The "Narrative Advantage": The Two Faces of Wellness Programs at Penn State and the Importance of Control Its Master Narrative

One of the most important aspecst of campaigns to win the hearts and minds of target populations is the ability to control the master narrative, the script that is used when we tell stories or understand what is going on around us. Master narratives (Jean-Francois Lyotard, The postmodern condition: A report on knowledge Manchester, UK: Manchester University Press 1984). Despite its political origins, the concept has become important to both business practices and academic understanding of the context in which people understand what is going on around them.  "Our adherence to a master narrative dictates how we frame stories, whom we interview, the questions we ask and ultimately the work we produce, which typically reinforces our belief in the master narrative."  (What is a Master Narrative, Covering Communities) Once an institution or institutional actors can assert substantial control over the master narrative, they can easily manage populations to their point of view. Indeed, public relations companies, including those with a relationship to universities, now rely heavily on the theory of master narrative to refine their own work on behalf of their clients.

(Dan Lochmann, Senior Account Supervisor, Edelman Japan, "Master Narrative: Four Keys to Unlock Your Company's Essence," Blog post July 4, 2013; "Over the years at Edelman, we have worked on a large number of Master Narrative projects together for companies big and small, Japanese and Western. As we approach each Master Narrative project, we are presented with a different set of challenges depending on the client and its objectives. But there are always a number of things that we try to keep in mind throughout the project to ensure the final narrative really captures the essence of the company and makes the most impact possible once it is communicated to stakeholders: 1) Stay focused on your audience, not the company itself; 2) Tell a story, not a corporate message; 3) Find a niche that you can own and build on; and 4) Keep it short and sweet."  It should be noted that "Penn State announced today that it has retained Edelman and La Torre Communications to immediately support the University in corporate communications, media relations and stakeholder engagement."Penn State retains Edelman and La Torre Communications, Penn State News,

April 25, 2012)

Control of the story, then, is essential to managing the interpretation of the "facts" deployed to reinforce a particular perspective and to deepen that perspective as the only "natural" way of seeing things.  That suggests, of course, that challenges to the premises of the master narrative are not merely wrong, they are deviant, anti-social and disruptive--the sort of challenge that might well justify discipline. (Jan M. Broekman and Larry Catá Backer, Lawyers Making Meaning: The Semiotics3of Law in Legal Education (Dordrecht: Springer, 2012).

Currently two narratives are competing to serve as the master narrative of employee benefits and of Penn State as an institutional actor.  One seeks to situate the narrative in the benign and engaging efforts of a caring university in which employees may trust their superiors, the other situates the narrative in adversarial relationships in which a commodified labor pool of faculty and staff are viewed as a factor in the production of cash flow and in which there is little trust between university administrators and employees about each others' motives and objectives. The first suggests a mutually engaged relationship built on trust and deference in which there can be a certain level of trust that employee interests will be valued in administrative decisions focused on other objectives; the second is built on distrust and the need for vigorous outside monitoring to ensure that employee interests are protected. This post highlights the way both variants of competing master narratives are being deployed to win the "hearts and minds" of both employees and the wider communities (some of them important university stakeholders or with the power to affect stakeholder perception) with an interest in this.  

Here is an example of the way ion which Penn State University is seeking to build a master narrative through which the progress and character of its wellness program might be understood.  From Wellness program participation increases, questions being answered, Penn State News (August 16, 2013):

Wellness program participation increases, questions being answered
August 16, 2013

Employee participation in the "Take Care of Your Health" initiative continues to grow. As of Aug. 12, 6,548 employees have scheduled biometric screenings, filling 47 percent of available appointments. Those who still need to complete the wellness profile or physical exam certification should visit https://www.highmarkblueshield.com/ and then log in and click the "Rewards Program" link.

"We appreciate how many of our employees have been proactive in completing the required steps," said Susan Basso, vice president for Human Resources. "At the same time, we understand that employees may be hearing conflicting information about our wellness initiatives, so we want to address their concerns with the most up-to-date information possible.

