MS. DIANE REHMThanks for joining us. I'm Diane Rehm. Wellness in the workplace initiatives are hugely popular with nearly three-fourths of employees covered by some kind of program. To look at how effective these programs are in keeping people healthy and in keeping down costs here with me: JoAnn Volk of Georgetown University, Susan Dentzer of the Robert Wood Johnson Foundation, Ron Goetzel of Truven Health Analytics and Maria Ghazal of the Business Roundtable.

MS. DIANE REHMAnd I do welcome your participation. Let's hear about what's going on in your workplace. Join us by phone at 800-433-8850, send us an email to drshow@wamu.org, follow us on Facebook, or send us a tweet. Welcome to all of you.

MS. SUSAN DENTZERThank you.

MS. MARIA GHAZALNice to be here, Diane.

PROF. RON GOETZELThank you.

REHMGood to see you. Susan, give us some background on these workplace wellness sites. When did we begin doing this, and how effective are they?

DENTZERWell, a lot of these programs have been around for a couple of decades. I think they really picked up steam in the '90s and the 2000s. As your intro said, the estimates that about three-quarters of the workforce now are covered by some type of a wellness program, and about half of U.S. companies overall are offering them. But when we say wellness program, though, that's a wide array of things.

DENTZERIt can be something as simple as offering smoking cessation in the workplace. It can be offering testing for cholesterol levels, all the way to gym memberships or what we're increasingly seeing are financial incentives put in place to encourage individuals to change their behaviors. So in essence, discounts off of premiums or other aspects of health coverage in order to help induce people to modify their health risks and change their behavior.

REHMSusan Dentzer of the Robert Wood Johnson Foundation and she is the on-air analyst for health issues for the "PBS NewsHour." Turning to you, JoAnn Volk, I gather some of these programs are voluntary and some use incentives. Talk about that.

PROF. JOANN VOLKRight. As Susan said, there really is a broad wellness programs, and it may just be to encourage you to walk during lunch hour. But there's a particular subset that I think can be problematic which is where employers tie premiums or out-of-pocket costs for your health care to meeting specific health targets, like the right BMI or cholesterol level. And that's where concerns come in about, you know, sicker patients paying more and potential discriminatory effects.

REHMAnd JoAnn Volk is research professor at Georgetown University Health Policy Institute. Ron Goetzel, you say many employers have these kinds of programs, but very few have really, really good comprehensive ones. Talk about what you mean.

GOETZELThat's right, Diane. The latest study that was conducted by the Office of Disease Prevention and Health Promotion found that only about 7 percent of employers of the United States have comprehensive well-designed evidence-based health promotion programs. So although many of employers may be saying I have a wellness program, now Susan said that may just consists of an online health assessment or preventive screenings or something that is very superficial really in terms of achieving true health outcomes and potentially cost savings.

GOETZELSo to have an effective program, you need to build in all of the elements that build success into that program, including providing an organizational structure and environment policies and support for workers to improve their health.

REHMRon Goetzel is director of the Emory University Institute for Health and Productivity Studies. Turning to you, Maria Ghazal, what about the cost in both savings and losses as far as business is concerned.

GHAZALDiane, business leaders really understand the importance of having a qualified productive and engaged workforce. They also know the problem. Almost 40 percent of all deaths in the U.S. are premature each year, and they're largely due to unhealthy lifestyle choices. So as the largest source of health coverage for nonelderly Americans, we feel that employers are in a great position to help tens of millions of Americans.

GHAZALAt the Business Roundtable alone, we employ almost 16 million employees. We provide health coverage to close to 40 million. And employers really want to help change the trajectory of employees' health.

REHMDo these programs really save employers money?

GHAZALOur members are looking at how they're affecting employees. We want our employees to know their numbers, to know what their health risks are and then to help them be productive on the job to avoid loss wages. We're looking at it more from the standpoint of helping the employees. Would it be -- is it good if it helps reduce health care costs? Of course. It's good for the employee. It's good for the employer. It's good for the nation. But at this point, we're still, I believe, looking at trying to help employees.

REHMThat sounds good, Maria, that it sounds to me as though the Business Roundtable would be more interested in making sure that the employers are the ones who are saving the money.

GHAZALWe're looking at it from the standpoint -- we certainly want health care costs to be lower, not higher...

REHMSure, sure.

