Today the Penn State University Faculty Senate released the agenda for the first full Senate meeting of the Academic Year (HERE).
As part of the meeting agenda, the University Faculty Senate will facilitate what it calls a "Special Presentation by David Gray, Senior Vice President for Finance and Business/Treasurer, Susan McGarry Basso, Vice President for Human Resources, and Highmark Representatives Take Care of Your Health Initiative" for which 30-40 minutes has been allocated for presentation and discussion (HERE).
As part of that Special Presentation, Mr. Grey and Ms Basso will present a version of their responses to a carefully crafted set of questions sent to both several weeks ago by the Senate leadership. This post includes both the questions forwarded and the written responses of Mr. Grey and Ms. Basso. I invite you to read and assess thew value of both the questions posed and the answers given both in terms of their relevance to the concerns of faculty, their value in exposing the failures of shared governance and the mistakes in the conception and roll out of the wellness program, if any. An analysis of the answers given follows.
University Faculty Senate
Questions on the Take Care of Your Health Initiative
Taking Care of Your Health
Why is a punishment-based, coercive approach necessary? Why is an incentive-based, voluntary approach not used?
Many of us already get regular, preventive medical examinations. Why do we need to go through the biometric screening or fill out the questionnaire? Can’t our numbers be obtained from our physicians?
The Survey, Security and Privacy, and Use of Data for Future Purposes
Why was the WebMD platform chosen for the survey?
WebMD has been hacked in the past. Why should we believe it would not be hacked again?
If our health care information is already saved in a secure medical database, then why must our information be stored in an additional database?
Will WebMD and/or Highmark share any portion of our information to third parties for marketing or other purposes?
To whom and in what form will WebMD and/or Highmark report results?
How will these data be used?
Will the collected data be used to charge premiums based on health conditions now or in
Value of the Program to Health Outcomes
What are the health care claims costs, the premiums paid by the employee and Penn State, and the administrative costs for the last five years, compared to those projected for next year?
Are there studies showing that programs similar to the “Take Care of Your Health” program have produced positive health outcomes and reduced health care costs?
How will you determine that compliance with the new policy has improved health outcomes and reduced health care costs at Penn State?
Martha Aynardi, 2013-14 Chair, Joint Committee on Insurance and Benefits
Ira Ropson, 2013-14 Chair, Senate Committee on Faculty BenefitsJo Anne Carrick, 2013-14 Vice Chair, Senate Committee on Faculty Benefits
August 20, 2013
2013-14 Officers of the University Faculty Senate
The reponses of Mr. Grey and Ms. Basso follow:
Taking Care of Your Health
QUESTION 1: Why is a punishment-based, coercive approach necessary? Why is an incentive-based, voluntary approach not used?
Penn State historically has approached wellness with a voluntary approach resulting in limited participation and marginal results. Since January 2008, approximately 1% of Penn State covered employees and family members each year completed the online Wellness Profile available to them on the Highmark Health Services Member Website. During that same time period, no more than 5% of Penn State employees participated in the voluntary Penn State Health Matters programs that were available to them.
There are numerous published studies that demonstrate the positive impact that financial differentials have on participation, behavior change, risk reduction and cost reduction for preventable healthcare claims.When financial factors are integrated with premium contribution level, articipation/completion rates in wellness programs can be expected to increase to the 75%-90% range. (Chapman, American Journal of Health Promotion, September/October 2008)
Whether structured as an incentive or disincentive, the creation of a financial differential between those who participate in wellness versus those that do not, significantly increases participation. The University could have structured its program as an incentive by overinflating health care premiums for all employees and then discounting for those who participate. However, the University did not feel that was fiscally responsible. The current strategy keeps premiums stable for all with no hidden costs.
QUESTION 2: Many of us already get regular, preventive medical examinations. Why do we need to go through the biometric screening or fill out the questionnaire? Can’t our numbers be obtained from our physicians?
Based on historical data, many members fail to get the recommended preventive services appropriate to their age and gender. For example, Penn State University’s compliance rate for physical exams submitted by physicians was a mere 17.3% for 2012. Further, Penn State University showed a non-user rate (defined as individuals who incurred no medical or prescription drug claims at all) of just over 10%for its active members in 2012. Non-use of the plan does not signify a healthy person–it suggests the potential existence of health risk factors for an individual who is not engaged in their health. The biometric screening opportunity raises awareness and encourages members to learn their numbers first hand. Additionally, Penn State employees are counseled, on the spot, when they receive the results of their screenings. For many people, this becomes a teachable moment, or “tipping point” for their health practices. For example, a risk detected early can motivate an individual to see their physician for treatment, begin to exercise, or change their nutrition.
