Are workplace wellness programs enough to make you sick?
Workplace Wellness Programs
Health Policy Brief
Health Affairs, May 10, 2012
The Affordable Care Act of 2010 will, as of 2014, expand employers' ability to reward employees who meet health status goals by participating in wellness programs--and, in effect, to require employees who don't meet these goals to pay more for their employer-sponsored health coverage. Some consumer advocates argue that this ability to differentiate in health coverage costs among employees is unfair and will amount to employers' policing workers' health.
Wellness program content
Typical features of wellness programs are health-risk assessments and screenings for high blood pressure and cholesterol; behavior modification programs, such as tobacco cessation, weight management, and exercise; health education, including classes or referrals to online sites for health advice; and changes in the work environment or provision of special benefits to encourage exercise and healthy food choices, such as subsidized health club memberships.
Inducements to participate
Although almost all workplace wellness programs are voluntary, employers are increasingly using incentives to encourage employee participation. These incentives range from such items as t-shirts or baseball caps to cash or gifts of significant value
Employers are also linking participation in wellness programs to employees' costs for health coverage--for example, by reducing premium contributions for workers who are in wellness programs, or by reducing the amounts they must pay in deductibles and copayments when they obtain health services. Another trend among employers who offer multiple health plans is to allow participation in a comprehensive plan only to those employees who agree to participate in the wellness program. Those employees who do not participate in a wellness program are offered a less comprehensive plan, or one that requires them to pay more in premiums or cost sharing.
What are the concerns?
There is widespread support for wellness initiatives in the workplace among both employers and employees. At the same time, there is conflict over programs that tie rewards or penalties to individuals achieving standards related to health status--and especially over those arrangements that affect employee health insurance premiums or cost-sharing amounts.
In general, business groups want employers to have maximum flexibility to design programs with rewards or penalties that will encourage employees to not only participate but also to achieve and maintain measurable health status goals, such as quitting tobacco use or reducing body mass index. They argue that individuals should bear responsibility for their health behavior and lifestyle choices and that it is unfair to penalize an employer's entire workforce with the medical costs associated with preventable health conditions as well as the costs of reduced productivity.
Unions, consumer advocates, and voluntary organizations such as the American Heart Association are generally wary of wellness initiatives that provide rewards or penalties based on meeting health status goals. They are concerned that, rather than improving health, such approaches may simply shift heath care costs from the healthy to the sick, undermining health insurance reforms that prohibit consideration of health status factors in determining insurance premium rates.
They argue that such incentives are unfair because an individual's health status is a result of a complex set of factors, not all of which are completely under the individual's control. For example, genetic predisposition plays a significant role in determining many health status factors, including such attributes as excess weight, blood pressure, blood sugar, and cholesterol levels. Consumer advocates also caution that poorly designed and implemented wellness initiatives may have unintended consequences, such as coercing an individual with a health condition to participate in an activity without adequate medical supervision.
Another concern is that tying the cost of insurance to the ability to meet certain health status goals could discriminate against low-income individuals or racial and ethnic minorities. These individuals are more likely to have the health conditions that wellness programs target and also may face more difficult barriers to healthy living.
These barriers may include some that are work related, such as having higher levels of job stress; job insecurity; and work scheduling issues, including shift work. Barriers outside of work may include personal issues, such as financial burdens, and environmental factors, such as unsafe neighborhoods, poor public transportation, and lack of access to healthy food.
In addition, some critics warn that wellness program requirements may be used to discourage employees from participating in their employers' health benefits plan by making their participation unaffordable. Employers might use a system of rewards or penalties totaling thousands of dollars annually to coerce employees who cannot meet health status goals to seek coverage elsewhere, such as through a spouse's plan; a public option, such as Medicaid; or a separate private plan purchased through the new health insurance exchanges.
By Don McCanne, MD
Altruistic employers who, out of the goodness of their hearts, offer wellness programs to their employees, also theoretically benefit by improving productivity through having a healthier work force. These are admirable goals. But employers are now playing the blame game as they use their programs to penalize employees who have medical needs, by reducing their health care benefits and increasing financial barriers to care.
Employers can enhance employee health through work-sourced exercise and nutrition programs, through work safety measures, and through programs such as smoking cessation. In sharp contrast, disease screening should be provided privately in an entirely separate primary care environment where the screening is a part of a comprehensive, integrated health care program that belongs to the patient, not the employer.
Above all, whereas the medical health status of employees should be maintained through the health care delivery system, never, never should the employer be allowed to reduce health care benefits because the employee has greater needs.
This is yet one more reason why health insurance should be totally dissociated from employment. If we had an improved Medicare that covered everyone, health care access would be continuous throughout life, and barriers to care could never be used to punish individuals unfortunate enough to have manifested or contracted medical problems.