Wellness

QUALITY: Is Safeway's The Best Way to Promote Wellness

Paul Testa — Thu, 05 Nov 2009 14:15:00 -0500

Residents of D.C. love to talk about their Safeways. Apparently, so do Members of Congress.

During the mark up of Senate Finance Committee's bill in September, Senators John Ensign (R-NV) and Tom Carper (D-DE) introduced an amendment that increased the financial rewards companies could offer their workers for meeting certain health goals and criteria such as losing weight, lowering their cholesterol or quitting smoking. Pushing hard for this change, were companies like Safeway which puts a great deal of stock in their efforts to help manage and improve their employee's health, as explained this week in by the LA Times:

Nationwide, 25,000 nonunion employees in Safeway's health insurance plan are eligible for the premium-reduction program, most of them in California. The company says that 74% have signed up.

Once a year, participants submit to tests of four health risk factors: smoking, obesity, blood pressure and cholesterol. If they pass all four, they receive a $780 annual discount, which is 20% of the total cost of their insurance. If they do not pass initially but make progress in some areas -- quitting smoking or losing 10% of their weight -- they can get a premium rebate.

After making several changes in the health policy offered to nonunion workers, Burd said, the company's healthcare costs have "flat-lined" over the last four years, while other companies' costs have gone up nearly 40% on average.

The Ensign/Carper amendment passed by a vote of 18-4. If enacted, it would raise the maximum discounts employers could offer their employees from 20 to 30 percent of insurance premiums and give HHS the authority to raise that threshold to 50 percent if it so chooses.

For some the amendment is common sense, especially given the lingering concerns about health reform's ability to control costs. Yet, as the LA Time's notes, not everyone is happy with the potential changes. The American Cancer Society, the American Heart Association, and advocacy groups worry that such incentives will become another way to discriminate against the sick and unfit while cherry picking the healthy.

Both sides have a point. On one hand it seems reasonable for companies to use incentives to encourage health and discourage behaviors which impose costs on others. Charging smokers more seems fair -- as long as they are provided with appropriate cessatiohn progams and encouragement to quit. On other issues, however, such as obesity or cholesterol it may be more difficult to separate the effects of personal choices from genetic dispositions.

The key is balance. As with an individual mandate, it's not just the size of the penalties that matter. As Ken Thorpe, an expert on chronic disease, writes on the National Journal's Health Care Experts blog:

While "sticks" can and are effective in changing behavior, carrots work best, which is the experience of most employers who lead in implementing successful wellness programs. ... [E]mployers are the best place to implement wellness programs, and in doing so, companies must have flexibility to carry them out. What works for a large company like Johnson & Johnson with over 80,000 employees around the world will not work for 12 person printing company with one office.

Kentucky's Employees Health Plan for state workers has had impressive results increasing enrollment in its wellness and chronic disease programs using relatively small incentives like gift cards for Target and Best Buy.

Changing behavior is tough. It requires both carrots and sticks, and a measured approach that is flexible enough to learn from what works and what doesn't. As New America's Director of Health Policy Len Nichols has written, "Compassion demands we present alternatives and limit the penalties, but basic fairness says it is ok to expect effort in exchange for cross-subsidies from the community."

QUALITY: Creating Incentives for Wellness Through Health Reform

Len Nichols — Mon, 28 Sep 2009 15:32:00 -0400

This post appears on the National Journal's Health Care Experts Blog where you can also see what other health policy analysts have to say about ways to promote wellness through health reform.

This is another example for which both God and the Devil are in the details. No one disputes that some behavioral choices -- smoking, diet, regular exercise, age and condition-appropriate screenings -- affect health status, expected health costs, and therefore, our collective average premiums. It seems perfectly reasonable, especially to economists and to those who make good choices already, to use incentives to encourage socially responsible choices and to discourage those that impose costs on others. At the same time, smoking is addictive and extremely hard to quit for some people who really want to, obesity can be caused or exacerbated by genetics and often comes with co-morbidities like depression that make financial incentives ineffective, and some people can only afford to live in neighborhoods with no stores that sell fresh fruits and vegetables and with little safe walking space. So how to reward good behavior without punishing the unlucky?

