Monday, November 30, 2009

Obesity, Health Insurance, and Employer Incentives

Federal health reform is the front page news, but states and businesses are the laboratories for change. Next to Governors, who have to deal with hideous budget problems driven by declining revenues and escalating Medicaid costs, employers who offer health insurance to their employees are most directly concerned about health care costs.

Health reform requires three ingredients: (1) facing facts, (2) thinking strategically and (3) embracing individual and population concerns. Given the virulent divisiveness of current U.S. politics, employers who offer health insurance are the most promising venue for applying this triad in a "businesslike" manner!

In previous posts I've written about how IBM promotes primary care and encourages employees to find a medical home (here), how Foundation Coal and Peabody Energy understand and act in accord with comparative effectiveness concepts (here), and how the Hannaford supermarket chain rewards employees who have surgical procedures like joint replacement in Singapore, where high quality services are available at lower cost (here). An article in yesterday's New York Times - "Health Care Savings Could Start in the Cafeteria" - describes a pilot collaboration between employers, a health plan, and The Full Yield, a start up health improvement company.

Starting in January, employees at John Hancock and the City of Boston will be able to enroll in a year-long Full Yield program that will provide access to healthful prepared meals, nutrition coaching, and other self-management tools. At John Hancock participants will get $100 worth of coupons that can be used at the office cafeteria and at local supermarkets that carry the Full Yield products. At the City of Boston, participants will have a series of biometric measurements taken at least three times during the year. The Full Yield is partnering with Harvard Pilgrim Health Care, the not for profit insurance company for which I run the ethics program, to administer and evaluate the program.

The Safeway company has apparently achieved the near-miracle of keeping its employee health insurance costs level since 2005. Steven Burd, the CEO, attributes its success to "creating a culture of health," part of which involves incentives for managing tobacco use, healthy weight, blood pressure and cholesterol levels. For achieving targets in those four areas, employees can reduce their contribution to health insurance premium, by up to $780 per year for individuals and $1,560 per year for families. (see here)

Incentives - especially if they're guided by insights from behavioral economics - work. (See, for example, this article in JAMA by Kevin Volpp and colleagues.) And, since obesity is a highly stigmatized condition that tracks closely with socioeconomic status, the wrong kinds of incentives could reinforce prejudice and discriminate unjustly. But those risks are reasons to use incentives carefully and monitor for negative impacts as well as success - just as good clinicians do for the treatments they administer - not reasons to avoid incentives altogether.

I continue to believe that employer/employee collaboration on behalf of promoting health and constraining health care costs within the workplace "family" is an extremely promising approach to transforming our national health non-system!

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