As an alternative to the biometric screenings, Penn State employees may ask their physician to perform the screenings or report results you obtained between January 1, 2013, and now. A Physician Derived Results (PDR) form and instructions for its use are included on the employee benefits website. Likewise, the Wellness Profile is also designed to raise awareness by providing the member with an individualized report after its completion. This report is something that can be shared and discussed with a member’s physician (ideally during an annual physical exam) which can also lead to opportunities for behavior change. Capitalizing on these opportunities contribute to the effort of long term reduction in claim trend and improved member health.
The Survey, Security and Privacy, and Use of Data for Future Purposes
QUESTION 3: Why was the WebMD platform chosen for the survey?
Highmark Health Services contracted with WebMD Health Services to provide a Personal Health Record, Wellness Profile, and many other related resources designed for individuals to manage their health. It is important to note that WebMD Health Services is different from WebMD.com which operates a separate public website that allows free access to health and wellness information and generates revenue through the sale of advertising on its site. The services and resources offered by WebMD Health Services are purchased by health plans and employer groups, and WebMD Health Services does not allow any advertising on its websites. Like many other national health insurance plans, Highmark Health Services determined it was more efficient and cost effective to partner with WebMD Health Services than to build these resources internally. Therefore, Highmark Health Services entered into a business associate relationship with WebMD Health Services. The decision to partner with WebMD Health Services was made after a
RFI (Request for Information) and RFP (Request for Proposal) process that evaluated available resources and tools, success in enabling individuals to modify lifestyle behaviors, and information security across a number of vendors.
QUESTION 4: WebMD has been hacked in the past. Why should we believe it would
not be hacked again?
Highmark Health Services is contracted with WebMD Health Services which is only available for direct purchase by Health Plans and Employer groups. WebMD Health Services has no evidence that a third party has ever gained unauthorized access to its systems and obtained information about end users. WebMD.com, the consumer-facing publicly available site operated by WebMD LLC similarly has no such evidence about its site. For these reasons, it is not clear what the question refers to when stating that “WebMD has been hacked in the past.” While no system is “hack-proof” WebMD Health Services employs state of the art security procedures to protect the information of end users.WebMD Health Services’security infrastructure complies with the HIPAA security rules and is audited by an independent third party on an annual basis. WebMD Health Services takes a multi-layered “Defense in Depth” approach to securing its web-based tools by implementing complementary security controls at the physical, network, system, and application layers. In addition to technical controls, WebMD Health Services’ overall security strategy encompasses security management practices designed to ensure that its
applications are not only built securely, but maintained securely as they evolve overtime. User access to all of itsapplications occurs via 128-bit SSL encryption, which ensures a high degree of confidentiality and data integrity between WebMD Health Services and its
QUESTION 5: If our health care information is already saved in a secure medical database, then why must our information be stored in an additional database?
There are two platforms that store our members’ clinical data. The WebMD Health Services platform includes the wellness profile, personal health record, and other resources like the tool for tracking which participants satisfied the “Taking Care of Your
Health” requirements. The Highmark Health Services’ platform utilizes information from the wellness profile as well as claim data to identify members who might benefit from case management, disease management or wellness coaching. Additionally, Highmark Health Services nurses responsible for care and case management benefit by having a more complete member profile, which in turn helps them to provide a more tailored approach when working with individuals. Information must be exchanged between the Highmark Health Services and WebMD Health Services databases in order for each of the platforms to provide the required functionality. This paired functionality is what leads to more effective case management and health coaching outcomes, which is another element critical to the effort of claim trend reduction and improved member health.
QUESTION 6: Will WebMD and/or HighmarkHealth Services share any portion of our information to third parties for marketing or other purposes?
QUESTION 7: To whom and in what form will WebMD and/or Highmark report results?
