"Wellness" — Or Else
Maggie Mahar on “The Health Beat” gives us a head’s up on yet another perverse incentive, this time one that superficially looks like one of those bleeding-heart lefty Wellness provisions, but will have the opposite effect if not patched up. (Note: Maggies post is built on AlterNet post here.
How Insurers May Use “Wellness Programs” To Target Pre-Existing Conditions
Under reform, insurers will still do their best to shun the sick…one way they may do it: by using “wellness programs” to penalize those who can’t meet health targets…
…A little-discussed provision of the Senate bill allows insurers to expand so-called wellness programs that let insurers penalize subscribers by hundreds—and even thousands—of dollars for not meeting certain ‘wellness targets,’ such as a particular cholesterol number, blood sugar measurement or body-weight target.
…one of the pro-business innovations of the Bush administration was to introduce into health insurance regulations a provision allowing employers to offer loosely defined “wellness” programs that carry incentives for employees meeting certain standards of premium reductions of as much as 20 percent. Sounds like a pretty good deal, right? Sure, until you realize that there’s no baseline for the original premium, meaning that, in reality, people who don’t meet the standards are really carrying the burden of others’ discounts and then some—paying as much as 20 percent more for a policy in which a family member’s failure to meet a wellness target forces up the entire premium for that family’s policy…
[…]
…while insurers may no longer be able to drop your coverage for a preexisting condition such as high blood pressure, under the Senate bill they will be able to charge you and your employer as much as 50 percent more for your total premium cost if you fail to meet a targeted blood pressure or cholesterol measurement.
For instance, there is the widespread problem of obesity.
“Obesity doesn’t seem like a subtle disease,” adds Dr. Lee Kaplan, who heads the Weight Reduction Program at Mass General Hospital. “But it is. If something is off kilter by just 1 percent in your system that can lead to a 100 pound weight gain. More than 400 genes are involved in weight regulation. And that doesn’t include the environmental factors.”
…Dr. Michael Rosenbaum, a Columbia University researcher working on an NIH-funded study on weight control [points out that] “Obesity is the one disease where your body fights the cure.”
[…]
Under the wellness programs Stan [at AlterNet] describes, employees suffering from such a flaw in body chemistry would be punished.
[T]he American Heart Association does not object to employer-sponsored wellness programs per se, but only to financial penalties imposed on those who don’t participate in “voluntary” wellness programs or cannot meet wellness targets. As the AHA points out; “the causes of obesity, hypertension, and high cholesterol are many, and vary between individuals.” For instance, genetic predisposition is an important factor in many conditions. Therefore, penalizing individuals for their risk factors sometimes means penalizing them for their genetic makeup which is beyond their control.
[…]
Moreover, the AHA points out, “Even health factors that are theoretically controllable in the best of circumstances may be vastly more difficult to control for those who are: (1) low income; (2) working more than one job; (3) working parents; (4) dealing with chronic mental or physical conditions; or (5) caring for sick parents, children or other family members.
[…]
Stan concludes that what is most troubling is how the penalties zero in on “people least likely to be able to control the circumstances that lead to their inability to meet wellness targets—the poor and those with genetic predispositions to certain conditions … So, unless regulators intervene, insurers will continue to discriminate against those who most need high quality, affordable care.
Go read both articles, there’s quite a lot more over there.
If medical science knew anything about medicine, wellness programs might make sense. If anything it knows less about its area of interest than economics does. In point of fact people operating within the formal rules can and do publish huge volumes of contradictory conclusions. With the notable exception of the connection between tobacco smoking and lung cancer, one can find studies that support just about any point of view one chooses to take.
Epidemiologist John Ioannidis has published a number of papers on this. As far as I can tell, he is taken seriously and there is broad based agreement that he is probably correct. Ioannidis maintains that most studies are wrong — some dead wrong, and others seriously wrong about major details.
I’ve looked into this enough to know that medical science may well have a pretty good fix on diabetes (albeit no treatment for Type II that doesn’t damage the patient), possibly on triglycerides, seems to have (to my surprise) very little idea what it is about with hypertension. And that it’s definition of obesity is preposterous. (Using data from their biographies, it has been shown that according to Body Mass Index Brad Pitt, George Clooney, and Matt Damon are obese).
IMO, Wellness Science is currently about as scientific as Christian Science and should have no place in the nation’s health program until it grows up.
Safeway supermarkets did this, and it seems as if it had some success:
http://online.wsj.com/article/SB124476804026308603.html
You forgot to blame obesity on Bush.
VtCodger,
I agree with your opinion of “Wellness Science”, and I have an opinion that is void of science to an extent. My wife and I are in our 50s and we grew up in California. But for the past 7 years we have lived in Texas. And guess what our visiting relatives notice about Texans more than anything else, if you guessed “how fat the people are here”, you got it right. And it follows that we have the opposite reaction when we return to California.
