Editor’s Note: The post below, by Jaan Sidorov, is the third in a debate concerning provisions of Senate-passed health reform legislation governing workplace wellness programs. Sidorov’s post responds to an earlier post by Alan Balch, which in turn responded to an initial post by Sidorov.

While the Obama Administration’s campaign to reform the health care system certainly has had its ups and downs, one remarkable aspect of the debate has been the steadfast commitment by the majority of the employer community to providing health insurance for their employees and dependents.  And it hasn’t stopped at basic sickness insurance, but also encompasses interest in providing access to wellness and prevention programs.  Just how these programs are configured in terms of workforce desires, the prevalence of chronic conditions, affordability, local resources, culture and shareholder support varies considerably and is undergoing rapid evolution.

The art and science of successful worksite wellness has taught us that these programs need to be multi-dimensional.  This includes, but isn’t limited to, health risk assessments, providing multiple opportunities for participation in overlapping programs, clear and frequent communication, credible “C-suite” support, careful repeated measurement, and rewards.  The last item can take a variety of forms, including cash, gift certificates, raffles, time off or special status, such as a favored parking spot.  

Recognizing the employers’ stake in wellness, the Senate’s health reform legislation addressed the topic of incentives with an increase of the monetary value of the reward from 20 percent to 30 percent (and possibly as high as 50 percent) of the total premium.

Critics of this provision, such as Preventive Health Partnership Vice President Alan Balch in his Jan. 28 Health Affairs Blog post, point out that such incentives could be fashioned by manipulative employers into a two-pronged attack on their workforce: 1) any cash reward can be used to offset premium increases, functionally leading to a discriminatory 30 percent employee differential based on health behaviors and 2) cash rewards can be exclusively linked to ”attainment” goals (i.e., successfully changing a health status measurement) in lieu of ”participation” goals (i.e., joining in a sponsored activity).  As a result, critics say, the risk pool will be fractured, persons unable to change their health status will effectively be shut out from affordable insurance, and employers’ bottom lines will benefit on the backs of the unhealthy.

By way of example, Mr. Balch cites one company’s marketing pitch to employers: Raise deductibles and then allow employees to bring the level back down by meeting various health attainment goals. Since the sole use of attainment goal setting is neither common nor condoned, the repeated citation of a single outlier program seems better suited to condemning all worksite wellness programs than fashioning reasonable public policy.

Indeed, while the argument against the Senate provision might make sense on its face, how realistic is it?  As surprising as this may sound, worksite wellness programs are designed not to game risk pools, but to promote worksite wellness.  In addition, state-of-the-art, employer-sponsored wellness programs always rely on employee input about the incentives, which typically are multidimensional, not solely attainment-based and, therefore, highly unlikely to discriminate against single individuals on the basis of a single health issue.  The lack of any reports of repeated employee harm based on alarmist scenarios suggests concerns about employer gaming are overblown.

Further, existing Health Insurance Portability and Accountability Act (HIPAA) rules guard against incentive plan abuses. HIPAA limits reward amounts (the percentage now in question); requires that programs be reasonably designed to promote health; requires annual requalification for incentives and that incentives be available to all; and, most important, provides for alternative standards or waivers for employees who, for medical or other reasons, cannot achieve attainment goals.

A Way Forward

A reasonable interpretation of current law and pending legislation suggests that it already addresses critics’ concerns.  That being said, perhaps the way forward is for all stakeholders in worksite wellness to work together to create the language necessary to completely eliminate the low possibility of employer chicanery while also increasing the use of incentives in the worksite battle against preventable – and expensive – disease.  

Ultimately, the science of workplace wellness programs is limited by a lack of prospective clinical trials that examine the roles of various types of financial incentives.  From a public policy perspective, therefore, the question is whether the lack of any evidence of ironclad employee safety is enough to condemn all workplace financial incentives, or, alternatively, if the lack of any evidence of employee harm is enough to permit continued employer creativity in this area.  Given the remarkable interest in the employer community in employees’ wellness, support from rank and file employees and the pressing need for all stakeholders to address preventable illness in the population, why would any organization oppose giving employers even more leeway in tackling prevention and wellness in their workforce?  Who can blame the Senate or the employer community for supporting legislation to increase that leeway?