Health risk assessments are used by most wellness program providers and employers as the key to opening the door to employee health improvement.

These questionnaires usually consist of 15 to over 150 questions and ask the participant to record their exercise habits, eating habits, alcohol consumption, biometrics and a range of other health risk and habit information.

For employers, HRAs are meant to provide valuable insight for designing suitable programs. For participants, they offer a valuable report, summarizing their risks and providing guidance on how to mitigate those risks over time.

They are sold as the first step towards an effective wellness program and the impetus for better health habit choices for the individual. But are they really?

Because HRAs are voluntary, the information they provide is often a very biased sample of the entire population. Unless participation is over 80%, the data they reveal is almost certainly skewed.

Worse, it is not always possible to tell in which direction the data is skewed. If the healthier people in the population complete the HRA - as is usually, but not always, the case - the results may look much better than they should and vice versa.

For a non-biased picture of the health risks in your company, you're better off assuming you have the same general prevalence of health risks for similar people in each state - data that are readily (and freely) available from public resources such as the Centers for Disease Control and Prevention.

Other factors, such as who is issuing the HRA - insurance company, third-party wellness vendor or the employer - company culture and recent events at the organization can all play a role in influencing who will complete the HRA. Even at high rates of completion, the information gained is inaccurate because of the way that people remember and record their answers.

Poor memories

Another confounding problem is that people have very poor memories. Research on poor eyewitness accounts in the courtroom, where witnesses are influenced by the suggestions of experienced litigators, provides an example.

Simple suggestions about details of a crime scene can be implanted into eyewitnesses' memories by questions such as, "On the night of January 23rd, can you remember seeing the defendant, Mr. X, leaving the bank in his red getaway car?"

Despite the question seemingly being about Mr. X, by the next time the witness is asked a question, they may well remember seeing a red car, even though they never did.

With HRAs, the problem is worse, since everyone knows what the optimal answers should be. For example, do you think the "right answer" for how many alcoholic drinks you consume a week is:

a) None

b) 1-4 drinks

c) 5-19 drinks

d) More than 20 drinks

Regardless of your personal truth, everyone knows that either A or B is probably the answer that will make you look the best.

Other forces at work

Now add three other biasing forces. The first is employees' suspicion about what their employers or insurers may do with the information. These fears encourage employees to record answers that are safe and that will not result in them being targeted or subjected to disease management calls or, worse, fired.

Despite assurances about privacy protections from HIPAA, many employees still mistrust HRAs and leave the experience feeling uninspired and targeted.

Second, when employers offer wellness incentives for HRA completion or even for mitigating risk factors, it sends a clear message: Good-looking answers are best.

Many employers celebrate the seemingly positive impact of their new incentive program on the health of employees, blind to the fact that all they have done is pay people to report answers that are more positive.

Third, assuming you believe in the honesty of your employees and that they would not be swayed by incentives to misreport their health habits, consider that mentally healthy employees should misreport on their HRAs.

Psychiatrists tell us that one of the symptoms of depression is realism about one's talents and abilities.

That is why more than seven out of 10 of us regularly answer that we are better than average drivers, thinkers and workers, and that we are better-looking than average. It's not (only) lying; it's what keeps us going when we face failure or disappointment.

Therefore, an overly generous depiction of one's own health habits is healthy, but nonetheless provides an inaccurate picture of our actual state of wellness.

Experience with comparing answers on an HRA to answers that come from blood tests (for example, a cotinine test for recent tobacco use) often shows that as many as 50% of people who smoke say that they do not. HRA supporters say that you can trust people to tell the truth, mostly.

The issue is not dishonesty, it's that we're very bad at remembering our own habits; we're generous to ourselves when in doubt and we're very good at defining our habits in a way that looks good to others.

I have to confess that for more than 10 years, I called myself a non-smoker, who only occasionally smoked socially. I just happened to be very social! When I finally realized that I was lying to myself and reframed myself as a smoker, it was the beginning of the end of that habit.

Design key or monkey wrench?

Even if you admit to some bias in how people answer, proponents will still argue that HRAs provide the necessary, even crucial, data needed to design effective wellness programs. While valid for treating diseases, this model is not applicable to wellness. Here's why: Regardless of your age, income, family size or even health status, the wellness prescription is always the same:

1. Exercise daily for an hour.

2. Eat well, mostly freshly harvested raw plants.

3. Sleep more than seven hours a night.

4. Avoid unhealthy behaviors, such as using tobacco, abusing alcohol or prescription or other drugs, and avoiding unsafe or polluted environments/situations.

As a final plea, defenders of HRAs argue that despite the bias and the self-reporting problems, they at least provide a way to measure changes over time.

Again, this is not true, as people actually change their answers over time, especially as they become better and better at being generous to themselves or as employers and insurers start to base incentives, access to benefits, or rewards on HRA completion.

Designing wellness programs simply does not require HRA data. If you work in wellness, have you ever noticed that the programs suggested happen to match those available from the vendor?

If you are the head of wellness for an employer, did the HRA data really provide you with new insights? Likely not. Probably, you knew what the program would look like before you started.


Contributing Editor Andrew Sykes is chairman of Health at Work. He is a qualified actuary, a licensed health insurance broker, an HIAA managed health professional and an accomplished speaker on the topic of consumer-directed health care and wellness. He can be reached at andrew@hatwork.com.

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