact of premium-based and cost-sharing incentives on participant behavior and the role of such programs in changing behavior and the effectiveness of different types of rewards
Financial incentives have become a commonly used tool to promote employee engagement in worksite wellness programs, and employers are expanding their use. According to the employer survey results, financial incentives are offered in a variety of forms, such as cash, cash equivalents (e.g., discounted gym memberships), and novelty items (e.g., t-shirts or gift cards). Evidence from the peer-reviewed literature suggests that targeted incentives can help to influence behaviors in the short-term and increase participation in wellness programs. Among employers who offer workplace wellness programs, 69 percent use incentives to encourage utilization of a wellness program. Monetary incentives for Health Risk Assessment (HRA) completion and lifestyle management programs are most common and offered by about 30 percent of employers with those particular wellness programs. Employers also linked cost-sharing incentives to health coverage for program participation and/ or attainment of health goals, including cost-sharing incentives related to the employees’ share of health plan premiums (37 percent), and employer contribution to Health Reimbursement Accounts (5 percent). Based on the survey, incentives are typically framed as rewards for engaging in wellness programs. Only 2 percent of employers frame their incentive offerings only as penalties, and 11 percent of employers reported framing incentives as both rewards and penalties.
The use of incentives targeted to achieving specific health outcomes such as smoking cessation and reductions in body-mass index remains uncommon. The survey suggests that nationally only 10 percent of employers with more than 50 employees use any such incentives, and only seven percent link the incentives to the premiums for health coverage. The average maximum incentive amount for these employers was less than 10 percent of the total annual cost of coverage, far from the 20 percent regulatory ceiling imposed by the Health Insurance Portability and Accountability Act (HIPAA).
There was too little variation in the rewards offered by employers in the CCA database to be able to assess effectiveness of different types of rewards. To date the most common trigger for incentives is participation in screening activities, and the studies’ results suggest that such incentives, particularly payments above $50, are effective. Incentives are also commonly used to increase participation in wellness interventions, such as weight loss programs, but the evidence for their effectiveness remains weak. A smaller number of employers tie incentives to achieving health standards, primarily with regard to smoking cessation. With respect to effectiveness, the analyses of employer data in the CCA database imply that incentives for HRA completion and program participation can significantly reduce weight and smoking rates and increase exercise. The size of these effects, however, is small and unlikely to be clinically meaningful.
Other Factors affecting program success
The RAND case studies and the review of the literature also highlight a number of factors that may affect wellness program success in the workplace. Effective communication with employees about program goals and benefits, accessibility and alignment with employee needs, leadership support, creative use of resources, and continuous program improvement all appear to be factors that can improve employee health and increase the effectiveness of worksite wellness programs.
The Affordable Care Act addresses employers' ability to reward employees who participate in certain wellness programs offered through employment-based group health plans and which require individuals to meet health goals. A number of federal laws and regulations impose requirements and regulate the use of financial incentives in certain types of wellness programs. Section 2705(j) of the Public Health Service Act, as amended by the Affordable Care Act, raises the allowable value of wellness incentives provided through employment-based group health coverage that require satisfaction of a health-related standard from 20 percent to 30 percent of the cost of coverage in 2014 and provides discretion to the secretaries of DOL, HHS, and the Treasury to increase the reward to up to 50 percent of the cost of coverage if they determine that such an increase is appropriate. It also codifies in statute the HIPAA regulatory standards for health contingent wellness programs.
