Why Health Risk Assessments Don't Deliver

July 25, 2017

Health Risk Assessments (HRAs) have been a core component of corporate wellness programs for more than 20 years, despite growing evidence that they fail to achieve the outcomes that they are purported to deliver. The rampant use of HRAs was originally based on the theory that if people understand their health status and risk factors, they will be motivated to improve their health. These 40+ question surveys are sold by vendors and consultants as tremendous tools for collecting invaluable health data, stratifying populations into risk buckets (for later introduction of life-changing interventions), and driving awareness of health status. The benefits sound great in theory. But the reality is that mere awareness of health status and risk doesn't motive people to change their behaviors. Employers are spending a lot of money to show that their population gets less and less “healthy” each year.

 

HRAs come up short for several reasons:

 

Employees find them invasive.

HRA questionnaires typically cover 10-15 risk factors, from biometric values (BP, cholesterol, blood sugar, etc.) to lifestyle and mental/emotional health. Some HRAs even ask employees about their sexual practices (really?!). And employers introduce big incentives (or penalties) to coerce employees into completing these lengthy, invasive questionnaires each year. Not surprisingly, employees often have concerns about their privacy and question why employers would want to pry into their personal lives.

 

Information overload causes analysis paralysis.

Assessing 10-15 health risks requires dozens of questions that can confuse participants. Some vendors provide HRA participant reports that are over 25 pages long! When presented with so much feedback about complex health topics, participants are unlikely to be able to recognize and digest the most critical information, and they are even less likely to act on it.

 

Self-reported data has major limitations.

When responding to questions, human beings are susceptible to a wide range of response biases that influence the accuracy and truthfulness of our responses. This is especially true in activities that involve self-reported data, like participant surveys. In some cases, participants might strive to provide an answer that the questioner (i.e., employer) will find the most pleasing. In other cases, participants might provide answers that they believe will increase the likelihood of earning an incentive or avoiding a penalty. For example, an employee might be reluctant to self-report that he or she is a smoker if there is a sizable tobacco surcharge attached to the benefits plan.

 

And the use of self-reported data across 10-15 health risks can generate misleading results. From one year to the next, many employees will migrate from one risk strata to another, even without an effective wellness program. The intervention? Just time. This “regression-to-the-mean” phenomenon leads many vendors and consultants to claim unbelievable ROI figures, even though the risk factors that the program targets (e.g., weight loss and exercise) barely budge.

 

Low completion rates

Finally, few vendors successfully motivate a large enough percentage of the employee population to complete HRAs for the data to be meaningful.  The industry average response rate is about 50%, even with substantial incentives, resulting in substantial selection bias. With less than half of eligible employees completing HRAs, one simply cannot assume that the respondents are representative of the whole employee population.  

 

Recommendations:

 

  1. Limit HRA questionnaires to health risks that the wellness program can actually address.

  2. Keep it brief. Less is more when it comes to HRA questions.

  3. Reassure employees that their individually identifiable health information (i.e., PHI) is not shared with their employer.

  4. It’s fine to provide rewards for HRA completion, but make sure the incentive isn’t so large that it feels coercive, and don’t tie incentives/penalties to actual responses.

  5. Give employees multiple options for HRA completion (paper, web, etc.).

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