Insurance Health Insentives

Washington Post
Firms make it their business to push health
Incentives, monitoring programs aim to cut employee costs

CYPRESS, Calif. – At age 45, Rick Graham was 5-foot-8 and 235 pounds. His blood pressure was soaring, and he didn’t have as much energy as he did when he was younger. The business analyst tried every diet in the book, but the weight kept coming back. Finally his employer decided to do something about it.
If Graham would try to eat better and exercise, PacifiCare Health Systems Inc. offered a novel reward: cash.
So now, once every 24 hours or so, Graham logs on to a computer system managed by his company and types in everything he has eaten: packet of instant oatmeal (104 calories), can of V-8 juice (35 calories), mini box of raisins (42 calories), Mandarin chicken (280 calories), wedge of banana cream pie (300 calories), pepperoni pizza (560 calories), eight cups of water (0 calories) and so forth. He then inputs any exercise he has done, which on this particular day happened to be nothing but is usually 25 minutes on a treadmill and 20 minutes on a stationary bike.
For keeping track of his food intake and his fitness routine, PacifiCare pays him about $15 every other week, or $390 a year.
Carrots, sticks and pedometers
The monetary incentives are part of unconventional new programs being rolled out by PacifiCare and other corporations around the country to try to coax, push — or even force — workers to become healthier.
The move is driven, the companies say, by soaring health insurance costs. They say that the fitter their workers are, the fewer claims they are likely to file. But some workers rights groups worry that these programs, while well intentioned, set a precedent for allowing employers to get involved in private aspects of people’s lives.
“Do we really want employers conducting an extensive survey of employees’ every unhealthy lifestyle choice? Do you really want your boss asking you what you eat and what you do for recreation?” said Lewis Maltby, president of the National Workrights Institute, a spinoff of the American Civil Liberties Union.
PacifiCare is among the more ambitious in its incentives. In addition to cash, the health management company offers its 9,100 employees rewards for participating in classes to stop smoking or to manage their diabetes or asthma. Workers can also earn credit for non-health-related activities, such as trying to manage their personal finances better, learning about art or music, washing their car or teaching their children not to play so many video games. The credits can be converted into iPods, spa certificates, water noodle toys for the pool and other goodies.
Smokers under the gun
A number of other companies are trying similar approaches on a smaller scale. Many efforts focus on smokers, and some are not voluntary.
A Florida sheriff’s office is requiring some applicants to take a polygraph test with questions about their smoking habits. Omaha-based Union Pacific Corp. last fall stopped hiring smokers in seven states. And Navistar International Corp., a Warrenville, Ill., truck manufacturer, is introducing an extra charge of $50 per month for health care coverage for those who smoke.
The question of how far companies should go was raised recently when seven employees resigned from Weyco Inc. of Okemos, Mich., in January rather than submit to a nicotine test.
The degree to which companies can impose health-related requirements on employees varies across the country. Thirty states, including Virginia, plus the District of Columbia have laws preventing discrimination against smokers, while others, such as Maryland, do not. Thirteen states prohibit employers from regulating alcohol use during non-work hours. But only four states — California, Colorado, New York and North Dakota — have passed broader privacy laws protecting people’s activities away from the job.
The question of how deeply employers should get involved in their workers’ health arises as half of all deaths in the United States continue to be attributed to a limited set of largely preventable behaviors. The Centers for Disease Control estimates that each year there are 440,000 deaths from tobacco use, 400,000 deaths from poor diet and physical inactivity, and 85,000 deaths due to alcohol consumption.
PacifiCare’s incentives program is the brainchild of Sam Ho, the company’s chief medical officer and executive vice president. Ho is a self-proclaimed health nut who practices yoga religiously, is a vegetarian and prides himself on needing only three to four hours of sleep a night.
Ho said his inspiration came from an assessment program the health management company uses to grade physicians’ performance. Once doctors were told what they were doing right and what they were doing wrong, there was a marked improvement in patient treatment, he said. Ho theorized that he could apply those lessons to employees and their own health.
Reaction mixed on incentive program
PacifiCare officials declined to say how much the company is spending on the program, except to describe the amount in the “high six figures.” Ho predicted the program would more than pay for itself over the first two years in health care savings.
