When Dave Lagerstrom became president and CEO of a manufacturing company over a decade ago, he set out to make his employees healthier — in body, mind and soul. Turck Inc., near Minneapolis, already offered classes on lifestyle and nutrition, Weight Watchers memberships, and screenings for metrics like blood pressure at an annual health fair. It had also just established an in-house clinic.

But like many companies, Turck’s main “wellness” prong was to offer employees a discount on their health insurance if they completed a health questionnaire and got a risk assessment in return. Lagerstrom knew from his own experience that it was only too easy to bend the truth about diet and exercise habits and to ignore advice offered back. He wanted the company to do better.

Turck had about 500 US employees back then, and has closer to 750 today. Thirty-three languages are spoken on the factory-room floor, and cultural attitudes about health care vary widely — many workers didn’t avail themselves of regular checkups and screenings. So Lagerstrom and his colleagues began by thinking mostly about additional aspects of health: cholesterol, cancer screenings and the like.

Very soon, though, they embraced a far broader framework laid out in the 2010 business and self-help book Wellbeing , by Tom Rath and Jim Harter, which breaks down wellness into five elements: physical, social, financial, career and community. Lagerstrom began to reflect on how each could be integrated into the company’s values and mission.

What resulted was a cornucopia of changes.

To enhance employees’ social well-being, Turck instituted flextime, part-time and telework possibilities and allowed employees to organize intramural sports at the fitness center. And to boost career well-being, Turck offered tuition reimbursement and mentorship so that workers could advance within the company. Turck also hired a full-time wellness coach, and more recently, a financial coach, to offer advice on saving for retirement and children’s college education.

Turck still offers the health insurance discount. But today, employees and their adult dependents must do more than that health risk assessment. They must undergo preventive screenings it recommends — have a mammogram, say, or a blood glucose test. And employees must work with the wellness coach on one well-being goal a year, be it “I want to lose weight” or “I want to volunteer in my community.” As of this year, spouses must take on a well-being goal, as well.

It goes on. The company pharmacy dispenses prescriptions for chronic conditions like high blood pressure or “bad” cholesterol at no cost. The clinic’s medical staff makes house calls, and those who need mental health help can access it confidentially. Employees can even create garden plots to grow vegetables for their families or receive subsidized weekly produce shares from a local farm.

Lagerstrom practically gushes, in an understated midwestern way, when describing what benefits this wellness overhaul has brought to the company. “Oh, boy. I mean, everything,” he says.

Based on employees’ use of health care, Turck estimates that the company has avoided $6.7 million in health care spending since 2007, and the amount saved has grown annually. Medical visits outside the more cost-effective on-site clinic are declining at a rate of about 5.2 percent per year, and behavioral health visits due to stress, anxiety and depression have dropped dramatically. In a confidential company survey, 93 percent of employees report that they give their best effort every day and 89 percent say they plan to stay at Turck for the next year or more.

Turnover is under 4 percent, compared to the industry average of 13 percent, and revenue is growing 6 percent annually. Lagerstrom attributes Turck’s growing market share in large part to the culture of well-being that the company has built. “We are seeing dramatically better growth than our competitors,” he says. “Employees’ willingness to do whatever it takes to make the company successful is evident at every level of the organization.”

Workplace wellness is a growing industry worth $9 billion in the US — and judging by national health statistics, it seems we may need what it’s peddling. Rates of obesity, high blood pressure and chronic diseases such as diabetes, asthma and heart disease are soaring, which is as bad for our collective wallet as it is for our health: The lion’s share of health care spending goes on treating such conditions, according to the Centers for Disease Control and Prevention.