On November 26, 2012, the Departments of Health and Human Services, Labor, and Treasury released a Notice of Proposed Rulemaking on the wellness program provisions of the Affordable Care Act. Final rules regarding incentives for nondiscriminatory wellness programs in group health plans were published contemporaneously with this report to Congress in early May 2013. The final rule increases the maximum permissible reward under a health-contingent wellness program offered in connection with a group health plan (and any related health insurance coverage) from 20 percent to 30 percent of the cost of coverage, as outlined in the Affordable Care Act. It also allows a maximum reward up to 50 percent for wellness programs designed to promote tobacco cessation, and clarifies that small group market plans including those offering workplace wellness programs may only apply the tobacco surcharge allowed under Section 2701 of the Public Health Service Act if they also provide a tobacco cessation wellness program (consistent with Section 2705(j) of the Public Health Service Act) that would eliminate the surcharge for participants. Finally, the final regulation clarifies several of the consumer protections required for health-contingent wellness programs.
Also relevant to workplace wellness are the preventive services for adults that are covered without cost-sharing in non-grandfathered group health plans as a result of other provisions in the Affordable Care Act. Section 2713 of the Public Health Service Act, as amended by the Affordable Care Act, requires non-grandfathered group health plans to cover a series of recommended preventive services without imposing cost-sharing, including diet counseling for adults at higher risk for chronic disease, cholesterol screening for adults of certain ages or at higher risk, and blood pressure screening. Tobacco use screening and cessation interventions to smokers are also included in the recommendations.
The federal government is engaged in many efforts to foster worksite wellness programs, both with employers throughout the nation, and as an employer of a large and diverse workforce.
National Prevention Council
The Affordable Care Act created the National Prevention Council and called for the development of the National Prevention Strategy to realize the benefits of prevention for all Americans’ health. The National Prevention Strategy, released in June 2011, focuses on both increasing the length of people’s lives and ensuring that people’s lives are healthy and productive. The National Prevention Council is comprised of 17 Federal departments, agencies and offices and is chaired by the Surgeon General. The National Prevention Council Action Plan, released in June 2012, outlines the Council’s commitment to implementing the vision, goal, priorities, and recommendations of the National Prevention Strategy. It also highlights important opportunities that the National Prevention Council and its 17 member departments – representing sectors such as housing, transportation, education, environment, and defense – are creating to ensure the health, well-being, and resilience of the American people. Example Council department actions to improve worksite wellness from the Action Plan include:
• Department of Defense is working to reduce tobacco use on its installations to promote health and mission readiness, help tobacco users to abstain/quit, and lead by example for all workplaces.
• Department of Veterans Affairs will implement a program for safe patient handling, including staff protocols and tools, in all Veterans Health Administration facilities in order to decrease musculoskeletal injuries among employees.
• Department of Homeland Security (DHS) will implement the DHSTogether program, a department-wide program for employee and organizational resilience designed to promote the health and well-being of the entire DHS workforce and ensure that employees have the tools and resources for balancing work-life issues and thereby reducing sick leave, absenteeism, and stress.
• Department of Labor will raise awareness among employers, group health plans, and issuers about benefits under the Mental Health Parity Act and Mental Health Parity and Addiction Equity Act through outreach and training to promote mental health and well-being in the workplace.
In addition, The National Prevention Council, through the combined efforts of all its 17 federal departments, has voluntarily committed to identifying opportunities to consider prevention and health, increasing tobacco free environments, and increasing access to healthy, affordable food. These commitments highlight the National Prevention Council’s efforts to improve workplace wellness and the health of and well-being of all the people they serve. The National Prevention Council Action Plan can be found here: http://www.surgeongeneral.gov/initiatives/prevention/2012-npc-action-plan.pdf
Centers for Disease Control and Prevention
The Affordable Care Act included provisions directing the Centers for Disease Control and Prevention (CDC) to provide technical assistance and evaluation support for employer-based wellness programs and to conduct a National Worksite Health Policies and Programs study. As an initial step, $10 million from the Affordable Care Act’s Prevention and Public Health Fund was awarded to two organizations with expertise in working with employers to develop and expand workplace wellness activities, such as tobacco-free policies, flextime for physical activity, and healthier food choices in the workplace as well as tools, resources, and guidance to build or enhance workplace health programs. While most workplace wellness studies have focused on large employers, the CDC’s National Healthy Worksite Program is working directly with over 100 small and mid-size employers to develop and provide the tools needed to create a comprehensive health place wellness program, including employer and employee assessments, program planning and implementation support and evaluation. 
