Health Care Wellness Programs: Silver Bullet or Bane?

Friday, May 13, 2011

In the face of ever higher and higher health care costs, organizations have exhausted a battery of efforts to control and manage their annual “spend” on employee health care. Having been on both sides of the fence, I have implemented new forms of health care, e.g., “managed care” for my employers and designed new products for clients, e.g., “utilization review”, “prior authorization”, “Rx carve-outs”, … etc. As employers and as carriers we have raised employee out-of-pocket expenses, designed networks to focus only on the top performing providers, and directed efforts at disease management. We have built entirely new forms of health care products to allow employees to become better “consumers” of health care services. We have passed historic and monumental legislation directed at controlling costs, which everyone agrees, is unsustainable. Moreover, much of our efforts have resulted in no discernable impact on either the trend in long-term health care cost of or the improvement in the collective health of employees and their families.

It is not that we do not know the causes of many of the public health issues plaguing employers and employees and their families. Lack of exercise, over-eating, an aging population, smoking, alcohol consumption, excessive weight, environmental and industrial exposures, life-style behaviors, … etc. The underlying causes of these issues have been well documented by the Centers for Disease Control and Prevention, National Institutes of Health, U.S. Department of Health & Human Services, numerous state and county departments of health, various medical journals, and private foundations. Hardly a day goes by when the public media is not spotlighting yet another report on the lack of wellness in most Americans lives. Surveys confirm that, in general, Americans know that certain behaviors are “unhealthily” and yet many are unwilling to change, even in the face of higher costs.

On the surface, it is clearly puzzling. Behavioral economics should drive a change in employee behaviors in the face of higher co-payments, co-insurances, deductibles, and overall out-of-pocket expenses. However, there is little evidence that greater cost sharing and higher out-of-pocket expenses are motivating employees to change their behaviors, which has lead to the chronic health issues many face today. Consider the following anomaly, gamblers are willing to continue to bet even though the odds are against them and favor the house. Employees will continue to over-eat, under exercise, smoke, and engage in unhealthily life-styles knowing that such behavior is a losing proposition for them and their families.

Can and will employee wellness programs change the behavior of individuals to improve the health of themselves and their family members? Not without both incentives and dis-incentives. Is not this contrary to what we know about behavioral conditioning and the role of positive vs. negative reinforcement? Both separately and jointly, positive vs. negative reinforcement have the ability to strengthen and direct behavioral change in a desired direction. Thus, a wellness program which includes both, stands a better chance of changing and sustaining the desired behavior, i.e., lose weight, exercise more, reduce bio metric measures, … etc. Furthermore, since we know that unreinforced behavior will eventually extinguish itself, the availability of incentives and dis-incentives must continue indefinitely.