When we lived in California we had a log furniture business. We harvested our own wood in the Tahoe Basin and the work was hard. I weighed a little under 200 pounds back then and probably ate considerably more than most men my size because I was considerably more active than most men in California. But, comparing my diet then to the diets of men here in Texas now, whether by caloric intake, or by volume, I was a whimp by this standard (local scientific term).
We eat out frequently and it is impossible not to notice how much the people here eat, and, how much they waste. We tried not to be judgmental at first, but now during this debate we are like food spies, and we lack the discipline not to look at what is everywhere around us. So we have adopted “the why fight it” attitude and made a casual study of the local eating habits as if on a mission. And our anti-scientific conclusion, after years of field work, is that eating,(for an ignored percentage of the population), has become recreational in the absence of alternative activities.
And of course there are cost factors, which we discovered, are best studied while waiting in line at Wal-Mart. It does not take a scientist to notice that poor people buy vast amounts of processed foods and “soft” drinks by the case. What seems the most telling to me, is that more often than not, as the shopping carts become more heavily laden, the person pushing the cart is typically heavier. In fact, the most heavily loaded carts require nothing less than a very large person to push them and these carts almost always include a disproportionate burden from liquids which are sweetened with corn syrup. But now I am getting too scientific.
Anyway, our study might be more conclusive if we had some sly method for weighing shoppers and restaurant patrons but we lack a solution to this problem. For now, the only conclusion we are certain of is that Texans consume substantially more than Californians do, and that high-school football teams that have bigger players usually win. And in Texas, the only thing more important than high-school football, is eating and drinking, but that is not to suggest that these are mutually exclusive. (the highly caffeinated energy drinks are commonly used here by participants in high-school sports [good spies never rest])
The most troubling aspect of our research is that our national health-care debate failed to include important considerations that are rather obvious. I remember an article by Dr. Krugman for example that compared the Swiss and US health-care systems. Our % of GDP as a result of health-care costs, and per capita comparisons were included, but prevalence rates were ignored. As it turns out, we have about 300% more diabetes than the Swiss do. But factors of this type were largely ignored, even though it is obvious that a nation with higher rates of illness and injury will have higher costs.
And at the risk of being mistaken as a Republican, what about those comparisons between private and public administrative costs. Private sector admin. costs include the protections against fraud that are costing Medicare untold billions and that nasty little fact was mostly lost in the confusion. As was the fact that medical providers do some cost shifting that allows Medicare costs to be relatively low. […]
noni
i am going to play devil’s advocate here because you are leading into ground that could scrap the whole idea of “universal health care.” first a disclaimer. in general i believe we all ought to go into a blind pool and pay the same rates. there are only pre-existing conditions we know about and pre-existing conditions we don’t know about.
background: my sister was “treated” for “obesity” when she was a slightly overweight teenager. the experience damaged her health and destroyed her self esteem. the treatment of choice back then was “appetite supprssants” in other words, “speed.”
so, you could say mildly that i really really hate doctors. also, i don’t trust them.
that said, if you are going to go to the American public and ask for special treatment (that’s the way they see it) because of a “weight problem” or smoking problem, or drinking problem, or “stress” problem or minimal mental health problem…. and just add it to their bill, they are going to revolt, and you won’t get anythig. did i mention a “problem” with unwanted pregnancy? same problem.
i would add in my best imitation Republican accent: life is not fair. if your genes make you fat, maybe that is just an extra cost of living for you. not so different in principle than the extra costs faced by people whose genes make them stupid… at least financially… or born in the South… I am being a little provocative here, because i can’t think of an good way to say that we all face different “challenges” and there is no apriori reason why i should pay for yours.
except, as i said above, we are all in this together.
but even so, i am very very leary of paying for dubious care of dubious problems. my grandmother was overweight and lived to 83. my mother was the picture of good shape and died at 66. so i don’t think much of the actuarial “facts” either, even if they are honest. at some point we need to refuse to turn ourselves over to what the insurance companies have to do to turn a profit.
which brings me back to universal health care with a single premium. as long as you don’t spend a lot of my money on “treatments”.
i hope this has been confusing enough for you.
WapnersPC,
The revolving door that connects the USDA and other related agencies, to Monsanto and other related agri-corps, could be, and have been used to make convincing cases that include Bush. But that is now best left to historians to sort out. Rest assured that they will be gentle. In a Democracy, blame is shared, as it should be, and Bush will thereby benefit on the pages of history.