Federal Workplace Health Collaborative (FHWC)
In 2009, the CDC created the Federal Workplace Health Collaborative (FHWC) linking federal government workplace points of contact to better promote workplace health practices and evidence based approaches to workplace wellness and disease prevention. In its first year, the Collaborative, in collaboration with the National Institutes of Health (NIH), gathered seminal workplace health resources for employers and employees from different Federal agencies to create the Federal Wellness Resource Guide accessible at: www.cdc.gov/policy/resources/federalwellnessresourceguide.pdf . FWHC members include workplace health contacts in Health and Human Services (CDC, Center for Medicare and Medicaid Services, Federal Occupational Health, Health Resources and Services Administration, NIH, Substance Abuse and Mental Health Services Administration), DOL, General Services Administration, Office of Personnel Management, Veteran’s Health Administration, the National Institute for Occupational Safety and Health, the Bureau of Engraving and Printing, and the U.S. Department of Agriculture.
Office of Personnel Management (OPM)
Through the Federal Employees Health Benefits (FEHB) program, OPM encourages the 90+ health insurers who participate to offer Health Risk Assessments, biometric screening, and other wellness services to enrollees. They also require that FEHB plans offer, at no cost to enrollees, all preventive services with an A or B recommendation from the US Preventive Services Task Force. In addition, OPM has had a pilot workplace wellness program in place for the last three years. The program, known as WellnessWorks (WW), offers comprehensive wellness services to OPM employees at the Theodore Roosevelt Building in Washington, D.C. Services include health risk assessment, biometric screening, health coaching, health education classes, fitness, and group challenges. Approximately 40 to 50 percent of eligible employees participate in one or more WW activity. The program is being formally evaluated by an independent third party, but those results are not yet available. The Healthcare Leadership Council has selected the program for its Wellness Frontiers Award.
Federal Occupational Health (FOH)
Federal Occupational Health, the largest provider of occupational health services in the federal government, serves more than 360 federal agencies and reaches 1.8 million federal employees. FOH has developed an innovative health, wellness, and work/life program named FedStrive. Launched in October 2009 at an event led by First Lady Michelle Obama and Health and Human Services (HHS) Secretary Kathleen Sebelius, FedStrive takes a highly integrated approach to help agencies create a “culture of health” for their workers.
Initially, FedStrive served as a pilot project for 3,000 employees at the HHS headquarters in Washington, D.C., offering comprehensive onsite and virtual programs that included:
· Online health risk assessment and lifestyle management tools
· Walk-in care at an onsite clinic, including health screenings, biometric assessments and immunizations
· Onsite Fitness Center
· Employee Assistance and Work/Life Programs
· Lactation Support
· Smoking Cessation
· Ergonomic Assessments
· Health education programs
· AED Program management and oversight
· Healthier nutrition choices at the work sites, including cafeteria offerings, vending machines, and a Farmer’s Market
· Lifestyle Coaching
FedStrive is well-integrated into the HHS organizational structure. FedStrive enjoyed engagement from high-level leadership that included HHS Secretary Kathleen Sebelius, Assistant Secretary Ned Holland and Surgeon General Regina Benjamin – who not only spoke at events but participated in activities. FedStrive received important input from the Office of the Secretary (OS) Wellness Committee which is co-chaired by FOH. This crosscutting employee-centric committee worked with management to help ensure programs were developed in accordance with employee needs, readiness for change, worksite culture, and workplace priorities.
In less than two years, FedStrive data showed significant behavior changes among its members and is now expanding nationally. FedStrive has already been formally launched in Kansas City, San Francisco, Seattle, Philadelphia, and Dallas. FedStrive has shown that an integrated health and wellness program – along with organizational and environmental supports - can produce significant behavior changes among federal employees and can indeed help create a “culture of health.”
