May 20th, 2013
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The Equal Employment Opportunity Commission (EEOC) held a long hearing on May 8, 2013 on employer wellness programs. Opponents made a strong case that there was virtually no way that a mandatory health-contingent wellness plan could not discriminate against protected classes of workers. (See statement of Judith Lichtman) On the other hand, the more pro-business representatives argued that Congress and the Administration supported the changes in the Affordable Care Act and the programs where here to stay. It seems that all parties are urging the EEOC to provide guidances to employers.
The testimony came amid a backdrop of waiting for the final regulations from the Obama Administration. The comment period closed in January and many were expecting we would have final regulations by now. Politico reported that a group of corporate CEOs with the Business Roundtable were in Washington recently to lobby the Administration to avoid further weakening of the regulations.
Forbes magazine was reporting the CVS-Caremark was penalizing workers $600 annually if they failed to complete a health risk assessment. The article noted that most companies did not provide such stiff penalties but many were moving in that direction.
Meanwhile, several research articles provide only lukewarm support for weigh loss employer wellness programs.
A Health Affairs article by Ron Goetzel and colleagues, found only 22 % of employer health care costs could be attributed to 10 modifiable health factors (including obesity). This is actually a drop from 24.9% in 1998, even though rates of obesity have increased and costs related to obesity have gone up. Obesity contributed the most excess costs at $347 per capita. Goetzel, Pei, et al,
Another recent paper was a longitudinal study at the worker productivity in terms of absenteeism, presenteeism and job performance associated with changes in 19 modifiable well-being risks. These included physical health risks, health behavior risks, social and emotional health risks work-related risks and financial health risks. The researchers found that, “Obesity, high cholesterol, tobacco use and excessive alcohol generally contributed to productivity changes insignificantly or unfavorable, possibly because of its multicolinearity with other risks that are closely correlated.” However, they noted that, “Health-related risk explained only a portion of the total productivity variances. For example, Riedel et al found that health risks accounted for 7.8% of the total variance in productivity impairment and acknowledged that the majority of the variation was left unexplained. Lenneman et al also found only 8.5% of the variance in productivity was contributed by health risks…We found that reductions in work-related well-being risks and financial health risks significantly contributed to improvement in productivity measures especially for measures of presenteeism and job performance that were not attributable solely to the more narrow definition of physical health.” They found modest numbers of workers were able to make improvements: 25% reduced their physical health risks 26% improved their health behaviors 16% improved their social and emotional health, 31% improved their work-related risks and 13% their financial health risks. Improvements in absenteeism, decrease in presenteeism and a modest improvement in job performance accompanied such changes. They calculated these improvements were equivalent to a savings of $468 per person per year. Shi, et al.
Ted Kyle reports in his blog that one program, Healthy Blue Living, requires obese participants to wear a pedometer which uploads their physical activity to the employer wellness program. The employees must meet daily step goals if they want to keep full health benefits. Not doing so could cost them each $2000 a year. Kyle notes (and I strongly agree) that this constitutes human experimentation without the protection of the federal regulation protecting human subjects, 45 Code of Federal Regulations Part 46. In fact, the program is not that successful. Promotional material notes that only 16% who agreed got their weight under a BMI of 30.
Yet another study published in Health Affairs looked at one hospital system’s wellness program. The program provide a substantial incentive/penalty for participation in a health risk assessment (which included automated feedback) signing a health pledge, health fairs and physician referrals. The study found a significant reduction in hospitalizations for conditions related to the conditions covered by the wellness program. However, there was an increase in medication costs. Combined with the costs of the wellness program and incentives, the authors concluded, “It is unlikely that the program saved money.” Gowrisankaran G, et al. A Hospital System’s Wellness Program Linked to Health Plan Enrollment Cut Hospitalizations But Not Overall Costs, Health Affairs 32 (3) 2013; 477-485. Gowrisankaran
A second paper also published in Health Affairs reviewed randomized controlled trials of workplace wellness programs. Their review raises doubts the employees with health risk factors such as obesity and tobacco use spend more money on medical care than others. They concluded that workplace wellness programs show little evidence of saving costs through health improvements without being discriminatory. To test the assumptions of workplace wellness programs the authors, “reviewed research on the relationships among financial incentives, behavior, health status, and medical spending. We focused on randomized controlled trials involving four conditions- smoking, hypertension, high cholesterol and obesity- that are typically included in health-contingent programs. In our review, we found mixed evidence that employees with these conditions have higher health costs than other employees, which undermines the argument that employees with the conditions are particularly effective targets for incentives. We also found little evidence that working-age people change their behavior as a result of financial incentives, particularly over the long term. These findings suggest that program savings many not, in fact, derive from health improvements. Instead, they may come from making workers with health risks pay more for their health care than workers without health risks do. If true, this conclusion would jeopardize long-standing regulatory efforts, maintained in recently proposed Affordable Care Act regulations to prevent workplace wellness from being “a subterfuge for underwriting or reducing benefits based on health status. (citations omitted) Since low-income workers disproportionately suffer from conditions typically targeted by health-contingent programs, savings arising outside of health improvement may entail hidden, regressive redistributions increasing the burden imposed on low-income workers. “
In effect, they point out, wellness plans shift costs with the most vulnerable employees, those from low income groups with the most health risks probably subsidizing the healthier workers. Horwitz, JR, Kelly, BD, DiNardo, JE, Wellness Incentives in the Workplace: Cost Savings Through Cost Shifting to Unhealthy Workers, Health Affairs, 32 (3), 2013:468-476. Horwitz
The Agency for Healthcare Research and Quality (AHRQ) has issued another independent review. This time they reviewed studies of strategies to prevent weight gain in adults. The reviewers looked at 51 trials involving 555,783 subjects with at least one year of follow-up and a weight outcome. A meaningful difference between groups was considered to be 0.5 kg of weight (1.1 pound) or 1 cm of waist circumference. They found moderate evidence that workplace programs for the prevention of weight gain in adults. One study combining diet, physical activity and environmental components resulted in meaningful and statistically significant prevention of BMI change at 12 months and another that combined internet based diet and physical activity counseling resulted in significant prevention at 24 months. However, a third study found no difference. AHRQ Strategies to Prevent Weight Gain Among Adults, Comparative Effectiveness Review No. 97, AHRQ
Similar findings are reported by Gudzune and colleagues in an article published in Preventive Medicine, Gudzune K et al Strategies to prevent weight gain in workplace and college settings: A systematic review, Prev Med. 2013 Mar 22. Gudzune
November 28th, 2012
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The Kaiser Family Foundation has issued a new report on implementation of Medicaid expansion under the Affordable Care Act. Kaiser Commission on the Uninsured and Medicaid Report
October 17th, 2012
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If you follow developments in obesity at all, you are familiar with the CDC maps showing the increases in obesity across the nation. Likewise, it is clear from these maps, the obesity is a major problem in the South.
