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How healthy is your office?

November 7, 2012

In February this year, CoreNet Global released their projections that by 2017, the average US worker will be allocated less than 151 square feet for the first time in modern history. This compares to an average of 225 square feet in 2010. Some 40% of companies are projecting that they will offer as little as 100 square feet per employee, achieved in part by assigning more than one person to a given work station. This sounds like a whopping drop, and is perhaps precipitated by our recent economic woes. Regardless, will cramming more people into the same space make people even more stressed, less healthy and perhaps, even more likely to “go postal?” Less space is just one aspect of our offices that might affect our health, but there are many more. Perhaps it is time to rethink how we create healthy workplaces.

How important is our office space to our health?

Because of a phenomenon called situational blindness, we tend to become so familiar with the usual places that we inhabit that we stop noticing things about them. Think of a messy kid that seems not to notice the pile of clothes and other garbage on the floor of his room or her. They simply don’t notice it anymore. A similar effect makes us oblivious to the layout of our office space and therefore to its impact on our health. Two recent articles from the New York times, referring to the impact of sitting on longevity, suggest that long periods of sitting each day can lead to a reduction of a few years or more in expected length of life, even if you exercise each day!

Furthermore, we usually eat at least one of our meals at the office, or during the workday. But our offices often harbor even more dangerous food traps. The candy bowl at reception meant for visitors (that we often dip into every time we return to the building), the jar of M&Ms on offer on at least one person’s desk, the frequent birthday cake parties and, perhaps the worst offender, the vending machines of death. With their high-sugar, high-sodium, high-fat, preservative-laden treats from heaven, it’s no wonder we have an obesity epidemic. In many offices, free sugary sodas on tap are still considered a perk (ever visited the back room of most law firms?).

Work and the lack of personal time and fatigue that results from work are the most common reasons cited by most employees for their stress levels, lack of exercise, poor sleep and poor diets. Even the most luxurious work places seem to make people sick!

How exactly does office space affect our health?

The obvious examples of workspaces that make us sick are the toxic spaces that lead directly to disease. Sick building syndrome – such as offices with too little light or worksites that expose employees to safety hazards – are pretty easy to imagine. What is less obvious is how very clean, safe, modern offices can impact our health. They do this by affecting our health habits, and as we’ve discussed in previous articles, health habits explain at least 50% of our health outcomes. If you consider who designs office spaces today, and what they’re thinking about when they do that, you start to understand why we have unhealthy offices. Workplaces are designed for work, not for being healthy. The underlying assumption is that people arrive at work healthy, and that the only consideration therefore needs to be designing a workplace that makes work easy, efficient and comfortable. Lean consultants sometimes get involved and often exacerbate the health problems by making workplaces even more efficient. They do this by examining ways to put employees and the tools they need as close together as possible. The unintended consequence is that many people can spend eight hours sitting at a desk, without the need to get up during the day, apart from “natural breaks.” Someday someone might even try and avoid those breaks too. Adult diapers anyone?

The good news is that an increasing body of research is showing that office spaces designed with employee health in mind can also enhance employee productivity. One trend is toward standing desks (or their more active cousins, the walking treadmill desk), both of which can take up less space than a traditional chair and desk. Standing and walking while we work are good for our health, since exercise, even in five-minute bursts throughout the day, has been shown to increase overall health, self-control, patience, cognitive skills, and decision making ability and leads to reduced stress, fatigue and health risks. Not a bad payoff for something that employees love having access to at work.

Onsite health clubs, on the other hand, are usually NOT well attended, since they don’t allow employees to work out and work at the same time. So in many companies, being seen taking an hour to go to the onsite gym is like being seen sneaking off to play hooky for an hour. However, when exercise equipment is incorporated INTO the workspace, the implied message from management is clear: “we want you to exercise while you work.”

Why do we work in just one place, when our tasks change?

Have you ever considered why you work in the exact same place all day long, yet work on a variety of tasks? Probably not. But now consider the research that shows that certain environments nudge people to do certain tasks better than others. If you need to proof read a document and catch every last mistake do it in a room painted red, signaling your brain to be on high alert, and expect to catch about 20% more mistakes than in other environments. If you need to brainstorm for a new product, do it in a room painted sky blue, especially on the ceiling. This literal interpretation of “blue-skying” has been shown to lead people to more creative, more imaginative solutions. If you need to check your email and remain focused, but have a backache, sit on the office massage chair with your laptop for half an hour, in a slightly darkened room.

