Factors to Consider When Offering Preventive Health Screenings

HR executives face myriad challenges when research questions the validity of employers' preventive screening practices. Bob Merberg from Paychex Inc. explores this topic in a back-and-forth exchange with the author.

A few years ago, an HR leader consulted with me about a change in her company's short-term disability experience. There was an unusual up-tick in absence claims related to early-stage cancer diagnoses -- specifically, breast and prostate cancers. When we reviewed the life-insurance-claim experience, however, there was no change in the employee-death rate.

We hypothesized that the company's approach to employee preventive screenings over the last several years, which included on site mammographies and Prostate-Specific Antigen tests -- along with testing reminders -- may have driven what looked like a cancer epidemic.

The company made the decision to alter its preventive screening approach to reflect evidence-based recommendations. Within a couple of years, the incidence of new cancer diagnoses returned to expected levels and the death rate continued unchanged.

I was reminded of this experience last month as I followed the controversy surrounding the release of a New England Journal of Medicine-published observational study questioning the impact of screening mammographies on advanced breast cancer incidence and associated death rates. The debate about the conclusions was so intense, one of the authors uploaded a YouTube video to explain the study to lay audiences.

The video was terrific but, for me, David Newman best summarized the issues in a New York Times post he wrote titled, Ignoring the Science of Mammograms. One sentence in particular stood out: "For years now, doctors like myself have known that screening mammography doesn't save lives, or else saves so few that the harms far outweigh the benefits."

I found myself reflecting on how employers might respond to these research results. So, I turned to Bob Merberg, the employee health and wellness manager at Rochester, N.Y.-based Paychex, Inc., who is both a colleague and a friend. I consider Bob to be one of the top people in the field of employer-based health and wellness. He has written several excellent blog posts over the last several years on the pros and cons of screenings.

Much as I did with Harvard's Ron Kessler earlier this year, I invited Bob to participate in an exchange with me on this topic.

CH :      When research results on topics like screening mamographies are released, how do you consider them?

BM:      None of the questions in employee wellness are easy. One of the things that makes it very difficult is there are no clear answers or directions.

No one at Paychex is a clinician. We don't give clinical advice and we don't take a stand on issues like mammograms or PSA testing. We let the employees' physicians decide with their patients how to address preventive screenings.

That said, when I review how we're going to offer onsite preventive screenings, I turn to expert organizations for guidance, including the U.S. Preventive Services Task Force.

CH:       The USPSTF is an excellent resource because, to quote their mission, they "rigorously evaluate clinical research in order to assess the merits of preventive measures."

So, given what you know, which preventive screenings do you offer onsite?

BM:      We have [more than] 100 locations where we used to provide a full blood panel, including kidney and liver function along with TSH and iron levels. Employees loved it but physicians with whom we spoke did not support this broad approach.

So we changed our practices and now give employees the option to have a finger stick lipid panel with triglycerides and glucose as well as blood pressure screenings, weight and height measurements and their calculated body mass indices.

CH:       Employers increasingly are turning to outcome-based wellness as a way to manage health costs and ensure peak employee productivity. They are using screening programs as a success measurement for the lifestyle programs they put in place. How do you view this approach?

BM:      I've been pro-prevention for a long time -- as long as it's evidence-based.

At Paychex, we offer a program that used to tie participation in screenings, as well as other activities, to the employees' medical coverage levels. Over the years we reduced the frequency of the screening requirement based upon the USPSTF recommendations. Now, there is no more incentive offered for employees who participate in screenings.

We continue to offer screenings, but don't push it. They remain a popular activity for our employees and give us an opportunity to communicate their role in relation to other wellness activities, such as exercise and eating well.

CH:       In many ways, you're headed in the opposite direction of most employers.

BM:      I find the public health community has embraced the appropriate use of preventive care, but many employers are lagging.

Employers with self-funded medical plans are pushing appropriate health care utilization, including how and when to access an emergency room and take antibiotics, but at the same time they're increasingly promoting screenings on an annual or more frequent basis. That is excessive and, again, is not evidence-based.

CH:       Aren't you afraid of leaving money on the table. Employers, wellness vendors and industry organizations are publishing and presenting case studies that tout the return-on-investment associated with screenings and lifestyle programs.

BM:      Employers pursuing wellness return-on-investment often assume that screenings offer their best chance of ROI. While evidence-based screening may provide excellent health care value, evidence is scarce regarding the ROI of employers' annual screenings. 

CH:       Wendy Lynch relates exactly the same experience.

I think we're turning prevention into an annual event instead of a daily action. Most Americans prefer singular activities such swallowing pills or supplements, or participating in screenings to getting up early to exercise or make a good breakfast.

BM:      It's as though health and wellness is something done to you as opposed to something you do.

Our emphasis should be on lifestyle behaviors such as exercise levels, eating healthy, psychological wellness and eliminating tobacco use. I would also include appropriate care-seeking and preventive care as essential behaviors worth promoting.

Instead, it feels as though we're becoming more focused on medical surveillance than wellness.

CH:       Over the past several years, I've heard both employers and wellness vendors relate singular stories about employees whose lives were saved by preventive screenings.

BM:      Many employers rationalize that "if it saves one life, or prevents one heart attack" it is worth it. All screenings have risks and people don't get that.

One should carefully study the risks of screening and know the true odds of a screening saving one life or preventing one heart attack before making such a sweeping statement.

It's not so simple. Preventive lung X-rays for kids and PSA tests are good examples of screenings that were once believed to be "worth it" on these grounds, but that faith in the test appears to have put many people at risk.

CH:       So, what's an HR leader to do when considering their preventive screening program?

BM:      The best and most important approach is to be an alert consumer. Turn to the guidance of leaders in the field such as the U.S. Preventive Services Task Force and then monitor the results.

Note: Bob Merberg will be speaking at the Human Resource Executive ® Health & Benefits Leadership Conference in an April 22 session, titled "The Long Road to Employee Wellness at Paychex: Toll Roads, Potholes, Short Cuts and Scenic Detours." For more information on his session and the entire conference agenda, visit www.benefitsconf.com.

Carol Harnett is a widely respected consultant, speaker, writer and trendspotter in the fields of employee benefits, health and productivity management, health and performance innovation, and value-based health. Follow her on Twitter via @carolharnett and on her video blog, The Work.Love.Play.Daily.


Dec 17, 2012
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