MR. KOJO NNAMDIFrom WAMU 88.5 at American University in Washington, welcome to "The Kojo Nnamdi Show," connecting your neighborhood with the world. Have you been meaning to use your company's gym, but you just haven't had time? What if I offered you a free iPad for working out 30 minutes a day there? No? Would $300 do the trick? While you're deciding, your company's benefits managers might be weighing these same questions as they work to keep health costs down.

MR. KOJO NNAMDIIn the past decade, U.S. health premiums have shot up 97 percent, mirroring the upward trend in obesity and the health problems that go with it. So employers are turning to incentives, from prizes like iPads to discounts and cold hard cash to both motivate workers and cut health care costs. It's an approach to workplace wellness that's catching on fast, despite concerns that it discriminates against some workers with chronic conditions.

MR. KOJO NNAMDISo how do these programs work? Are they showing results, and just how far do they have to go to get workers healthy? Joining us in studio to talk about that is Katie Sweeney, workplace wellness manager for Arlington County, Va. Katie Sweeney, thank you for joining us.

MS. KATIE SWEENEYThank you, Kojo. It's a pleasure.

NNAMDIAlso in studio with us is Ron Goetzel. He is a research professor at Emory University's Rollins School of Public Health. He's also a vice president of consulting and applied research for Truven Health Analytics, which is a health care data and analytics company. Ron Goetzel, thank you for joining us.

PROF. RON GOETZELThank you for having us.

NNAMDIAnd joining us from studios at the University of Pennsylvania is Kevin Volpp. He is a professor of medicine and health care management at the University of Pennsylvania's Wharton School. He's also the director of the Center for Health Incentives and Behavioral Economics at the university. Kevin Volpp, thank you for joining us.

PROF. KEVIN VOLPPThanks for having me on the show.

NNAMDIIf you'd be interested in joining this conversation, give us a call at 800-433-8850. Do you participate in your employer's wellness program? What have you gotten out of it? 800-433-8850. Send us a tweet, @kojoshow, or email to kojo@wamu.org. Ron Goetzel, it used to be that if you work at an office that offered a gym discount or even an in-house gym, you had a pretty forward thinking employer, but workplace wellness has come a long way since then.

NNAMDIAnd now, access to a gym seems to be a minimum standard for keeping workers healthy. Tell us a little bit about the evolution employers have gone through in their approach to workplace wellness.

GOETZELWell, it does go back to the 1970s. In fact, one of the pioneer companies that introduced workplace health promotion programs, which is another way of calling wellness programs, Johnson & Johnson back in the late '70s -- actually the CEO of that company wanted to make J&J employees the healthiest in the world, so he did build fitness centers. He provided childcare services.

GOETZELHe made food offerings healthy for people, gave people an opportunity to have flexible times so that they could go and exercise when they needed to. And a lot of other companies adopted that simply because it worked. Now, there's a lot of research showing that not only did it improve health but it also saved the company money in terms of health care costs and reduced absenteeism.

NNAMDIJohnson & Johnson measured the return on investment over time, did it not? And from that, it worked well.

GOETZELIt worked very well. In fact, they did a series of studies in the 1980s and in the 1990s, and we just recently looked at their experience from 2002 to 2008, and the program is still improving health and still saving money.

NNAMDIStatistics seem to back up a shift in how workplaces approached their employees' health, a survey last year of 1,800 employers by the human resource consulting firm Aon Hewitt found that 63 percent of employers offer worksite wellness programs with another 9 percent looking to add them in the next year. In your work as a researcher and consultant, Ron, what kinds of questions are employers asking as they put these programs into action?

GOETZELWell, they don't have to be convinced that these programs make sense. Intuitively, it makes sense that if you improve the health and well-being of your workers, their morale goes up, quality of life improves, their focus, their energy is improved. What they're lacking is the know-how of how to do it, the resources, the technical assistance, the tools, everything that you need to put these programs in place. Those tools that are evidence-based, not just handing out brochures to people saying lose weight and stop smoking.

NNAMDIWell, people who have experience can be found in Arlington County. Katie Sweeney, Arlington County has had a wellness program in place since 1994. How has your program evolved since its early days?

SWEENEYOur program has evolved in many ways. Specifically in 1994, it came out of our Parks and Recreation Department, and a few years ago, we brought it into human resources in order to better align it with some of our benefits, planned design and some of the things available through our health care vendors. And as a result, we've been able to make more strategic approaches to the programming that we offer to employees.

SWEENEYSo looking at some of the exercise programs and the time of day that we offer them or recently -- actually, this is the one year anniversary of our onsite employee wellness clinic, and so therefore we've been able to look at that and use that as a way to get people to better understand their health, you know, blood sugar, blood cholesterol, things of that nature.

NNAMDIMoved it from parks and recreation to human resources, and that meant that you are able to give the program structure and that the data from the program could be assessed through the health provider.