Or, as we do in our offices, when we want to keep meetings short and focused, we hold balance ball meetings. Everyone sits on a balance ball (at $20 a ball it’s much cheaper than the usual $300 leather boardroom chairs), and meetings are very focused. People bounce around a little sometimes, but not so that it is distracting to others. Considering that lower back pain, often caused by poor core strength, is one of the leading causes of absenteeism in the US, our balance ball meetings not only get the job done, but also develop strong cores and healthier employees (with lower absenteeism). Because there is a risk of falling off your ball if you don’t concentrate, people spend less time playing on their laptops or phones, and more time participating in the meetings. As a result, our meetings are about half as long as they used to be. (Risk managers: note that more people fall off regular chairs and injure themselves at work, especially when they use them as make-shift ladders, compared with those injuring themselves by falling off balance balls. Personally, I’ve never been able to find a single case of a worksite accident involving a balance ball).

As office space continues to shrink, perhaps it is time to forget the idea of one cubicle per person and instead start to design office spaces with health and tasks in mind. People could move from one space to the next (getting that much-needed exercise boost as they do), as their needs change. They’d be more efficient while they’re in the spaces since the spaces could be psychologically and ergonomically designed to optimize certain types of task. Smart employers would place healthy snacks (perhaps also tailored to the tasks at hand) in each area, and banish those vending machines once and for all. Water cooler: come back, all is forgiven. Add a little Foursquare to allow check-ins and mayorships and work almost starts to sound like it could be fun. In fact, the “gamification” of work is a trend following hot on the heels of the gamification of wellness, but that’s a story for another time.

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Actuaries: Turn wellness from a dream into a real business advantage

June 12, 2012

From the Society of Actuaries guest blog post April 20 2012

Hardly a day goes by without another report of the possible and positive returns on investment available from wellness programs. Yet, with few exceptions, companies do not make the investments that they should in employee health. Getting a positive return on a minimal investment is not the point. Knowing how much and what type of investments to make to maximize the overall return (not just per dollar spent) for employers is no easy task, and that is where actuaries can shine. One of the reasons employers under-invest, despite the regular news reports of 3:1 ROIs, is that most studies on the returns available are less than credible. At least when examined by CFOs and CEOs with an eye for financial mathematics. The errors in ROI calculations run the gamut of statistical blunders from confusing cause with correlation, to ignoring many of the costs (lowering the real cost of the investment) or using “estimates” of what the return should be as a result of a certain level of engagement (often based on a wellness company’s single best case study). Creating credible studies of the return on investment from wellness programs requires a unique set of mathematical skills and tools and a particular way of thinking. This toolset and mindset is exactly that possessed by actuaries. Although many of us have spent years working on the negative side of health (death, disability, morbidity), the mathematics of the positive impacts of health habits on health outcomes is very similar, albeit with some important differences. With a change in mindset and some thought, actuaries could provide employers the missing link behind making and measuring investments in employee health: the credible business case for how much to invest and what to expect as return and a reliable method for measuring success (or failure) over time. Actuaries could help employers clear away the myths in wellness by helping them to apply an honest approach to evaluating programs. As we have found, when one does this, many of the assumed best practices in wellness are simply not supported by the data. Biometric screenings, for example, usually increase health claims over the short term rather than decrease them! Even considering the health failures avoided by early detection, the net impact of these screenings (taking into account the total costs and the higher drug costs that result from treating newly detected risk factors) is usually negative over the period that most employers would care to look. Just like health insurance itself was a new frontier for actuaries during the last century, I hope that in this century, wellness will become the industry in which our profession adds credibility, honesty and a serious approach to helping clients understand what truly works. In a field where common sense answers are often wrong, our critical evaluation skills will be in high demand from employers who understand the link between employee health and their companies’ performance. I urge actuaries working in health insurance to apply their minds to guide employers to invest in improving employee health habits instead of just paying for the health failures that result.