Two thoughts occur to this economist. First, if everyone in the country got their insurance through an exchange and/or pure community rating across all people and "groups" were the norm, then employers would not worry about differential health costs of their workers' vs. others (they would still care about average costs, appropriately) and one great fear of workplace discrimination would be erased. So we should develop reform proposals that move us toward this type of insurance system eventually.

Second, and more practically for the short run, why not allow reasonable and income-related incentives for good choices, or penalties for bad, but acknowledge our less than perfect knowledge about exactly how to accomplish smoking cessation and weight-loss etc., (otherwise, wouldn't we all be skinny and no one would smoke?) so that a person is exempted from the penalty if they engage in the remedy program chosen by the employer or health plan in the exchange, and such a program must be made available where behavioral incentives are in place This should encourage plans and employers and the government to hone and disseminate practical research on what behavioral programs work best, it will encourage people to take behavioral steps to address their problems rather than simply punish those who "fail" to cure themselves, and it will punish those who refuse to try and help themselves. That last is the behavior that breeds resentment among those who feel like they are otherwise forced to pay more for those who do not take proper care of themselves. Compassion demands we present alternatives and limit the penalties, but basic fairness says it is ok to expect effort in exchange for cross-subsidies from the community.

VOICES OF REFORM: Frist's View From Nashville

Joanne Kenen — Mon, 18 May 2009 18:07:00 -0400

Former Senate Majority Leader Bill Frist was in town the other day, and we had a chance to talk for a bit after he took part in a distinctly nonpartisan discussion about social determinants of health (and how much of it comes down to education). While he isn't closely involved in the health reform efforts in Washington, he is watching from afar - and he sounded a lot more encouraged as an outside-the-Beltway Republican than some of his colleagues sound here inside.

Frist divides his between teaching at Vanderbilt, work in global and public health, and his affiliation with a private investment firm focused on the healthcare industry.

He said he thinks it's highly likely we'll see legislation enacted this year that gets us "much much closer" to the goal of covering 100 percent of Americans. He didn't think we would necessarily cover absolutely everybody but he said he anticipated getting close on the coverage front, while also moving toward a delivery and payment system oriented toward "value-based' health care, instead of the current system based on volume and the quantity of procedures rather than the quality of care.

"We need to shift from unit- based (payments) to value- based," he said. He was also supportive of payment reforms such as bundling (which pays doctors and hospitals for an episode of care and provides incentives for keeping patients out of the hospital). Frist also lauded aspects of this year's stimulus bill (which almost all Republicans opposed) for investments in health and healthy communities.

Frist was in town for an Alliance for Health Reform event on The Robert Wood Johnson Foundation's Commission to Build a Healthier America (on which he served). He spoke a lot about public-private partnerships in wellness promotion, about investing federal resources in childcare, nutrition and early education. He also spoke about the need to take the long view— a very long view. Some of these investments won't pay off for a generation, and therefore don't "count" in Washington's five and ten year budget windows. But they need to be made.

Some of the measures he proposed might have raised eyebrows of some fellow conservatives still in Washington. For instance, it's common for conservatives to talk about how "consumers" should have "skin in the game," and pay out of pocket for the first dollar of their health care. Frist wanted to take some more skin out of the game, at least in terms of ending copayments for prevention, wellness and screening (although I should clarify that we didn't talk about this in detail and I'm not sure whether he meant across the board for all health plans or for specific populations, or whether this should be a voluntary policy or a regulation etc).

We suspect that some of our readers will wonder why Frist wasn't calling for more of these policies and investments when he was a position to do something about it. Fair enough. But given the partisan cacophony in Washington these days, it was still good to hear a conservative Republican doctor calling for major reforms and significant long-term federal investments in keeping Americans healthy (and educated) and getting them the care they need. Nothing Frist said, at the panel discussion or in our subsequent conversation, sounded like it marched off a page of Frank Luntz's memo.