"Foremost on most people's minds is privacy. I can assure you that the information you provide through the wellness screening is, and will remain, private. WebMD Health Services, which developed and is administering the wellness profile through Highmark Blue Shield, is bound by HIPAA privacy and security laws. Penn State will not -- and by federal HIPAA federal health privacy law, cannot -- have access to individual employee health records. We will never ask for an employee’s health records and will not charge an employee additional fees based on their individual health status," Basso said.

WebMD Health Services is one of the leading health and wellness authorities in the country. Like many other national health insurance plans, Highmark determined it was more efficient to partner with WebMD Health Services than to build its own health-related resources like the wellness profile. WebMD Health Services differs 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 are tailored specifically for protection of sensitive information.

The FAQ found on the Office of Human Resources website at http://ohr.psu.edu/assets/benefits/documents/TakeCareOfHealthFAQs.pdf addresses a number of questions, as does the main website for the initiative at http://ohr.psu.edu/benefits/benefits-enrollment/ online. In addition, here are answers to some of the questions asked more recently:

Question: Will my health care costs change based on information I provide through the Take Care of Your Health Initiative?

Answer: No. The wellness profile and biometric screening results will NOT be used for any type of punitive action under any circumstances now or in the future. You will not be charged more based on your health status nor will you be refused health care coverage. The wellness profile and biometric screenings are for your use to provide you an awareness of your overall health status.

Question: Does collection of our data through the wellness profile meet institutional research guidelines?

Answer: The University does not have access to individuals' information collected through the wellness profile and will not be using any information for research purposes. According to the Institutional Review Board (IRB), this initiative does not meet the definition of Human Participant Research, as defined by federal regulations, and is, therefore, in full compliance.

Question: Why is the data collected via the biometric screening/wellness profile being sent to a third party (WebMD Health Services)?

Answer: WebMD Health Services and ICH, as business associates of Highmark, are legally bound by contract to employe at least the same strict standards of confidentiality as employed by Highmark. Highmark has appropriate, direct contractual relationships with both parties, including executed Business Associate Agreements. Thus, both WebMD Health Services and ICH are required to comply with HIPAA, as well as the additional detailed privacy and security provisions contained in their vendor contracts with Highmark, when dealing with protected health information. View more information about WebMD Health Services’ security and privacy policies at http://ohr.psu.edu/assets/benefits/documents/WebMDPrivacyAndSecurity.pdf online.

Question: Do I have to go to a mobile unit for my biometric screening? This seems like a privacy issue.

Answer: No, you do not have to go to the screenings being offered on campus. You may also ask your physician to perform the screenings or report results you obtained between Jan. 1, 2013, and now. The physician directed results (PDR) form and instructions for its use are included on the employee benefits website at http://ohr.psu.edu/assets/benefits/forms/PSUPDR.pdf online.

Question: Is it legal to charge me $100 a month if I don't complete the wellness profile?

Answer: The imposition of the surcharge is within the scope of permissible variations in benefits permitted under HIPAA’s non-discrimination rules. As long as the wellness incentives are limited to 20 percent of the total cost of coverage (the “COBRA Rate,” rather than what active employees are charged) in 2013, and less than 30 percent in 2014, the wellness-related surcharges are permissible.

Question: Why must I comply with these requirements?

Answer: The program is not mandatory. Ultimately, participation in the Take Care of Your Health initiative is an employee’s personal choice. As individuals and families, we all have choices to make about our participation and how we allocate our personal health care dollars. Employees may opt-out of the wellness initiatives and instead pay the surcharge.

Question: Is there any proof that these actions will achieve savings for the University?

Answer: There have been a number of studies on this topic. One such research study published in the Journal of Health Promotion in March/April 2011 looked at 10,463 wellness participants and an equal number of nonparticipant employees in Pennsylvania. The study found that: "Between 2003 and 2007, the increase in medical expenditures of the participant group was significantly less than that of the non-participant group (31 percent vs. 46 percent). Also, the participant group showed a lower increase in professional service expenditures and greater utilization of preventive services." [http://ajhpcontents.org/doi/abs/10.4278/ajhp.100415-QUAN-119]. In addition, the Centers for Disease Control and Prevention (CDC) concluded that programs with health assessment and skill building (i.e. health coaching) reduce tobacco use, dietary fat consumption, blood pressure and cholesterol, and improve seat belt use, physical activity and overall health risk scores, and reduce heavy drinking. (‘The Community Guide” Worksite Health Promotion. http://www.TheCommunityGuide.org/worksite online). There are other studies available that calculate savings as well.