Personal Ability: The Missing Link in Wellness Thinking

April 8, 2012

Almost all efforts to drive participation in wellness programs focus on the question of motivation. Inspiring messages, rewards and incentives, attempts to “make it fun,” readinesstochange surveys, and activity tracking often try to address what common sense tells us is missing. People simply lack the motivation to change. Therefore, if we can “up the stakes”, threaten, bribe or convince people that they should change, we will help them over this motivation barrier and new habits will emerge. If you think a lack of motivation is the main problem, think again!

Ability, Confidence, Self-Efficacy

Most people with health or habit challenges (for example, those who smoke or are overweight) say that they truly want to be healthier. In other words, they are already motivated: they have the general desire or willingness to do something.

When people fail to change their habits, we naturally assume that they simply didn’t have ENOUGH motivation. They lack inspiration, commitment, guts, stamina and other similar concepts related to willpower. Popular culture and wishful thinking books like “The Secret” may harmfully lead people to believe that wanting something enough or thinking about it enough will make it a reality. As if there is some sort of yet undiscovered form of magnetism that transforms desires into outcomes.

I am the first to agree that motivation is important. In fact, my previous article spoke specifically about the Power of Purpose as a way of increasing motivation to drive change. However, the significant element that is missing from wellness and engagement programs today is the most important ingredient required for successful habit change: ability.

Personal ability is sometimes described as self-efficacy: confidence or a belief in one’s ability to change. Even when motivation is high, if self-efficacy is low or non-existent, change doesn’t happen.

 

What Limits Self-Efficacy?

One of the reasons why many people lack confidence in their ability to change  is related to their view of the locus of control over health habits and health outcomes.

External Locus of Control

Some people’s worldview is that the locus of control over events in their life lies somewhere outside of their power. They believe things happen to them and that other forces such as fate or luck are in control. People with this view naturally have little confidence that their actions directly affect their lives and their health.

In health care, the marketing and pharmaceutical campaigns, and the “doctor knows best” mindset of the medical profession, are pernicious forces that have led many people to believe that when it comes to their own health, the locus of control is in the hands of others.

Almost all diabetics are led to believe that their diabetes is irreversible when research from the Physicians Committee for Responsible Medicine has shown that up to 2/3rds of newly diagnosed diabetics can have their condition fully reversed with a few months of changed diet and exercise.

Similarly, countless people have been told that their high blood pressure, high cholesterol, cancer risk or other diseases are genetic (and therefore out of their control) and the only treatment option is drug therapy. I would argue that the misperception about the role of genes in health status is one of the biggest enemies to global improvements in health and one of the biggest friends to drug manufacturers and the sick care sector in general. So, lets explore this a little more.

Studies like the long-running Framingham Heart Health Study have shown us that high cholesterol, high blood pressure, heart disease risk and other risk factors run in families. This IS undeniable and the evidence is strong that family history strongly predicts health outcomes. Certainly, standard medical practice now includes taking a family history because, for hundreds of diseases, a family history is one of the main risk factors for your likelihood of developing a disease.

Yet, in apparent conflict, the Center for Disease Control and Prevention, the Institute for the Future and others suggest that genes only control 20% of health outcomes and that health habits and the environment control or predict 50% and 20% respectively. Either these statistics or the family history statistics must be wrong, because they appear to be in direct contrast. This apparent conflict can be resolved by thinking more deeply about HOW we inherit disease from our parents.

We simply assume that inheritance is genetic when we talk about family history as a risk factor. The medical community often makes the profound error of confusing correlation with cause. High cholesterol may indeed run in families, but it is not necessarily true that high cholesterol is caused by genetic inheritance. In fact, what we get from our parents is both our genes AND many of our habits. Our parents certainly control our nutrition for many years in our early lives (and evidence shows that even a mother’s dietary preferences during pregnancy affect her children’s food preferences into adulthood). Parents also lead by example in terms of TV watching, family outings, activities like exercising or hiking, and other health habits. It might be true that we suffer some of the same health outcomes as our parents, but it is often because we practice the same habits and not solely because we share their genes.

Of course, for almost all diseases, it is a combination of genes and habits with some diseases being driven more by one than by the other. The key point is that many people consider disease to be genetically driven because it “runs in the family.” The reality is that changes in habits can often be the key to prevention or cure. So, next time your physician says “it’s probably genetic, here’s a script to help you control your…”, think twice and consider changes in habits as a first step. But be patient, since the quick fix mentality that is pervasive in today’s world often leads us to prefer drug therapy, in spite of the many side effects that can accompany this approach, over the better alternatives of practicing healthy habits.

