how well wellness programs are doing

The issue: Employer wellness programs that provide incentives for employees to be healthier

The vocab: Incentives - how are they earned? The not-so-subtle difference between incentive-participation and incentive-attainment programs.

What's an easy solution to employers' rising healthcare costs? Make employees pay to have unhealthy habits. America's health

insurance system pretty much operates on the employer-provider model. People expect that the

ir employer provides a health benefits

package. Now some employers are holding

their employees accountable for the healthcare costs they generate by instituting incentives for employees to engage in healthy behaviors (such as exercise and eating right) and to disengage in unhealthy behaviors (such as smoking and having poor nutrition).

One example is Johnson & Johnson's wellness program, which is highly cited as one of the most successful large-scale employee intervention programs to date. If J&J employees participated in a yearly

health screening, they would be eligible for a $500 health insurance benefit. Those who had no "risky" health indicators were given the money; those who were "risky" (that is, they had indicators of risk for obesity, cardiovascular health, cancer, diabetes, or accidents/injuries) were required to participate in an intervention program in order to remain eligible for the money. The disease-specific intervention programs were fairly low-commitment - most entailed simply attending regular health education and preventive counseling sessions. In only 5 years, the percentage of J&J employees who were identified as "high-risk" decreased significantly pretty much across the board of health problems. But was this cost-effective? Probably. By some calculations, the $500 investment by J&J was more than compensated by its returns - less employee healthcare costs, fewer sick days from work, and a more productive workforce in general.

Great, right?

J&J's program is what I'll call an "incentive-participation" program. While J&J is obviously interested in the outcome of the interventions, employees received the bonus bucks just as long as they participated. That is, their incentive was not dependent on the actual health outcome - it was dependent on whether or not they tried.

Well, some employers have taken it one step further, utilizing "incentive-attainment" programs. In order for employees to receive some benefit, they need to be below a threshold risk (for example, they must be below a certain BMI or they they must not smoke cigarettes daily). Trying isn't enough - results are what matter here. It's the same principle as the "incentive-participation" model. The employer simply expects more.

Safeway has gotten a lot of media attention for using this type of incentive structure. Employees are regularly tested on BMI, blood pressure, cholesterol and tobacco usage. If they pass on all four measures, employees are given a sizable reduction in their health insurance premium (roughly 20% off). If they don't pass, they're given one year to show improvement in the health measure. If the employee improves, they're reimbursed for the past year and are given the reduction for the subsequent year; if the employee does not improve, they're back at square one. If you're wondering if this is all legal, it is. Well, within certain limitations. (The fine people at Harvard have a pretty good overview of what employers are legally allowed to do.)

It sounds a little harsh, right? But the logic is sound. Safeway is giving monetary incentives ABOVE what's normal. They're not exactly penalizing people for not being healthy, they're just rewarding those who are. And the outcomes-based incentive may actually be a creative way to address national health problems. Here's an excerpt from Safeway CEO Steven Burd's editorial in Wall Street Journal:

Safeway's plan capitalizes on two key insights gained in 2005. The first is that 70% of all health-care costs are the direct result of behavior. The second insight, which is well understood by the providers of health care, is that 74% of all costs are confined to four chronic conditions (cardiovascular disease, cancer, diabetes and obesity). Furthermore, 80% of cardiovascular disease and diabetes is preventable, 60% of cancers are preventable, and more than 90% of obesity is preventable.

Not a bad argument, really. And Burd has bigger plans for his program. There's some proposed legislation in the Senate (affectionately dubbed "The Safeway Amendment") that would raise the amount of reimbursement employers can offer from 20% of the employee's coverage to 30%. This would increase employee motivation to participate and strive to be healthier.

Well, theoretically. As you can imagine, this approach has gotten some legit criticism. The authors of a recent New England Journal of Medicine article argue (1) that it is unfair to not reward people who are earnestly trying to improve their health but are, for whatever reason, physically unable, and (2) that such a program worsens already existing inequities. Let me explain that second point a little further. The authors write:

There is a social gradient [in employees' ability to improve health]. A law school graduate from a wealthy family who has a gym on the top floor of his condominium block is more likely to succeed in losing weight if he tries than is a teenage mother who grew up and continues to live and work odd jobs in a poor neighborhood with limited access to healthy food and exercise opportunities.

