The Aetna Experience

By Andy Lee, MA

Chief Mindfulness Officer
Aetna

Stress at work is reaching epidemic proportions. Whether you are a teacher, a doctor, or a customer service representative, chances are very good that your job stresses you out. In fact, 80% of workers feel stress on the job, while 40% feel that their jobs are very or extremely stressful.¹

Stress has long been recognized as an important driver of employee illness and absence. Stress has a powerful effect on employees’ health. It is estimated that 75% of all doctor visits are due to stress-related symptoms,² and research suggests that 37% to 52% of all sick days are due to stress.³ Research led by the Harvard Business School estimates that altogether, work-related stress accounts for 5% to 8% of employers’ healthcare costs, and is linked to more than 120,000 deaths per year.⁴ Based on these staggering statistics, researchers often equate the overall impact of workplace stress to the effects of secondhand smoke.

How can stress — what is often seen as a simple state of mind — have such wide-reaching effects? The reason is that the stress response, also known as the fight-or-flight response, affects every system in the body. Stress is the reaction of the mind and body to a situation that is perceived as threatening or beyond one’s ability to cope. During a stress response, hormones such as cortisol and adrenaline are released into the body to prepare it for physical conflict or exertion. The result includes increased heart rate, shallower breathing, tensing muscles, and the release of glucose into the blood stream. Digestive activity and the immune system are depressed.

While small doses and short periods of stress can actually be beneficial to performance, if this physiological state is maintained over time it will begin to wear the body down. Research suggests that long-term exposure to stress can reset the baseline level of certain systems in the body, including the neuroendocrine system. This will cause the body to be triggered more readily by additional stressors. Finally, long-term stress leads to serious health issues including depression, heart disease, and Type 2 diabetes.⁵

Employers have responded to this stress epidemic in many ways, including expanding access to behavioral health resources. Yet it is clear that more must be done to combat the toll that stress is taking on both employees and organizations worldwide.

Paying Attention

Mindfulness training has emerged recently as a promising approach to help employees and organizations manage stress and its effects. By the end of 2017, more than 40% of employers will be offering some sort of mindfulness programs to their employees.⁶ Meanwhile, more and more absence management professionals are asking how to best leverage mindfulness to enhance well-being and reduce illness rates among their employees.

Five years ago, after an initial round of research on mindfulness and its impact on employee stress, Aetna launched further initiatives related to the relationship between mindfulness and stress. The findings led Aetna to offer free mindfulness training to all our employees and to continually expand the ways in which mindfulness is incorporated into employee programs as well as those offered to customers.

Mindfulness can be described as paying deliberate attention to your present moment experience with an attitude of openness and curiosity. It is about being attentive and observant about what you are doing, how you are feeling, and what is going on around you as you go through the day. While this may sound simple, it is not easy to do. In fact, our minds wander away from their present moment experience about 47% of the time.⁷

Unfortunately, the constant distractions and interruptions of today’s workplace may further increase this percentage, to the point where most of our day may be spent either in a reactive or autopilot state. Some examples of not being mindful include:

• Constantly checking your phone or email
• Being distracted from your work due to mental rumination about events in the past or future
• Not noticing that you are stressed until your shoulders begin to ache from strain
• Eating lunch without noticing whether you’re hungry, what you’re eating, or how it tasted
• Getting stuck responding to low-priority emails while important projects languish

These habits are not only unproductive, they actually cause or increase stress.

Mindfulness can be cultivated through fairly simple and effective training practices, also known as mindfulness meditation. A common training practice is to close your eyes and simply pay attention to the sensation of your breath. As few as 10 minutes a day of this practice can have positive effects on your stress level as well as your mental clarity and your physical well-being.⁸

Currently, academic interest in mindfulness is booming. The number of research articles on the topic has grown from 46 in 2005, to 203 in 2010, and to 674 in 2015.⁹

Genesis of a “New” Approach

In 2009, spurred on by the personal experiences and the passion of CEO Mark Bertolini,¹⁰ Aetna decided to investigate the impact that mindfulness training could have on stress and well-being among its employees. Led by consultant Kyra Bobinet, MD, MPH, they partnered with eMindful to develop a mindfulness program that could be made available to all employees. The program, called Mindfulness at Work, consists of one-hour weekly classes for 12 weeks. During this time, participants are also expected to spend 15 minutes per day doing mindfulness practice. The results of the initial study were published in a journal article in 2012.¹¹

The first interesting finding of the study came before it even started. As a pretest, participants took Cohen’s Perceived Stress Scale, a validated self-report stress assessment. Their stress results were then correlated with their healthcare claims. The people reporting average levels of stress had $2,196 in annual healthcare claims, while people with the highest stress levels had $3,648 in claims, an increase of 60%. While this correlation does not indicate a causal relationship, it is striking nonetheless.

The results of the program were also striking. Stress levels dropped 36% among participants during the course of the program, with the average stress levels of participants decreasing from the highly-stressed range, to well within the normal range. In addition, significant reductions in sleep disturbance and reported pain were observed. This suggests that mindfulness training is an effective way to combat stress-related illness and absence.