When people realize that they have more control over their health outcomes than previously realized, they’re often able to shift the locus of control internally, realizing for the first time in their lives that they do hold the power to change their future, and that power comes from their choice of health habits. Once they have this realization, wellness programs and change initiatives become attractive, empowering vehicles to regaining health.

Thus, while motivation is important, all the motivation in the world counts for nothing if people believe that they simply have no power to change things or to affect their own health. Wellness programs must think about both motivation and ability if they hope to really drive high and sustained levels of engagement.

What does it really take to change habits?

December 1, 2011

Original article prior to editing and publication in Employee Benefit News.

The Power of Purpose

Last time, we looked at the stages of change that we pass through on our path to successfully adopting new health habits. (See EBN October 2011). That’s a nice model and it aids understanding but it doesn’t answer the question of how to actually change a bad habit. Many wellness companies assume that the formula is simple: Educate people so that they know why they should be healthy, show them how to be healthy, provide incentives and then sit back and wait. If you think that model works, too, think again.

Motivation and Ability

A few researchers have led the way in discovering what it really takes to get someone to adopt (and keep) a new habit. They realized that it takes a combination of motivation and ability and that either one on its own is not enough. Looked at another way, before someone will choose a new habit, they have to ask themselves two questions, and answer both as “yes.” Question 1 is, “is it worth it for me to change?” and Question 2 is, “can I change?.” We have found that it is much harder for people to answer, “yes” to this second question.

Think of a person that has unsuccessfully tried to lose weight many times. Or who has lost weight only to put it back on again. When they’re thinking about trying the next new diet, it’s hard to argue that they’re not motivated to lose weight. Otherwise, they wouldn’t keep trying. What they usually lack is the faith that they CAN DO IT. Call it confidence, self-efficacy or belief in self, but it all comes down to how we answer the “can I do it?” question.

To help people change, we need to help them find their way to “yes” for both questions. Unfortunately, when we’re looking for answers to these questions we don’t just sit quietly contemplating the answer. Instead, we look around us for clues, guidance and information to help us answer those questions. We obeserve the people we know (family, friends and co-workers). We also look to the environment because our physical surroundings often contribute more to our motivation and ability to adopt a new habit than we know. Consider how “empowering” it is for a non-smoker to be in a non-smoking airport where they would have to go back through security and outside to satisfy their need for a cigarette!

The team at Vital Smarts has perhaps visiually put this model together best in a table (see below). Changing a habit means getting to yes in each of six “domains” or combinations of the questions we’re asking (motivation or ability) and the context in which they are asked (the personal, the social or the environmental).

The Six Domains of Habit Change

We need a “Yes”  in al six

The Motivation Question

The Ability Question

Should I Do It?

Can I do It?

Context where the questions are asked

Personal

Yes

Yes

Social

Yes

Yes

Environmental

Yes

Yes

Being human means that we are very good at finding excuses NOT to change our habits and this model helps us understand why most of us find it so hard to succeed. If we answer, “no” to even one out of six questions in one of the above domains, we will use that as an excuse to continue with our current bad habits.

It’s for this reason that most engagement programs (the things we do to get people to participate in wellness programs) fail. They usually employ one or two tools that help people get to “yes” in one or two areas, but they fail to cover all six domains and so, with the exception of a few people, most of us let the “nos” drive our inertia and never change beyond an initial attempt.

Getting to Yes in the Personal Motivation Domain: What Matters to you Now

The general way of getting people to answer “yes, it is worth it” in their own headspace (or the personal context) is by making the case to them of what they can get out of changing. For example, we can’t understand why most people don’t quit smoking when they KNOW it’s probably going to lead to an early death. So, we lecture them about the benefits of quitting and a future filled with energy, vitality and the ability to play with and perhaps see their grandchildren getting married. These things are important to us, and so we expect that they will be motivational. This is where the error lies. Motivation is that which is needed in the moment, and even though something may be important to us, it may not be motivational at the instant when we need it to be. Why is this?

The first reason is that we hyperbolically discount future events, which means that we discount benefits in the future using (effective) interest rates that are much higher than it is rational to use. Here’s an example.

