were largely invalid, due to a pervasive error in study design. low participation rates by employees could significantly limit the potential benefits of participating in workplace wellness programs, as could systematically differences between participants and non-participants. research performed by gallup indicated that out of the 60% of employees who were aware of their company offered a wellness program only 40% participated. a 2008 study from the university of minnesota provided insight into the likelihood of employee participation in an exercise promotion program. their findings illustrate barriers to program participation that may be applicable to other types of programs and workplace settings. employees were offered a financial incentive to attend a designated set of fitness facilities at least 8 times per month during the study period, and researchers administered a survey to over 3,000 program participants and non-participants to better understand their decision to participate. the research team included survey questions to assess each employee's attitudes and practices related to fitness prior to the program being offered, their marginal utility related to the financial incentive offered, the marginal cost of exercising (based on the cost of time and the financial cost of fitness center membership), prior history of chronic disease, and demographic characteristics related to age, gender, race and ethnicity, income, and employment type within the university system. based on these survey responses, researchers reported the marginal effects related to the probability of 1) signing up for the program and 2) meeting program participation criteria by exercising 8 times per month to receive the financial incentive. employees with a higher time cost of exercise, calculated by the campus where the employee worked and by the number of participating fitness sites in the employee's home zip code, had a lower probability of signing up for and completing the program. younger workers (ages 18–34) were more likely to sign up for the program relative to older employees, and women were more likely to sign up for the program than men. researchers also found that employees with diabetes or low back pain were less likely to participate. program participation reflects a different trend. when researchers investigated the likelihood that an individual would be a regular program exerciser, defined as a participant in the program who checked in at a participating facility at least 8 times per month, for at least 50% of the time period for which the financial incentive was offered. program participation in this sense means that an employee both signed up and completed the criteria to receive the reward. regular exercises were more likely to be older (ages 55+), male, and to be classified as regular exercisers before the program was offered. these findings suggest that there may be differences between employees who would like to, or intend to, participate in certain workplace programs, and those who are likely to be able to participate and benefit. while this study focuses specifically on exercise and participation, lessons regarding the time cost of participation, location barriers to participation, and age and gender differences in participation rates are all important considerations for a firm interested in designing an effective workplace wellness program, especially if the goal is to promote a new behavior. ongoing management support and accountability are critical to successful worksite health promotion programs. per research performed by gallup, "managers are uniquely positioned to ensure that each of their employees knows about the company's wellness program and to encourage team members to take part." by engaging workers in this organizational culture, employees become 28% more likely to participate in wellness programs than the average employee. methods in which leaders can overcome the barrier of engagement is to not only model behaviors of the program but to consistently and effectively communicate the value of the wellness programs to employees. by creating the time and focus to improve the overall health and wellness of employees, managers can present many health and costs benefits to all members of the organization. framework workplace wellness programs can be categorized as primary, secondary, or tertiary prevention efforts, or incorporate elements from multiple types. primary prevention programs usually target an employee population which is already considered healthy and encourages workers to more frequently engage in health behaviors that will encourage ongoing good health (such as stress management, exercise and healthy eating). secondary prevention programs are intended to reduce behavior which is considered a risk factor for poor health (such as smoking cessation programs and screenings for high blood pressure). tertiary health programs are designed to address existing health problems (for example, by encouraging employees to better adhere to specific medication or self-managed care guidelines). worksite wellness programs including nutrition and physical activity components may occur separately or as part of a comprehensive worksite health promotion program addressing a broader range of objectives such as smoking cessation, stress management, and weight loss. a conceptual model has been developed by the task force for community preventive services (the community guide) and serves as an analytic framework for workplace wellness and depicts the components of such comprehensive programs. these components include worksite interventions including 1) environmental changes and policy strategies, 2) informational messages, and 3) behavioral and social skills or approaches. worksite environmental change and policy strategies are designed to make healthy choices easier. they target the whole workforce rather than individuals by modifying physical or organizational structures. examples of environmental changes may include enabling access to healthy foods (e.g., through modification of cafeteria offerings or vending machine content) or enhancing opportunities to engage in physical activity (e.g., by providing onsite facilities for exercise). policy strategies may involve changing rules and procedures for employees, such as offering health insurance benefits, reimbursement for health club memberships, healthy food and beverage policies or allowing time for breaks or meals at the worksite. informational and educational strategies attempt to build the knowledge base necessary to inform optimal health practices. information and learning experiences facilitate voluntary adaptations of behavior conducive to health. examples include health-related information provided on the company intranet, posters or pamphlets, nutrition education software, and information about the benefits of a healthy lifestyle, including diet and exercise. behavioral