el problema con el paternalismo de incentivos en salud - h. schmidt, k. voigt y d. wikler

7/25/2019 El Problema Con El Paternalismo de Incentivos en Salud - H. Schmidt, K. Voigt y D. Wikler

1/3

Perspective

TheNEW ENGLAND JOURNAL ofMEDICINE

10.1056/nejmp0911552 nejm.org e3(1)

The current health care reformbills seek to expand the role ofincentives, which promise a winwin bargain: employees enjoy bet-ter health, while employers reducehealth care costs and profit froma healthier workforce.

However, these provisions can-not be given an ethical free pass.In some cases, the incentives arereally sticks dressed up as carrots.

There is a risk of inequity thatwould further disadvantage thepeople most in need of healthimprovements, and doctors mightbe assigned watchdog roles thatmight harm the therapeutic re-lationship. We believe that somechanges must be made to recon-cile incentive use with ethicalnorms.

Under the 1996 Health Insur-ance Portability and Accountabil-ity Act (HIPAA), a group healthplan may not discriminate amongindividuals on the basis of healthfactors by varying their premiums.But HIPAA does not prevent insur-ers from offering reimbursementsthrough wellness programs.These include what could be calledparticipation incentives, which of-

fer a premium discount or otherreimbursement simply for par-ticipating in a health-promotionprogram, and attainment incen-tives, which provide reimburse-ments only for meeting targets for example, a particular body-mass index or cholesterol level.Subsequent regulations specifiedthat attainment incentives must

not exceed 20% of the total cost ofan employees coverage (i.e., thecombination of the employers andemployees contributions).1

The health care reform mea-sures currently before Congresswould substantially expand theseprovisions (see box). However, eth-ical analysis and empirical researchsuggest that the current protec-tions are inadequate to ensurefairness.

Attainment incentives providewelcome rewards for employeeswho manage to comply but maybe unfair for those who struggle,particularly if they fail. The law

demands the provision of alter-native standards for those whocannot or should not participatebecause of medical conditions, butthose categories are narrowly de-fined. For all others, the implicitassumption is that they can achievetargets if they try. This assump-tion is hard to reconcile with whatwe know about lifestyle change.

Carrots, Sticks, and Health Care Reform Problems with Wellness IncentivesHarald Schmidt, M.A., Kristin Voigt, D.Phil., and Daniel Wikler, Ph.D.

Chronic conditions, especially those associatedwith overweight, are on the rise in the UnitedStates (as elsewhere). Employers have used bothcarrots and sticks to encourage healthier behavior.

The New England Journal of Medicine

Downloaded from nejm.org at UNIVERSITY OF ILLINOIS on April 13, 2013. For personal use only. No other uses without permission.

Copyright 2010 Massachusetts Medical Society. All rights reserved.


2/3

PERSPECTIVE

10.1056/nejmp0911552 nejm.orge3(2)

Most diets, for example, do notresult in long-lasting weight re-duction, even though participantswant and try to lose weight. At-tainment-incentive programs makeno distinction between those whotry but fail and those who donot try.

Proponents of attainment in-centives typically do not viewthis situation as inequitable.Steven Burd, the chief executiveofficer of Safeway, whose Healthy

Measures program offers reim-bursements for meeting weight,blood-pressure, cholesterol, andtobacco-use targets, compared hiscompanys program to automo-bile insurance, in which for dec-ades driving behavior has beencorrelated with accident risk andhas therefore translated into pre-mium differences among drivers.

In other words, says Burd, theauto-insurance industry has longrecognized the role of personalresponsibility. As a result, bad be-haviors (like speeding, tickets forfailure to follow the rules of theroad, and frequency of accidents)are considered when establishinginsurance premiums. Bad driverpremiums are not subsidized bythe good driver premiums.2

If people could lose weight,stop smoking, or reduce choles-

terol simply by deciding to do so,the analogy might be appropriate.But in that case, few would havehad weight, smoking, or choles-terol problems in the first place.Moreover, there is a social gradi-ent. A law school graduate from awealthy family who has a gym onthe top f loor of his condominiumblock is more likely to succeed in

losing weight if he tries than isa teenage mother who grew upand continues to live and workodd jobs in a poor neighborhoodwith limited access to healthyfood and exercise opportunities.And he is more likely to try. In

Germany, where both participa-tion and attainment incentiveshave been offered since 2004,participation rates among peoplein the top socioeconomic quintileare nearly double the rates amongthose in the poorest quintile.3

Incentive schemes are defend-ed on the grounds of personal re-sponsibility, but as Kant observed,ought implies can. Althoughalternative standards must be of-

fered to employees for whom spe-cific targets are medically inap-propriate, disadvantaged peoplewith multiple coexisting condi-tions may refrain from makingsuch petitions, seeing them asdegrading or humiliating. Thesepotential problems are impor-tant in view of the proposed in-creases in reimbursement levels.

The reform proposals prohib-it cost shift ing, but provisions inthe Senate bill could result in asubstantial increase in financialburden on employees who do notmeet targets (or alternative stan-dards). On the basis of the aver-age cost of $4700 for employee-only coverage, a 20% incentiveamounts to $940; 30% wouldequal $1410 and 50%, $2350. Inpractice, insurers may stay be-low the maximum levels. Some

may elect to absorb the full costof reimbursements, in part be-cause some or all of these costsmay be offset by future savingsfrom a healthier workforce. Alter-natively, however, insurers mightrecoup some or all of the costsby increasing insurance contribu-tions from insurance holders. Inthe extreme case, the incentive

Carrots, Sticks, and Health Care Reform Problems with Wellness Incentives

Summary of Wellness Incentives in the Current Legislation.