The study also used the Work Limitations Questionnaire (WLQ) to assess the extent to which employees’ current health status interferes with their ability to perform their job. While scores on the WLQ also decreased significantly as a result of the program, they were not significantly different from those of the active control group.

These results inspired Aetna to make mindfulness training available to all employees at no cost. Since then, more than 4,900 people have completed the weekly Mindfulness at Work program. Aetna has continued to collect pre- and post- program results and continues to see decreases in stress levels and WLQ results in the 20 to 25% range.

In the last three years, Aetna has also made the Mindfulness at Work program available to its customers. Customers have seen exceptional benefits for their employees who have taken the program, with stress decreases exceeding 30% and WLQ decreases nearing 50%.

Mindfulness and Absence Management

Given the relationship between stress and illness, it would stand to reason that mindfulness training could reduce illness-related absence in organizations. However, at this time very little research has been done on this topic. Mindfulness training did lead to fewer sick days in a study of teachers.¹² In a Norwegian study, mindfulness training contributed to people returning to work more quickly by improving their quality of life.¹⁰

In terms of general trends, Aetna has also seen a decline in its illness-related absences over the period during which mindfulness training was implemented. That said, numerous other wellness-related programs have been implemented during this time, so there is no basis for inferring causation here. Yet the trend is encouraging.

More information is coming. Aetna is currently partnering with Ruth Wolever of Vanderbilt University Medical School to assess the healthcare utilization of the thousands of participants who have completed the Mindfulness at Work program, as compared to matched controls. Given the size of the sample and the direct assessment of costs, the results may be a watershed event in the study of the impact of mindfulness training on health and well-being. A second study on the impact on human resources variables, including turnover and absence measures, is planned as a follow-up.

Building on Success

Based on the success of the Mindfulness at Work Program, Aetna has continued to integrate mindfulness into its programs and services. These currently include:

• Developing a second eMindful program called Metabolic Health in Small Bytes, which helps members take a mindfulness-based approach to managing their metabolic health. Results to date show that of 56% of participants with metabolic syndrome saw the reversal of at least one of the five risk factors during the program. While weight loss is not an explicit program goal, participants have lost an average of 2.5 pounds, with 35% losing 5 pounds or more.
• Making mindfulness a core element of the Healthy Lifestyle Coaching program, Aetna’s premier health coaching service, by providing mindfulness training to coaches and using mindfulness-based tools and practices to support participant well-being and healthy behavior change.

In addition, Aetna is taking steps to integrate mindfulness more fully into the corporate culture. Current initiatives include launching an annual month-long Mindfulness Challenge event; creating a Mindfulness Center to host in-person mindfulness practice as well as workshops and courses; and training a cadre of Mindfulness Advocates to champion mindfulness across the employee population.

The Work Ahead

So far, mindfulness has proven very effective in reducing employee stress, which is a significant driver of employee illness and absence. There are still many important questions to answer. To what extent can mindfulness reduce stress? What forms of mindfulness training are most effective for different employee needs or operating environments? Can mindfulness also accelerate return to work? Aetna is pressing forward for these answers because with a belief that employers have a great opportunity to use this new approach to advance the effectiveness of this powerful approach to employee well-being.

References

1. The National Institute for Occupational Safety and Health. Work Organization and Stress-related Disorders. July 1, 2009.
2. A Perkins. Saving Money by Reducing Stress. Harvard Business Review. 72(6):12. 1994.
3. Allen P, L Bourgeois. The True Picture of Workplace Absenteeism. Morneau Shepell. 2015.
4. Goh J, J Pfeffer, SA Zenios. (2015). The Relationship Between Workplace Stressors and Mortality and Health Costs in the United States. Management Science. March 13, 2015.
5. Ganster DC, CC Rosen. Work Stress and Employee Health: A Multidisciplinary Review. Journal of Management. 39(5):1085–1122. 2013.
6. S Smolkin. Corporate Mindfulness Programs Grow in Popularity. Employee Benefit News, July 14, 2016.
7. Killingsworth MA, DT Gilbert. A Wandering Mind Is an Unhappy Mind. Science, Nov 12, 2010.
8. Howells A, I Ivtzan, F Eiroa-Orosa. Putting the ‘App’ in Happiness: A Randomised Controlled Trial of a Smartphone-Based Mindfulness Intervention to Enhance Wellbeing. Journal of Happiness Studies. 2014. doi:10.1007/s10902-014-9589.
9. American Mindfulness Research Association. Retrieved from https://goamra.org/resources/
10. D Gelles. At Aetna, a C.E.O.’s Management by Mantra, The New York Times, Feb 27, 2015.
11. Wolever RQ, KJ Bobinet, K McCabe, ER Mackenzie, E Feteke, CA Kusnick, M Maime. Effective and Viable Mind-Body Stress Reduction in the Workplace: A Randomized Controlled Trial. Journal of Occupational Health Psychology. 17(2):246–258. 2012.
12. Vindholmen S, R Hoigaard, GA Espnes, S Seiler, S. Return to Work After Vocational Rehabilitation: Does Mindfulness Matter? Psychology Research and Behavior Management. Feb 26, 2014.