Most companies — and the vast majority of large ones, with 200 or more employees — have health promotion programs of some kind or other that are meant to improve worker health and rein in costs. According to an annual survey of employee health benefits conducted by the nonprofit Kaiser Family Foundation, last year 85 percent of large companies (58 percent of smaller ones) offered their workers opportunities to participate in smoking cessation, weight loss or other lifestyle-modifying programs. Sixty-eight percent offered their workers help managing chronic conditions such as diabetes and asthma, and 69 percent offered a health risk assessment of the kind used at Turck, a clinical exam or both (the numbers for small companies are 40 percent and 44 percent, respectively).

To many, this might sound wonderful — but it all sounds better than it is. Just a small fraction of companies go whole-hog on wellness like Turck does, while a larger group provide a middling array of benefits. Mostly they offer what one might call “random acts of wellness” — an annual health fair, say, or flu shots or a section on healthy lifestyles on the company intranet.

“You have this very small number of companies that do things very well. But then probably 90 percent of companies do something,” says Nico Pronk, president of HealthPartners Institute, a health policy nonprofit in Minneapolis, and chief science officer with the insurance company HealthPartners. And that “something” may do little or nothing to boost employees’ well-being or, for that matter, companies’ bottom lines.

Chart showing the three prongs of workplace wellness programs: screening for health problems, managing lifestyle and risks, and keeping tabs on diseases. Each of these components comes with a range of potential services, from bone density screenings to stress management programs.

Wellness programs generally consist of some combination of three prongs: screening for potential health problems, keeping tabs on diseases, and promoting healthy lifestyles to reduce health risks. Each of these components comes with a range of services, from bone density screenings to stress management programs.

The science isn’t settled: Data from studies of individual wellness programs have been mixed, and ones that pool results from multiple studies often note the paucity of good-quality evidence.

And despite the programs’ aims, some detractors call the efforts misguided — they say it’s not clear, for example, that obese employees require or use more health care than non-obese ones. Vendors in the profitable commercial wellness industry also have been known to make unrealistic promises of enormous returns on health care costs, and companies have been known to tout misleading outcome numbers. “These intrusive programs benefit no one except the vendors and consultants who make their livings off them, at your expense,” write Al Lewis and Vik Khanna, cofounders of the health literacy company Quizzify, in a blistering 2014 book, Surviving Workplace Wellness.

Financial incentives raise special concern for some critics. These are often presented as discounts on insurance premiums for those who agree to take a health risk assessment or maintain healthy metrics for weight or blood pressure. But they can equally be viewed as penalizing those who decline to participate or cannot reach goals for medical reasons, and sometimes overtly levy penalties for activities such as smoking.

In a nutshell, the messy and varied landscape of wellness programs makes it hard to assess whether they work, for either employee or employer — and if so, what works best. “There are a bunch of sub-questions here. Number one is: What do you mean by ‘work?’,” says Ron Goetzel, director of the Institute for Health and Productivity Studies at Johns Hopkins Bloomberg School of Public Health, and vice president at the company IBM Watson Health. “And the second, more important question is: What is a wellness program?”

Workplace wellness takes root

The concept of wellness at work stretches back at least 300 years to an Italian physician named Bernardino Ramazzini, who described the ailments and hazards dogging workers in dozens of professions in his 1700 book, Diseases of Workers, and is considered the father of occupational medicine.

In the US, employers didn’t really dig into workplace wellness until around the turn of the twentieth century, when a handful of progressive manufacturing companies such as Pullman and Ford, realizing that healthy employees were productive employees, added exercise facilities and other health-promoting benefits to their campuses. A trickle of other companies followed suit.

The real seeds of the US push for workplace wellness were planted in the decade after World War II, as health care became inextricably linked to the workplace through the rise of employer-based health insurance. In 1970, President Richard Nixon signed the Occupational Safety and Health Act, paving the way for other government initiatives promoting health at work. During this decade, too, companies adopted executive fitness programs to keep managers from keeling over from heart attacks and other stress-induced ills.