SWEENEYAbsolutely. We meet regularly with our health plan provider to look at trends that we're seeing and to identify areas for improvement.

NNAMDIKevin Volpp, having a wellness program is one thing, but motivating people to use it quite another. What gets people motivated to use these kinds of programs at work?

VOLPPThis is one of the central challenges that employers struggle with. A lot of employers have found that for some of the programs they offer, participation rates are low, and I think that's driven a lot of the interest in economic incentives as a way of increasing participation rates. It's a challenge, though, because a lot of the incentive programs out there are still not all that well designed.

VOLPPThey tend to rely on standard economics, which is assumed said if you provide a reward, the size of the reward is all that matters. And we've learned a lot in terms of behavioral economics, in terms of the types of mistakes people make, the ways in which they're predictably irrational which suggests that there's a lot more than the size of the reward that really matters in terms of its effectiveness.

NNAMDIWhat kinds of rewards tend to work best in getting people to practice healthy behavior, Kevin?

VOLPPI think the key is to really have a system which is fairly simple. A lot of the reward programs out there have evolved in a way that makes them incredibly complex. Another key dimension is to have a program that has very salient, very visible rewards. And a third element is to have relatively frequent feedback, asking somebody to go to the gym today in exchange for a reduction in their premiums next year won't motivate them today. There's going to be a natural tendency to procrastinate, which is part of human nature.

NNAMDISo you've got to get them something that they can see today.

VOLPPWell, not today...

NNAMDIOr pretty close.

VOLPP...this week or at least this month. The end of the year is too far off.

NNAMDI800-433-8850 is our number. We're talking about incentivizing workplace wellness and inviting your phone calls. Do you feel employers should take a greater role in helping their workers stay healthy? Do you participate in your employer's wellness program, and what have you've gotten out of this? Call us at 800-433-8850, or you can simply go to our website, kojoshow.org, and join the conversation there. Katie, you used a range of incentives in Arlington to get your employees to improve their health. What have you found works best in motivating your workforce?

SWEENEYI think what works best is capitalizing on their competitive spirit and, you know, their willingness to use time that meets their needs. So, for instance, we have exercise classes that we offer on site at a couple of our locations, and we hear regularly that it's not so much about the amount of money we're willing to give or how many gym memberships we're willing to cover. But if we can give that new mom time during work or ease of access during work so that she can flex her schedule at her lunch hour to work out, that's more valuable to her than if we gave her 10 gym memberships.

NNAMDIThis question for all of you, the U.S. is not the only place where these kinds of programs are taking root. Abu Dhabi, which is the richest sheikdom of the United Arab Emirates, has the first state-sponsored health incentives program. It's giving away airline miles, grocery discounts and even cash to people who need to lower their risk of developing type 2 diabetes, which is way too common in that country. Do we see other countries putting their money -- pardon the pun -- where their fat is, Ron?

GOETZELI think there is a lot of interest in incentive programs, and looking at what motivates people to adopt a healthy lifestyle. But, you know, the work that Kevin Volpp has done is very instructive, very illuminating because eventually what you need to do is move from an extrinsic incentive to an intrinsic incentive.

GOETZELIn other words, people will want to do things. They'll want to live a healthy lifestyle. They want to look better, feel better, think better, but it's got to come from the inside. They've got to have their own reason for doing it, instead of just being paid for doing it.

NNAMDICare to add to that, Kevin?

VOLPPYeah. I think it's a really important point. A lot of times, the incentive programs can be helpful in helping people overcome the initial inertia, the activation energy that's required to change a longstanding habit. So, for example, we ran a study among employees at General Electric a few years ago where we used incentives to help people quit smoking. We know that 70 percent of smokers around the U.S. want to quit smoking, but only 2 to 3 percent per year actually succeed.

VOLPPAnd what we did is we provided people with incentives that were tied to staying smoke free initially for six months and then for another six months. And we found that at 12 months, about 15 percent of people who were randomized to an incentive group has quit smoking compared to about 5 percent in the control group.

VOLPPAnd the key there is that if you can help people do what they wanted to do, then if you can stay in that new equilibrium for six months, 12 months, then there's a pretty good chance they'll be able to carry it on themselves. And that's in fact what we found six months after stopping the incentive program. We still had a quit rate ratio between the incentive group and the control group of about 2.6, so not quite as good as the initial 2.9, 3.0 ratio, between 15 percent and 5 percent, but still pretty close.

NNAMDIOn to the telephones. The number again, 800-433-8850. We go to Andrew in Alexandria, Va. Andrew, you're on the air. Go ahead, please.

ANDREWYeah. Hi, Kojo. Thanks a lot. I really enjoy your show. What I was thinking about hearing this was, you know, the gym, the daycare, I thought was a good idea. The gym is OK, you know? I thought just in of itself was a great reward. So trying to find other rewards for people, I just couldn't understand that.

NNAMDIWhy they should find -- you know what...

ANDREWWell, other incentives, yeah.