For most people, if given a choice of rewards, they’d prefer to have $10 today, rather than $20 one month from now. This makes no sense given that when interest rates are about 0.1% per month or less, we should be happy with anything over about $11 in one month. However, we over-discount delayed gratification so massively that in today’s terms, even important things get very diminished in value.

Losing weight over the next three months may be very important to us, but when we’re faced with a bowl of M&Ms, the immediate satisfaction of eating the whole bowl overwhelms the (massively) discounted value to us of losing weight and the scales tip in favor of immediate gratification.

“Making Meaning” In Your Daily Life

A second reason why people fail to change habits is that we find it hard to admit to ourselves how much of what we do is about looking good to others. We’d like to think we’re motivated by higher goals, but when we watch most people (and when we’re honest with ourselves) we find that a lot of what we choose has to do with being right, looking good, not looking bad or proving others wrong.

A fundamental flaw with the culture of most companies is that the unwritten rules about what “looks good” at work, includes things like working all night, not taking vacations, certainly not taking time out at lunch to go and work out. The iconic road warrior eats on the road, drinks hard, works hard and never takes an exercise or stretch break. In fact, at many companies if you announced before lunch “I’m off the gym because I want to have lots of energy this afternoon so I can get lots of work done” most people would think you’re either crazy, lazy or soon to be fired. We’ve simply not connected the dots for most leaders that they need to reframe the idea of a good employee to include taking responsibility for their own health.

Here’s an example of the power of linking employee participation in a wellness program to the meaning that people find in their work. A school district in Colorado had 11 people complete their Health Risk Assessment in 2009. 11 out of 7,000! To say their wellness program was failing is an understatement. We helped the school district to reframe the invitation to teachers to participate as follows:

“We’d like you to participate in our wellness program because teachers that do are better teachers. They have more stamina, make fewer errors, and can do more with less. They set a great example for their students, and we know that healthy students get up to 30% better grades than unfit students. Looking after your own health habits is not just smart, it’s what we expect from you and it’s part of how we recognize who our best teachers will be in the future.”

Did it work? One year later, over 5,000 employees were participating in a pedometer program, exercising in groups, competing in interschool competitions and losing tons of weight. In fact, results were so good that insurance rates stayed flat for two years so far and the health plan turned around a negative result into a very positive one. That’s the power of purpose, of linking participation in a wellness program to what the organization will gain (not just cost savings) and to what the people that employees serve will gain (in this case students). Find a way to make people connect wellness with what they care about in their career and you’ll be well on your way to helping them answer “yes” to the question of personal motivation.

When and Why Incentives Fail

July 2, 2011

Original text from an article written for EBN.

An increasingly common feature of wellness programs is the existence of incentives, and sometimes even penalties, to encourage people to engage, participate and succeed in their efforts at getting healthy. It stands to reason that incentives will work, since incentives seem to work to improve work performance in general. Employees who are asked what it would take to get them to exercise or eat better, almost inevitably tell us “incentives and rewards”. It’s no surprise therefore that the wellness industry has become convinced of the power of incentives. If you are too, think again.

Why incentives fail

There are four keys reasons why incentives fail.

1. The golden rule of incentives

If you care about getting value for money from your wellness program consider that for most people the size of the incentive required to get a new behavior, is greater than the savings that comes from the new behavior. Some smokers will quit for $50 but most of us, most of the time, only respond when the size of the incentive is much larger.

Now, the savings usually only arise several months or even years after the new habits have been in place, so employers need to consider not only the time value of money but also the likelihood that employees who are “bribed” with health incentives now may be working for someone else when the savings finally show up. If the savings only come from a sustained change in habits, then incentives need to be offered on an ongoing basis, so the total of all incentives over time must be compared with the savings over the same period.

When we do the mathematics required to take into account these points, we find that most incentives fail the golden rule of incentives:

“Only offer incentives when the total value over time of all the incentives required to drive the new behavior is less that the total savings over time that the new behavior generates”.

2. Reward the wrong people (or the wrong behaviors)

The biggest financial problem with incentives is that they are often simply paid to those who are ALREADY practicing good health habits, and they do not stimulate a change in the habits of these who really need to change. Even for those few for whom incentives do drive change, we’ve found that incentive fatigue sets in, meaning that people expect greater and greater incentives each year for the same behavior.