GHAZAL...absolutely. But we're looking at results as well. I mean we have one large employer with nearly 1,000 -- 100,000 employees and whose results have shown on average of a three-year period that employees have lower their blood pressure by seven points, reduced cholesterol by 11 points and improved their cholesterol ratio by nine points. These are things that -- these are the winning numbers as far as employers are concerned.

REHMBut, Ron Goetzel, as you said, I would think it depends on just how effective these programs are.

GOETZELThat's right. You can't just throw the entire idea of workplace wellness, of workplace health promotion into one bucket and ask the question are they effective or not effective. There are some programs that are very, very effective. In fact, we document the effectiveness of those programs on a website called the healthproject.com, which is the annual C. Everett Koop Award to those organizations, businesses, as well as smaller organizations that have documentary evidence that these programs improve health and save money.

GOETZELBut it's not true that all programs uniformly regardless of how they're designed and how they're administered will save money and improve health. Some do. Some don't.

REHMDo you know who's at the top of that list?

GOETZELCertainly, there are some outstanding programs...

REHMSuch as?

GOETZEL...that have been around for many, many years. Johnson & Johnson stands out as a program that's been around for over 30 years. They began their program in the 1970s with the aim of improving the health and wellbeing of their workers, and they spent a lot of money developing their program but also a lot of money evaluating the program, looking at its effects on smoking rates, on exercise, on absenteeism and health care costs and moral and published those studies in the 1980s in peer review journals.

GOETZELThere are studies published in the 1990s, revisiting the program, and then we recently revisited the Johnson & Johnson program and looked at its effects in the 21st century and found that indeed it's still improving health and still saving money.

REHMSusan Dentzer, what about chronic health problems like overweight, like diabetes, like high blood pressure, things like that?

DENTZERWell, as Maria said, the big picture here is that we have overall a very unhealthy population. A very important study was published in January of this year by the Institute of Medicine, "U.S. Health: An International Perspective." And it showed that relative to 28 other rich countries, we're almost at the bottom. We lose before the age of 50 twice as much lifespan due to premature mortality, death before age 50 than compared to the average of all the other rich countries combined.

DENTZERSo we have a problem here, and the assumption, I think, is fair that because people spend so much of their days at work, 155 million in the workplace, where are you going to get the kind of influence that will help, first of all, show you what your numbers are, as Maria said, encourage you to know what your cholesterol is, your weight, all of the factors that contribute to the conditions that you mentioned, diabetes in particular.

DENTZERSo knowing your numbers and then knowing what you can do to take steps to address those is very important. And if you get that encouragement through a wellness program, you can reduce -- we -- as Ron said, we see evidence that your risk factors can be reduced. And we know if you reduce those risk factors, you will reduce the incidence of disease.

REHMMaria.

GHAZALSo one way to think about these programs is that right now for most benefits, the employer has to treat all the employees the same. In this -- in the case of the wellness program, we're permitted to give extra services to those people who need them the most, and that's really how we are looking at it. And that's why we advocated for this.

GHAZALWe haven't gotten to the law yet, but in the Health Care Reform Act, in the Affordable Care Act, there is a provision -- it had bipartisan support in both committees. We had the support of people like Sen. Carper, Sen. Enzi, Sen. Ensign, Sen. Wyden. All of those senators came together and supported that we could have the ability to do this under the law.

REHMAnd what will that mean going forward? Will more businesses, will more employers get involved in these wellness programs?

GHAZALWell, we've already have -- we have many. I mean different statistics show 80 percent, 92 percent I think what it will mean is we'll see more innovations, and we'll see more attention being paid to this. The whole health care system is becoming in many ways more personalized. People, you know, are -- you know, many employees are being moved to consumer-directed plans.

GHAZALThere's more cost in quality information coming out either through the government or through private sector initiatives. People are being given more responsibility. Employers know that people will have, you know, different employers throughout their lifetime. So this is part of that whole movement.

REHMMaria Ghazal, she's vice president for the Business Roundtable. Short break here. And when we come back, we'll talk to Dr. Paul Terpeluk of the Cleveland Clinic about the program at that institution.

REHMAnd joining us now as we talk about wellness programs in the workplace: Dr. Paul Terpeluk. He is medical director for employee health services at the Cleveland Clinic. Good morning to you, sir.

DR. PAUL TERPELUKGood morning, Diane.

REHMTalk about the history of the program at the Cleveland Clinic. How did it start, and why did it begin?