WebMD Health Services will report program participation and wellness profile data only to Highmark Health Services. Highmark Health Services will provide a list of those who
completed the requirements of the “Take Care of Your Health” Program to Penn State in
order that the the financial differential can be administered. Highmark Health Services will also provide aggregate data to Penn State in order to help in the development of health promotion strategies or for other health plan operation purposes. Highmark Health
Services will not report individual results to Penn State. Member information received by Highmark Health Services related to biometric screenings and wellness profile results are
used for health plan operations. Highmark Health Services uses this information for case management, care management and engagement with Health Coaches. Reporting provided by Highmark Health Services to our clients generally includes aggregate reports to help the client develop more targeted health promotion strategies as well as a list of individuals who completed the requirements of a program like “Take Care of Your Health”. WebMD Health Services provides reporting only to Highmark Health Services.
QUESTION 8: How will these data be used?
Member information received by Highmark Health Services and WebMD Health Services will be used for health plan operations purposes. This includes developing strategies for health promotion and wellness and for identifying members with acute, chronic and / or potentially life-threatening conditions in order that these individuals can
be offered disease management services. In addition , the data are used to identify those
who may benefit from wellness coaching provided by a Highmark Health Services RN Health Coach or Wellness Coach and to reach out to these individuals to offer these services.
QUESTION 9: Will the collected data be used to charge premiums based on health
conditions now or in the future?
Penn State will never have access to an individual’s health records, will never ask for those records and will not charge an employee additional fees based on individual health status now or in the future.
Value of the Program to Health Outcomes
QUESTION 10: What are the health care claims costs, the premiums paid by the employee and Penn State, and the administrative costs for the last fiveyears, compared to those projected for next year?
Penn State Health Care Cost
Fiscal Year 08/09 09/10 10/11 1/12 12/13 * BAU 13/14 *Prop 3/14*
Total Health Care
$150.4 $169.2 $174.8 $177.2 $193.0 $217.0 $210.4
Penn State Costs
$118.9 $134.9 $138.4 $143.3 $161.3 $180.2 $175.5
$31.5 $34.3 $36.4 $33.9 $31.7 $36.8 $35.0
< 5% < 5% < 5% < 5% < 5% < 5% < 5%
QUESTION 11: Are there studies showing that programs similar to the “Take Care of Your Health” program have produced positive health outcomes and reduced health care costs?
Positive ROI (Return on Investment) and trends in health care utilization and expenses have been well-documented in rigorous studies which are published in peer-reviewed journals. Examples are below:
1.A systematic literature review conducted by The Community Guide to Preventive Services, housed at the Centers for Disease Control and Prevention (CDC) and led by Dr. Robin Soler, evaluated carefully screened studies of health promotion programs and policies introduced by employers over the course of the past thirty years. Applying Community Guide systematic review methods, Soler et al. examined behavioral, biometric, and business-relevant outcomes reported in 51 studies that met inclusion criteria established by the Task Force.The overall conclusion of the review was that comprehensive, well-conceptualized, and theory-based worksite programs do exert a positive influence on certain health behaviors, biometric measures, and financial outcomes important to employers. The Task Force found strong or sufficient evidence that comprehensive programs can reduce rates of tobacco use, dietary fat consumption, seat belt non-use, high blood pressure, total serum cholesterol levels, high-risk drinking, and the number of days absent from work because of illness or disability among participating employees. They also found improvements in workers’ physical activity, overall health and well-being scores, and health care use, especially in terms of reduced hospital admissions and days of care.The Community Guide Task Force performed an economic analysis to determine whether these programs save money and whether they deliver a positive ROI. The results were promising, underscoring the potential for evidence-based programs to achieve a financial payback to employers implementing worksite programs. Estimates by researchers and economists at Harvard cite a $3.00 return for every dollar invested, over a three-year time horizon, from effective worksite health promotion programs.2.A study was published in 2008 in the Journal of Occupational and Environmental Medicine which demonstrated savings of $1.65 in health care expenses for every $1 spent on Highmark Health Services’ comprehensive employee wellness program that includes:
Health risk assessments
Onsite fitness center facilities
Online and onsite wellness interventionsThe study showed Highmark Health Servicessaved $1.3 million from 2002 to 2005 and demonstrated that total health care expenditures grew more slowly for wellness program participants than for nonparticipants, particularly in regard to inpatient expenditures.3. Highmark completed a four year evaluation in 2009 of 11,438 matched participants from 51 employer groups with established worksite wellness programs to determine the impact on the employee population and health. Results from this study demonstrated that employers who participate in wellness programs for two and four years respectively have statistically significant lower medical expenses relative to no wellness program participation. Wellness program participants demonstrated significantly lower increases in overall medical, inpatient and professional expenses and incurred a greater increase in clinical preventive service expense than the matched control group participants:
18.7% higher preventive care services
17.3% lower medical expenses
23.4% lower inpatient expenses
30% lower professional services utilization4. A study published in the March/April 2011 edition of the American Journal of Health Promotion found health care costs rose at a 15 percent slower rate among wellness participants than a comparison group when employers consistently offered a wellness program to their members. The four-year study of select Highmark Health Services employer group wellness programs showed savings per participant as $332 annually, indicating substantial savings may result for group customers once a worksite wellness program is established.