Unfortunately, and tragically for many obese poor persons, the governors of Florida, Louisiana, Georgia, South Carolina and Texas have now been joined by the governor of Mississippi in rejecting the expansion of Medicaid in their states. The expansion is authorized under the Affordable Care Act (Obamacare). St.LouisPostDispatch_Mississippi Decides Medicaid Dollars not Worth Cost
Under the Affordable Care Act, the federal government will pay 100% of the cost of expanding Medicaid from 2014 to 2016. Between 2017 and 2020, the federal share drops to 90% and the states’ contribution gradually rises. The Kaiser Family Foundation projected that Mississippi would receive $23 dollars from Washington for every $1 from the state.
While state budgets are clearly under pressure, many see politics at work as all of the Governors in these states are Republicans and are opposed to Obamacare. Regardless, Mississippi has the highest rate of childhood obesity in the nation with nearly 40% of children up to age 17 meeting the obesity criteria. In all of these states, the lower income groups, who would be covered by the expansion of Medicaid, have major health problems. Refusing to participate in the Medicaid expansion only perpetuates these issues.
October 9th, 2012
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Evidence, while not definitive, indicates that a large proportion of the uninsured population is probably overweight or obese. In one study of a free health clinic, higher than normal rates of smoking and obesity among the uninsured were observed. PubMed: Analysis of the demographic characteristics and medical conditions of the uninsured
I have always assumed that many people who have severe obesity are likely to be unemployed and uninsured but I have no data. We do know that the uninsured are more likely to be young, childless, a member of a minority and have a chronic health condition.
A 2005 study using the National Health Interview Survey found that nearly half of all uninsured, non-elderly adults reported having a chronic condition. Many did not have a usual source of care and many did not get medical care or drugs because of costs. Common chronic diseases included diabetes, hypertension, high cholesterol, arthritis-related conditions, heart disease, cancer and stroke. UrbanInstitute: Uninsured Americans with Chronic Health Conditions
Since 2005, a lot has changed. Some of the uninsured may have gotten insurance or at least better access to care. On the other hand, the recession and resulting unemployment and loss of individual net worth, may have increased the ranks of the uninsured. We probably won’t know for a while.
Nevertheless, it is important in the context of the Presidential election to evaluate the candidate’s health plans and their possible impacts on the uninsured. Fortunately, the Commonwealth Foundation has done it for us, comparing baseline data on the uninsured with implementation of the Affordable Care Act and the proposals put forth by Governor Romney. It is worth reading. CommonwealthFund: Health-Care-in-the-2012-Presidential-Election
The chart above is from this article by Sara Collins, Stuart Guterman, Rachel Nuzum, and colleagues.
June 10th, 2012
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The June 10th Washington Post has an insightful article on the federally-funded food desert initiative in Philadelphia. The article describes how an hypothesis (lack of access to healthy foods leads to eating unhealthy foods which leads to obesity) becomes a large experiment before research is done to determine if it is going to work. WaPo: Will Philadepphia’s experiment in eradicating food deserts
Last month, at the Weight of the Nation conference, Department of Health and Human Services Secretary Kathleen Sebelius took the hypothesis one step further elevating food deserts into a cause of obesity. She said, “Obesity can be caused by any combination of factors. For some it’s an addiction like smoking. For others it’s a lack of fresh fruits or vegetables near their home. “ This is pretty sloppy work for a conference so highly organized by the CDC and HHS. An addiction? Still being researched I believe. People are looking at whether certain foods may be “addictive” not whether excess adipose tissue itself is addictive. When a national health leader elevates putative causes like addiction and food deserts to actual causes, a disservice is done and real progress is delayed.
May 19th, 2012
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Exposure to air pollution while in the womb may contribute to childhood obesity, according to a study just published in the American Journal of Epidemiology by Andrew Rundle. Polycyclic aromatic hydrocarbons (PAHs) are common air pollutants caused by burning coal, oil, gas and cigarette smoke.
The study followed 700 pregnant women in New York City who were African-American or Dominican and lived in relatively poor areas of the city. Pregnant women with high exposures had children who were 1.8 times more likely to be obese at 5 years of age and 2.3 times more likely to be obese at 7 years than children with lower levels of exposure. PubMed: Air pollutants and Obesity
September 27th, 2009
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