On top of that, there's some doubt that the program is even effective in changing the health profile of the Safeway workforce. The problem with the incentive-attainment structure is that it assumes people can change because they want to and because they try. But there are serious barriers to success that the employer would need to keep in mind (like helping the aforementioned single mother get gym access and be able to locate and afford healthy food) - and overcoming those barriers is going to be much more costly than simply the 30% reimbursement. If Safeway is willing to foot the extra bill for the people who need extra help, then the incentive-attainment program makes perfect sense. But the program becomes much less cost-effective when you start adding in these equalizers, and it's unlikely that Safeway (or any company, for that matter) would be willing to finance a wellness program that comprehensively.

Employer wellness programs are ubiquitous - and in some peoples' eyes, they're expected. But you have to read the fine print about whether you'll receive incentives for participation or for attainment.

do people support health reform, or "health reform"

The issue: Kaiser Family Foundation's recent poll about Americans' knowledge of and opinions on healthcare reform

The vocab: If people are in favor of the idea of "healthcare reform" vs. if people are in favor of the specific provisions of healthcare reform

Not surprisingly, Americans are split pretty evenly on whether they support or oppose Obama's health reform bill - however, when respondents had the specific provisions of the proposed legislation explained to them, they generally supported healthcare overhaul more.

This month's Kaiser Family Foundation poll found that while only 42% of people said they supported the bill (and 41% oppose), there tended to be much higher rates of support when they were told about reform's specific aims. Here's an excerpt from Kaiser's press release:

"After hearing that tax credits would be available to small businesses that want to offer coverage to their employees, 73 percent said it made them more supportive of the legislation. Sixty-seven percent said they were more supportive when they heard that the legislation included health insurance exchanges, and 63 percent felt that way after being told that people could no longer be denied coverage because of pre-existing conditions. Sixty percent were more supportive after hearing that the legislation would help close the Medicare “doughnut hole” so that seniors would no longer face a period of having to pay the full cost of their medicines."

These findings suggest, basically, that while people tend to have opinions on a general abstract idea of "healthcare reform," these opinions may not reflect how they would feel about the legislation if they were more aware of its specific, tangible aims. Check out the numbers. (The full results I'm discussing start on page 9.) Not surprisingly, though, not every aspect of the bill was embraced by the public. People weren't so stoked about (1) the projected price tag, nor (2) the possibility of being mandated to have health insurance. Respondents said that they were less likely to support a bill with these provisions attached - but the way people would actually weigh these downfalls against the potential benefits wasn't surveyed.

Even though healthcare reform has been on the national agenda for almost a year now, the average American doesn't know a great deal about what changes could be imminent. Perhaps health reform advocates have been going about garnering public support all wrong. Senate democrats have been trying to convince people that health care reform is needed - but maybe all they really need to do is explain it.

The moral of this story is that lawmakers may be too hasty in using broad, abstract phrases like "health reform" and "healthcare overhaul" - the general public would be able to more accurately figure out their stance if the bill were explained in more specific terms. Maybe information about how the bill helps small businesses, Medicaid recipients and the millions of uninsured Americans will help people realize that they're actually in favor of the bill; maybe information about the cost of the program or about the anticipated date of full implementation (not until 2013) will help people realize that they're actually against the bill. But at this point, it seems like too many people are relying on party affiliations and inadequate information in forming their opinions - and not enough on their support of the actual makeup of the bill.

brown vs. coakley: and who can be trusted to define "quality healthcare"

The issue: The Massachusetts Senate seat, which opened up after the death of former Senator Ted Kennedy

The vocab: Improving the "quality" of healthcare Americans receive. Which candidate defines the word quality most appropriately?

Let's start by breaking down who's backing the two candidates. It's not particularly relevant to the issues themselves, but fascinating nonetheless...

The pro-Brown celebrities: Scott Brown and his family are practically celebrities in their own rights - Scott was a star athlete in high school and played college ball at Tufts (and, in a baffling decision for an aspiring politician, posed very nude for Cosmopolitan magazine); Scott's wife, Gail, is a popular Boston-area television news reporter; One of Scott's daughters, Ayla, competed for 3 weeks in the fifth season of American Idol. On top of this all-star family cast, Scott Brown also has the support of ex-Red Sox pitcher Curt Schilling (who actually even contemplated running for the seat himself) and ex-BC quarterback Doug Flutie.