One topic that didn't come up - either in our conversation or at the Alliance event itself. How much of a public health "two-fer" is there in how we finance health reform, ie. how much bang for our buck (and how many bucks!) could we get by taxing sugary drinks or junk food? But the alliance helpfully included in a packet of articles distributed at the event (and available online) a New England Journal of Medicine perspective calling a sugary beverage tax "a key took in efforts to improve health." The co-author: Thomas Frieden, whom President Obama just tapped to head the CDC.

(PS. An update -- Just after we posted this, the Senate Finance Committee put out a paper on financing options for heatlh reform -- and the sugary drink tax is in the mix.)

HEALTH REFORM: For Citywide Wellness, Scrap the Fryolator

Joanne Kenen — Wed, 03 Dec 2008 14:20:00 -0500

Truth be told, we are not exactly sure what a "fryolator" is, but it's probably a good thing that the Somerville, Mass high school no longer has one.

With bike lanes and pedestrian crosswalks on its streets, healthful food in its school cafeterias, and cheap salsa classes offered by its recreation department, Somerville has become a model "Fit City." Healthy policy, the town has found, creates healthier people, and other communities are paying attention, the Boston Globe reported this week.

Five years after the Boston suburb embarked on an ambitious collaboration with Tufts University called Shape Up Somerville to see whether systemic changes that encourage healthy eating and physical activity would help children stave off obesity, 10 communities across the country have begun testing whether they can replicate Somerville's success. In a separate initiative, the Robert Wood Johnson Foundation plans today to name Somerville one of nine "leading sites" for a $44 million "Healthy Kids, Healthy Communities" program that will spread to 70 communities. The state expects to launch a wellness program informed by innovations in Somerville and elsewhere.

Businesses promote wellness, city workers join gyms, farmers can sell at a local market, schools not only serve healthier food, some of them even have their own gardens. Eight year olds gained one pound less during a school year than counterparts in a control group—and if that doesn't sound like a lot, nutritionists think the impact is significant in a community where 44 percent of children are overweight or at risk of being overweight. Think of it as a 16 ounces of prevention. It's reflected in adult behavior as well. At City Hall, the newspaper reported, climbing stairs instead of taking the elevator is a fad. And it's free.

Healthy living doesn't mean we don't need a sound and solid health care system, but ideally they do go hand in hand. So we're all for a population with more bike-riding, vegetable-eating, salsa-dancing insured people, without the fryolators.

COST: A Worthwhile Wellness Investment?

Joanne Kenen — Wed, 22 Oct 2008 18:58:00 -0400

A few months ago we wrote about a provocative study that questioned whether job-based wellness programs really paid off—and if so when, and for whom. If a business pays for wellness and prevention in 2008, would any of the workers still be on that payroll when the health-savings accrued years in the future (assuming that the investment did pay off in better health and lower costs?)

It's going to take more than one more study to answer that question, but new research from Blue Cross and Blue Shield of North Carolina does provide some encouraging results. According to a report in the Raleigh News and Observer, companies willing to make even modest investments in wellness initiatives—such as health screenings in the workplace or giving workers paid time off for doctor's visits—saw a healthy return (pun intended) within a few years.

"The things that employees value the most aren't always the things that cost a lot of money, and in fact, it can be just the opposite," Don Bradley, chief medical officer for Blue Cross told the newspaper. "You don't have to build a gym, but just give the opportunity to get outside and do some exercise."

The study found that companies offering comprehensive wellness programs see a 25 percent to 30 percent decrease in medical and absenteeism costs in about 3.6 years. Tthat's a lot more attractive way for businesses to save money than shifting more costs onto their workers.

In North Carolina, 70 percent of employers offer at least three workplace wellness programs, the newspaper reported. Four percent offer none. The study found:

The average return on investment for employers is $3.14 per $1 spent on employee wellness.
The four most commonly offered workplace wellness programs are smoke-free workplace, paid time off for doctor's visits or health care needs, on-site health screenings and health fairs.
The four programs with the highest participation rates: paid time off for doctor's visits or health care needs, healthy cafe or vending options, health fairs and physical activity during work hours.