TERPELUKYes. Well, we've actually started wellness, I'd say, about five or six years ago through the efforts of our CEO, Dr. Toby Cosgrove, and we've been building a cultural wellness now for over that period of time. And one of the things that we recognize is that wellness, by itself, probably isn't as effective as integrating wellness with levers that can help people actually change their behaviors. So what we've done is we've actually incorporated our wellness programs as part of incentives to move people to do the right thing.

REHMYou're talking about financial incentives?

TERPELUKAbsolutely. So we built this cultural wellness. It reduces the barriers to participate in our programs by making things free, like going to our fitness center, joining weight watchers or curves, changing the menu with the hospital, reducing trans fats, encouraging no sodas. And including with that, we actually tie them into our premium for our health plan. We have 42,000 employees, and we basically encourage people to do these things. If they do the right thing, we actually give them a lower premium.

REHMI see. What diseases, would you say, are of greatest concern to the clinic?

TERPELUKWell, we found that there was about five or six chronic illnesses that represent about 40 percent of our total cost of which about a third to a half of our employees actually have. That includes high blood pressure, high cholesterol, diabetes, smoking and asthma. So we focused on those as opportunities to get people to incentivize the people to actually go to their doctors and allow the doctor to work with us with a health plan to create a plan for them to meet certain metrics that actually are good outcomes.

TERPELUKAnd over the period of doing that, we've been able to get about 53 percent of our people in these programs. And we've been able to actually have quality measures like diabetics who don't go to the emergency room and actually take their medication and see a doctor for their eyes and have their blood sugars checked. They are much better than people who don't -- or who are not in these programs. And at the end of the day, what we've seen is we've been able to reduce our health care spend, actually flatten it to about one to 2 percent.

REHMInteresting. Do I understand correctly that the Cleveland Clinic does not hire people who are smokers?

TERPELUKThat is correct. In 2007, we made a decision that we would exclude smokers from our workforce by essentially testing them when they came on board. And if they were smokers, we would give them the opportunity to quit smoking over a 90-day period. If they choose not to do that, then we would rescind their offer.

REHMAnd how did employees react, or potential employees react?

TERPELUKActually, over the four or five-year period we've been doing this, we've only had about 300 people who actually failed the test…

REHMI see.

TERPELUK...out of almost 30,000 people that applied.

REHMAnd do I also understand that originally there was a McDonald's on site?

TERPELUKOh, there still is a McDonald's on site.

REHMAnd so your employees can still partake of those kinds of foods?

TERPELUKOh, yes. Oh, yes. Yes, they can. We encourage them not to. In our general cafeteria, we've actually made some substantial changes that encourage people to eat properly. But, yes, we do we have a McDonald's on site.

REHMOK. So if an employee wants to exercise for an hour, does the employee have to choose between lunch and exercise?

TERPELUKThat would be correct.

REHMSo it's one or the other. You can't take an hour to exercise and an hour to have lunch.

TERPELUKYes. So we basically will make the fitness center available free. You can go to the fitness center. It's open usually about 12 to 18 hours a day. We would not pay for you to go to the fitness center while you're actually working. Now, if you choose to go there on your lunch hour, that's certainly what most people do.

REHMGreat. And finally, how high is your employee participation?

TERPELUKHow high is the employee participation?

REHMYeah.

TERPELUKWell, prior to instituting these programs, we had about a 10 to 15 percent participation rate, which is about average for the country for disease management and focused programs that encourage people to take care of themselves. After instituting these programs, we've been able to climb up to about 53 to 55 percent of our population are in these programs, which is remarkable. That's essentially 18 to 20,000 people.

REHMAnd I did mean to ask, are there any penalties for not participating?

TERPELUKNo, no. The way we approach this was a carrot rather than a stick. We think the stick doesn't work instituting wellness programs tied to incentives. So the first thing we did is make things basically free. And then what we did is we gave people a base premium, and if they actually participated and met their goals, that premium would be reduced.

REHMI see. And Susan Dentzer of the Robert Wood Johnson Foundation has a question for you.

TERPELUKSure.

DENTZERHow -- it's very clear that you did attempt to fashion this as a carrot, but to the degree that you may have employees who are not meeting the criteria, they're obviously having to pay more, they probably perceive it as a stick. How do you deal with that set of perceptions among employees, and do the less healthy employees feel discriminated against in any way?

