Wellness: Carrots and Sticks
There's danger in expecting wellness programs to work miracles and abandoning them when they don't.
Wellness is breaking out all over. Not that we're all eating whole- grain pasta and factoring an hour of exercise into our day. But more of us are at least thinking about healthy habits. And so are policy makers.
It's the next new thing for containing health costs. If we only took better care of ourselves, the health care system wouldn't have to dole out so many pills or admit as many people to hospitals. And it can work. Look at Arkansas Governor Mike Huckabee: He was lumbering toward serious obesity, diabetes and heart disease before he dropped 100 pounds. Now his cholesterol numbers are way down and he's running marathons.
We can't all be like Mike, but there are a growing number of public programs that key in on incentives to encourage employees or program beneficiaries to take better care of themselves--and thereby cut down on the cost to the health care system of taking care of them. The approaches range from kid gloves (subsidized health club dues) to tough-love (higher health insurance premiums for those who "don't cooperate").
Arkansas, for instance, cuts health insurance premiums $20 a month for state employees who take a voluntary health-risk survey. And South Dakota forks over up to $300 for an employee's purchase of such health-maintenance items as exercise equipment or membership in fitness and nutrition centers. And if state employees take a health assessment and use it to set personal goals ($50 bonus for taking the assessment), the state will pay that employee $100 for reaching one of those goals.
At least four other states take a tougher stand: Alabama, Georgia, Kentucky and West Virginia impose a surcharge on the insurance premium paid by employees who smoke.
King County, Washington, is setting up an ambitious program. The county's employees and family members insured by the county (not including children) will have to answer survey questions about their weight, daily exercise regimen, eating habits, whether they smoke or speed while driving. The information will be confidential--the county will not see it; a third party will administer the program--but it will be used to set personal plans to improve each employee's health. For smokers, for instance, that might mean enrolling in a smoking- cessation class.
Those who refuse to answer the survey will feel the pain in their pocketbook. They will be classified as "bronze level" and bronzes will pay more toward their health care. Details are being worked out, but they are likely to have to pay the first $1,500 of their annual medical costs and 20 percent of their subsequent bills. Silver- and gold-level employees--those who are more cooperative on the survey and goal-setting--will pay progressively less. Gold, for instance, might have to pay only $300 in deductibles and a 10 percent co-pay.
From the county's point of view, something had to give. Last year, its 39,000 employees and their dependents racked up $136.7 million in claims--a 57 percent increase in four years, while the cost of living rose only 14 percent. Health care costs for the county, which is self- insured, were projected to climb to $205 million by 2009. The county hopes its wellness program can shave $40 million from its benefits bill between 2007 and 2009.
The King County approach is reinforced by a recent study in the journal Health Affairs that put the increase in the tab for caring for the surge in obesity (and treating the diseases spawned by that condition) at 10-fold between 1987 and 2002. In 2002, the study found, spending on medical care related to obesity accounted for 11.6 percent of all private health care spending, compared with 2 percent in 1987.
Public employees aren't the only targets of public wellness policies. Iowa is expanding its Medicaid program to people it had already been serving through state and county indigent-care programs. But these new enrollees will play by different rules. Upon enrollment, their health will be evaluated and they will be given a personal health care plan-- with goals such as losing weight or quitting smoking. A self- assessment of compliance with the plan will be tracked by the state, with rewards for achieving "wellness" goals.
Who can doubt that this is all to the good? We should take better care of ourselves and encourage others to do so. And that will have a salutary effect on our well-being as well as on the health care tab.
But it will have only a small effect on the latter. Wellness can't cure what ails the health care system. There is the danger of putting too much on the shoulders of a tiny piece of the problem--expecting it to work miracles and then abandoning it when it doesn't. Wellness is too good an idea for politically grand expectations.