Incentives Tied to Wellness Data Provoke Backlash

Changing workplace culture, outreach to chronic-condition sufferers could be a better way

By Greg Goth Nov 14, 2016
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An increasing amount of health information has been digitized, aggregated into various demographic categories and then analyzed in an attempt to lower health care costs. In the aggregate, such as through an analysis of health insurance claims, that information can point to workforce issues, such as high diabetes rates, that can be addressed by offering medical compliance support to those with chronic conditions or by changing the workplace culture away from, say, pizza and pastries as the go-to refreshments at meetings.

But when personal health data is collected through individual health screenings, with the results tied to financial incentives—or penalties such as being assessed a higher share of health care premiums—employees may consider this a heavy-handed approach that intrudes on their privacy.

Whether the effort of collecting biometrics such as cholesterol readings and weight measurements from employees—as many employers do—is worth the investment is becoming a more pointed question. For example:

  • In October, AARP brought a suit in federal court seeking to block the implementation in 2017 of the Equal Employment Opportunity Commission's (EEOC's) final rules regarding the use of personal health data in workplace wellness programs. The suit claims the EEOC rules, which allow employers to offer incentives of up to 30 percent of the cost of individual coverage to those who supply the data voluntarily, actually serve to coerce employees, who feel pressured to supply such data or face financial ramifications.

  • The 2016 Global Benefits Attitudes Survey by consultancy Willis Towers Watson revealed employee doubt about the usefulness of such data, according to Jeff Levin-Scherz, M.D., co-leader of the firm's North American health management practice. "We are finding employees are actually very unhappy at the thought an employer would penalize somebody with a high body mass index (BMI), and that includes employees who don't themselves have high BMIs and who are supportive of the employer playing a positive role in health care."

Waterbury, Conn.-based labor attorney Eric Brown said he was recently approached by a man who expressed concern about his wife's health insurance premium being based on participation in her employer's wellness program. Brown said young, healthy individuals aren't particularly apprehensive about sharing such data but he understands the uneasiness of others who fear the inequity over being charged more for not wanting to undergo biometric screenings at work. "Those dollars add up and they matter, particularly for lower-income people."

While Levin-Scherz said the scenario in which an employer uses an individual's data to target him or her in some way is unlikely, the concern among workers is real.

Beyond the risk of antagonizing employees and stoking fears, incentive-based wellness programs may unwittingly and ironically be contributing to growing numbers of "worried well" individuals, leading to overtreatment and higher costs—exactly the opposite of what such screenings are intended to do.

Levin-Scherz noted that two of the usual hallmarks of a workplace wellness biometric screening are cholesterol tests and BMI readings, yet research is emerging that calls the role of both in accurately addressing health status into question.

  • In May 2016, researchers at Kaiser Permanente published the results of a study that demonstrated a widely used tool to assess cardiovascular risk, which uses total cholesterol and "good" HDL cholesterol levels in its equation, grossly overstated the likelihood of heart disease by a factor of five- or six-fold among both men and women in each predicted-risk category. The only group in which risk was substantially close to the risk predicted by the tool (offered by the American College of Cardiology and the American Heart Association) was adults with existing diabetes who were not treated with statin therapy.

  • For almost a decade, researchers have battled over how accurate BMI readings are in providing clues to a person's overall health. For instance, a 2013 meta-analysis of studies covering nearly 3 million people by the Centers for Disease Control and Prevention's National Center for Health Statistics showed that people in the "overweight" category (a BMI of 25-29.9) actually had lower all-cause mortality than "normal" weight people. A 2016 study published in the American Journal of Medicine showed that analysis of cardiorespiratory fitness, for which no convenient clinical measuring tool exists, improved on BMI- and waist-circumference-only models in assessing risk.

Vindication for Wellness Gadflies?

Such findings were no surprise to wellness program skeptic Al Lewis, who with Vik Khanna founded the health education platform Quizzify. In an essay the two published in Health Affairs in 2013, they estimated that the cost to prevent one heart attack using biometric screening was exorbitant.