NNAMDIOK. Andrew, hold on a second because, you know, the answer to your question may be coming from Edo (sp?) who is calling from Silver Spring, Md. Edo, you're on the air. Go ahead, please.

EDOHi, Kojo. Yeah. So from, you know, just started one this past year, and on the one hand, I didn't really need it because I'm already, you know, I've been running for a few years and -- but the thing is, is that for me what drove me to go ahead and join and participate was the economic incentive. I mean, they gave you a bit of a stipend to buy, you know, to get a health club membership, which I've used.

EDOAnd, you know, they've also provided for a reduction in my health care premiums, which, to be honest with you, I have just been seeing them go up. Even though I'm in excellent physical condition, it just -- they keep going up.

NNAMDIKatie Sweeney, talk a little bit, in answer to Andrew's question, about why an employer might feel it is their responsibility to establish a wellness program.

SWEENEYSure. And Andrew might be some of the chosen few who have that already built-in intrinsic motivation to be healthy and be well and feel that physical effect. But all too often, especially in D.C. Metro area where commutes are long and stressful, the last thing somebody wants to do when they get home is get their tennis shoes on and go out for a run.

NNAMDIHey, I'm tired.

SWEENEYYes, exactly. So, you know, we use the incentives as a way to sort of get them in the door and them to that point where they're seeing that more intrinsic motivation. They have more energy. They're sleeping better. They're better able to manage their stress. In fact -- and I have a handful of what I call my wellness rock stars, and they definitely know who they are. And about three years ago, we had an employee who hadn't really thought much of their health, didn't think much of their cholesterol.

SWEENEYBut we brought an on-site cholesterol screening to their work location, participated. It might have been a friendly badgering to get them in line, but they definitely got in line and found that they have elevated cholesterol and they never realized that. And so they followed up with their doctor. At the same time, a group of their colleagues were doing a weight management challenge, sort of a, you know, who could lose the most weight.

NNAMDIThe little competition, yes.

SWEENEYExactly. And so he joined that and he ended up winning that competition. He reduced his body fat percentage. He got his cholesterol down into a healthy range. And I saw him actually just a few months ago -- this is, again, three years later -- he still looks great. He still has his cholesterol down. He's maintaining those healthy behaviors. And he really cites that first screening opportunity where he went from no knowledge to 100 percent knowledge for getting him in the door and leading him to this now ongoing life -- change in his lifestyle.

NNAMDIBut why would that be important to his employer?

SWEENEYWell, you know, healthier employees, they tend to better engaged at work, healthier, happier.

NNAMDILess absences.

SWEENEYLess absences. There's something called presenteeism, which is sort of, you know, out there and sounds a little odd. But if you've ever been at work and you know you're sick or you know that you have other family stressful things going on, are you really 100 percent present? You may be at your desk, but are you truly there functioning as much as you could?

NNAMDIRon Goetzel, same question.

GOETZELWell, there's a lot of research. In fact, probably over the last 20 to 30 years, there are two to three dozen good, well-conducted studies showing that those employees and those sites that participate in these programs do have lower health creolization and increased productivity in form of absenteeism. In fact, the CDC Community Guide Task Force did a literature review on the topic, as did the Harvard School of Public Health and their researchers. They found that these programs work, both improving health and saving money. So that's why employers are interested.

NNAMDIEdo, thank you very much for your call. Andrew, does that, in fact, your question or your concern?

ANDREWYeah, I think that's fine, I think. But it's very generous to do that. I think -- I like this -- about the insurance being reduced if I take care of myself. I mean, I like that idea a lot. So yeah, there are certainly applauses here. The day care, the flextime, I think, were also a great ideas.

NNAMDIAndrew, thank you very much for your call. We're going to take a short break. When we come back, we'll continue this conversation. So if you have called already, stay on the line. If you'd like to call, the number is 800-433-8850. Would you try to lose weight or to stop smoking if you could get a discount on your health care payments? 800-433-8850. You can also send us a tweet, @kojoshow. I'm Kojo Nnamdi.

NNAMDIWelcome back to our conversation on incentivizing workplace wellness. We're talking with Ron Goetzel. He is a research professor at Emory University's Rollins School of Public Health. Ron is also a vice president of consulting and applied research for Truven Health Analytics, which is a health care data and analytics company. Kevin Volpp is a professor of medicine and health care management at the University of Pennsylvania's Wharton School.

NNAMDIHe's also the director of the Center for Health Incentives and Behavioral Economics at the university. And Katie Sweeney is workplace wellness manager for Arlington County, Va. You can call us at 800-433-8850. Kevin, there are carrots and then there are the sticks. Is it more effective to threaten people with something they could lose if they don't meet certain health criteria?

VOLPPWell, Kojo, it's an interesting question. There's an academic literature in behavioral economics that shows that people respond much more to losses than they do to equivalent dollar gains. And one sees evidence of this in all sorts of other context. Like how people behave when the stock market goes down, a lot of people tend to sell their stocks even though that may be exactly the wrong time to do so.