TERPELUKNo, because we require this for both healthy and non-healthy employees. So if you're actually healthy and you don't have one of the chronic illnesses that we've identified, you also can participate in the program by doing one of our fitness programs that is required. And it's actually -- you have to go through a process where you have to turn in your steps and be involved in order to get your premium discount.

TERPELUKAs far as discrimination or the feelings of being picked on, if you have of these chronic illnesses, actually, the opposite has been true here. We actually measured engagement in our institution, but we have studies -- we have engagement scores of both before and after. And what we have found is actually these programs enhance engagement at the institution.

TERPELUKSo people actually believe, and I actually sincerely believe this too, that when you offer programs that address their issues, and most people know they have these issues, whether it's obesity, whether it's diabetes, when you offer programs that are easy to get to that you care about them and you build a culture of wellness around, and they actually believe because it's true that you're caring for them in a way that perhaps other employers aren't.

REHMNow, I want to jump in here because you've said that if a potential employee is a smoker, you give that person a certain amount of time to make a decision as to whether to quit or not. What about an individual potential employee who is significantly obese? Are there any sort of rules or regulations required to have them decide that they're going to reduce their weight or not?

TERPELUKThe direct answer to that is no. We don't treat obesity and overweight as like we do with smoking by screening people being hired here. We actually have our -- when someone is overweight that we hire, we encourage -- this is why we have these programs is we basically encourage them to join our disease management programs, to see their doctor, to help them lose the weight because we can actually reduce their disease burden for themselves and for us. So the answer is no. We don't treat obesity like smoking on a new hire basis. We don't discriminate against them.

REHMAll right. But suppose they are hired and do not choose to enter any of the wellness programs, then what happens?

TERPELUKWell, what would happen is when they get hired, their basic premium rate is what we call our bronze level, and they would not be able to be rewarded with the reduced rates if they didn't join the program. That's essentially the only thing would happen. These are all voluntary programs.

REHMDr. Paul Terpeluk, he is medical director for employee health services at the Cleveland Clinic. Thank you for your time.

TERPELUKThank you.

REHMAnd turning to you now, JoAnn Volk, tell me about the program at Georgetown University and how that works.

VOLKI'm sorry, the...

REHMThe program at Georgetown University, the wellness program?

VOLKThe workplace wellness program? Well, we don't have one that's linked to the premiums. They do what I think a lot of employers do, which is that we get a -- an email newsletter telling us some options for, you know, walk at lunch or on-site gym services. But we've done research on the potential effects of these, the Affordable Care Act provisions that Maria talked about, allowing employers to increase the premiums and cost-sharing for workers who don't meet the right targets.

VOLKAnd I think we heard in Paul's example, you know, carrot or stick. The effect is that people with unhealthy conditions are going to pay more. And so I think the concern is, across the board, are we reducing costs for employers, or are we shifting costs to unhealthy workers? And there was a study in Health Affairs recently that suggested that that's exactly what's going on is that unhealthy workers are paying more, and there is potential discriminatory effect because some of these diseases targeted -- obesity, diabetes -- may have a higher incidence among women and racial and ethnic minorities.

REHMSo what you're saying is that it would be employer cost shifting onto the employee.

VOLKPotentially. And I do want to say, you know, I think there's broad recognition, as folks here have said, that it is -- it makes sense. It's a laudable goal to use the workplace, where, you know, 150 million people who have health -- employer health coverage spend the bulk of their waking hours, to use that as a way to make as accessible as possible the resources people need to modify their behaviors and get healthier.

VOLKAnd many -- very few of the programs in existence now actually do tie the financial incentives to health plan costs, although that could grow with the Affordable Care Act. But as Maria said, one of the interests here is allowing employers to innovate and see how they can do programs that would achieve different results. And I think the concern is that innovation is good, but we need to learn from that innovation.

VOLKAnd we really don't know. We don't have a lot of evidence of how these programs work, in particular the ones that tie financial incentives to your health plan costs. And so, in fact, the RAND study that was done as part of the Affordable Care Act called for a study of employer programs 'cause there is not a lot of independent research about the effects of premium incentives.

VOLKThe RAND study said that even though employers overwhelmingly expressed confidence that their programs were working to reduce costs and absenteeism, in fact only about half the employers were doing an evaluation, and only 2 percent were doing a formal evaluation. So it seems if we're going to allow this innovation, we should learn from that experience and really identify the interventions that actually work and what it means to increase costs for people who have particular health conditions.