“…that said, if you are going to go to the American public and ask for special treatment (that’s the way they see it) because of a “weight problem” or smoking problem, or drinking problem, or “stress” problem or minimal mental health problem…. and just add it to their bill, they are going to revolt, and you won’t get anything. …”
Ah, the American public, so ready to cut off their own noses to spite somebody else’s face…
Those rare times I head into the waiting room, I will see all of the above, plus Native homeless people, obese people, and young reckless men sporting gunshot wounds, car crash injuries and alcohol toxicity. I’m pretty healthy, so almost all the people there are worse off than I am, and many of them due to “lifestyle choices” (what a loathsome phrase.)
But we take all comers, patching them up, providing wheelchairs, homecare, diet plans, foot washing, and all the gazillion things people need whose self-neglect has ruined their health.
And yet we STILL pay about half what the USA pays for health care, per capita.
Give a man a fish — it’s cheaper.
Noni,
I assume that you now live in Canada. But from your recent post on Tuna and Salmon, I remember something about Minesota?
“And yet we STILL pay about half what the USA pays for health care, per capita.” This means very little without knowing illness and injury rates. We have a problem in this country that is far more serious than how we pay for medical care. We have a diet-related disease epidemic and even before jobs seemed to be a serious isssue, it was a serious issue. We had a manufacturing and agricultural empire that tens of millions of people in
noni
since i mostly agree with you, it’s kind of hard for me to make the point that you are missing.
health care in this country is too expensive. as far as i have been able to tell a major reason is that we allow doctors to over-treat us. if you are asking the american people to pay the bill, you might give some thought to holding down costs.
i still have my nose, thank you. managed to make better lifestyle choices before it was too late.
Noni,
If the US has illness and injury rates that are twice those in Canada, just think how misleading and harmful your claim would be:
“And yet we STILL pay about half what the USA pays for health care, per capita.”
We don’t know our illness and injury rates because a great many of us don’t seek care that we would if we could afford to. I once cut off the tip of my left thumb and just had a co-worker “tape it up”; I have also pulled 2 of my molars, and I have had broken ribs twice and a collar bone completely separated from my sternum, but in all of those cases and many more, the only care I sought was when one the aforementioned molars imploded from the pressure of my pliers, which forced me to have a dentist remove the roots. Other than that, at 54, I have used the services of a medical professional only one other time and that resulted in my receiving a cortisone shot in my elbow.
Anyway, I know my medical history is unusual, but I also know that a great many millions exist outside the “participation rate”. And I know too that many of us would seek care far more often than we do if the prospects were not so expensive, and/or demeaning.
There was this guy who believed very much in true love and decided to take his time to wait for his right girl to appear.
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You may painfully regret, only to realise that it is too late.
Just to take a peek at this from another direction. Let’s say we want to reward healthy behavior. Let’s say we see money as a reasonably good incentive in changing behavior (turns out this is not a very reliable assumption, but let’s accept it for the sake of argument).
Measuring cholesterol doesn’t tell us much about behavior. Measuring weight doesn’t tell us much about behavior. The goal that is served by using physiological measurement is to bring medical status directly into account when setting rates. Physiological measures are not direct measures of behavior. As noted by other commenters, genetic luck is a big mediating factor between behavior and results.
So, if we want to use money as an incentive to healthy behavior, rather than as a back-door means of boosting premia for those who represent a higher risk of filing claims, they we need to measure behavior. This is problematic because basing rates on measurements taken once (repeat the cactus cholesterol story here) is easier than basing them on behavior because for behavior, we’d either have to monitor constantly or rely on self-report.
Doing a good job of promoting wellness with wellness plans is one thing. Using them as a trick to boost rates is quite another. It is pretty clear, though, that if the real goal is discrimination in insurance premia, means actually promoting good health is a subsidiary goal at best. If we want to promote health, then let’s do that.
harris
let me play devils advocate in the other direction (the devil is well known to be on both sides of any conflict).
we can’t measure behavior without tyranny. we can measure cholesterol. if the measure is taken under controlled conditions (not Cactus’ experience) and if the measure does correlate with future medical costs, then it would be reasonable (but maybe not optimal) to charge a premium for high cholesterol. then those who could lower theirs might be motivated to do so, and this would show up on their next test and get them lower premiums. meanwhile a higher premium is not exactly a cruel and crushing burden. just having high cholesterol is evidence that nature itself is not “fair.” no reason that “man” needs to be unfair to everyone else just to make up for what is otherwise a small cost to you. seriously, this is a slippery slope that could lead to everyone being compensated for whatever an effective pressure group can convince the government it deserves to be paid for, to make up for the injustice of god.
that said, i still prefer a single-premium we are all in this together universal coverage, regulated by government, paid for by a payroll tax. once that’s in place, the actual doctors and social workers can do what they can to reduce “behavioral” contributors to high medical costs.
we all have prior conditions, ones we know about, and ones we don’t know about yet.
hmm. i am not so sure i ended up taking the opposite side from myself here.