There are no shortage of conference case studies that purport to show massive returns of investment on incentive programs when in reality, all they are showing is that people who are already healthy (with lower claims) show up to claim all the incentives! The incorrect conclusion is one of cause when really all that has been found is the obvious and expected correlation between those who practice healthy habits and so get all the incentives, and their lower claims. We already know that healthy habits reduce claims by improving health. Pretending to ourselves that it was the incentives that drove this behavior is where the danger lies.

What makes these case studies compelling is the salience of the individual testimonies that distract us from a proper review of the data. Hearing about one Jane Doughy who was offered an incentive and proceeded to lose 50 pounds, run a marathon and cure her diabetes is very inspiring. It sounds so logical and even fits with how we think we might behave in a similar circumstance. We incorrectly believe that was has tripped up our own prior attempts to be healthy was a lack of motivation and thus incentives might be just the elixir that we have been missing. Studies of habit change have shown us that in fact what is usually missing is learning the new skills, even basic ones, that make the new habit stick.

For example, when quitting smoking, you’re better served by changing your route home from work to avoid the convenience store where you normally buy cigarettes than by promising yourself a new set of golf clubs if you stay tobacco free for a year.

3. Mental Buckets

When our employer offers us an incentive for a certain behavior we reclassify the activity in our minds. What might once have been something that we did for fun or pleasure now becomes something that we will only do for money. The real problem with this mental reclassification is that when the incentive is removed or reduced, people often revert to even lower levels of the behavior than before an incentive was ever offered. Thus, incentives can sometimes backfire so badly that we would have been better off never trying incentives in the first place! It turns out the incentives can change behaviors in the short term, but they often fail to make these new behaviors stick.

It’s useful to think of the difference between behavior change and habit change as follows: If a force is applied (like a gun to your head or the promise of a large incentive) it is possible to change your behavior. But once the force is removed,  if the new behavior does not stick then you have not created a new habit. A habit, by definition, is something that people do repetitively WITHOUT the stimulation of an ongoing incentive or external force. Wellness is the game of changing habits and we should not be satisfied only with short-term behavior change.

4. “If then” vs “now that” incentives

Incentives that are offered on an “if then” basis are less powerful than those given on a “now that” basis. For example, compare these two approaches:

  1. Saying to employees: “IF you get your cholesterol under 100 THEN we’ll give you $100”
  2. Saying to those employees who do succeed in lowering their cholesterol, “NOW THAT you’ve reduced your risk, we wanted to recognize your hard work with a token of our appreciation in the form of $100”.

The second is much more powerful. Notice that you are almost compelled to compliment the person and express appreciation in the second version, whereas the first sounds like (and is) a common bribe. Try telling your spouse that you think they would look good if they lost a few pounds. A few months later, try telling them instead that you’ve noticed how good they look, and asking if they have lost a few pounds. Let me know if the first approach works better than the second!

The reason why we are committed to “if then” incentives is because they are easy to communicate and administer and because we think we ourselves will respond to such offers. “Now that” incentive programs take effort and imagination, but for that effort the return to employers can be much greater since the effect is longer lasting than with the bribe approach. The reason for this is that as soon as an “if then” deal if concluded by the delivery of the incentive, employers need to “re-up” the ante or the new behavior will cease. The surprise element of “now that” incentives often leaves people glowing with pride and doubly committed to continuing with their new health habits.

The lesson for employers and for each of us, is that a penny of appreciation, from people we like, trust or admire is worth a pound of incentives from an otherwise uncaring employer. The latter often leaves us feeling bribed or conned, especially by an impersonal incentive program that is long on “stuff” but short on appreciation.

 

A.S

How healthy are your employees, really?

May 21, 2011

Have you ever wondered: “Can we really measure the improvement in health that comes from wellness programs?” Most companies are using biometric screenings as their key tool for measuring health, on the assumption that it accurately measures the kind of health that matters most. Think again.

Health failures and risks versus health performance

When it comes to measuring health, there are many options from which an employer can choose. They range from measures of how often health fails (mortality rates, disability, absenteeism and hospital admission rates), to how expensively it fails (insurance premiums and claim severity statistics), to how likely it is to fail in future (health risk factors such as BMI, cholesterol and blood pressure) and finally to how people feel about their own health (HRAs). What all these measures have in common is that they predominantly measure the “negative” side of health: failures and risks, and they are not sensitive to differences on the “positive” side of health.