“Everybody knows we have a health care crisis, exemplified by both cost inflation and an obesity epidemic, in the United States. It was only a matter of time before employers started taking action,” Ho said.
Health insurance premiums have skyrocketed since 2000, growing 59 percent, far faster than the 12.3 percent rise in average pay, according to the Kaiser Family Foundation, a nonprofit research firm in Menlo Park, Calif. Studies have shown that nonsmokers alone save companies an average of $1,000 a year.
When PacifiCare’s health credits program was announced last summer, the reaction from employees ranged from enthusiasm to suspicion. About half the employees signed up, with about 15 percent doing enough to qualify for the $15 biweekly credit.
“Some people said I don’t want anybody to know this stuff,” said Jennifer Horn, 31, chief of staff of the corporate health services group.
The company assured employees that individually identifiable data would be kept confidential and made available to health professionals only with the employee’s permission. There were also complaints from people who reported that some co-workers were cheating, that the person next to them was eating a candy bar or chips and was still getting the credits for healthy eating.
Mandatory exercise on the horizon
While PacifiCare’s program is strictly voluntary and is currently based on the honor system, Ho said the company plans to introduce modifications to make it stricter in the next few years. Parts of the program may become mandatory, and there may be monitoring of reported indicators of health such as weight loss and exercise. Perhaps, he said, the company may conduct weigh-ins, give out pedometers linked to a computer system or issue swipe cards for gyms to record the amount of a time an employee spends there.
“Some of these behaviors like exercising regularly and eating right should be the default. Soon, those that don’t do this may have to pay more or risk a penalty,” Ho said. “This is the future of health care.”
But even voluntary programs worry people such as Mark A. Rothstein, director of the Institute for Bioethics, Health Policy and Law at the University of Louisville School of Medicine. He said lower-paid employees may feel greater pressure to participate.
“I think it’s a tax that some of the lower-paid workers perhaps can’t afford,” Rothstein said.
Under the PacifiCare system, employees earn incentive credits in various ways, whether by using an online diary to log their food and exercise, by participating in one of 16 health education classes or even by maintaining a gym membership. The company’s main Southern California campus just outside of Los Angeles is being transformed to match the company’s new emphasis on health. Vending machines are being stocked with water and nuts rather than soda and chocolates. Posters encourage people to take the stairs. On-site yoga classes have begun.
For some, benefits easy to digest
Sharon Richard, 62, an executive associate in major accounts whose family has suffered heart attacks and stroke, said she signed up because she had started an exercise program when she turned 60 and wanted a way to continue her progress.
“It’s about a lifestyle change and your company supporting you in that,” Richard said.
As a first step in signing up, employees fill out a detailed assessment form with their height, weight and family health background. A computer program suggests exercise programs and menus based on a person’s background and stated goals. Among the input it might give is that a person’s caloric intake leans too much to starches or that the calories are not balanced enough throughout the day.
PacifiCare’s program allows employees to consult with dieticians and fitness experts via e-mail. The workers have the choice of allowing these “coaches” to look through their diet and exercise logs, or not.
Graham, who works for the company’s dental and vision division, said he had not exercised in years and was becoming increasingly worried by his doctor’s warnings to exercise more and eat better. Two of his co-workers have dropped out of the program, but he and another woman have stayed on and are happier for it. Graham has lost 45 pounds, he said, and his “diet partner” 40 pounds.
He said the privacy he has given up is worth the results he has received, especially since the program is voluntary.
“Forcing workers is one thing — I don’t think that’s really right,” said Graham, a five-year employee who recently turned 46. “But incentivizing, I think it’s awesome. Everybody wins. The company wins because they save money on health care premiums, and the employees win because they are in better shape.”
He said the interactive nature of the program keeps him on track, monitoring every move like his mother might once have, and giving him unsolicited advice and admonishing messages when he is not fulfilling his goals.
“I feel guilty when I don’t do it,” Graham said.

© 2005 The Washington Post Company

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