Except that “rewarding” good blood chemistry is just another name for punishing bad chemistry. Much of the health care reform effort has been aimed at not punishing bad luck, including bad chemistry that results from bad luck. So I suppose I was taking the heatlh care debate as context.
We know the consequences of rewarding good chemistry. It ends up being a method to charge more for bad chemistry. In many cases, that’s nothing more than luck. Luck is its own reward. I want to reward behavior.
Tyranny? Well, a rewards-based tyranny, I suppose. Anyone who would rather not participate in a program actually aimed at health (instead of aimed at back-door risk profiling), could simply decline to report behavior or have behavior observed.
In addition to that, I’m not sure there is a difference in tyrannous quality between taking blood and keeping track of how far I walk every day.
Now, there are lots of reasons one might want to limit firm size, some of which serve democracy and freedom, but economic efficiency isn’t one of them.
Once we admit that we are not able to afford unlimited medical care for all, maybe then we will see that we have a choice of taxing either good, or bad behaviors. Then too perhaps it will be clear that not taxing unhealthy foods etc., is the same as taxing healthy food choices etc.. This of course due to the fact the healthy must pay more than their share and the unhealthy must pay less than their share. Of course this seems over simplified until our food and beverage industries and their impact on not just our health, but on health throughout world is considered. We as a people are not having an honest debate and it is doubtful that we are willing to do so until things get much worse. The good news is that things will almost certainly get worse if we continue to delude ourselves, so in a slow and painful way our underlying problem, self-deception, should solve itself. At the very least we should then at least be ready to admit that our agricultural subsidies are part of the problem.
harris
it would take a good bit more watching you to keep track of your walking than to do a controlled blood test along with your annual physical. hence the door to “tyranny.”
you and noni are right about the dishonesty of the “wellness program” scam.
i, in my humble way, was just pointing out that a 10% surcharge for “bad chemistry” was not going to materially change your life. just another in my undending series of posts recommending people stop feeling sorry for themselves and demanding the government make it up to them. i know this sounds like right wing knuckle dragging hypocriscy to you. to me it sounds like a plea for mental hygiene in the midst of looking for a way to help the people who really need it.
for what it’s worth, i don’t have my blood checked.
love
no doubt… but ag subsidies get us a little far afield. i’m just looking for a reasonable way to hold down health care costs. along with regulating the insurance companies, and using a payroll tax to get people to understand there is a link between how much they pay and what they get.
if we had a “everybody pays the same” system, and the insurance companies bid for blocks of randomly chosen persons, then the insurance companies would have an incentive to try to influence behaviors. but they couldn’t do it by government mandate. and they couldn’t do it by raising the premium for non compliance. they might be able to do it by education or even giviing kickbacks to people who did enroll in their “wellness program.”
coberly,
I was not suggesting that we should discuss ag subsidies, and I meant to convey that we are not ready to have that debate yet.
You seem to be a very smart person but it is naive to think premiums might be restricted by anything other than market forces. Kickbacks for a wellness program may make a small difference but profits and jobs will always outweigh all else. And your plan will apply to less than half of the population. The Guv might eventually squeeze some of the inefficiencies out via the MLR or whatever, but there isn’t as much to squeeze as we were lead to believe. And the Guv’s current squeeze on the bankers is considered bold if gets the tarp funds back. And bankers could do with a major squeeze but that infringes on our misguided notion of what it means to be free. Then too it seems that many among us feel that the negative externalities of our ag production have something to do with freedom, but there I go again. This health-care debate is just so hard to ignore.
rl
I live in Texas also. DFW and I don’t see that fat that you do except when i go to Walmart. And I’ve found that to be true reguardless of what state your in (Virginia, Maryland, Ohio, California, Colorado, New Mexico have shown that attribute).
Maybe I live too close to the college here, but I don’t see the flab…and last time I was in California I was amazed at how plump everyone was (in San Francisco…). And don’t get me started about Merced.
Islam will change
You could just as much blame the obesity on LBJ for all I know. (WapnersPC I kknow your being sarcastic, all failures from any cuase can be blamed on Bush, it makes blame assignment easy for the left). That revolvoing door has a distinctly bi-partisan flavor…
Islam will change
buff,
Until a few months ago I lived near Ft. Worth in the mid-sized town of Cleburne. We did much of our shopping in the Metroplex and agree that obesity in and around the big cities is less prevalent. I was too vague above and probably have millions of Texans trying to find me so as to exact revenge. I may deserve it.
My in-laws live in Millbrae overlooking SFX so my exposure in California is to a middle-class area. So if what you said is combined what I am now saying I hope that fills in the blanks. The readers here are smart enough to fill in any remaining blanks. The next time I accuse someone of stereotying I “should” be more understanding.
buff,
Comments that are guilty of what they accuse the innocent of, are nearly always combinations of extreme bias, and presumption.