For example, biometric screening results might be the same for two people, showing no current health risks for either. However, one person could simply be (currently) riding their luck while they continue to eat poorly and not exercise, while the other person could be exercising every day and eating well. Yet, these two people could show up as equivalent in the data derived from a biometric screening.

Having health risks and being sick at work reduce one’s productivity, a phenomenon we name presenteeism. The reality though is that the negative impact on productivity that results from health risks is often smaller than the positive impact that results from practicing healthy habits every day.

If a company is investing in employee health because they are interested in the total productivity gains that come from employees living healthier lifestyles, then measures of health failures are sufficient. It’s like measuring how a new smart phone performs by only looking at how often the battery fails and how likely it is to malfunction in the future, rather than considering what the phone can actually do!

Smoking costs employers anywhere from $1,500 to $5,000 per smoker per year in additional costs and lost productivity. Exercising for half an hour every day increases stamina and productivity by 100% during the last two hours of each day (says NASA). Assuming an average salary of $50,000 per year, this suggests that the positive payoff from daily exercise FOR every employee, every day, would boost productivity ten times more than getting all smokers to quit. This does not mean that trying to get smokers to quit is a bad idea, it just illustrates that the payoff from exercise, measured in terms of increased productivity, is greater.

The types of health measures that most strongly predict productivity are not the ones being used today in most companies.

Claims vs Lifestyle Analytics

Actuaries are taught to look backwards in time for data to help us predict the future. Thus was born predictive modeling and disease management programs that assume we can easily identify next year’s high claimants. However, of the 20% of people who will spend 80% of next year’s claim dollars, three out of five will not have been high claimers in any of the last five years. Predictive modeling based on claims data and biometrics screens is a less accurate science than we would like to believe.

This shouldn’t be that surprising when we remember that 70% or more of our health failures are the result of our health habits and environments. When predicting how healthy and productive someone is likely to be next year, the most useful data might come from credit card records, not claims records. Knowing where people spend their money, and how they spend their time tells a story with greater predictive power than their claims data or current health risks. Hard to believe? Perhaps; but the future of underwriting and cost management appear to lie in the field of lifestyle analytics and not in predictive claims modeling.

What’s an ideal measure of health?

The best measure of overall health (for employers who want an ROI) considers the question of what type of health matters most to drive productivity. For nurses, this might be upper body strength (as this predicts, to a degree, how long they can work at patients’ bedsides). However, for any work that requires your brain (and few jobs don’t) the most important measure of health is a person’s fitness level. This is because fitness drives brain performance, not just musculoskeletal performance. Fitness can be measured using a simple 3-minute step test or in many other ways. Fitness testing is almost never included in a biometric screening but should be, because a change in fitness level drives greater improvements in performance than a reduction in risk factors. The best news is that since many risk factors can be improved by exercise anyway, there is a payoff in this area too.

– A.S

What is a Wellness Dashboard really supposed to look like?

May 18, 2011

Over the last three months, I have taken on the validity of Health Risk Assessments (HRAs) and biometric screening data to powerfully track the performance of a company’s wellness program. This has prompted many readers to ask: “So what do you suggest instead?” If you think that tracking wellness program performance, ROI and cause and effect is impossible, think again.

A Healthy Balanced Scorecard (or dashboard)

If your wellness Vision is something like: “To effectively compete in our market by having the healthiest employees”, and your wellness strategy and programs are the Vehicle that will help you reach this vision, then the Mission you need to be on is to change those things that improve employee health. A (Healthy) Balanced Scorecard borrows the tool from Kaplan and Norton who developed it to help companies track their progress towards their corporate vision. We have found that the same tool, applied specifically to a company’s wellness strategy, produces equally valuable results. In the analogy of your Wellness Vision as the destination and your Wellness Strategy as the Vehicle, the Healthy Scorecard is the Dashboard on that vehicle, telling you how fast you are going, how much fuel is left, and other critical data about how your vehicle is performing. The picture below visualizes the relationship between these elements.