The study evaluated the impact of worksite wellness programs on health care costs and utilization over time by matching approximately 10,000 wellness program participants at 47 Highmark employer groups with a risk-matched, gender-matched, and age-matched comparison group. At a minimum, the employer groups offered Web-based wellness programs from Highmark Health Services to their employees consistently for three or more years. The study also found that wellness program participants developed a greater tendency to pursue preventive services such as preventive physicals, mammograms and cancer screenings, than their comparison group counterparts, possibly as a result of self-care knowledge obtained from their work site wellness programs. Preventive care measures often cost employers more in the short term, but can help to save longer-term health care costs.
QUESTION 12: How will you determine that compliance with the new policy has improved health outcomes and reduced health care costs at Penn State?
As Penn State remains committed to its Take Care of Your Health strategy for the long-term, participation, risk reduction, and preventable claims costs will be assessed using population health management evaluation tools. Highmark Health Services will measure and quantify results including behavior change, risk reduction, and impact on trend. However, the success of a worksite wellness program alone is not enough to effectively control the escalating rate of healthcare costs. Organizations who experience the most success often employ a multi-faceted approach that encourages an optimum balance of transparency, consumerism and engagement through the use of effective health plan design, cost-share and incentives. Like most employers its size, Penn State University self-funds its health insurance plan and uses Highmark as the administrator of its plan. Because the medical and prescription drug claims comprise more than 95% of the total health plan cost, embracing innovative strategies such as those being implemented are critical to the long term financial viability of the plan. In short –Penn State University controls its own destiny through the willingness to embrace such strate
David Gray, Senior Vice President for Finance and Business/Treasurer
Susan McGarryBasso, Vice President for Human Resources
My short analysis of these responses.
Question 1: The Penn State administrators had been frustrated with the lack of positive response to its voluntary wellness programs. Clearly, faculty and staff were not getting the message. Something more was needed. And so they decided, based on centuries of economic analysis, that hitting employees in the pocketbook would be the most effective way of making voluntary participation more effective, that is by creating financial incentives or disincentives. Citing (somewhat unnecessarily given the wide acceptance of this premise int he economic literature) a 2008 study, the answer then admitted the obvious-- one can manage the behaviors of subject populations in almost every way through proper use of financial tools readily available to employers. As such, it didn't really matter what you called it, and there is a sense of wonder about what the fuss was about, because, it is clear that since the university has the authority to deploy financial tools to manage its employee populations and it has done so, it shouldn't matter to those managed what one calls the use of that tool. But of course, this response reminds one of the reasons for the level of anger at the roll out of the wellness program. Merely to suggest that power will have its way, and that power does not recognize a limit of its use in the management of employee lifestyle choices as long as there is even the smallest connection with thew employment relationship, is unlikely to inspire trust in employer motives or raise moral. The answer, then, is technically correct, but evidences a coldness that may ultimately detract from the university's efforts and do little to develop any relationship of trust between administration and subject population of employes. More important, perhaps, was what the answer omitted--there was no sense of any effort to analyze the structures of the current and underutilized incentive programs; perhaps they were ignored because they were badly designed or inadequately structured. There was no sense that any work was undertaken, as an alternative, to improving the current model. Rather, one gets the sense of a decision to purchase an off the shelf product from a preferred vender and then top market that as the only possible means of moving forward Bit that sort of decision might well have profited from more open, transparent and consultative engagement with the faculty and staff.