The Affordable Health Care for America Act (House of Representatives), section112, requires that qualifying programs:

Be evidence-based and certified by the Department of Health and Human Services

Provide support for populations at risk for poor health outcomes

Include designs that are culturally competent [and] physically and program-

matically accessible (including for individuals with disabilities)

Be available to all employees without charge

Not link financial incentives to premiums

Entail no cost shifting

The Patient Protection and Affordable Care Act (Senate), section 2705, proposesto increase reimbursement levels to 30% of the cost of employee-only cov-erage, or up to 50% with government approval. In part restating provisionsfor current wellness programs, it also requires that qualifying programs:

Be available to all similarly situated individuals

Have a reasonable chance of improving the health of, or preventing diseasein, participating individuals

Not be overly burdensome, [be] a subterfuge for discriminating based on a

health status factor, [or be] highly suspect in the method chosen to pro-mote health or prevent disease

Provide an alternative standard for employees whose medical condition ascertified by a physician precludes participation in attainment-incentiveprograms

Not pose an undue burden for individuals insured in the individual insurancemarket

Entail no cost shifting

Be evaluated in pilot studies and a 10-state demonstration project





3/3

10.1056/nejmp0911552 nejm.org

PERSPECTIVE

e3(3)

might then simply consist of be-ing able to return to the previouslevel of contributions. Similar ef-fects can be achieved by varyingapplicable copayments or deduct-ibles.4Direct and indirect increas-es would disproportionately hurt

lower-paid workers, who are gen-erally less healthy than their high-er-paid counterparts and thus ingreater need of health care, lesslikely to meet the targets, and leastlikely to be able to afford highercosts. Some employees mightdecide to opt out of employer-based health insurance andindeed, one wellness consultingfirm, Benicomp, implies in its pro-spectus that such a result might

be desirable, pointing out thatemployees who do not complymight be motivated to considerother coverage options and high-lighting the savings that wouldresult for employers.4

Proponents emphasize that well-ness incentives are voluntary. Butthe scenarios above show that vol-untariness can become dubiousfor lower-income employees, if theonly way to obtain affordableinsurance is to meet the targets.To them, programs that are of-fered as carrots may feel morelike sticks. It is worth noting thatcountries such as Germany gen-erally use far lower reimburse-ments ($45 to $130 per year, ora maximum of 6% of an em-ployees contribution) and often

use in-kind incentives (such as ex-ercise equipment, heart-rate mon-itors, or vouchers contributing tothe cost of a wellness holiday)rather than cash.3

There are also questions aboutthe effect on the therapeutic re-

lationship. When the German Par-liament passed a law making lowercopayments conditional on pa-tients undergoing certain cancerscreenings and complying withtherapy, medical professionals re-jected it, partly out of concernabout being put in a policing po-sition.3 American physicians ex-pressed concern when West Vir-ginias Medicaid program chargedparticipating doctors with moni-

toring patients adherence to therequirements set out in the mem-ber agreement.5 Requiring phy-sicians to certify an employeesmedical unsuitability for an in-centive scheme or to attest to theirachievement of a target mightsimilarly introduce an adversari-al element into the doctorpatientrelationship.

Incentives for healthy behav-ior may be part of an effectivenational response to risk factorsfor chronic disease. Wrongly im-plemented, however, they can in-troduce substantial inequity intothe health insurance system. Itis a problem if the people whoare less likely to benefit fromthe programs are those who mayneed them more. The proposed

increases in reimbursement levelsthreaten to further exacerbate in-equities. Reform legislation shouldtherefore not raise the incentivecap. Attainment incentives thatprimarily benefit the well-off andhealthy should be phased out, and

the focus should shift to partici-pation-incentive schemes tailoredto the abilities and needs of lower-paid employees. Moreover, it iscrucial that the evaluation of pi-lots include an assessment of thesocioeconomic and ethnic back-grounds of both users and non-users to ascertain the equitabilityof programs.

Financial and other disclosures providedby the authors are available with the full

text of this article at NEJM.org.

From the Harvard School of Public Healthand the Harvard University Program in Eth-ics and Health, Boston.

This article (10.1056/NEJMp0911552) was pub-lished on December 30, 2009, at NEJM.org.

Mello MM, Rosenthal MB. Wellness pro-1.grams and lifestyle discrimination the le-gal limits. N Engl J Med 2008;359:192-9.

Burd SA. How Safeway is cutting health-2.care costs. Wall Street Journal. June 12,2009.

Schmidt H, Stock S, Gerber A. What can3.

we learn from German health incentiveschemes? BMJ 2009;339:b3504.

Detailed overview, 2009. Ft. Wayne, IN:4.BeniComp Advantage. (Accessed December22, 2009, at ht tp://www.benicompadvantage.com/products/overview.htm.)

Bishop G, Brodkey A. Personal responsi-5.bility and physician responsibility WestVirginias Medicaid plan. N Engl J Med2006;355:756-8.Copyright 2009 Massachusetts Medical Society.

Carrots, Sticks, and Health Care Reform Problems with Wellness Incentives




el problema con el paternalismo de incentivos en salud - h. schmidt, k. voigt y d. wikler

Documents