Increasingly, workplaces began embracing health and wellness programs of the types around today; interest grew as the decades passed in response to rising health care costs. In 1979, pharmaceutical giant Johnson & Johnson launched its full-fledged wellness program, then called Live for Life. The first to report major savings in health care costs, it’s still considered an industry trendsetter today.

Both Johnson & Johnson and Turck offer what Laura Linnan, director of the Carolina Collaborative for Research on Work and Health at the University of North Carolina at Chapel Hill, would call a comprehensive wellness program. Linnan has been studying worksite health promotion programs for more than 30 years, and back in 2004 she and her colleagues did a thorough survey of offerings, for the first time defining what a comprehensive program should look like.

Chart showing workplace wellness offerings from a 2015 survey of companies with 50 or more employees. About 80 percent of employers said they offered some sort of wellness program to workers, but the programs vary in what they offer and how well they dovetail with other employee services like employee assistance, or how well they integrate into company culture. About 13 percent of employers said they offered all five elements of what health experts deem a “comprehensive” program.

In a 2015 survey of companies with 50 employees or more, about 80 percent of employers said they offered some sort of wellness program to their workers. Programs vary in what they offer and how well they dovetail with other employee services like employee assistance, or how well they integrate into company culture. About 13 percent of employers said they offered all five elements of what public health experts deem a “comprehensive” program — the components shown on this chart.

It doesn’t just offer health screenings and behavior-change programs, the scientists wrote. It exists within a healthy work environment. The cafeteria sells nutritious food, bosses support taking breaks, there are on-site exercise spaces or walking trails. It dovetails with a company’s other benefits and safety policies; after all, if you’re breathing chemical fumes on the factory floor, you might scoff if an employer urges you to quit smoking.

This may seem straightforward, but in 2004, just 6.9 percent of workplace wellness programs hit that sweet spot. Last year, Linnan led a new survey that’s soon to be published; the percentage has more than doubled, she says, but it’s still a far cry from the Department of Health and Human Services’ stated target of 75 percent for employers with a staff of more than 50.

If you build a wellness program, will it work?

Given that most employee wellness programs are a grab bag, it’s no surprise that studies evaluating their effectiveness have been mixed.

Certainly, Johnson & Johnson’s wellness program has been analyzed backward, forward and sideways because of the company’s size and the program’s longevity. One report commissioned by the company, focusing on 2002-2008 data, found savings of about $565 annually per employee in health care costs and determined that workers had lower rates of obesity, hypertension and tobacco use than average. Other major corporations, such as Lockheed Martin and Ford, show benefits, too.

Johnson & Johnson has a much-studied corporate wellness program. This chart shows how estimated health care costs at the company (solid blue line) grew at a slower rate than estimated health care costs at 16 comparable companies (dotted blue line) between 2002 and 2008, according to a 2011 analysis.

Johnson & Johnson has a much-studied corporate wellness program. Estimated health care costs at the company (solid blue line) grew at a slower rate than estimated health care costs at 16 comparable companies (dotted blue line) between 2002 and 2008, according to a 2011 analysis.

But the research has been scant on how these rosy conclusions transfer to smaller companies or ones that are launching a wellness program but don’t have millions to invest up front in it.

That’s partly because of the sheer diversity of wellness programs. And it’s partly because the studies are not easy to do: All require large datasets to ferret out population-level impacts and all of the available methods have their imperfections.

Studies of small companies are especially hard to pull off because they don’t have big enough numbers, and pooling data from lots of them to bring up the sample size is difficult because programs and company cultures vary so much.

The literature is certainly biased, scholars add, because negative studies are far less likely to get published. And if a program does work, which bits of it are the most effective and which are a waste of time? That’s something a company might want to know if it doesn’t have bottomless funds.

“I would argue that because there are dozens and dozens of published studies that have shown an impact, there’s an excellent base out there showing these programs can work,” Goetzel says.