VOLPPSo in general, if you compare a program, which is structured as a penalty as opposed to one that is based on rewards, a direct comparison would suggest the penalty program will be more effective. However, employers need to be careful in terms of balancing this versus other objectives like, for example, how will your employer feel about the program?

VOLPPHow will the employer feel about you as -- sorry -- how will the employee feel about you as an employer? And our general sense is that these types of penalty approaches need to be used selectively because if employees feel like they're being beaten over the head repeatedly with these sticks, that they're not going to feel like this is a very enjoyable place to work.

NNAMDIKatie Sweeney, have you had that in your experience in Arlington County and had to make appropriate adjustments for it?

SWEENEYYou know, we've had that experience, though we've never actually used or pursued using sticks. Though, depending on which side of the equation you're on, a carrot, to you, may be considered a stick. But we do try to take that carrot approach and specifically really connect with the employees. We're fortunate to have myself and another health educator on staff.

SWEENEYSo we try to convey the fact that we truly do care about our employees. That's -- one of the most enjoyable things about my job is meeting with employees and showing them it's about your health, and it's about you're health also because I care about you're retirement.

NNAMDIGlad you mentioned that a carrot to one person may seem like a stick to another. That allows me to bring Robin in Washington, D.C. into our conversation. Robin, you're on the air. Go ahead, please.

ROBINHi there. I just wanted you to know I don't disagree that employers have, you know, interest in incentivizing health and wellness in the workplace and among their employees, but I think it's really important that those programs be done in a more sensitive manner than I think that they are at a lot of places now.

ROBINKatie, you mentioned those kinds of weight loss competitions, and those can be really, really fraught for a lot of people. Making people's numbers and percentages and how often they're working out public to their, you know, to their co-workers can be really upsetting to people who have body image issues or, you know, eating disorders that are really rampant or people who have a history of an eating disorder.

ROBINSo it seems like those workplace competitions or -- for weight loss or, you know, buying credits to be able to be able to eat junk food or getting credit for eating healthier, you know, those things can be really troubling and really upsetting to lots of people for whom exercise and fitness and their body size and eating habits are really intensely personal.

NNAMDIGlad you raised that issue. Ron Goetzel, you have a chronic health condition like heart disease or diabetes. This whole carrot-and-stick approach in the same way that Robin was describing it might seem a bit unfair. How are companies trying to level the playing field in these workplace wellness programs for people even with long-term health problems or the kind of eating disorders that Robin's talking about?

GOETZELNo, it's absolutely an important point. These programs have to be constructed in ethical, practical and legal manners. So for people who, you know, if you're bound to a wheelchair, for example, you're not going to be able to run a mile at a certain period of time, there have to be alternatives. There have to be waivers. There have to be ways at which people are able to fulfill the requirements in other ways, especially if they've got a good reason, especially a medical reason.

GOETZELSo I agree that you don't want to structure these programs in a way that are penalizing people who, for one reason or another, can't participate. However, you do want to provide incentives for people to lead healthy lifestyles. And there's ample evidence that if you do that through financial incentives, people will at least come to the party and think about whether they want to participate or not.

NNAMDIAnd when we're talking about eating, Katie Sweeney, always at the ready, seems to have brought show and tell today for...

SWEENEYYeah, certainly.

NNAMDI...those of us who do shows at lunchtime and may have bad eating habits. Exactly what is this I'm holding up?

SWEENEYSo you're holding up a trail mix that we tend to promote with our employees. We partner with Michelle Powers, who's a registered dietitian and chef in the area, and she does on-site cooking demos. And one of the things she had shared, one of the gems we've taken away is this trail mix recipe, and it's just a great mix of carbohydrates, protein, fiber, healthy fats. And, you know, you can tailor it for whatever your taste might be. In fact, I made some last night that has peanut butter puffins in it 'cause I happen to be a huge fan of peanut butter. But you can...

NNAMDIDid you bring any of those by any chance?

SWEENEYI have a little bit, if you want to try that. But the mix I gave you is my other favorite.

NNAMDIWorks for me.

SWEENEYBut, you know, it's just a great thing to have on hand in your car, in your purse, at your desk so that when that 3:00 hour or that long commute home comes up, you don't feel the need to steer off into the drive-through and get a choice that, maybe, in the immediate feels great, but long term, you know, you're paying for with your health or just with not feeling like you are in control when you could have been.

NNAMDIWhat provisions do you make in your wellness programs in Arlington Country for Arlington employees who may have chronic health conditions?

SWEENEYYou know, employees who have chronic health conditions are very important to us, and we want to meet their needs. So we have programs available to them through our health plan provider. We also have coaching resources through our on-site employee wellness clinic. And so, you know, those are employees we truly do want to engage and have them understand their numbers and what steps they can take.

SWEENEYAnd so, you know, as far as incentives go for that, it's really again that caring, ease of access and then making sure that they have a coach that they're comfortable with to make those changes long-term.