The pro-Coakley celebrities: President Obama is backing Martha Coakley, as well as the late Ted Kennedy's widow, Victoria Kennedy - i.e., some of the most powerful Boston-area political voices.

Tomorrow, Massachusettans will cast their votes in the Senate race between Republican attorney Scott Brown and Democratic Massachusetts Attorney General Martha Coakley. While there's been a lot of controversy bubbling over the negative campaigning that the candidates

have directed at one another (in fact, Brown is filing a defamation claim against Coakley for some mailings her party sent out), the biggest issue here is the implications in the healthcare reform vote.

Currently, there are 59 Senators who have voted in favor of the president's health care reform bill. The Senate needs 60 votes to push the reform through the Senate - and Coakley if elected, will be that 60th vote. If Bay Staters instead elect Brown, he has vowed to be the 41st vote against reform, which would effectively kill the legislation. According to the most recent poll, Brown (with 50%) leads Coakley (with 46%). While Brown's lead is within the statistical margin of error (translation: statistically, Brown and Coakley are tied), he's a lot better off than he was expected to be. Massachusetts is a predominately Democratic state - only about 13% are registered Republicans - and the state hasn't had a Republican senator since 1972. For Brown to even be in the same ballpark as Coakley is a testament to the voters' recognition of the implications of this race.

According to their campaign web sites, here are the candidates stances on health care issues:

• Coakley: She supports Obama's health care reform because she believes it will increase medical insurance coverage, will improve quality, and will lower costs (due to greater industry transparency and a change in the way incentives are used).
• Brown: He plans to vote against the reform bill because he believes it will raise taxes, will increase government spending, and that it compromises quality of care (especially for elders on Medicare). Instead, Brown is in support of bolstering the existing private insurance system, making it more affordable for people to obtain insurance.

Yes, it's undeniable that health care reform will lead to more government spending to pursue its goals of covering the uninsured; the question here, really, is if the spending is worth it. Both candidates want more people to be insured (but really, what reasonable person wouldn't?), but have different routes to achieving it - and the federally-funded vs. free market solution is a partisan debate as old as Lou Holtz.

But what I'm fascinated by is this: Both of the politicians claim that their solution will lead to a better healthcare quality. They can't BOTH be right (although I suppose, theoretically, both could be wrong). If we look at the evidence, who is being most empirically truthful?

First, let's operationalize the buzzword "quality." A high-quality health care system, according to the U.S. Agency for Healthcare Research & Quality, is one that does "the right thing at the right time in the right way for the right person and having the best results possible.” Translation: Every patient has different needs, and a good system allows healthcare professionals to address those needs in such a way that every person has the best health outcome possible.

How do we determine "quality"? Central to Obama's health reform bill is the utilization of comparative effectiveness research. The health outcomes of different treatments are compared (i.e., for different conditions, different levels of severity, by gender, etc.) with the goal of figuring out the optimal evidence-based treatment for different types of patients. This info would be distributed to healthcare professionals as well as patients. This would lead to (1) all stakeholders knowing more about their treatment options, and (2) less utilization of unnecessary and ineffective treatments, thereby saving money and healthcare resources. (The Kaiser Family Foundation has a great review of this concept, for those interested.)

Actually, private insurance companies are also in favor of improving quality/lowering costs using comparative effectiveness research. The real difference between the two perspectives is who is doing the research. Either the insurance company would figure out the best practices themselves, or the federal government would do the research. The biggest problem I see in the private market research is with the credibility of their findings. We make pharmaceutical companies hire third-party analysts for their clinical trials data for this very reason - when a private company holds a financial stake in the outcome, their results could very easily (and are quite probably) biased. Sure, the federal government isn't perfectly transparent, but we certainly can't expect private businesses to be more transparent.

Both Brown and Coakley are claiming their political standpoint to be more conducive to high quality healthcare. But Coakley's got the upper hand: When it comes to being able to trust the conclusions of quality/effectiveness research, this is best left in the hands of the federal government, which is required to be transparent and will be thoroughly scrutinized if it biased results in any way. Private companies may very well have health's best interest in mind, but because the industry doesn't lend itself to the same level of scrutiny and peer review, I'm not sure if private insurance company's findings would be trustworthy.