Chart of a 2011 analysis of Johnson & Johnson’s long-running wellness program. Employees were less likely to use tobacco, be obese or have high blood pressure compared to employees at six other companies. But the news wasn’t all good: J&J employees were at higher risk for depression (as well as stress, not shown), and there was no difference in blood cholesterol profiles.

In a 2011 analysis, researchers used employee health data to estimate the percentage of Johnson & Johnson employees at high risk for a variety of health problems. Data from the company’s long-running wellness program indicated that Johnson & Johnson employees were less likely to use tobacco, be obese or have high blood pressure compared to employees at six other companies. But the news wasn’t all good: J&J employees were at higher risk for depression (as well as stress, not shown), and there was no difference in blood cholesterol profiles.

The bottom line, though, is that very few programs are rigorously evaluated.

In a rare example of a randomized controlled trial — considered the gold standard in clinical science but tricky to pull off for this kind of question — in January researchers reported results from a trial on a wellness program at the University of Illinois. Some 4,800 of the institution’s employees were assigned to either participate in a workplace wellness program or sit it out.

The program was designed to be on the “comprehensive side” of what many workplaces offer, says study coauthor Damon Jones, a public policy researcher at the University of Chicago: Employees underwent both a biometric screening and a health risk assessment, then had the opportunity to take one wellness course that aligned with their health goals in the fall, and another in the spring. They received differing levels of financial perks to participate.

It was representative — and one year in, ineffective.

Participants didn’t take up more healthy behaviors, like exercising, nor did they get any healthier on measures such as weight and blood pressure. And the company didn’t curb its health care spending. Those most likely to participate were people who were healthier to begin with, Jones says.

Goetzel isn’t surprised. “The intervention is very low-dose,” he says — plus one year is too soon to see returns on even an effective intervention. Jones says the researchers will report again at two and three years.

More encouraging data do exist. One of the most widely cited studies on workplace wellness is a 2013 congressional report produced by the Rand Corporation, a nonprofit think tank. The researchers looked at insurance claims, health risk assessments and other data pooled from seven large companies around the country, including a government agency in the south and a midwestern manufacturing company.

The findings were encouraging: Workers improved on all health measures except blood cholesterol levels, though the gains were generally small. “The basic conclusion is that these health and wellness programs can improve employee health,” says Harry Liu, a senior policy researcher at Rand and one of the lead authors of the report. “I think, in general, it’s a good deal for employers.”

It’s also a basic public health matter, says Karen Pollitz, a senior fellow at the Kaiser Family Foundation who studies employee health benefits. “Public health is all about making basic wellness and prevention so easy to do that you trip over it,” she says. “We spend most of our waking hours at work, and it’s good to work in a healthy workplace.”

Stick or carrot

Another major issue — an aspect of workplace wellness programs that is sometimes described as invasive, even coercive — is the so-called financial incentive. Incentives offer workers discounts on their health insurance, or other perks, if they do a health risk assessment or biometric screening, refrain from smoking, or achieve some other kind of health benchmark.

Often, the policies are in effect penalties, even if they’re packaged as incentives, says Pollitz. “It’s two sides of the same coin if people pay two different premiums based on whether they participate in the program, or whether they are a normal weight or not.”

Legally, companies can charge smokers more for their health care, but only if they offer smoking cessation programs. According to 2017 Kaiser Family Foundation data, 16 percent of firms with fewer than 200 employees have smoker penalties — as do half of companies with more than 5,000 employees. A study published in March, though, showed that nearly half of small employers with such a penalty don’t offer quitting help. “I think that’s really bad,” Liu says. “It shows that those small employers just want to transfer the cost.”

Studies do suggest that incentives can lure people to participate in wellness programs. But, says Pollitz, programs that rely on them “have not ever been shown — not by any scientific study — to produce meaningful gains in health status.”

Chart showing workplace wellness incentives. An estimated 32 percent of large companies with wellness programs entice workers to participate with incentives. At those large companies, defined here as having 200 or more workers, incentives can take different forms (top) and be worth varying monetary amounts (bottom).