NNAMDIAnd, Ron, are employees sometimes hesitant, as Robin was indicating, to divulge their personal health information? After all, they may feel it could be used to discriminate against them in determining the condition, say, of their health plan.

GOETZELWell, that's against the law. It's illegal to share that information with the employer. So your job can never be in jeopardy based upon your health status or the information you provide. And the data that are collected are typically collected by third party. And so they're in charge of helping you improve your health and well-being. But it is illegal. You cannot actually share this information with your supervisor. No employment decisions could be made about upon health status.

NNAMDIThank you very much for your call, Robin. Robin, does that answer your question?

ROBINIt does. I just -- as Katie was saying, you know, they can -- they want to make sure that employees who have long-term health concerns or problems, you know, want to make sure that they have all the resources they need to, you know, to be healthy along with the problems that they have. But you shouldn't have to, at any point, tell anyone, quite frankly, that you have those problems. So it can be really hard.

ROBINThere shouldn't be a way in which employees are sort of coerced into participating. And I hear what you're saying about the, you know, it's illegal to share that information with employers, that it's great when there's these outside companies doing, you know, these health programs. But a lot of them are just workplace, you know, fitness competitions, and that stuff is public. And while it may not be used to discriminate, it can still be used in a way that is really humiliating to some people.

NNAMDIThis is true, Robin, and I suspect everybody who is interested in this would want to seek to avoid that. But is the alternative doing nothing at all?

ROBINNo, of course not. I just think that they're, you know, I think that these incentives in providing, you know, a gym space is great. But, you know, I just think some sensitivity or some -- just something that goes along with starting these programs to really make clear to everybody that, you know, people need to be sensitive and careful about the things that they're saying. There's already, you know, in a lot of workplaces, people sort of feel pleased about their lunch choices. You know...

NNAMDISo you do -- I do understand that...

ROBIN...some sensitivity training would be great.

NNAMDIYou do want to be sensitive. Ron, wellness programs are supposed to be voluntary. What if you're fined -- essentially being fined from not participating? Is it really voluntary then?

PROF RON GOETZELYou know, first, let me respond to Robin.

NNAMDISure.

GOETZELOne thing that's important is to know that these programs are, nowadays, often performed on your own time, in other words, on weekends, in the evenings. You don't actually have to physically go somewhere like a fitness center or a room or anything to do anything. All you've got to essentially demonstrate is that you are leading a healthy lifestyle either physically active, eating healthy, not smoking and so forth.

GOETZELI don't think it's an issue being fine. The way that most of these programs are structured is that there's a credit that you're given. In other words, you're given a reduction in your annual premium if you participate in these programs.

NNAMDIPrecisely. And, Kevin Volpp, I'd like you to jump in on this too because a comment posted on our website from Stephen, who says, "My company requires me to enroll in a wellness program in order to receive a lower co-pay. Can you comment on this trend?" Which is exactly what Robin was just talking about. Kevin.

VOLPPYeah. Well, I think these programs do have to be voluntary. And it's an interesting question of what determines how big an incentive can be, how effective it can be and still be regarded as voluntary. So based on current law, employers can now have a reward that's worth up to 20 percent to the total premium starting Jan. 1, 2014 as part of the Affordable Care Act. That percentage goes up to 30 percent for outcome-based measures like blood pressure, cholesterol, body mass index.

VOLPPAnd if they include smoking, it can actually go up to 50 percent. So when you consider that the average individual premium is about $6,000 a year for a family, it might be about $16,000 a year, that's a lot of money that's potentially at stake, and it does raise an interesting set of issues where it has not been, I think, clearly adjudicated as to what could be constituted as voluntary.

VOLPPThe implicit assumption that most employers have gone under is that 20 percent standard for outcome-based incentives is the current standard that would still be considered voluntary, and that new standard, 30 to 50 percent, will, in fact, be the new standard going forward.

NNAMDIOK. Thank you very much for your call, Robin. We move on to Catherine in Springfield, Va. Catherine, your turn.

CATHERINEHi. Obesity is a very visible measure of any kind of progress, and this -- I was super morbidly obese for my entire adult life. I'm in my 60s now. It -- carrots and sticks where something like that is concerned. There is obesity that is not responsive to things like lifestyle programs and trail mix and dieting and has to be treated in a different way. I ended up taking my life in my hands, going to Brazil and having bariatric surgery.

CATHERINEMy company did not help. The insurance companies did not help. And I guess my point is in a workplace where, you know, there is this wonderful fitness thing going on, it's very evident who is not succeeding. And, thanks, fat girls have been punished enough. This is just -- this is nuts, you know? Having a program like this leads to expectations that it will actually succeed. With some people, it does not. Those people will be punished.

NNAMDIOK, allow me to have our panelist respond to that. First, you, Ron Goetzel.