REHMRon.

GOETZELYeah. Let me just respond to some of the points that JoAnn made. One is that the issues that she brings up -- which is, is it ethical, is it legal, is it practical to have these programs in place -- was something that was on the minds of the lawmakers, and they wanted to make sure that it was balanced, that it was fair. And when they put these programs in place -- first of all, very few employers had incentive programs for health outcomes.

GOETZELMost of the programs were based on participation, meaning, you know, you get a -- an incentive, a gift card or credit on your insurance if you participate in the program, not if you achieve certain outcomes. Now, certainly we are seeing a greater movement towards outcomes-based incentives, but what the legislation did was provide several rules associated with that.

GOETZELFor example, the reward needs to be available to everybody in the workplace, that everybody needs to be able to qualify, that the program itself should be reasonably designed to improve health and well-being so that you wouldn't just have an aromatherapy program, but, most importantly, there was a reasonable alternative standard that would be available to people if they couldn't meet the requirements.

REHMAnd you're listening to "The Diane Rehm Show." JoAnn, you had also raised concerns about projections and protections for employees who cannot meet health targets. What happens?

VOLKWell, so the rule that Ron is talking about, I mean, another piece of this that -- the protections -- there are protections, but I think that they could go further. So, for example, programs -- one of the protections is -- and if you're going to put significant cost-sharing on the line here as an incentive, under the law, up to 30 percent of the premiums for health targets, or up to 50 percent if what you're trying to target is tobacco use, 50 percent of a premium -- that's $15,000, on average, for a family -- is a lot of money.

VOLKOne of the requirements is the program has to be reasonably designed to promote health. But that's it. I mean, I explicitly rejected the notion that it has to be evidence-based and did allow for innovation. And that can be an important thing. We can learn from this experience, but only if we collect the data and understand who's being targeted, what kind of incentives are being put on the line for outcomes here, what are the effects of those incentives, who does not meet the target, who does and what are the implications for people who have higher health care costs?

VOLKSo it might tell us, for example, is this being discriminatory? Are we finding that, for example, the effect of these programs that target diabetes or high blood pressure or high glucose levels -- sorry, cholesterol levels, are they disproportionally affecting older workers, women, certain minorities? That would -- we would know that from better data collection, as the Health Affairs article pointed to. We would also know what specific interventions actually work.

REHMYeah. And, Susan Dentzer, I gather there are some programs that are activity only, and there are others that are outcome-based programs. So talk about the difference.

DENTZERWell, I think Ron made the point that sometimes you just get a benefit for showing up, you know, a gift card or something like that. Others very much are key to you reducing, say, your level of cholesterol or showing some actual outcome. Those are known as health-contingent programs. And I think back to this general concern, one of the things that the Affordable Care Act did, of course, is for people in the individual insurance market, it got away from pre-existing condition restrictions held against you. We moved away from the notion that you could be disenfranchised in any way because...

REHMRight.

DENTZER...you had a pre-existing condition.

REHMRight.

DENTZERThere is a concern that we're sort of inadvertently, through the back door, maybe creating a situation where, for people in the employer coverage community, creating this kind of differential treatment so that if you already have pre-existing health conditions, somehow you're going to be disadvantaged 'cause you might have to pay higher premiums. So there are lots of protections, as people have said, that are built into the law now through regulation, bans on discriminatory practices.

DENTZERAny kind of a program that looks like it's a subterfuge to get around anti-discrimination provisions is clearly going to be illegal under the regulation. But we're going to have to see how this plays out over time, and I think it's just a message to the employer community that it's got to be very careful as it designs these programs going forward to make sure that they really are compliant with the law.

REHMSusan Dentzer, senior policy adviser at the Robert Wood Johnson Foundation, also on-air analyst on health issues for the PBS NewsHour. Short break now, and when we come back, it's time for your calls. I look forward to speaking with you.

REHMAnd it's time to open the phones first to Cambridge, Mass. Hi there, Steve. You're on the air.

STEVEDiane, increasingly, companies like the Cleveland Clinic are refusing to hire smokers, as you pointed out, and even dismissing long-time employees who do not give up the habit. Now, smokers are disproportionately low income and are also often associated with people with mental issues. My questions are, one, does such a policy have a bad effect on the health of the smoker? Two, does it have a bad effect on, perhaps, the children who the smoker is trying to provide for? And, three, does it raise issues about worker self-autonomy?