Question: Why does Penn State feel it should be involved in the management of my health?

Answer: Penn State introduced the "Take Care of Your Health" initiative as a way to help control the rising costs of health care for both the University and for enrolled individuals and their families who pay monthly health premiums. Helping our employees become aware of their risk factors and directing them to the appropriate resources to take action to mitigate those risks is an important aspect of the initiative. While many employees live a healthful lifestyle, follow the Highmark preventive schedule, and manage their risk factors, many other employees do not. Research has shown that participation in wellness programs does result in medical cost savings (see previous answer). Our wellness strategy is a deliberate and aggressive attempt to reduce the rate of health care cost increases — something that we have been unable to do previously and something we must do if we hope to maintain a quality benefits program. Despite several million dollars in University expenditures over the past decade in support of voluntary programs for health and wellness, only a very small percentage of faculty and staff have participated. Penn State's insurance plan is self-funded. On average, our benefits-enrolled employees pay about 17 percent of health care costs and the University pays the balance, or about 83 percent. If we can improve the health of our participants through increased awareness and engagement in their own health, the rates of our health insurance can be maintained at current levels or even reduced. This opportunity is too great to ignore.

A variant narrative, more bracingly direct perhaps, can be found here (Without Comment: The University Speaks to Its Wellness Program, Monitoring University Governance, Aug. 9, 2013). Together this provides a structural framework for the reception and interpretation of the "facts" that make up both the university's actions and the character of the appropriate relationship between university administrator and employee,  within the context of "shared governance."

The master narrative painted by this story (and similar others) is challenged by those who have opposed this program, and important elements of the American media establishment. Here is an example of the counter narrative that is challenging the hegemony of the narrative the university is seeking to have accepted as the basis for conversation and understanding. From Anna Wiles Matthews and Timothy W. Martin, "Penn State Employees Protest Wellness Effort: Petition Calls for Cancellation of Program That Asks Workers to Provide Health Information or Face Penalties of Up to $1,200 a year,"  The Wall Street Journal, Aug. 15, 2013:

Pennsylvania State University employees are protesting a new wellness program that requires them to provide detailed health information or pay penalties that can total $1,200 a year, in an unusually public backlash against an increasingly common employer practice.

An online petition calling for the program to be canceled, launched by Penn State art-history professor Brian Curran, has gathered more than 2,000 signatures. Associate professor of political science Matthew Woessner has called publicly, in a letter on a faculty-group website and in a column for a local newspaper, for university employees to resist the initiative through steps such as giving "nonsense" answers to a health questionnaire. Both professors have raised concerns about privacy and said the effort is coercive.

Employer wellness programs offering financial carrots and sticks have been growing for years. According to a survey conducted last fall by the National Business Group on Health and Fidelity Investments, 86% of employers were linking incentives to health-related activities this year, up from 57% in 2009. The most common activities were filling out health-risk assessments, getting biometric screenings and participating in smoking-cessation programs.

Penn State's program will charge employees $100 a month starting in January if they—and covered spouses—don't fill out the health questionnaire and certify that they are having a physical exam. To avoid the penalties, employees also must get biometric screenings, including blood-sugar and cholesterol tests and body-mass index measurements.

A university spokeswoman said Penn State was "addressing cost concerns on multiple fronts, and the change is to empower employees to be more informed about their health status and health risks."

The university has said the results would be used to help employees identify ways they could improve their health, including resources to help with weight loss and exercise.

Penn State won't have access to individual employees' results, only aggregated, de-identified totals, complying with federal health-privacy law, the spokeswoman said.