GOETZELYeah. I think it is unrealistic. I agree with Catherine that if an employer says you've got to be a certain BMI, 25 or below, two-thirds of the American population is not going to be able to satisfy that requirement. So that is an unrealistic goal. I think most employers are moving in the direction in which people are moving or trying to improve their health and well-being, and it's much more focused on physical activity and healthy eating, not so much on obesity per se.

GOETZELSo if you make progress, if you're actually participating in programs that increase your physical activity, that improve your eating habits, employers will say, well, you're going in the right direction, and we're not going to penalize you if you're not at a BMI of 25 or better. And I think that's the right ethical way of proceeding on this.

NNAMDICatherine, thank you very much for your call. Katie, can offering...

VOLPPKojo, can I add one thing to that?

NNAMDIOh, please go ahead, Kevin. Yes, I'm sorry.

PROF KEVIN VOLPPSo we're also seeing a lot of employers who are thoughtful about this, recognizing that having a single threshold is not only unfair but it's unlikely to motivate people who aren't near that threshold. So if I have a BMI threshold of 25, that's a very nice incentive program, for people whose BMIs are 26 or 27, it's not likely to be useful to others.

VOLPPSo we're seeing a lot of places where they are offering the full incentive if you make progress. And it can be along the line to what Ron said in terms of participation and an evidence-based program, or it can be progress from the stand point of, let's say, losing 5 percent of body weight or a 10-minute of the threshold. And we strongly discourage employers from just using a single threshold.

NNAMDIOK. Back to the telephones. Lap -- Larry in Shepherdstown, W.Va., looks, in a way, at the other side of that coin, I think. Larry, your turn.

LARRYThank you, Kojo. I'm here in Shepherdstown, which is the home of Shepherd University. I just retired here. It's a great place. And one of the things I note -- I just turned 70, and we have a wellness center at the university, and I play racquetball three days a week, and I love it. My biggest concern...

NNAMDIOne of my -- that was my favorite sport till I got my tooth knocked out playing doubles in racquetball by a guy who wouldn't look behind him. But that's another story.

LARRYSo I wear, you know, face protection and all the rest of the guard. But I feel that, you know, staying healthy is the best health care plan, and I'm fortunate. I would be concerned -- I totally support the idea of corporations. I work for a company that had an incentive like this, and it wasn't punitive. It was voluntary, and it created a -- incentives for people who stay healthy.

LARRYMy biggest concern are people -- and I see them here at the college -- who exhibit risky behavior in terms of smoking and not eating well and alcohol, you know? And these are young people, and I think we need to create incentives for people to develop good habits. And...

NNAMDIBut you also wanted to talk about disincentives for people who are cultivating bad habits.

LARRYRight. Yes, I do. And, you know, I'll use as an example the Cleveland Clinic, which is one of the top research facilities in the country which actually has a program that if you smoke or drink excessively, you cannot get hired by the Cleveland Clinic. They believe in leadership by example. They serve all the area around Cleveland. If you have a weight problem, they will say, OK, we'll hire you on a six-month basis, and you have to show evidence that you're, you know, working on that.

LARRYAnd so I, you know, I support, you know, employers as well as universities and so on being able to say to people that if you're not willing to pursue a wellness -- we're part of the community -- eventually all those costs come back through the insurance customers along that you're going to pay more. And I...

NNAMDIOK. Larry, I think we understand the point you're making. I'd like to go to Ron Goetzel. I think we might be in lawsuit territory here, but go ahead, Ron Goetzel.

GOETZELI think many of the points being made by your callers, Kojo, is that it's -- it shouldn't just be the individual whose responsibility it is to improve health. Really, the employer pays a -- plays a very important role in this. So if they only have vending machines with junk food, if their cafeteria choices are awful, if they don't give you flexibility in terms of work and family and work life and so forth, if they don't provide those kinds of resources and they're kind of forcing you to be in a situation which is unhealthy to you, they bear some of that responsibility.

GOETZELSo I think it's wrong for employers to say, you're the problem. You need to fix yourself. They are as important in improving the health and well-being by providing the environment that's a healthy environment.

NNAMDIThe reason I said we're in lawsuit territory is because if the employer says, I'm making this a condition of your employment -- if you do not take steps to improve your health, you can no longer work with us -- seems to me that somebody is going to be filing a lawsuit against that at some point. Got to take a short break. Larry, thank you very much for your call. If you have called, stay on the line. We will get to your call.

NNAMDIThe number is 800-433-8850. Are you comfortable sharing your personal health information with your employer? 800-433-8850. Or do you think employers should take a greater role in helping their workers to stay healthy? You can send us email to kojo@wamu.org or send us a tweet @kojoshow. I'm Kojo Nnamdi.

NNAMDIWelcome back to our conversation on incentivizing workplace wellness with Katie Sweeney, workplace wellness manager for Arlington County, Va. Ron Goetzel is a research professor at Emory University's Rollins School of Public Health and vice president of consulting and applied research for Truven Health Analytics, a health care data and analytics company.