GOETZELYou know, that's an important point that you're making. But let me kind of ask you the question and refocus it. When cigarette taxes have been increased, for example, in New York City, I think it cost somewhere around $15 or something to buy a pack of cigarettes.

REHMA pack. Wow.

GOETZELIt's a huge, huge amount of money.

REHMYeah.

GOETZELAnd there are some states where it's very expensive. Other states, of course, it's very, very cheap.

REHMRight.

GOETZELThe greatest effect of taxation on smoking rates is those states which have very high taxes and it does disproportionately reduce the number of smokers among poor people because they can least afford to pay the higher amount. So it actually has a beneficial effect from a societal standpoint and from a personal standpoint on people when you increase the barrier -- the cost barrier to buying cigarettes. So it actually works in a way that helps people from a societal perspective as opposed to hurting them.

REHMMy question was, how long has it been legal not to hire employees who smoke?

GOETZELAs far as I know, I'm not a lawyer or an expert in this area, but as far as I know, all the challenges against that provision of employer's rights to hire or not hire people based upon smoking status has been upheld in the courts. So that's been a legal precedent for many years. Now, there are some states that do not allow that, and they have laws and rules forbidding employers against discriminating against smokers. But in many, many states, that is legal.

REHMAll right. And, Susan, did you want to add something?

DENTZERI just want to say, I think it's important to underscore here that the science also is evolving about addictions. And we now know that addictions have a very similar pattern in the brain, whether it's addiction to tobacco or addiction to food. So as we learn more and more about this, I think, our -- even our understanding of how to shape behavior change through wellness programs will evolve, and it should evolve because sometimes people are not entirely as in control of these behaviors as we would like to think.

REHMAll right. Here's an email saying, "Please discuss the fact that most workplace wellness programs are not covered by the HIPAA privacy rule or any other privacy regulations, so the employer is not limited in how they may use or disclose the health information of their employees collected in wellness programs." JoAnn.

VOLKWell, I'm not a privacy expert, and my fellow panelists here can correct me if I'm wrong. But the HIPAA privacy rules apply to health plans and anyone they use -- a vendor that they might use, for example, to do the piece around them to health benefits. So the HIPAA privacy rules would apply. They do not apply to employers who do this directly, unless they use a vendor -- well, if the vendor is acting on their behalf. So -- but, I mean, I want to -- so you can set the record straight on the...

REHMRon, what's your...

VOLK...sort of the legal implications. But also I want to point out that, you know, how this actually looks in practice though, I think, can also be a concern still for employees, even if there are firewalls established between who's collecting the health data and who's making employment decisions about who's hired and all the way, just for an example, where that firewall apparently doesn't exist.

VOLKNo, in terms of the Cleveland Clinic that, you know, because you're a smoker, you're not hired. But, anyway, even where the firewalls exist, I think there's still some concerns among workers that if they're signing up for these programs, are they treated differently in the workplace? But do you want to talk about why employers are doing this directly?

GOETZELYeah. I mean, certainly, HIPAA rules apply, meaning that patient information -- and this is considered patient information -- is held private. It cannot be shared with your employer, with your supervisor. It cannot be used for any hiring, firing or any other decisions that are workplace related. That is the law. Now, the way the data are collected and stored, typically, it's by third parties or medical entities. But again, there's a pretty high firewall protecting the individual worker against the employer finding out their health habits.

DENTZERThere's another law that applies here, too, which is the Genetic Information Nondiscrimination Act, which essentially would forbid an employer from asking you about your family health history because that would be genetic information.

REHMAll right.

DENTZERSo it's not just the HIPAA statute that governs this.

REHMLet's go to Ann Arbor, Mich. Hi there, Gregory.

GREGORYHello? Can you hear me?

REHMYes. Go right ahead, sir.

GREGORYOK. Well, I've worked in corporate America for about 30 years inside the utility industry, and I've seen most of the programs described by your panels today. And recently at Detroit Edison, they implemented the option for the employees themselves to purchase these electronic devices which they can wear, which are sophisticated pedometers which measure not only your steps that you walk in a day but the number of flights that you climb in steps and whether or not you're having heavy walking activity or heavy exercise activity.

GREGORYAnyways, my point is that out of all the program incentives of the health care programs, we have health coaches, and we've had gym membership...