and social strategies attempt to influence behaviors indirectly by targeting individual cognition (awareness, self-efficacy, perceived support, intentions) believed to mediate behavior changes. these strategies can include structuring the leadership involvement and social environment to provide support for people trying to initiate or maintain lifestyle behavior changes, for example, weight change. such interventions may involve individual or group behavioral counselling, skill-building activities such as cue control, use of rewards or reinforcement, and inclusion of coworker, manager/leader or family members for support. health economics of workplace wellness programs wellness programs are typically employer sponsored and are created with the theory that they will encourage healthy behaviors and decrease overall health costs over time. wellness programs function as primary care interventions as they are an example of primary prevention methods to reduce risks to many diseases or conditions. workplace wellness programs have been around since the 1970s and have gained new popularity as the push for cost savings in the health delivery system becomes more evident as a result of high health care expenditures in the u.s. employer wellness programs have shown to have a return on investment (roi) of about $3 for every $1 invested over a multi-year period, making them appealing to many as an effective way to achieve results and control costs. most recently, the 2016 winner of the "best wellness program" award, wellsteps, was shown to have harmed employees at the boise school district and fabricated its savings figures. workplace wellness programs have many components to help improve health outcomes and decrease health disparities. these components include smoking cessation programs, fitness center memberships, nutrition aids, and biometric screenings, often in exchange for health insurance premium reductions. the benefits of wellness programs are not limited to corporations and their employees; otenyo and smith argue that engaging in such programs produces positive spillover effects for society that are not reflected in markets, leading to them under consumption. owing to their positive spillover effects on society, the social marginal benefits of wellness programs are higher than their private marginal benefits, leading to their under consumption. workplace wellness programs benefit employers as well; while the various components of the wellness programs helps to keep employees healthy, employers are able to increase recruitment and retention of workers. some employers have also utilized penalties to improve employee participation within the company wellness program. while wellness programs promote healthier lifestyles and can bring significant cost savings, concerns about invasion of privacy and participation costs have arisen. the future of wellness programs as a valid method of preventative healthcare is still up for debate. evidence of improved health outcomes for participants is mixed in terms of effectiveness. some studies attempt to address the question if "more is always better in the workplace," and the value that can be found through wellness program components and their outcomes. one large study though, did not find health improvements for premium incentive-based workplace weight loss programs. writing in the new york times, frank and carroll laid out several concerns with wellness programs, including limitations in empirical studies and the possibility that employers use these programs to shift costs to employees. that said, the 2019 kaiser family foundation employer health benefits survey indicates that organizations continue to enact such programs due to their perceived benefits for employee health, morale, and productivity. wellness programs have created a $6 billion industry due to its reputation of reducing health care costs. in their 2013 workplace wellness programs study, rand corporation researchers concluded that while lifestyle-focused wellness programs can reduce risk factors and motivate healthy behavior, the reductions in healthcare costs are less than previously reported. however, most wellness studies that report the positive results of the wellness programs are not of high quality, indicate only short-term results, and do not justify causation. moreover, these studies are sponsored by their own wellness industry, creating bias. other studies find that the programs don't improve health outcomes or reduce health care costs. in fact, a decrease of employers' health care costs has been simply passed on the employees. based on the affordable care act, employers are able to charge unhealthy employees up to 30 to 50 percent more of total premium costs. this has resulted in pushback from employees who have not met mandated health goals like quitting smoking or reducing body mass index (bmi). on the other hand, research on the 2003 pepsico healthy living program suggests that the wellness plan helps reduce health care costs after the third year of implementing the disease management components of the program. but, the wellness program does not show evidence of lower costs due to the lifestyle changes in the short run. this result is consistent with the one-year study with the 3,300 employees of the university of illinois at urbana-champaign in 2016. the study indicates that participation in a wellness program does not result in healthier employees or reduced health care costs. the research also shows that without an incentive, about 46.9 percent participated in the wellness program. then, the change in monetary incentive from $0 to $100 increases participation by 12 percent, from 46.9 percent to 58.5 percent. an additional incentive of $200 increases the participation from 58.5 to 62.5 percent. this study shows that when the company increases participants by only 4.5 percent or reduce 4.5 percent of non-participants or high medical spending employees, it will compensate the total cost of the specific wellness program. this result is consistent with other studies that the wellness programs do not help lower health care costs, but only have passed on the costs to other employees. regarding the employment and productivity, the participants believe that management places an importance on health, fitness, and safety. however, the study shows no significant difference on the happier feelings or more productive at work among the participants. workplace wellness programs have the potential to lead to healthier outcomes and decreased costs, but the economics are still unclear, and more research is required. affordable care act and effects on workplace wellness there are conversations surrounding the role of the affordable care act and in general insurance on its effects on workplace wellness. sixty percent of americans obtain their insurance coverage solely in their respective workspaces. however, larger companies are