NNAMDIAnd Kevin Volpp is a professor of medicine and health care management at the University of Pennsylvania's Wharton School, where he's also director of the Center for Health Incentives and Behavioral Economics. You can call us, 800-433-8850, or send email to kojo@wamu.org. Katie, I started to ask you before, can offering incentives trap you in a vicious circle, in some ways? For instance, do you have to keep boosting the level of the prize or the financial reward to keep people's interests maintained?

SWEENEYYeah, absolutely. You know, that's actually something that we've even seen at the county where you start off offering an incentive, and you feel the need to increase it the next year, and you feel the need to increase it year over year over year.

SWEENEYAnd especially with the nature of our budget cycle, we're not always able to increase, and we see the effect of that when we sort of have to level off an incentive, which is why we have to think sort of creatively and outside of the box and have it go beyond that financial reward and more into the realm of a friendly competition, getting co-workers together, understanding the benefit, the importance of the information.

SWEENEYFor instance, we do a health assessment, a health risk assessment every year. And I recently had an employee, and, my gosh, it's enough effort just trying to get everybody to take it one time a year. I recently had an employee say, you know, I find this more valuable if you ask me to take it more often, you know, ask me to take it and then maybe two months later take it again. And I thought, oh, my goodness. I would just like everyone to take it once a year. But if you want to take it more often, then, you know, by all means.

NNAMDIIt's your prerogative. Kevin, has research found that there's a price you can reach where a larger financial incentive just is not effective anymore?

VOLPPWell, I think the usual rules apply in terms of standard economics where larger incentives have larger effects, but, of course, you can run into ceiling effects. One of the really important considerations, though, that hasn't come up on the call so far is that you have to think about all the money that's available through the employer as a pool of money that the employees are providing to improve their health, and you have to look at the whole bucket.

VOLPPYou can't look at just the two or 3 percent that's spent on wellness programs. You have to look at the other 97 percent and look at how well that's being spent because it's really money that's being generated by the employees that's part of their total compensation. And the key question, which I know Ron has written about as well, is what is the -- what are the investments that are going to maximize the return in terms of employee health?

VOLPPAnd if you're wasting a lot of money on treatments that don't work very well or very cost-ineffective, then that limits your ability to invest and keeping your population healthy. So...

NNAMDIHere -- go ahead.

VOLPPYeah. So there's a lot of programs that don't work, there are a lot of treatments that don't work very well and we have to apply the same lens to both. And our general sense is when you think about the wellness bucket, it's a little bit of an artificial divide to focus on that and what is the return on investment for that two or 3 percent of the employee benefit dollar. You really need to look at the whole bucket and say, how do we maximize the health of our employees given the resources we have available?

NNAMDIOn to Alex in Washington, D.C. Alex, you're on the air. Go ahead, please.

ALEXHi. Yes, Kojo. Thank you very much. Without sounding too harsh, I do agree with a lot of what Katie, Ron and Kevin say. But I do believe that out of some of these reforms are seemed disingenuous, I think on a basic level, you know, citing one study that says that your shift work in general is dangerous for our health.

ALEXI think that we have to do more comprehensive changes rather than just adding a gym that feels like this is just about squeezing productivity out of an already unhealthy community. I mean, whatever happened to giving a maternity leave and creating conditions that are not prone to isolation? Thank you very much.

NNAMDIThis is a conversation we were actually having in the break, Alex, that there are other factors in the workplace and one that Katie and Ron certainly want to address. Katie.

SWEENEYYes. You know, it goes beyond just having access to a gym or exercise classes. At Arlington, we called them movement classes. But it's also about looking at -- especially like you mentioned, the shift worker where you are working off hours, it becomes a very stressful work environment. So what is available as far as stress management for your employees?

SWEENEYWe recently did a 28-day yoga challenge for our employees where they signed up in the month of February and they got a daily tip of a yoga move or something just to be more mindful of their personal well-being, again, taking it beyond the gym and pounding the pavement but more into that internal well-being.

NNAMDIAnd you want to provide the kind of workplace environment, Ron, it seems to me, where stress levels would be reduced.

GOETZELAbsolutely, in fact, if you can think of over 100 things that employers can do to improve the health and well-being of their workforce. In fact, there is something on the CDC website called the CDC Worksite Health ScoreCard, and it's a checklist. It's a 100-item yes-no checklists of things that employers can do to improve the environment and include things like stress management and providing those kinds of connections that workers need and also the organizational structure itself. So the points that are being brought up are absolutely right.

NNAMDIThank you very much for your call, Alex. I want to continue in that direction with Ellen in Alexandria, Va. Ellen, your turn.

ELLENHi. Yeah. That really does connect, which is that I know a large proportion of health care cost these days is mental health care. And I don't believe we've heard much about that on the show, and I think it's also a component of what -- I believe it may have been Robin or one of the earlier callers who was talking about with things like people who are averse to exercise or are concerned about body image and that kind of thing. And even healthy behaviors, there can be a component of mental health. So I'll just be interested on any comments on that.