REHMSure. Sure.

GREGORY...and just all those things, matching these electronic devices with social media where we can all compare ourselves within the office within work groups, this has by far been, in my opinion, the most effective way to improve health. People have lost weight rapidly.

REHMWhat do you think of that, Maria?

GHAZALI think it's terrific, and it goes back to the point that -- of flexibility and allowing employers to innovate. We have an example like the caller just gave us. We also have, you know, at some of our companies where you have devices that they're trying out for -- to track your diabetes, to track your numbers.

GHAZALAnd, you know, each company just like in providing health care benefits, which, you know, has been voluntary up until next year, has been something that we are telling them to our workforce, telling them to make sure that they are well-received, that they are doing the best they can do for employees.

REHMJoAnn.

VOLKWell, I think the caller also points out that engagement is more than just putting a bunch of money on the line. And I know, Ron, you've done a lot work on the comprehensive programs and what that means to engage workers, and maybe it is a sort of inter-office competition about who walks the most flights of stairs in a day or other strategies.

VOLKBut I think it's important to remember here that, actually, the premium incentive piece of this makes health care more expensive, either to buy the plan or to get health care once you're enrolled is a subset here that's currently very small but particularly problematic and just another caution that there are many ways to engage employees here with effective results.

REHMHere are two very, very different reactions, the first from Jason in Ypsilanti, Mich. He says, "My employer instituted healthy choices incentives this past year. I screamed bloody murder in the HR meeting when I found that I was going to have to quit smoking or pay 250 percent of my card health insurance premiums. But I did it, going on seven months smoke-free." Congratulations, Jason. And he goes on to say, "Now, I'm very grateful to have had the coercion. Money is a powerful motivator." Susan.

DENTZERWell, that's clearly the case for many people. Money will get many people's attention. I think back to the previous caller, though, we heard very clearly that what matter there was the social context.

REHMSure.

DENTZERAnd as we know from all kinds of social science research, social connections matter. People who knows somebody who is obese, who have a friend who is obese are more likely to be obese themselves. People tend to quit smoking in groups. We see these connections all the time. So whether it's financial incentives motivating behavior or this very indirect social peer pressure, other kinds of contexts, we see that we have different tools to create behavior change, and it just depends on which one works best for which set of individuals.

REHMBut here's a very different perspective from Brian, who says, "This is the reason I'm leaning toward the Libertarian Party. This is a gateway to force employees to eat a certain way and exercise. I refuse to do the health assessment where I work for fear the results will be used against me. I go to my own gym daily. I don't want to be forced to by my employer." JoAnn.

VOLKWell, and I should have said you started the call by -- I mean, the show by asking, you know, are all of these voluntaries? So with this subset, they were talking about the HIPAA exception that says that you can modify premiums and benefits for workers based on health status if you meet these rules. It says, as long as you meet those rules, including that no more than 30 percent of their premium costs are on the line, that is technically voluntary. But I think there's a question about, does it feel voluntary to the worker if their costs go up by 30 percent? How voluntary is that? So...

REHMAnd, Maria, I gather your organization had not actually support the Affordable Care Act but did support this particular provision.

GHAZALThat's correct, Diane. You know -- and just to come back to what JoAnn was saying, I mean, I think we need to go back. I mean, this whole notion of are things voluntary or, you know, like the emailer sent in, you know, they don't want to feel forced, I think, though as a nation, we have to remember, almost 40 percent of all premature deaths in this country are due to unhealthy lifestyle choices.

GHAZALWe have to be all focused on this. And just like we changed as a society with smoking, we really need to focus on a number of other numbers that people need to know about their health.

REHMAll right. To Raleigh, N.C. Srinath, (sp?) you're on the air. Srinath.

SRINATHHi, Diane. I've listened to your show almost every day.

REHMThank you.

SRINATHAnd I'm glad you took my call today.

REHMGo right ahead, sir.

SRINATHMy question is with sort of the lopsided nature of power that is operating here and -- 'cause it seems to me that corporate America today has -- is resisting every kind of regulation that the public wants, whether it's pharmaceutical companies, whether it's energy companies. I'm sure you've heard that fracking is soon going to be legal in North Carolina. Our air and water is saturated with chemicals. Chemical companies, food companies don't want to label genetically modified food.