"Vik and I posited—and were never rebutted—that it costs about $1 million to prevent a heart attack using biometric screening," Lewis said. "But the elephant in the room is that U.S. Preventive Services Task Force guidelines are quite opposed to annual screenings. Why do something that the leading experts in the field have concluded, quite rightly, is a bad idea?"

Khanna, a trained physician's assistant, said the fetishization of health data and the belief that data can predict disease has been the result of a misdirecting narrative that a technology-loving society has been eager to embrace.

"It plays to people's fears," he said. "The average American worker is in his or her late 30s to early 40s. The vendors play on this fear that you need to be screened now so you don't get cancer or a heart attack or diabetes that eventually leads to cardiovascular disease and eventually a stroke. What they never tell people is that [the likelihood of those outcomes] is age-related."

[SHRM members-only toolkit: Designing and Managing Wellness Programs]

Time to Phase Out Incentives?

The rising concern about exactly how accurate and fair the use of individual health data really is might signal a shift in employers' practice away from such a wide net.

"I do think there are some employers who wonder if this is really the best use of a subsidy or premium discount," said Christopher Sears, a partner in the employee benefits group of Indianapolis-based law firm Ice Miller, citing the Pareto principle, the 80-20 rule that postulates 20 percent of a given population usually accounts for 80 percent of costs.

"Could that money better be used to pay a vendor and do a deep dive into the data and target chronic diseases and disease management programs to help the 20 percent manage their disease? They're starting to think they should try to promote prescription compliance and diabetic-diet compliance to try to tackle those larger costs."

Sears noted a more complicated regulatory climate around the programs; for instance, he said the new EEOC rules call for not only an affirmative notice to employees who are contemplating participating in a wellness program but that to get a spouse involved under the Genetic Information Nondiscrimination Act, an employer would need to go further and get affirmative consent.

"I hear employers talking about this," Sears said. "I'm not saying these plans should not be regulated, they should be—but at some point employers will view that regulation as burdensome and say, 'It's really not worth my time or money. I'm just going to charge employees the premium I was going to charge them.' "

[SHRM members-only how-to guide: How to Establish and Design a Wellness Program]

Culture, Not Carrots and Sticks

The doubts expressed about how useful and fair the collection of all this data really is may present an opportunity for a reboot that could lead to a climate of better education and a healthier work environment.

According to Levin-Scherz, the trend away from direct incentives targeting the workforce generally can be expected to accelerate in the near future, and company survey data backs that observation up: Of 487 U.S.-based employers surveyed in Willis Towers Watson's 2015-16 Global Staying@Work survey:

  • 70 percent said their primary strategy to promote healthy behaviors was to offer direct financial incentives, but only 47 percent said they expected financial incentives to be their primary strategy in 2018.

  • 34 percent said they focused their health-promotion efforts primarily on strategies to create an organizational culture around workforce health and well-being, but that rises to 64 percent who expected to pursue that route by 2018.

Said Khanna, "When you give people support and good information they can trust, they can and do change [to healthier lifestyles] on their own. People migrate across risk categories all the time."

But healthier behavior, "to make a difference, has to be sustained, and it is not likely that one-time, once-a-year payments of relatively small—or even large—amounts of dollars will actually mean a population will weigh less or better control its blood pressure," Levin-Scherz said. "This might not be the best place to promote [the use of] incentives."

Greg Goth is a freelance health and technology writer based in Oakville, Conn.

Related SHRM Articles:

AARP Lawsuit Casts Shadow over Wellness Programs, SHRM Online Employment Law, October 2016

EEOC Issues Final Rules on Employer Wellness Programs, SHRM Online Benefits, May 2016

Court: Employers Can Require Health Screenings for Insurance, SHRM Online Benefits, January 2016

Time to Set Limits on Wellness Screenings?, SHRM Online Benefits, January 2016

Groups Offer Guidance on Biometric Health Screenings, SHRM Online Benefits, October 2013

 

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