NNAMDIKevin Volpp.

VOLPPYeah. I think the key here is really focusing on how do you -- using the programs you have available, how do you really lower health risks for your employees? Mental health is clearly a huge contributor, co-factor to all sorts of other chronic diseases, other areas like blood pressure, cholesterol, smoking, also incredibly important. And what ideally employers would do is they would make good programs available to their employees in these areas either for free or very low cost.

VOLPPSo you don't have cost barriers to participating in those programs. And then think about how do you tie that to what you're doing and benefit design in a way that really augments the potential of lowering risk for this population of people. There's a lot of, you know, I think the challenge-type programs around wellness are well and good. I think they probably have more of an impact in changing the culture. But as various callers have alluded to, they're not for everybody.

VOLPPThe key is to really think about how do you make programs available that have an evidence base that can help your higher-risk people become lower risk and really lowering any disincentives that might exists to participate in those programs because sometimes they're high costs. And then thinking about how do you reinforce that in ways that are going to be useful to the employees.

NNAMDIRon Goetzel.

GOETZELYeah. I think the point being made here is very important, which is these programs needs to be comprehensive in evidence based. They need to address biometric risk factors like weight and blood pressure and cholesterol, behavioral risk factors like smoking, eating and exercise, but also psychosocial, stress depression, things like that are very important. We published a study just a few months ago called the hero study with 92,000 workers in that study.

GOETZELAnd the number one variable that predicted the highest health care costs was if someone said I am depress on a health risk appraisal. That was more predicted than any of the other risk factors. So unless you can help people who self-identify as having psychosocial mental health issues and get them to the right treatment, the other programs are not as going to be as effective.

NNAMDIKatie, how does the mind-body approach enter into Arlington's programming?

SWEENEYSo the mind-body approach comes in a -- couple of different ways. You know, we partner with our organizational development team to bring wellness into our series of our cohorts from first-line supervisors, mid-level managers, and we really try to focus in with them on a concept of work-life balance, what does that mean. And I love it because it's really defined by each individual.

SWEENEYAnd so we try to hit that home especially with leaders in our organization so that they can not only manage their own personal well-being but also have that trickle down to maybe somebody on their team or another direct report or an indirect report. And we also recently did a mindfulness-based stress reduction program, which we did right around the holidays.

SWEENEYWe were a little uncertain if people would have the time to focus on it. But, quite honestly, it ended up being the best time frame 'cause we got feedback that people were managing their well-being not only at work but also with some of those personal interactions that happened around the holidays.

NNAMDIRon, you are involved in a program that is based on the late Surgeon Genera Everett Koop. And I wanted to talk a little bit -- these are among your duties both at Truven and Emory. It's the president -- and you're also the president and CEO of The Health Project, which is responsible for the C. Everett Koop National Health Awards.

NNAMDIWe should mention, of course, that C. Everett Koop passed within the past week or so and will be clearly be missed. These awards recognize some of the best workplace wellness programs in the country. Tell us about some of the winners of the award and what makes their program so effective.

GOETZELWell, these awards have been given out for the last 20 years, and they include many large companies. I have mentioned some already -- Johnson & Johnson and Motorola and Dow Chemical and Prudential and large corporations but also some small companies. Now, what differentiates these companies and what earns them the award is that they have evidence.

GOETZELThey've got documentary evidence that their programs do two things. One is they improve health and save money. So we've been able to accumulate over 60 examples out there with all of their information transparent and available to anybody who wants to look at it at thehealthproject.com to learn from that experience, so that they can replicate the experience of these organizations at their own work site.

NNAMDIKevin, we are running out of time, but a lot of people might be motivated by an office contest to lose weight, but keeping it off long after the contest is over is more challenging. What have study shown about the long-term effectiveness of incentives as behavior modifies? You only have about 30 seconds.

VOLPPOK. Long-term effects for smoking of incentive programs are good. Obesity remains a big challenge. With the evolution of what's happening in the employer setting, it's not clear that these programs needs to be time limited as a lot of employers are offering these incentive programs on an on-going basis.

NNAMDIKevin Volpp, he is a professor of medicine and health care management at the University of Pennsylvania's Wharton School. He's also the director of the Center for Health Incentives and Behavioral Economics. Kevin, thank you for joining us.

VOLPPThank you for having me on the show.

NNAMDIKatie Sweeney is workplace wellness manager for Arlington County, Va. Katie, thank you for joining us.

SWEENEYThank you, Kojo. It's a pleasure.

NNAMDIAnd Ron Goetzel is a research professor at Emory University's Rollins School of Public Health, where he's also a vice president of Consulting and Applied Research for the Truven Health Analytics. That's a health care data and analytics company. Ron, thank you for dropping by.

GOETZELThank you, Kojo, for having us.

NNAMDIAnd thank you all for listening. I'm Kojo Nnamdi.