As part of its evaluation of FedStrive, FOH is developing a new Return on Investment (ROI) Model. The model allows FOH to help government agencies project future cost savings and ROI from risk reduction efforts in addition to retrospectively estimating cost savings and ROI for existing programs. Preliminary analysis of the FedStrive cohort data shows an ROI of $1.60 for every $1 invested in the program in just the second year and an even greater ROI of $2.14 for every dollar invested in the third year. Like private sector employers, the federal government can achieve benefits from both lower medical spending and a more productive workforce.
Healthy People provides science-based, 10-year national objectives for improving the health of all Americans (www.healthypeople.gov ). For four decades, Healthy People has established benchmarks and monitored progress over time in order to: (1) Encourage collaborations across communities and sectors; (2) Empower individuals toward making informed health decisions; and (3) Measure the impact of prevention activities. Healthy People 2020 includes several national objectives aimed at improving worksite wellness, including those listed below.
Educational and Community-Based Programs
Infant and Child Health
Nutrition and Weight Status
This Workplace Wellness Programs Study Final Report contributes to an improved understanding of current worksite wellness program participation, impact and the role of incentives, and has also identified priority areas for future research.
· Long-term impact of wellness programs: The study was able to detect statistically significant and clinically meaningful effects of wellness programs on health risk factors after examining six years of CCA data. Given the latency between health risks and development of manifest chronic diseases, a much longer follow-up period would be required to fully capture the effect of worksite wellness programs on health outcomes and cost.
· Impact on broader range of measures: Measures such as absenteeism, productivity, and retention are of critical importance to employers as they directly affect business performance. Determining program effect on quality of life measures can inform the broader policy question on welfare implications of wellness programs.
· Program design and delivery: A more granular look at program components would provide valuable insights into determinants of program success, and could investigate a possible dose-response relationship, i.e., whether more contacts are more effective and cost-effective and the relationship between size of incentives and participant response.
· Employer factors and employee characteristics: Employer characteristics, such as workplace culture, and factors impacting employee engagement such as demographic characteristics, psychological states, and educational attainment might modify the effect of wellness programs. Understanding the role of such modifying factors would require data from a large sample of employers with differences in program implementation and characteristics to compare and contrast.
 The Health Insurance Portability and Accountability Act of 1996 (HIPAA) prohibited employment-based group health plans from discriminating against individuals based on health status. Specifically, under HIPAA, individuals may not be denied eligibility or continued eligibility to enroll in a group health plan based on any health factors they may have and an individual may not be charged more for coverage than any similarly situated individual is being charged based on any health factor, including being charging a higher premium. HIPAA provided an exception to the nondiscrimination provisions that allowed employment-based group health plans to provide rewards for participation in wellness programs. The HIPAA regulations released in 2006 defined two types of wellness programs: those available to all similarly situated individuals that do not require participants to meet a particular health status standard, and those that are contingent on meeting a health status standard. Programs that fall in the first group are not required to meet any additional non-discrimination standards under HIPAA or the ACA. Programs in the second group, called health contingent wellness programs, were required to meet certain standards under the HIPAA regulations, including that the reward could not exceed 20 percent of the total cost of coverage under the plan. See the regulations published in the Federal Register Volume 71, No. 239, at page 75014, December 13, 2006. See also, "Health Policy Brief: Workplace Wellness Programs,” Health Affairs, and Updated December 04, 2012. Accessed at: http://www.healthaffairs.org/healthpolicybriefs/brief.php?brief_id=81
 "Health Policy Brief: Workplace Wellness Programs," Health Affairs, Updated December 04, 2012. Accessed at: http://www.healthaffairs.org/healthpolicybriefs/brief.php?brief_id=81
 CDC Workplace Wellness site: http://www.cdc.gov/nationalhealthyworksite/index.html