Evidence to action

Last week, the Duke University Margolis Center for Health Policy hosted the Transform North Carolina conference.

It was awesome. North Carolina’s health care systems are in the process of swinging for the fences. The big things is the Medicaid system is moving from fee for service to managed care with a significant focus on social determinants of health and the private/employer systems are moving away from fee for service and towards accountable care organizations and longer shadows of the future.

One of the panels stuck with me though. It was the employer panel.

We know that broad wellness programs don’t work if the objective is to improve overall population health. Usually what happens is that the wellness program showers incentive payments on behaviors that would have occurred anyways without the incentives or there are incentives for behaviors that don’t change morbidity.

Increasing the cost of non-compliance runs into significant ADA issues. Nicholas Bagley has a good summary from December 2017:

The trouble was that the Americans with Disabilities Act prohibits employers from compelling employees to undergo medical exams, including taking a medical history, unless they’re “voluntary.” And most wellness programs require employees to fill out a health assessment, which is a kind of medical history. As I explained:

[That’s] where the EEOC’s argument falls apart. The average premium for a family plan in 2015 is $17,545; 30% of that is $5,263. Under the EEOC rule, then, an employer can dock an employee with a family more than $5,000 if she doesn’t take a health assessment. With that kind of financial inducement, it’s nuts to say that the assessment is voluntary. Sure, the employee could always turn down the $5,000. But no reasonable person would. The health assessment is mandatory in every meaningful sense of the word.

The EEOC went ahead anyway, saying that it wanted to harmonize its rule with HIPAA, which the ACA had amended in an effort to promote wellness programs. In a subsequent article published in Health Matrix, Adrianna, Aaron, Austin, and I pressed the ADA point again, and identified a handful of other legal problems with the EEOC’s rule, including its inconsistency with the Genetic Information Discrimination Act, or GINA.

The AARP picked up on these arguments and filed suit against the EEOC. Yesterday, the highly respected Judge Bates in Washington, D.C. held that the rule was unlawful for substantially the same reasons that we’d identified….

We also know that the high deductible health plan (HDHP) paradigm of “good” shopping has failed. Right now, people do a horrendous job of differentiating between high value and low value care. Anyways, most of the health care spending is for goods and services that are above the deductible limits anyway so basic incentives don’t matter all that much if we assume complete rationality (which we should not).

The evidence is strong that this paradigm of employee wellness programs tied to high deductible, consumer directed health plans does not work. It saves money in the short term and it does a wonderful job of screening employees by health status but it does not change the underlying cost structures. It merely shifts payers.

The challenge from a policy formation perspective is how to move the evidence into action?

15 replies
  1. 1
    Brachiator says:

    Wellness programs seem intrusive. I always wonder if they seek to identify employees with health issues so that their health benefits can be reduced or costs increased.

    Also, some of the wellness programs seem gimmicky and not tailored to specific employees or specific health issues.

  2. 2
    burnspbesq says:

    I did the math when I started my current job three years ago. High-deductible plans are a sucker bet if you have relatively constant demand for care or drugs.

  3. 3

    Trust is an issue sometimes too.

    My company has made it painfully clear in many ways that they have little regard for any employees outside of top management. I know that some employees believe the information the wellness initiatives collect will eventually be used against them.

  4. 4
    Yarrow says:

    @Ghost of Joe Lieblings Dog: Yep. The contract between the company and the employee goes one direction only. Employees must do what the company says or wants and the company can whatever the hell it wants and fire you at any time. Employees know that so they are rightly skeptical not to trust what companies might do with health information.

    The best idea is to decouple health insurance from employment and then people don’t have to worry about their employer snooping to find out about their health issues.

  5. 5
    daveNYC says:

    HDHP’s are like reverse-mortgages. There’s a certain very specific group of people that can make good use of them, but for everyone else they’re a garbage fire waiting to happen.

  6. 6
    Barbara says:

    @daveNYC: Yes, this is true. I think a lot of employers have become inured to these overall issues. They tried restricting choice and got tremendous blowback, so now they give you all the choice you want, but you have to pay more and more for it.

  7. 7
    Yarrow says:

    @Barbara: Is that true? When did that change toward more options start happening? I only see people complaining about having only one or maybe two options, where one of the options is so expensive that basically everyone has to choose the one with the high deductible. I haven’t seen companies offering many choices. And I’m even including large multi-national companies that have employees working in most states and around the world.

  8. 8
    Kelly says:

    @daveNYC: HDHP + HSA works well for us. Our very specific case is using the HSA to avoid the Obamacare subsidy cliff and we can fund the HSA from an IRA. Not the best plan for very many folks.

  9. 9
    dr. bloor says:

    @burnspbesq: Not necessarily. My family is in precisely the situation you describe, and the high deductible plan (with an HSA that we can fund) is inevitably the lowest cost option on our menu of choices.

  10. 10
    Another Scott says:

    My take is:

    1) People’s lives are full as it is. “Voluntarily” compelling them to do something won’t be accepted.

    2) Instead of pushing all the responsibility on the people to take time and money out of their days to change, why don’t companies make it easier for people to do the right thing?

    Have free cafeteria food with good food. Free is compelling!

    Have a free mini-gym with some exercise equipment (for rainy/cold days) and landscaped grounds where people will be interested in walking around. Free is compelling!

    Give people 30 minute breaks in the morning and 30 minute breaks in the afternoon so they can walk/run/exercise. Don’t take it out of their pay, or make them work an additional hour, pay them the hour. Free is compelling!

    Congress could give tax breaks for such things (though I’m generally opposed to special carve-outs in the tax code – just make it easy and cut the overall rate instead) – it wouldn’t have to cost businesses much at all (and making work places more humane will encourage good people to work there and stay there, so it would be beneficial even without a tax break).

    My $0.02.


  11. 11
    Raven says:

    Ours sucks, the website used for tracking is very difficult to use and, after I emailed the people in charge and they were no help, I gave up.

  12. 12
    Barbara says:

    @Yarrow: We might be talking past each other. I have no options on which plan I join — my company has one. That plan is now HD for everyone, but it has legions of doctors and hospitals in-network, and I can get payment for out of network if I really want to do that. Back in the day, employers began trying to shunt people into HMOs and relatively restricted benefit designs and received so much blowback they gave up.

  13. 13
    Yarrow says:

    @Barbara: Oh, right. Yes, the move away from HMOs does seem to have happened to a certain extent. It could be state by state, too.

  14. 14
    burnspbesq says:

    @dr. bloor:

    It may depend on whether or not insulin is part of what you’re buying on a regular basis. It has the capacity to really shift cost structures.

  15. 15
    Arclite says:

    The vast majority of healthcare costs come from preventable diseases, most of them poor diet related. The elephant in the room is how to deal with corporations that continue to push junk on us. When was the last time you saw a commercial for broccoli?

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