When a 2014 portion of the Affordable Care Act comes into effect, employers will be able to use financial rewards and penalties to encourage healthier behaviors. Last week the Obama administration released its final rules regarding these employer-based wellness programs.
Still, critics are concerned that an annual premium adjustment isn’t likely to change behavior, and will just end up penalizing those with poorer health.
According to Dr. Kevin Volpp, Director of the Center for Health Incentives and Behavioral Economics at the University of Pennsylvania, it isn’t as simple as just paying someone for doing the right thing. People tend to respond to immediate, short-term rewards (e.g. the satisfaction of eating one more piece of pizza) more readily than to delayed consequences (weight gain). The science of “behavioral economics” has found that when people are offered immediate incentives and penalties to do the healthy thing, they are more likely to make the right decision, sort of like having a swear jar for healthy living.
But not all incentives are created equal, and some behaviors are harder to change (e.g. quitting smoking) than others (taking your kid for a routine check up). The impact of an incentive depends a lot on how it is framed, and the context in which it’s offered.
People also respond differently to rewards and penalties. Volpp studies show how different types, sizes, and frequencies of incentives impact people’s behavior.
In one study, Volpp and colleagues teamed up with General Electric to develop financial incentives to get employees to quit smoking. All smokers received information about smoking-cessation programs, but half were chosen at random to also receive financial incentives. In the financial incentive group, smokers were given $100 for completing a smoking-cessation informational program, $250 for quitting smoking within six months of joining the study, and $400 if they were still not smoking six months after they quit.
The smokers in the incentive group were three times more likely to join a smoking-cessation program, and three times more likely to quit smoking than those who were not offered financial rewards. But when GE rolled these financial incentives to quit smoking to the rest of their workforce, employees complained about rewarding smokers to do something they should be doing anyway. From their perspective, GE turned the program into a penalty rather than reward program.
“If you make it all about rewarding smokers, you’ll predictably get the reaction, ‘No, we shouldn’t be rewarding smokers, we should penalize them,’” Volpp said. But we already are paying for the health consequences of other people smoking, eating poorly or not exercising. According to him, the response to the financial incentive might have been different if GE had done a better job of explaining to its workforce that getting employees to quit smoking would also save money for everyone else.
Volpp also cautioned that you have to be careful about overusing penalties if you are trying to help people improve their health. Penalties can create distrust and drive unhealthy behaviors underground, making them that much harder to tackle.
King County, Washington, was one of the first local governments to use rewards and penalties to encourage healthier behaviors. A decade ago, the county panicked as health care costs were growing at a pace of 15 percent every year. Then-executive Ron Sims convened a task force that included physicians, health care policy and legal experts, economists and labor and business leaders to develop a strategy to address health care costs from the perspective of both patients and the employers paying for their coverage.
Sims told the Seattle Times at the time, ”I refuse to sit back and allow the county and its employees to be victims of these seemingly uncontrollable cost increases. Further, I refuse to accept there are only two choices: reducing benefits to our employees and their families, or paying crippling annual increases. Tweaking the edges of the problem will no longer work.”
Out of the task force’s recommendations was borne Healthy Incentives—a voluntary wellness program for its employees and their families. While everyone receives the same medical benefits coverage, their out-of-pocket costs (deductibles and co-pays) vary according to their level of participation in the Healthy Incentives program. Those who choose not to participate receive a Bronze status, with the highest out-of-pocket costs. To attain a Gold status, with the lowest out-of-pocket costs, you need to complete a health risk assessment and complete a personal wellness plan. The individual action plans might include texting in a log of healthy activities, joining Weight Watchers at Work, attending YMCA classes to learn how to prevent diabetes through nutrition and exercise, or working with a Quit for Life coach on the phone to quit smoking. The difference between the Bronze and Gold tiers can make a difference of as much as $2,400 per year for a family of four.
When she started working for King County three years ago, Lynn Argento was automatically enrolled in the Gold tier after completing her health risk assessment. Failing to complete her personal wellness plan, Argento got bumped down to the Silver level the following year. “It was an eye opener in terms of the differences that I was paying for my deductible and co-pays,” she said. “It was a big reminder that my wellness activities had a significant financial connection to what I was paying out-of-pocket.” But Argento wasn’t upset with King County. She was disappointed in herself. “It was pretty clearly laid out to me. I knew what I needed to do, and I didn’t follow through on it,” she said.