Still, Dr. Woessner said he was concerned that the contractor employed by Penn State might not be able to adequately protect the data. Penn State has said the contractor will keep the information secure.

In an Aug. 9 letter to employees, Penn State's president, Rodney Erickson, said the changes were aimed at reducing costs as the university tries to hold down tuition. Penn State's health-care costs are projected to grow 13% in 2013-14 from the previous year if it doesn't trim the tab, he wrote, and previous "voluntary programs for health and wellness" have drawn little participation.

Penn State also plans to start charging workers a $100 monthly fee to get coverage for their spouses if the spouses are eligible for health benefits through their own employers. A third new initiative levies a $75-a-month penalty on tobacco users. Dr. Curran's petition calls for those efforts to be canceled as well.

It is relatively rare for employees to publicly protest such efforts. CVS Caremark Corp. CVS -0.14% this year asked employees to report measures such as blood sugar and body fat, or pay a $600 penalty. The move sparked objections from employees and workers' rights groups. More than 80% of covered CVS Caremark employees ultimately completed the wellness activities, according to a spokeswoman.

The 2010 federal health-care law is increasing the size of incentives that employers can tie to workers' results on health measures such as cholesterol levels. However, there is no federal cap on penalties tied to activities that aren't linked to employees' health status, such as filling out questionnaires, said Steven P. Noeldner, a partner at Mercer, a unit of Marsh & McLennan Cos.

The Penn State penalties are at the high end, according to polls of employers. A 2012 Mercer survey found that at large employers, the median maximum annual incentive—which could be a reward or a penalty—for filling out a health-risk assessment was $150. However, a handful of employers go much further, according to the National Business Group on Health survey—they yank workers' coverage altogether if they don't complete wellness requirements.

The Mercer survey also found that among large employers offering wellness programs, 42% used a financial reward as an incentive, and 15% had a financial penalty. Penn State has said that to structure its program as a reward rather than a penalty, it would have had to inflate employees' premium charges and then offer a discount to workers, an approach it said was wasn't "fiscally responsible."

Dr. Curran said he objected to the "incredibly invasive character" of the questionnaire. According to screen shots provided by Dr. Woessner, the questions include details about employees' diet, emotional state and history, alcohol and recreational drug use, and health—including whether they had recently driven after drinking too much and whether they perform regular testicular self-exams.

Dr. Curran also pointed to continuing debate over the cost-effectiveness of many employer wellness programs.

In a study commissioned by the federal government, Rand Corp. researchers said their analysis suggested that participating in a wellness program over five years was "associated with a trend toward lower health care costs and decreasing health care use," but the effect wasn't big enough overall to be statistically significant. The study also said some published research has shown cost decreases, but other evaluations haven't.

Critics argue that the programs often cost more to implement than they can save. "The numbers don't add up," said Al Lewis, president of Disease Management Purchasing Consortium International, a group that includes employers and health insurers.

For a similar narrative, see,  Sharon Begley,  "Penn Staters protest wellness program's steep fines,"
Reuters, Aug. 15, 2013 ("For Penn Staters, the WebMD survey includes questions that may lead to more healthcare spending. The 12-page form, reviewed by Reuters, asks for data on glucose, cholesterol, weight, about feeling sadness or guilt, experiencing problems with friends or supervisors or finances, and a long list of screenings, all of which can trigger more doctors' visits, invasive tests and surgery that may not improve health.").  This counter narrative suggests an entirely different interpretive framework, one in which the underlying values structures are quite different (primacy of privacy and autonomy protections versus cost savings; value of deeper bottom up engagement versus more vertically drawn command structures, etc.).

Master narrative does not imply their either narrative is true--it merely posits that the narrative, whatever its relationship to reality--will have a powerful effect on perception and therefore on the ability to manage relations among stakeholders. Taken together, these narratives present substantially incompatible realities.  Each leads to substantially different discursive foundations from which to approach the issues at the center of the Penn State wellness debate in particular, but also helps provide a basis for understanding the likely shape of the discursive structures in which similar contests will be waged across labor markets in the United States.