Cash, Credits, Peer Support Incentives To Alter Bad Health Habits
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Cash, Credits, Peer Support Incentives To Alter Bad Health Habits

Ellen Wu walks the walk, even when she’s working.

Wu, executive director of the California Pan-Ethnic Health Network, not only works to promote better health in underserved communities, but she has slipped a few things into her Oakland workplace to keep herself and fellow workers a little more fit.

“We put in a tread desk,” Wu said. “It’s essentially for conference calls and you walk on the tread desk as you do your work.”

And, she added with a little smile, “There’s always a line of people wanting to get on it.”

Wellness incentives have become a major push in California. The variety of incentives is almost unlimited. Wu hopes efforts by her not-for-profit can help turn the tide toward a healthier society.

“I think there is tremendous evidence of the effectiveness of wellness programs,” Wu said. “I’d like us to make sure we include health wellness in all of our [government policy] discussions, and in all employer plans.”

In general, she said, our society concentrates its medical efforts on identifying and fixing specific diseases. “High-tech developments and illness-focused treatment are seen as necessary, but coaching [to promote wellness] tends to fall below the line,” Wu said. “Even though some of those things might actually be more cost-effective than the sexy, high-tech things like transplants.”

Buying Better Health

The ticket to increasing people’s overall health is to offer them incentives to live healthier lives through their work, according to Kevin Volpp of the Center for Health Incentives at the University of Pennsylvania School of Medicine, who was a panelist at a recent Sacramento briefing put on by the California Endowment and two legislative health committees.

“Many of us are aware of the high rates of preventable diseases. Many of those chronic conditions are not easily modified through medication and treatment,” Volpp said, referring to high blood pressure, diabetes, obesity, cardiac and pulmonary disease.

“What’s left, then, is behavior,” he said. “Modifying behavior is a big opportunity, but a big challenge.”

Employers have a stake in keeping employees healthier, Volpp said, because disease is expensive. Missed time at work, low productivity, stress in the workplace from ill health or poor family health, high health costs from crisis care — all of that adds up on a business’s ledger, he said.

“Poor health habits are the greatest barrier to bringing down the cost of health care,” Volpp said. “That’s why so many businesses are offering wellness incentives, trying to bring costs of health care down.”

There are many approaches to wellness incentive programs, Volpp said.

Some employers lower the cost of employees’ insurance premiums if they take a smoking cessation class or log a certain number of hours per month in a gym. But according to Volpp, that distant-reward system is flawed.

“Adjusting premiums is not likely to change behavior,” he said. “People focus on the here and now, on what’s in front of me. For instance, on a cold day in March, I’m thinking of going to the gym, and the reward of a premium adjustment in December is not likely to motivate me,” he said.

“If you put $100 in direct deposit, or if it’s taken off my premium payment, well, no one would really notice that. But put $100 in someone’s hand, that’s something,” Volpp said. “Anybody would notice that.”

Cash rewards have shown excellent results in changing people’s unhealthy behaviors, Volpp said. Other variations on wellness incentives also are picking up speed, he said.

“One of the things we’re working on is trying to figure out how to structure programs so that people are more willing to use biometric monitoring devices,” Volpp said. “We’re also looking at mentoring programs, led by people who had poor control and now have good control, that kind of thing. One of the big questions is what is the most cost-effective way of doing this.”

Change Over Time

From the employer point of view, if cash is going to be spent on making people healthier, it’s important that those healthy behaviors last, according to Steve Noeldner, researcher at Mercer Health & Benefits, an insurance brokerage and consulting firm.

“The crux of the matter is to effect long-term health behavior change,” Noeldner said. “We know that incentives do entice people to change. But can we move from extrinsic to intrinsic commitment, that’s the question.”

Sometimes, when you offer people cash to change their eating habits, those changes can last as long as the money does.

“You know that when you’re going to a wedding or a class reunion, you’re motivated to lose that weight and afterwards you gain it right back,” Noeldner said. “And maybe even a little more.”

The same thing happens with handing out cash payments at work, he said. “It takes a lot more than an incentive to determine the effectiveness of that incentive,” Noeldner said. “It’s about communication, and leadership support, and marketing a culture of health. Those things all enhance whether incentives will work.”

According to Esther Nash of OptumHealth — a division of United Healthcare, one of the country’s largest health insurers — interest in wellness incentives and the emphasis on quality and outcomes in national health care reform are a marriage made in health heaven.

“We’re really at a crossroads,” Nash said. “We have a unique chance right now to build health and wellness into the essential benefits of health plans. Health and wellness programs are not new, but we’ve seen them adopted more in the mainstream business community, and it’s now trickling down into smaller employer groups. And now, through the exchange,” she said, “the possibilities are big.”

Wellness programs have been moving from participation-based incentives to outcome-based incentives, she said.

“We’re studying how persistent the behavior change can be,” she said. “The cash [incentive] gets them off the fence, but will they stick with it? If they get the money and then get out, that’s not reaching our goal.”

Volpp cautioned that you have to be wary of the cookie-cutter approach to managing people’s health and wellness.

“You know, if we think of the automobile insurance paradigm, this all makes sense,” he said. “If you drive carefully, you pay less. The risky driver pays the higher premium. You don’t want the good driver to subsume the risky driver’s more expensive behavior,” Volpp said.

“Health care is a little different,” he said. “If someone is morbidly obese, how much of that is volitional and how much of it is genetic or environmental? When your health risks are due to factors you can’t control, you shouldn’t be punished for it.”

Community Incentives

The state of California is taking another approach to laying out incentives for people to live healthier lives.

Mary Rousseve works for Network for a Healthy California, a state program that creates worksite wellness programs with a different motivator than money.

“It’s a 10-week program where a person sets their own wellness goal,” Rousseve said. “And they’re rewarded by recognition.”

It has been a successful program, she said, because people want to improve their own health, and their family’s health, and most people just need a little direction and support to do that.

“We’ve had less sick time taken, people have more energy at work, employees are happier and more productive,” Rousseve said. “When business leaders become part of a positive change, part of a group making commitments for better health, it helps everyone.”

One hidden benefit of the program is that the families of participants benefit, too, Rousseve said. “They started eating better at home,” she said. “It’s contagious. It goes into the community, and that’s the best way to look at it — when we’re all invested in health.”

That philosophy rings true for Wu at the California Pan-Ethnic Health Network.

“We’d like to see health and wellness concepts in all policies,” she said. “We’d like to change state policies to incorporate health.”

That includes proposed legislation to bring fresh produce to low-income neighborhoods, making sure health factors are considered in regional plans and requiring vending machines to offer healthful foods and beverages.

“There’s that old adage about an ounce of prevention being worth a pound of cure,” Wu said. “But we never really put our resources into prevention. Even though that’s where change can be made.”

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