Yesterday afternoon, CMS released a call for states to participate in a demonstration project to deploy wellness programs on the individual market.
- Workplace wellness programs don’t change healthcare spending
- Most benefits flow to people who were already in good health/shape/habits
- Administratively a nightmare
My first thought that this is an invitation for cherry picking. Employer based wellness programs, in well controlled randomized evaluations, don’t work (Song 2019, Jones et al 2018). Or at least they don’t work in changing healthcare spending for people with moderate chronic diseases who are healthy enough to be employed enough hours to get insurance through work.
Wellness programs have been a big deal for over a decade now. The ACA allows for significant “voluntary” incentives (which is another way of saying penalties) for compliance/non-compliance with workplace wellness programs. The theory of change was facially plausible: the US has a lot of lifestyle amenable chronic diseases (hypertension, diabetes, obesity etc) so getting people to walk more, go to the gym a couple of days a week and show lower blood pressure readings after six months or a year could theoretically lead to lower costs and healthier people. That just never happened. But it was a facially plausible way to save money, and improve health while embracing the rhetoric of choice and individual responsibility all while without touching the prices paid to providers nor interfering with patient-provider decision-making. It sounded facially plausible.
Workplace wellness programs are, however, a good way of shifting net costs to sicker folks and shoveling goodies to people who are likely to have low valuation on health insurance as part of their compensation package because they barely use health insurance. For instance, if Duke had a general wellness program that paid for half the cost of a gym membership conditional on it being used at least twice a week, I would accept the extra cash and not change my behavior at all as I am already going to the gym three or more days a week. I would also probably qualify for good blood pressure control rewards as my current resting baseline is between 110/60 and 115/70. The incentives would not change my behavior as there is no need for my behavior to change. However the screening and administrative problem of targeting people who could see clinically and economically significant health improvements for small incentives and small changes in behavior is a complex problem. Most of the benefits go to people who don’t need to change their behavior.
The ACA individual market has not had wellness programs. The ACA individual market is an extremely high churn market. People churn in and out of the ACA individual market from other forms of insurance and uninsurance. People also routinely switch from Insurer A to Insurer B. Twenty four months of continual coverage at a single insurer in a competitive region is a very long length of stay for anyone who is not seriously ill. Most people are also significantly subsidized and the subsidy structure strongly encourages the people with the lowest probability of using care to go to narrow network, low actuarial value plans already. There is a cream skimming system already in place that is counter-acted by the risk adjustment transfers that pulls money out of Bronze premiums and sends it to Silver and Gold.
The request for participation in these programs are asking for the administrative moon:
Any state applying to participate in the wellness program demonstration project must clearly show that its program will not result in any decrease in coverage or increase in cost to the Federal Government in providing financial subsidies through the Exchanges. States must also ensure that their wellness programs do not discriminate based on health status.
We should not expect significant net cost claims cost savings to occur if the ACA individual market experience is anything like the employer sponsored insurance experience. Costs have to be neutral to the federal government so that means any incentives that are paid out in the form of lower than expected premiums or rewards to folks who meet administrative criteria have to come from whatever pool of likely small to non-existent savings, or from other funds or from other premiums. If there are other, state based funds coming into the individual market to make everyone whole, that is a weird way to support the individual market, but at this point, we have Silverloading doing a Herculean task effectively but inefficiently so one more weird twist is no big deal. However, I think that is unlikely.
Instead, the extra revenue has to come from somewhere, and the most likely spot is from non-participants’ premiums. The proposal layers on administrative burden and frictions for opt-outs and exemptions. The people who are most likely not participating in wellness programs are those with significant health expenses and barriers to access and ability to navigate complex administrative systems. Given the criteria laid out in the request for participation, lawsuits are almost certain to happen as state programs that are not the recipients of significant local funding will have a hard time meeting these hurdles.
And from the state perspective, they would be getting an administratively complex and expensive system to set up. It would probably be “easiest” to set up a program like this on a state based marketplace/exchange data stack instead of Healthcare.gov but the states that have their own marketplaces don’t, as a class, want to push health insurance in the direction that the current CMS wants it to go. I’m trying to figure out what is going on here beyond lawyer full employment?
Xboxershorts
Perhaps the reason wellness programs that require payments don’t work might be because so many people living paycheck to paycheck can’t afford the extra funds taken out of their pocket to pay for a wellness program.
PS, I bet the Venn Diagram of paycheck to Paycheck families has significant overlap with those who deal with chronic diseases.
Elliottg
Why isnt your first thought that it is a way to channel grift to friendly business people. That the entire proposal was probably developed with the help of “consultants” who are also grifters/lobbyists.
Mike Furlan
Wellness programs are a well thought out method of moving health information out from HIPAA protection. 20 years from now, we will be reading a report on how that information was used to determine which employees to lay off first when the inevitable economic recession/depression occurs.
raven
The wellness plan at my former employer (as of today) was a nightmare to access. I complained and they gave me some bullshit directions that didn’t work so I just bailed.
Ohio Mom
Do wellness programs include those inane Nurse Calls, where some nurse who knows less about my chronic conditions than I do (not that I know much beyond the basics) interupts whatever I was doing with a chirpy phone call?
I tell her I don’t have any questions and usually follow with a story about a denial her colleagues made (I will be ever sore about two of them). Then a week later, I get a form letter saying the Nurse Line will always be available to me, should I change my mind.
The insurance company already meddles too much, why would I voluntary give them more information they can use against me?
@Xboxershorts: The other Venn Diagram is older workers and chronic conditions. I often wonder if there is as much age discrimination among employers in other countries where companies are not on the hook for paying for the chronic conditions typically appearing in late middle-age.