Just like in a car, you want to see the most important information with the least effort, you only want to see what’s important (when it’s important), and you want to make sure that warning lights and important indicators are working properly and really tell the truth about what’s going on with the vehicle. If you’re lucky enough to have a navigation system as part of your dashboard, you want that to be easy to read, to give you directions well in advance (but not too far so that your memory is taxed) and you ideally want it to change your route as traffic arises or when new and better routes become available.

With that analogy in mind, let us answer the question: What should our wellness program’s balanced scorecard, or dashboard, look like. The next picture summarizes my view on how the ideal scorecard should appear to the head of wellness (and to the CEO) of any company serious about getting results.

Let’s discuss each dial or warning light in turn.

Health Status is a measure of how healthy employees are, on average. It might comprise an index of factors, but it should NOT be a summary of health failures like biometric screening results or HRA answers. As I’ve argued before, if you had to choose a single metric to best describe the positive side of health status, it would certainly be fitness levels (as measured by sub-max VO2 scores and there are many ways to do that). Other elements of the Health Status Index might be things like strength, flexibility, the ability to climb ten flights of stairs, or other similar indicators of positive health the kind of health that most powerfully predicts productivity.

Health Habits are the “leading indicators” of future health status. We know that 70% of our health is driven by habits and the environment and we are quite confident of which habits have the biggest impact. We know, for example, that frequency of exercise, quality of diet, hours of sleep and the use or non-use of tobacco and alcohol are the “big four” health habits that explain most of our non-genetic health outcomes. If all four of these can be tracked (and increasingly technology is making this possible), then an index of health habits can be created. Currently, at the very least the most powerful health habitthe quantity of daily exercise can be quite accurately tracked. There is an increasingly strong body of data (with more to come soon) showing that exercise, much more than health risk factors such as obesity, hypertension, or cholesterol, predicts future health outcomes and health care costs.

Satisfaction is a measure of how happily employees are participating in the programs. It’s one thing to force employees, it’s quite another to have them enjoying the opportunity to participate as a benefit offered by their companies. Done right, wellness can have wonderful spin-offs for employers in terms of how it expresses their message of care to employees, not to mention how it can improve overall engagement levels. To measure satisfaction, we like to use the single, powerful statistic that Fred Reichheld calls “The Ultimate Question”:

“How likely is it that you would recommend our wellness program to a friend, work colleague or family member?”

When asked to score their answers on a 1 to 10 scale, 10 being “very likely” and 1 being “not likely at all”, Reichheld says we can calculate the Net Promoter Score (NPS). The NPS is the number of people who answer 9 or above (promoters) less the number of people answering 6 or below (the detractors) and it ignores the 7s and 8s (the passives). In his book by the same name, he makes the case for how the NPS is the only statistic you need to judge, in this case, employee satisfaction with your wellness program.

Why does satisfaction matter? Ultimately, if employees are not satisfied or excited by the program (so much so that they would recommend it to their friends and families), expect that future participation will decline.

Return on Investment (ROI) is a measure of the overall impact of the wellness strategy compared with the costs of implementation. Because of all the complexities of calculating a reliable estimate of ROI, I will address this measure in a future article. For now, suffice to say that without a credible (and sizeable) ROI an employer SHOULD NOT continue to invest in employee wellness. Like everything else that employers do, it should add value, not just be the right thing to do. Fortunately, effective wellness programs can satisfy both goals.

Last but not least, we get to the warning lights, measures that indicate that we are failing to improve the health of employees. Many readers wrote to me saying: “Do you see no value in biometric screening data or HRAs at all?” If there is a place for that data, it is here, in the warning lights section of the dashboard. Absenteeism, health risk factors and health care costs are indicators of our FAILURE to improve or maintain the health of employees. They are good warning signals and deterioration in their levels is a very worrying sign. Similarly, reductions in these measures can be seen as one of the welcome “byproducts” of improving employee health. They should be a nice bonus and not the key measure of health, since the real ROI comes from the productivity that results from improvement in positive health much more than it comes from reductions in these symptoms of our health failures.

If you’re a practitioner that just “can’t let go” of doing HRAs and biometric screens, at least I hope that I’ve given you some perspective on where the data from these tools belongs on a Healthy Dashboard. When relegated to their useful roles as a measure of how we’re failing, and when better measures of success are included (and given priority), such as health habits and positive measures of health, the dark side of these tools, discussed in previous articles, also become a little less worrying.