Question 2: The university appears concerned that its employees do not go to the doctor often enough or for the right reasons. According to them that requires employee compliance with professional benchmarks for appropriate wellness behaviors. This includes both resort to medical check ups and the ingestion of drugs offered through its drug taking subsidy programs. So what appears to be cost savings through lower use of services is actually viewed by those who appear to be experts in this area as a danger sign --one grounded in the unwillingness of employees to more completely expose themselves to the ministrations of the medical profession. Because complete medical transparency and submission to examination at periodic intervals, along with a bench marked ingestion of drugs appears to be the standard to which all employees must aspire, it would appear necessary as well for the employer to exercise its authority to ensure that its employees act appropriately with respect to their health. Near constant monitoring, the answer suggests will induce healthier life styles. It will also provide a greater opportunity for appropriate instruction by health care professionals in the way in which employees ought to order their health lives--all of which, of course, is to be appropriately memorialized and the data stored, distributed and used in appropriate ways by those empowered to make such use. There is nothing sinister here, of course, and the effort is designed to reduce benefit claims in the long run by reducing the likelihood that critical medical conditions will arise during the term of employment. But the language suggests the acceptance of premises about health care and the cultures of acceptable health care routines that the university has deemed it necessary to adopt for its employees without much debate or participation on their part. To that extent, the answer suggests a necessary passivity on the part of employees and, as part of their conditions of employment, a necessary acceptance of those routines that others think best for them.
Question 3: The answer explains why WebMD was chosen in the most beniogn way--they appeared best suited to creating university approved wellness profiles and to operate systems that permit employees to manage their health. There should be confidence in WebMD because, like many things that Penn State does, the choice was made on the basis that lots of other institutions now use them as well. What could be safer than a benchmarked and middle of the herd product for employee use? The answer also explained that WebMD was chosen because it was cheaper for Highmark to outsource this service than to do it themselves. This is also OK because lots of other national health plan also do this. There is strength here, in numbers and safety in the middle of bell curves. Moreover, the answer assures us, the appropriate procedures were followed to find a provider most efficient in managing individuals to make lifestyle changes to suit the tastes of the program and employer.
Question 4: With respect to hacking, the answer assures us that there is no cause for alarm, because there is no evidence that hacking has happened in the past. That is assuring, I am sure. It goes on to say that while there can be no guarantees against future hacking, everyone works hard to minimize, as far as they are able, the chances that this will happen. That is also assuring, as is the further assurance of compliance with a host of standards. One could expect no less. However, nothing is mentioned about the consequences of breach or failure--who is responsible for any damages that follow, what obligations do these providers or the university have to make individuals whole for losses suffered as a consequence of breach? While the routine assurances are well received, the failure to address the critical issue raised int he question is troubling.
Question 5: It appears that individual health care information will be located on two platforms because each platform serves distinct purposes. One is to be used for personal lifestyle choice management (WebMD) under the guidance of professionals, of course. The other is to be used for more deliberate interventions for the good of the individual and more importantly perhaps for claim management (Highmark). The object is not just to save money through case management, but also to layer lifestyle management so that the individual both internalizes the appropriate markers for good employee health behaviors but can also be managed into such behaviors when she strays. The employee will be healthier, the employer will be able to enjoy higher productivity and claims will decrease. The platforms move us closer to the ideal of the model employee living a model life--something that employers have sought since the 19th century and the need to deal with employee behavior management of all kinds (from the use of gin, to the benefits of sport, to the value of religion, to the importance of a model family life as defined form time to time). The move to health and wellness control then continues a centuries long effort for private employers to manage their subject populations. But all for the greater good and in harmony with a tide of employer behaviors that is both global and crosses industrial sector lines.
Question 6: The answer to the question about marketing is interesting on several levels. First, third parties will not receive member information for marketing purposes. But they may receive it for other, unspecified purposes. That might benefit from some further explanation. Of course, the informational use and fulfillment supply chain might stretch along an infinitely long line and so it is also important to note that WebMD may not be the last subcontractor for the health services of this wellness plan. But that raises a more serious question about the completeness of the answer to Question 4 about hacking--it appears that the WebMD Highmark construct could open itself up to a "Edward Snowden" problem of its own for which the risks and responsibilities are not explained with any clarity. Liability and responsibility issues ought to be at the foreground, but these answers tend to background these most important considerations to the detriment of clarity and responsiveness. I hope this can be corrected. Moreover, there is little in the answer that references the authority of these providers to aggregate information and to sell that; no information about arrangements Penn State has made with respect to profit sharing in the event that occurs; and no indication of who bears liability for any breaches as a result of the application of modern dis-aggregating techniques (for example).
