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.
James Sills: Low uptake of employee wellness programs. Would greater financial incentives translate into better, healthier, more productive employees? #TransformNC
— Kristin Tully (@KPTully) February 8, 2019
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?