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Dr. Matt Grawitch: March 2009 Archives

At the Psychologically Healthy Workplace Conference in Washington DC, Dr. Rebecca Kelly presented on health and wellness programs. She made an interesting point about cost shifting. Specifically, punishing behaviors can be a slippery slope. We punish smokers for their behavior, we punish people who eat fast food for their behaviors, and we reward people who exercise 30 minutes or more five days each week for their behaviors.

Here’s an interesting question, though: Should we be punishing (rewarding) behaviors or punishing (rewarding) outcomes? Though this perspective may be controversial, it seems that focusing on behaviors is missing the boat. Recent studies indicate that people who are overweight are not necessarily more costly than people who are not overweight. Other studies also suggest that former smokers may cost more than current smokers. And exercise is not all the same. Low impact exercise is less “beneficial” than high-impact exercise, and sometimes high-impact exercise can be dangerous (e.g., high contact sports prone to physical injuries, runners prone to knee problems).

Somewhere along the way, somebody decided what behaviors we would punish and what behaviors we would reward. When was the last time your company’s wellness program asked you about other risky behaviors, like failing to wear your seat belt, skydiving, or riding a 4-wheeler or motorcycle? When was the last time your wellness program offered rewards for people who actually got the proper amount of sleep (or punished voluntary sleep deprivation)? These are all behaviors that have been shown to be predictive of health outcomes, but they are not a part of the equation in most insurance programs (some are considered in life insurance plans, however).

While we can reward or punish behaviors, this seems to miss the point. The goal is to reward or punish outcomes, because outcomes are what drive illness. Eating fast food by itself is not a problem. However, it becomes a problem when it leads to high cholesterol. Smoking is associated with high blood pressure and increased pulmonary problems. But, if a smoker shows no signs of these problems, should they be penalized? Finally, exercise means nothing if it does not help to lower body weight and blood pressure.

Altering food habits, sleep habits, drinking habits, and tobacco use would seem to be effective strategies for bringing people’s biometric results (weight, blood pressure, cholesterol, glucose levels) more in line with “healthy” outcomes. But, they are not health outcomes themselves; they are simply possible strategies (out of many) for achieving those outcomes. We often forget that the behaviors themselves do not produce negative health outcomes. In addition, research has not fully explored the interaction between nor the relative impact among several behaviors (i.e., does exercise negate poor eating habits, is smoking worse than poor eating habits and no exercise?). The behaviors can (but not always) produce changes in biometric outcomes, which is where the real concern lies. Does that mean we should ignore unhealthy behaviors, like smoking, drinking, seat belt use, or other behaviors? No, of course not! We should encourage people to be healthy in all aspects of their lives and promote a comprehensive lifestyle that encourages wellness. However, we should also be aware that focusing on a selective group of “behaviors” misses the larger goal of actually impacting health outcomes.

In organizations, we primarily reward performance outcomes, we don’t reward behaviors that may or may not lead to outcomes. In health and wellness, we might be advised to do the same thing!