Yes, I’m in a grump mood this morning.
David Anderson
@Ohio Mom: Some of that is coming from the wellness program. I am betting more of the nurse calls are coming from the risk adjustment and risk stratification programs. Phone calls are cheap to make, not particularly effective in moving costs, but they look like they are doing SOMETHING!
PenandKey
And this, right here, is why I categorically refuse to participate in any work-linked wellness program. The information they can gather from such programs is none of their business.
Xboxershorts
@Ohio Mom:
I bet I’m grumpier…
I just hit 60 today with 3 chronic conditions that show no signs of improving, including the chronic pain of a previously broken 1st n 3rd Lumbar vertebrae
I wish you well…and yeah, got wiped out after the crash, laid off, rebuilding now, next to nothing put away for retirement.
A wellness program that needs money from my pocket ain’t ever gonna be a reality.
Cheryl from Maryland
Wellness programs are a scam as well as a violation of HIPPA. My husband suffered for years from such “well-intentioned” scolding and misdiagnosis regarding his heart issues, high blood pressure, and peripheral neuropathy (a side effect of diabetes II). He played the game of exercise and diet as dictated — nothing worked. Turns out he had neural sarcoidosis, genetically compromised kidneys and the family trait of calcium buildup in his arteries, which we didn’t find out for a decade after locating an open-minded teaching specialist.
Another Scott
@raven: Happy First Day of Retirement! Enjoy your new adventures.
Cheers,
Scott.
Another Scott
@David Anderson: “Hi, I’m a nurse with BC-BS and I’d like to talk with you about your COPD.”
J – “I don’t have COPD.”
“Oh, Ok, but let’s talk about it anyway…”
That cycle repeated about 6 times over a year until they finally accepted that she doesn’t have COPD.
:-/
I wonder how things like that will go when our Glorious AI Future is finally here….
Cheers,
Scott.
Feathers
I was in a brainstorming session about why the company fitness center had such low utilization. There was talk about studies looking at friendship linkages showing how overweight people tended to be friends with other overweight people. The whole focus was on how do we fix the attitudes of the out of shape to be wonderful like us.
I pointed out that every example and statistic that they gave also fit the narrative of fit and slender people bullying and excluding the overweight. That had not been considered at all and it was clear that I would not be invited to another brainstorming session. Note: the fitness center people were all white and young, with very low body fat with visible muscles. The look of disgust on their faces about diversifying hiring to be more welcoming and be closer to the fitness levels of the employees was palpable. There were some big wigs there, I hope they noticed. I am no longer there.
StringOnAStick
My husband’s company does these programs, and since that’s how I get my health insurance, I do them too. The way they force participation is if you score enough “good health” points then it cuts the monthly cost of your insurance. The problem is that the physically fit are who participates, and the ones who could benefit from the proposed interventions are all of the “fuck it, I’m not changing my behavior” camp because they see making any changes in how they eat or exercise (if they do) as a bridge not only too far, but of zero interest. Where I lost interest is in how they are still pushing the HDL/LDL stuff and not noting how the more important marker for heart disease in triglyceride level.
This year’s event is in a couple of weeks. I have a few observations. One is that deciding you want the extra blood tests offered (like CRP, Vitamin D, etc) are at a cost; since we met our max out of pocket this year thanks to my knee replacements it makes more sense for me to have my annual physical order these tests, where they will be fully paid for. Another is that both my husband and I score in the highest ranges on everything because we are active and at normal BMI, though none of these tests picked up his CLL or my chronically arthritic knees so it’s not like there’s any correlation between our high scores in the annual wellness test sweepstakes and our actual medical costs. We do make the overall health of the company look better though. Hell, even our family doctor didn’t pick up his CLL, I did because I made my husband ask the doctor why his WBC had been slightly elevated for 3 years straight and I wasn’t buying the previous explanation that “oh, you must be getting over a virus” occurring every year just in time for his annual physical. Just because my husband is super fit and very active doesn’t mean he can’t get a genetically-linked condition like CLL, but if we only relied on the annual free blood work like a lot of his co-workers do, we’d never know any of this.
Mai naem mobile
Hey, David I got my rebate or whatever they called it from last year I guess. They applied to my payment for this month and will apply the rest of it towards next month. I know it was getting money back that I had put in myself but nevertheless it was a nice little(emphasis on little) pot of unexpected money.
ProfDamatu
@Mai naem mobile: Nice! I’m still waiting on mine; I think they’re going to have to actually cut a check, because I’m in Virginia and a subscriber of the company (Optima) that egregiously overpriced for 2018….I’ve heard the rebates will be something like $1800-$2600.
Ohio Mom
@Xboxershorts: Belated (this thread is old) Birthday Wishes!
Only four and a half more years until you get constant Medicare telemarketer calls…
You are right, if I had two screwed up vertebrae, I’d be even grumpier. Hang in there.
Mai naem mobile
@ProfDamatu: I actially haven’t seen a paper with the amount written. I only found out when I called to make my October payment and they gave me the option to apply it to the payment or get the check and I just let then apply it to the payment but because it’s a call to the insurance company nothing can be simple. Anyhow I long story short I think its around $1100 but I’ll know for sure when I get the paperwork.
ProfDamatu
@Mai naem mobile: Ah, I see! Assuming that it’s correct that even subsidized people are eligible for the MLR rebates, and it is indeed $2k or so, they’d have to cut me a check because I just paid October’s premium, and my last two months’ worth for the year will be just under $600 (and they have no guarantee yet that I’m staying with them, though I probably will….devil you know and all that).