Both candidates claimed that their standpoint on health care reform would "improve quality," and as is evident, these claims can't be taken at face value. It's clear how Coakley's health reform "yea" vote would improve quality, but the same can't be said for Brown's "nay." Massachusettans cast their ballots tomorrow, and I hope everyone who votes has looked past the celebrity battle and has looked into the legitimacy of the aspiring Senators' rhetoric.

medicinal and general-use marijuana

The Issue: The Marijuana Control, Regulation and Education Act (A.B. 390)

The Vocab: Medicinal Marijuana and General-Use Marijuana

Last week, the California Assembly's Public Safety Committee, with a vote of 4-3, favored legislation that would make marijuana legal in the state of California for adults at least 21 years of age. With the

committee's approval, A.B. 390 will be put forth to the full California Assembly sometime in 2011. The Committee's decision has been claimed as a victory by the Marijuana Policy Project, the self-proclaimed "fastest-growing marijuana policy reform organization in the United States." The MPP has the explicit support of both celebrities (like Jack Black, Bill Maher and Adam Carolla) and politicians alike - former governor Jesse Ventura and former U.S. Surgeon General Joycelyn Elders are advisors for the organization, too. (Elders' one-year stint as Surgeon General was apparently wrought with controversy ... it's technically irrelevant to the present post, but a fascinating and recommended read.)

Marijuana legislation is not new to state-level politics. Fourteen states currently have legalized medicinal marijuana, six of which allow privately-owned dispensaries to sell pot to those with a prescription: California, Colorado, Maine, Montana, New Mexico, and Rhode Island. (Interestingly, according to an article by the Denver Post, Denver has more pot dispensaries than Starbucks coffee shops, public schools, and liquor stores.) But what the state of California is proposing is pot legalized for any use, regardless of its medicinal purposes. Medicinal marijuana use was an easier sell, in terms of its proven benefits for those with certain health problems. A report by the NIH posits that pot can mitigate nausea (which is especially problematic for chemotherapy patients), stimulate appetite (in AIDS and chemotherapy patients, for example), can treat glaucoma, and is a mild pain reliever. In these past debates for marijuana legalization, it was framed as a health policy and healthcare issue. Now, California lawmakers are faced with deciding marijuana's acceptability as a recreational issue.

Proponents of A.B. 390, as well as the advisors for MPP, make the standard arguments for the general (i.e., not just medicinal) legalization of marijuana: taxation can bring in revenue, money can be saved on law enforcement, and less drug trafficking-related violence. People like Jack Black, however, are a little more frank about their motives. Jack Black is a notorious marijuana user - he wants it to be legal because he thinks it's fun and harmless. But is it really harmless?

The FDA's official stance on the matter is, on the contrary, that marijuana is a harmful substance with "a high potential for abuse" and "has a lack of accepted safety for use" even under medical supervision. (The FDA has since been slammed with criticism that these statements were politically-motivated, and not empirically derived.) Sure, there are health risks with marijuana use - there are studies that suggest that it increases lung cancer risk, can potentially lead to psychiatric disorders, that its use can impair driving ability. There's also the omnipresent "gateway drug" theory - that marijuana use can lead to the use of more serious, addictive, and destructive drugs. These are legitimate risks that we have to weigh in - most would agree that the risks are worthwhile for those benefiting medicinally, but are the risks worthwhile for merely recreational users?

It's a thorny web of pros and cons, and when it comes down to state-level legislation, it depends on the particular state's values and priorities. (For example, in my home state of Nebraska, casinos are banned because of the perceived "vices" of gambling. I find it unlikely that Nebraskan lawmakers will ever allow the words "marijuana" and "legalization" to be spoken in the same sentence.) My take on the issue? Medicinal marijuana legalization may be worth the risks because of its particular ameliorating benefit for ailing patients, like for those with cancer and AIDS. While guys like Jack Black are charismatic advocates, and the campaigns from his beloved MPP make persuasive arguments, marijuana use in the general public just may not be worth the negative health side effects.

Can legalization bring in revenue? Sure. Should we stop criminalizing marijuana use to lighten the burden on the law/drug enforcement system? I can see that. But simply put, as a health policy issue, non-medicinal pot use is probably not going to make Americans healthier.