An estimated 32 percent of large companies with wellness programs entice workers to participate with incentives. At those large companies, defined here as having 200 or more workers, incentives can take different forms (top) and be worth varying amounts (bottom).

“They absolutely can produce savings for employers — to the extent that they shift cost,” she adds. If a worker chooses to not get screened, for example, her employers might now pay 60 percent of her insurance rather than 80 percent.

But not everyone is so down on incentives. Michael Roizen, chief wellness officer of the Cleveland Clinic in Ohio, believes they’re key to the changes he’s seen among the Clinic’s 50,000-plus employees. The Clinic is among the minority of companies (less than 14 percent with more than 200 people, according to that Kaiser Family Foundation survey) to require participants to meet goals such as a healthy weight and blood pressure to win their reward.

Roizen says he worked hard to make those changes possible. The six-point plan he developed includes free access to programs for weight loss, stress reduction, smoking cessation and other lifestyle tweaks; a buddy system for working toward wellness goals; and relentless support from management. The Clinic doesn’t hire smokers, but provides smoking cessation help to prospective employees. The organization estimates that it has saved $261 million in health care costs since 2010, and since 2007, when it launched the wellness program, health care costs have risen by 14.6 percent, compared to 54 percent at other organizations. Fifty percent of the Clinic’s staff has a chronic condition compared to a national average of 70 percent.

The money metrics: Do corporate wellness programs result in savings?

For employers, a key motivator for investing in wellness programs is cost-saving — it’s the other main way to measure whether a wellness programs works. Companies tabulate how much money they spend on a wellness program against how much they save by implementing it.

So do companies see a return on investment? Here, too, studies offer mixed findings.

One widely cited 2010 meta-analysis — which combined data from 36 previous studies, mostly of firms with more than 1,000 employees — reported a reduction in company medical costs of $3.27 for every dollar spent on wellness programs, and a reduction of $2.73 per wellness dollar spent in the cost of employees missing work. The authors offer some cautions, though: Most of the studies they examined had flaws, and the companies analyzed were probably the ones most likely to benefit.

A 2014 Rand analysis of PepsiCo’s wellness program also looked at the money end of things, and managed to sort out the different parts of wellness programs to see which ones delivered financial returns. It found significant differences.

On the one hand, helping workers manage ongoing chronic diseases returned companies about $4 for every dollar spent, the team found. On the other, components that focused on identifying risk factors and promoting healthy behaviors in people without chronic diseases offered no return. In fact, they came at a cost, returning about 50 cents for every dollar spent.

That makes sense, says Liu. After all, workers with health problems are already seeking medical care for their conditions, so if they seek less, the company wins. Those participating in prevention are using resources for some hypothetical future benefit.

But researchers are increasingly asking whether it’s even the point to expect a return on investment from a wellness program. They don’t expect to directly profit from other employee benefits, like vacation and health insurance. Many argue that companies should focus on “softer” dividends — not just improvements in health and productivity, but also loyalty, morale and reputation — benefits gleaned from simply being a good employer.

It’s that culture, as much as any specific health program, that keeps people well at work. “If you’re working for a [rotten] boss and you’re getting abused and you feel completely unhappy and miserable at work, the odds of you proactively taking care of yourself go down,” says Jeffrey Pfeffer, a business theorist at Stanford University and author of the 2018 book Dying for a Paycheck.

Based on Turck’s experience, Lagerstrom agrees that true workplace wellness means looking beyond the dollar. “I’ll tell anyone: From a business standpoint, you cannot go into this to save money — it doesn’t work,” he says. That’s not to say that you don’t save money ultimately, he would hold, but the financial returns —and the establishment of a company culture that fosters well-being — take five years or more to emerge.

“The day-to-day decision-making that is always in the back of your mind is, what is the best thing for our employees?” he says. “That’s what really makes this work.”