You Heard it Here First

Well, it’s not such a new idea, but it was mentioned here in the last post. Now, Ron Goetzel has brought the issue of incentives for modifiable risk factors to the fore again with his Health Affairs Blog. [Does it seem strange to anyone else that his blog is accessible in the public domain, whereas his paper on the same subject in the Nov issue of Health Affairs is not?] What prompted all this attention was a paper by Jill Horwitz (also not accessible) suggesting that workplace health promotion programs do not save money.
This is an important point, and Dr. H seems to be swimming upstream. The numbers are not entirely clear, and both sides may be technically correct, with enough footnotes and disclaimers.
The Accountable Care Act (ACA) allows employers to reward employees for participation in health assessment programs and for achieving goals, such as losing weight. There are lots of caveats and concerns over whether this is OK or may be unfair to some employees. Somehow, I have trouble with the “unfair” issue. If you have a modifiable risk factor, say obesity or smoking, why is it unfair to charge you more for health insurance? Some of this depends on how the program is structured. Is it better to pay for good behavior or charge more for bad behavior?

Part of the fairness issue rests on whether a given risk factor really leads to increased healthcare costs. There is a lot of soft data, but the longitudinal studies are missing. If you are obese, do you have increased healthcare costs over the next 5 years? And if so, how much? The related question is, if you reduce your weight to the normal range, does that added healthcare cost burden disappear? For example, it takes ex-smokers at least 10 years to join the normal mortality curve.

Here’s a far out idea: should the government encourage smoking as a way to decrease Social Security costs? The answer seems to be no. The mortality would be higher (helping SSA), but not enough to offset the increase in Medicare costs. Think again.

The workplace is a logical point to address modifiable risk factors. Employees spend most of their lives in the workplace, and employers have a vested interest in healthy workers. Employers are interested in illness that hampers productivity or increases use of healthcare resources, but they are not concerned with mortality. Those who advocate moving health insurance out of the workplace will have to find another access point for population health.

You would think that if an individual recognizes that a given behavior diminishes his health he would welcome the opportunity to change. Buzzer!! Doesn’t work that way. Everyone knows that smoking is detrimental to health, but many persist. Many of us would feel better if we lost 20 pounds or more, but . . . I’m not having much luck, are you?

Money works. People will change their habits if you pay them, and Goetzel suggests that around $500 is the tipping point. Pay them to take a health assessment test and then pay them when they achieve some goal (stop smoking, lose 20 pounds, etc.).

Now, is there a return on that investment? If I lose 20 pounds, will I spend $500 less on healthcare every year? The answer seems to be yes, for some risk factors but not for all. Here’s the list of the Significant Seven:

1. Smoking
2. Obesity (not just overweight)
3. High blood pressure
4. Inactivity
5. High blood glucose (Is this the same as obesity?)
6. High stress (self reported. What does this mean?)
7. Depression (self reported).

Interestingly, high alcohol use isn’t a factor unless/until it interferes with social or work performance. In other words, it’s the effects of alcohol abuse, not the alcohol itself that is a problem. But we knew that.

What’s an effective program look like?

1. First, as stated above, it works better if it  includes money as an incentive.
2. General wellness education. Target the Significant Seven risk factors.
3. Health assessment for each employee, with individual advice on things to change.
4. Provide the means to the end. A gym, discounted fitness club membership, smoke free workplace, individual counseling, healthy food choices in the cafeteria, etc. Make healthy lifestyles part of the corporate culture.

Does it work? Probably yes, if it’s done well. Here’s one accessible reference that suggests a $3 return for a $1 investment.

Got to quit now. I’m off to the gym.