SRINATHSo I'm wondering at this juncture where corporate America is resisting every form of democratically implemented control that they are controlling or attempting to control the behaviors of people right down to what they eat. And I know that autonomy -- the idea of individual autonomy is sort of the mirage, but don't you think that people who are talking about health in the social context need to be a little more reflexive about the politics and...

REHMAll right. Sir, thanks for calling. Ron.

GOETZELWell, I mean, your positioning it as a control mechanism. I don't see it that way. I see it as companies providing opportunities free of charge for people to improve their health and well-being.

REHMBut that's one way to frame it. Others may see it as an attempt on the part of employers and the government trying to control our body, Susan.

DENTZERWell, let's just point out that this argument takes place all over the society.

REHMOf course.

DENTZERMayor Mike Bloomberg in New York...

REHMTried.

DENTZER...was accused of trying to control people's soda consumption by virtue of the regulations that he was proposing on a size of soda containers. So we have a lot of arguments about the nanny state in this country and they will take place for a long time.

REHMAnd you're listening to "The Diane Rehm Show." And to Charles Town, W.Va. Hi there, Gary.

GARYHello there. I wanted to mention that I have refused to participate in my company's wellness program 'cause I was afraid of being fired. The legal protection is an absurdity. It's very easy to get around that by saying, oh, it was just insubordination or something. When I was hired years ago, I was a 240-pound weightlifter with a 35-inch waist, a 52-inch chest and a 405-pound bench press. I bicycled about 30 miles every weekend. And I never smoked.

GARYThen I became sick. I had chest pains, shortness of breath, anemia and crippling leg pain. And with the five cardiologists who told me that chronic chest pain and shortness of breath was nothing to worry about, honest to goodness, what they said was, everything's fine. I had to stop exercising 'cause I started to black out. Some of the chest pain episodes resulted in me falling to the floor and expecting to die. The leg pain was diagnosed as a pinched nerve in my back, and it didn't respond with any treatments, including two surgeries.

REHMOK, Gary. But what you're saying is that you were afraid you would get fired?

GARYRight because they say it must be your fault. You're doing something wrong.

REHMAll right. Susan, what do you think?

DENTZERI frankly don't know what to say about that because the circumstances seem somewhat murky. But, you know...

REHMAnd personal.

DENTZERAnd, frankly, given what you've described, it would have been illegal probably for an employer to fire you under other aspects of federal law.

REHMAll right. One last question from Detroit, Mich. Alba, you're on the air.

ALBAOh, thank you. Good morning.

REHMMorning.

ALBAActually my question relates a little bit to what the previous caller was saying. The Institute of Medicine has issued a report showing that chronic pain actually affects more people than cancer, diabetes and heart disease combined. And across the nation, over 600 billion each year in medical treatment in lost productivity.

ALBAAnd yet I have -- something that I have not seen addressed in any wellness programs because I've participated in a lot of conferences and actually presented a lot of conferences. I've only seen it addressed in one program. That and also stress-related conditions, which are estimated to account for up to 90 percent of issues for which people see the doctor...

REHMWhat about stress? How do you deal with stress in the wellness program, JoAnn?

VOLKWell, I don't know how you deal with stress in the wellness program. I mean, I suppose there are programs that, you know, resources that address that. But I think it does point out that behavior modification -- some of these things can be -- some of these outcomes can be affected by behavior modifications. But not everything is within in our control.

VOLKAnd if you work double shifts and you're a single mom and a caretaker of kids, and, you know, there are barriers beyond just whether or not that gym membership is free at the office to getting regular exercise. And I think that's one thing to keep in mind here, is that not everything can be addressed with behavior modification. It's a very complicated thing. Anyone with a child knows that modifying behavior is difficult.

REHMAll right. We'll leave it at that. JoAnn Volk, Susan Dentzer, Ron Goetzel, Maria Ghazal, thank you all for being with us. And thanks for listening. I'm Diane Rehm.

ANNOUNCER"The Diane Rehm Show" is produced by Sandra Pinkard, Nancy Robertson, Denise Couture, Susan Case Nabors, Rebecca Kaufman, Lisa Dunn and Danielle Knight. The engineer is Tobey Schreiner. Natalie Yuravlivker answers the phones. Visit drshow.org for audio archives, transcripts, podcasts and CD sales. Call 202-885-1200 for more information. Our email address is drshow@wamu.org, and we're on Facebook and Twitter. This program comes to you from American University in Washington, D.C. This is NPR.