Argento resolved to earn back her status. She runs on a treadmill during her lunch breaks at a worksite activity center, where employees can also attend yoga, tai chi, Zumba and kickboxing classes. Argento’s husband is now also on her plan, which means that he too has to participate in wellness activities to earn Gold status. Argento has noticed not only the financial but also health benefits of her wellness activities. “I have a lot more stamina,” she said. “I often have to sprint for a bus because I’m running late, and now I can do that without wanting to pass out when I get to the bus.”
Argento also used to miss a couple days of work or leave the office early each month due to migraines, but the frequency of her migraines has gone down significantly since she started eating regular, healthier meals to complement her training schedule. And the Healthy Incentives program has been self-reinforcing. Argento and her co-workers talk about work-life balance and making space for wellness during the workday.
During the first five years of the program, 38 percent of obese participants lost at least 5 percent of their body weight, and almost a quarter lost at least 10 percent. Smoking rates dropped from 12 percent to 7 percent, which is lower than both national and state averages. Between 2007 and 2011 King County saved $14.6 million due to the improved health of its employees and their families. According to Brooke Bascom with the Healthy Incentives program, “It is so much better than cutting people off and making health care inaccessible. We give them the support they need to make changes.”
The state of Oregon, like King County, saw a need to reign in its health care costs, having spent $1.6 billion on costs related to obesity alone in 2006. The Oregon Educators Benefit Board and Oregon Public Employee’s Benefit Board, which provide health insurance coverage to the state’s teachers and public employees, have also used financial incentives to encourage healthier behaviors. During the first year of the program, they charged employees $17.50 per month if they failed to take a baseline health risk assessment and follow through on recommendations. 70 percent of employees completed their health assessment and took the suggested health actions. With a switch the following year to a reward of $17.50 per month per person for participation and a $100 higher deductible per person for those not participating, 7 percent more employees completed wellness recommendations. Through a combination of these financial incentives and a partnership with Weight Watchers, rates of obesity decreased from 28 percent to 22 percent among the state’s teachers between 2009 and 2012, at a time when rates of obesity were increasing among the general population.
Employers’ interest in using worksite wellness and incentive programs is expanding rapidly, but not all have the resources to develop their own, so some outsource to companies like The Vitality Group, which relies on behavioral economics to structure programs. Vitality might track your gym visits, activity using pedometers and accelerometers and attendance at Weight Watchers meetings, and in exchange you earn redeemable points that can be used to purchase items—movie tickets, iTunes gift certificates, hotel stays—from the Vitality Mall. Your behaviors also earn you points towards your Vitality Status. The higher your Vitality Status, the more prizes you are entitled to win.
Vitality recently partnered with Walmart to offer members a 5 percent credit on purchases of healthy foods that can be used towards future purchases at Walmart — another immediate reward for a healthy action. But one of Vitality’s greatest successes in the U. S. was in partnership with Alcon Labs, which involved not just the incentive program, but creation of a comprehensive wellness program.
A key feature of this program were “Vitality Champs,” employees who volunteered to be trained to lead and encourage their co-workers in wellness activities and to organize events, ranging from 5K run/walks to mobile mammography screening to flu shot campaigns. And those people are the key to these programs. We are influenced by the people around us, and when there’s a culture of health in the workplace, we are more likely to do the healthy thing ourselves.
“Incentive programs are not wellness programs,” said Dr. Ronald Goetzel, Director of Emory University’s Institute for Health and Productivity Research and President and CEO of The Health Project. “That can be a component, when done smartly, of a comprehensive program, but if that’s all your program is going to be, you’re going to fail miserably, and people are going to be resentful,” he explained. According to Goetzel — who has studied worksite wellness programs at large corporations such as Dow Chemical and Johnson & Johnson, and is being funded by the Centers for Disease Control and Prevention to study best practices in the field—incentive programs can help get people excited about health and keep them on track, but ultimately people’s habits will only change if they are given the resources to change them and if the workplace norms and environments change.
Without the other pieces to facilitate behavior change—healthy cafeterias, opportunities to exercise, flexible work hours, supportive leadership and middle managers, and health risk assessments and coaching—incentive programs will only penalize, not change, those who are least healthy.
Celine Gounder, MD, ScM, is an infectious-disease and public-health specialist.
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