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Civil Disobedience Comes to Wellness

If HR leaders look closely enough, they should find some valuable lessons in a Penn State professor's call for action.

Wednesday, August 28, 2013
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When I was in seventh grade, my class went on strike -- for a week.

Our action was not the simple ranting of a group of 12-year-olds. Instead, it was a silent protest taken from our energetic teacher's review of history, which included Gandhi's use of passive resistance and Martin Luther King's sit-in movement.

To this day, Mrs. Costello is one of my favorite teachers. She found a way to take 48 boys and girls who sat in six straight lines a la Ludwig Bemelmans' Madeline and transform us into inquisitive, independent-thinking young adults.

Mrs. Costello allowed us to redesign the configuration of our classroom. She let us reorder how we covered our daily curriculum. And she succeeded in inspiring us to voluntarily read books like Herman Hesse's Siddhartha. Pretty heady stuff for a classroom packed with students who'd gone through six years of parochial education.

Our classroom life was good, until the school's principal unilaterally decided to move us back to our six straight lines and all that accompanied that configuration. When Mrs. Costello broke the news to us, we requested a meeting with the principal.

I can still remember the principal's single-sentence response when we asked why she mandated the change: "It's time you learned to do as you are told."

By the next morning -- without the benefit of text-messaging and Facebook -- we planned and executed our strike. We silently sat at our desks and, over the course of five days, learned the power of a unified group with a reasonable cause.

And we actually achieved what we wanted by our civil protest -- a line-by-line discussion with our principal regarding each element of the changes we had made in our classroom.

I hadn't thought about that strike for years until I read a blog post calling for civil disobedience by Matthew Woessner, a Penn State political science and public-policy professor, regarding several elements of the university's new Take Care of Your Health Initiative.

Woessner took issue with three key elements in what PSU describes as a wellness program designed to address rising healthcare costs: (1) completion of an online health-risk assessment, (2) agreement to take a preventive physical exam, and (3) participation in biometric screening. If the employee and his or her spouse -- or same-sex-domestic partner -- refuse to cooperate with the program, Penn State will levy a $100 monthly surcharge.

Paychex's Bob Merberg wrote an excellent investigative summary of the issues associated with the Penn State program and Fran Melmed zeroed in on PSU's communication-plan opportunities. Instead of repeating my version of similar points already made, I want to focus on the merits of this protest.

In the weeks that followed Woessner's blog post, several human resource executives contacted me with essentially a single question: How do I avoid something like this from happening at my company?

My best advice is to understand the merits of the policies you're putting in place, be able to clearly explain the wisdom behind the direction you've chosen and give your employees time to become familiar with changes to your programs.

As for the specifics of Woessner's call for civil resistance, Fran Melmed and I had the opportunity to interview both the Penn State professor and Dee Edington -- the recently retired University of Michigan researcher who is an icon in the employer-based wellness space -- on our CoHealth Checkup radio broadcast.

Three main themes stayed with me related to Woessner's comments on the show: the ethics associated with collecting personal data about employees, the question as to whether a financial penalty is a form of coercion and Woessner's desire to understand how each part of the initiative would help Penn State save healthcare dollars.

Ethics and coercion are tough themes to address and go well beyond the space I have available in this column. However, I will attempt to highlight some thoughts to consider.

Woessner questioned whether it was ethical to ask employees or their spouses and domestic partners to answer many questions that are routinely posed on health-risk assessments. The professor's examples included queries about matters such as depression, alcohol use and whether the respondent was ever charged with a DUI.

From a research perspective, there is often an association found between how someone answers one of these questions and healthcare utilization. And, from a pure health-treatment perspective, many of us are concerned, for example, with the number of people with untreated or poorly treated depression.

That said, my ethical concerns escalated this year when I interviewed a well-known healthcare leader in front of a private conference's audience. He explained that the health-management programs his company sold to employers embraced a three-prong philosophy: Complete a health-risk assessment, talk with a health counselor about results that were out of the norm and then "do what you are told." His statement was eerily reminiscent of my elementary school principal.

Woessner made an intriguing analogy between the requirements of Penn State's internal board that reviews academic studies involving human subjects and the health initiative's monthly $100 penalty for failure to fully comply with the wellness program. Specifically, studies or surveys that involve human subjects must be conducted with the participants' full consent and must be free from coercion -- physical, financial or psychological -- of any kind.

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What further made this analogy interesting was Dee Edington's assertion that participation in HRAs should be voluntary -- this coming from a researcher who has been involved with the distribution and collection of more than 12 million health-risk appraisals.

While employers have been and are allowed to use incentives and penalties with wellness initiatives, the violation of the survey tool's design -- in this case, coercing participation in HRAs with the threat of financial penalty -- is questionable.

Finally, Woessner was clear that he understood healthcare's rising costs and the financial impact to his employer. He was skeptical, however, as to how participation in a preventive physical exam, HRA and biometric screening would drive down healthcare costs. Woessner and his colleagues were open to meeting with university leaders to learn how each initiative would specifically impact healthcare costs.

As someone with expertise in this area, I would be hard-pressed to find cost savings, or even cost maintenance, associated with each of these programs.

Health-risk assessments are essentially population-health-surveillance tools and, as such, do not produce cost savings. As Peter Mills and Howard Gough pointed out in a column I wrote about multinational health and wellness initiatives, HRAs used with employees who live outside the United States can give employers a snapshot of overall employee health. This can be helpful for health-and-productivity-management programs in countries where healthcare is provided by the government. But, HRAs themselves do not save money, nor do they provide better outcomes.

As David Lui summarized in a blog post this year, "Comprehensive annual physical exams have no scientific value." And, in much the same way, broad-based biometric screening largely does not make sense -- and may even do harm. Neither one is attached to large-scale savings in healthcare costs.

I believe what made Woessner and the Penn State story attractive to the media is the combination of an organization recovering from a scandal (i.e., Jerry Sandusky's imprisonment on child-abuse charges and related probes into PSU's handling of the case) and an articulate university professor talking about ethics, privacy and coercion.

The university's unwillingness to discuss the matter privately with Woessner and others represented a much larger issue than the implementation of a wellness program. As Edington pointed out, wellness programs are better for identifying gaps in the workplace culture than for saving healthcare dollars.

And that may be the real lesson here for human resource leaders.

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.

 

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