Question 7: This answer provides a window on the supply chain operations of the Penn State plan providers. Its is useful as far as it goes--the subcontractor will report to the contract etc. The university, of course, must receive data on individuals in order to assess the appropriate benefits related charges. That is the essence of this plan. It also seems that the employer will also receive aggregated data about employee health choices and activities. That raised an eyebrow, especially since that data will be used by the university to engage in further employee lifestyle choice management. That the university would undertake these tasks without a close consultation with its employees suggests both a remoteness and arrogance that I am sure the university does not intend. Yet, taking it upon itself, unilaterally (though for the best reasons) to develop health promotion strategies" on rather than with its subject population is mot likely to advance either shared governance or a sense of community.
Question 8: It is not clear what "health plan operations purposes" means where the answer assures us of the benign uses to which client information is harvested. What is clear is that thsi is used to develop strategies for health promotion (but we do not know what they have in mind, though my guess is that they have a clear sense of the parameters) and to target health offenders for further intervention. It also will be used to use target individuals who are deemed outliers enough to merit special attention for "wellness coaching". These are quite laudable goals--the goals that were no doubt at the core of these plans when they were entirely voluntary. But what appears as an implied threat--one that is not denied anyway in the answers, is that, having been offered wellness coaching or other interventions, will a refusal to accept these interventions have consequences for plan participation or cost. The answer may be yes--if not now then in some near future time--and to avoid this in the answers creates the possibility of no doubt inadvertent misrepresentation that ought to be cleared up at the earliest opportunity.
Question 9: Much as I want to take the answers at face value and in good faith, it is troubling that the answer to this question seems to contradict the answer to question 7. While it may be true that the university will never have access to individual records, it will have constant access to aggregate data and to individual records of choices to participate in this wellness initiative or incur the benefits penalty. As such, the answer, while strictly true, is also misleading. Aggregate data will be used, we have been told already, by the university in decision making about further modification and the character of health related interventions, into the lives of employees. That this is done through aggregate rather than individual records may make little difference. Moreover, the the university doesn't know that Mary has condition X when it decides based on aggregate data that condition X requires interventions of some kind or have other employment related consequences, will make little difference to Mary. Of course, she will face these consequences secure in the knowledge that the decision was not personal. That is an important comfort.
Question 10: this answer provides valuable data on health care costs, including claims costs, and cost sharing. We should be grateful to learn that administrative costs are less than 5% of costs. Our administration is to be congratulated on that score. It might have been useful to see projections of costs savings under wellness programs as against our "business as usual" plan. That would provide employees with a means of accountability for the claims made on which this programmatic choice was made.
Question 11: This answer is quite useful for providing the studies on which the university's decision to move forward with this wellness program may have been based. It was not clear, however, whether the university's program was identical to those that were the subjects of these studies, especially those that reported positive financial or health effects. And if there is a deviation there is no indication about the effect of these deviations on the possibility of replicating the reported positive results. This ambiguity might be simple to fix. It might also have been useful to explain why those studies that were less positive about these programs were rejected as unhelpful. To consider only studies that say what you want to hear, and to fail to explain why the others are not relevant, may suggest a weakness that may not be present in fact in the analytical approach used to adopt this plan.
Question 12: The answer here serves a s reminder that one of the consequences of this program is that the rate and scope of data harvesting on employees will likely become more comprehensive over the coming years. While the university itself resists transparency, as does the University Faculty Senate, all of the university's employees will stand essentially naked before the health data gatherers. But the assessment parameters are also troubling in some respects--behavior change in particular suggests that the program will be assessed on its ability to transform behavior on an ongoing basis and that, as a consequence, program design may create incentives to ensure behavior changes, whatever the need. In short, it seems, Penn State "controls its own destiny" by managing the behaviors of its employees. Where this is done solely through the offices of high level administrators, where such parameters are declared in the manner of imperial ukases, then both the buy in from employees who truly want to participate and the strength of the community of shared values and obligations that are the hallmark of this great institution, may suffer. That, perhaps, is the greatest lesson our senior administrators might learn from the wellness program implementation events--the failure to engage in deep consultation, the hierarchical and secretive approach to policy making that affects areas of private lives of employees and the tendency to become defensive, circle the wagons and refuse to engage or compromise in the face of opposition may not affect the university's power to enforce its will, but may substantially erode the morale, trust, and sense of community that it has taken years to build.