Wellness Programs

Question 1

How does the strategy behind the concept of consumerism help contain increases in healthcare?

Answer 1

When applied effectively, healthcare consumerism does more than simply shift costs; it more appropriately helps engender greater responsibility on the part of the health plan member for decisions involving lifestyle, healthcare consumption and cost.

Question 2

What are the objectives of employer-sponsored wellness programs?

Answer 2

The objectives of employer-sponsored wellness programs are to promote healthy lifestyles among employees by targeting the risks that result from poor nutrition, lack of physical activity, excessive stress, tobacco use and other unhealthy habits. These risk factors can lead to expensive chronic diseases and health issues that also affect workforce productivity, absence from work, safety and employee morale.

Question 3

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Answer 3

Over the years, researchers have observed that preventable illness makes up a significant portion of the total cost of healthcare

Question 4

Provide examples of modifiable health risk factors.

Answer 4

Nutrition, weight control, physical activity, cholesterol, blood pressure, tobacco use, safety and mental well-being. Health promotion programs seek to reduce these risk factors by promoting healthy lifestyle choices and by discouraging behaviors and attitudes that are detrimental to good health.

Question 5

What is the role of incentives in wellness programs?

Answer 5

Incentives are a tool to help focus attention on health risks and to motivate desired behavior changes. People generally do not change their behavior without good reasons that outweigh the pain and annoyance associated with giving up long-standing habits. The purpose of wellness incentives is to help provide those good reasons.

Question 6

What is an optimal incentive program?

Answer 6

An optimal incentive program utilizes the simplest, most cost-effective incentives that cause the maximum number of individuals to move from a state of contemplation to action. Also the best incentives will promote long-term lifestyle changes to such a degree that, even when the rewards are removed, desired behaviors will continue due to intrinsic reinforcements. These reinforcements are the consequence of several factors, including successful goal achievement (such as weight loss or smoking cessation), as well as the boost and well-being and self-esteem that often accompanies health improvement activities.

Question 7

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Answer 7

Unfortunately, the prospect of living a longer, healthier life does not motivate individuals to adopt healthy behaviors. Research shows that among heart attack patients, for whom behavior change is an immediate life and death issue, 90% do not change their unhealthy habits even one order to do so by their doctor.

Question 8

What are three key motivators that employers should use to help their employees adopt and maintain healthier behaviors?

Answer 8

One of the key motivators is education. It plays a role in raising awareness and building a desire for change.

A second motivator is pure pressure as well as other intangibles both in the workplace, where individuals seek a sense of belonging and accomplishment; and at home, where they feel a sense of accountability to those they love.

A third motivator, the tipping point that moves individuals from in action to action, is the use of external incentives.

Question 9

What are some advantages of incentives?

Answer 9

Among the advantages of incentives is their potential to have powerful behavioral effects. When incentive rewards and rules are well-designed, they can induce a significant change in behavior for a significant percentage of the target population. They also can be flexible, relatively simple to comprehend and easy to administer. Additionally, incentive rewards can be combined to increase motivation, for example, combining a tangible reward (cash) within in tangible reward (recognition).

Question 10

What are some disadvantages of incentives?

Answer 10

Possible disadvantages do exist. For instance, with certain reward approaches some individuals may exploit the program by gaming the system or being dishonest and self reporting such as smoking cessation. Also, some incentives may inadvertently reward unhealthy behaviors, for example, a per pound weight loss incentive could encourage unhealthy or hazardous weight-loss practices. Finally, desired behavior may last only as long as the reward does.

Question 11

Most employers are not prepared to use severe punitive tactics in their health promotion programs and most experts agree that pleasure or reward is a more effective long-term motivator then fear or punishment. List and describe types of positive incentives that are tangible.

Answer 11

Tangible incentive rewards include:

Cash
Merchandise
Vacation days
Avoidance of costs (such as health care premiums or deductibles)

Question 12

List and describe types of incentives that are intangible.

Answer 12

Intangible incentive rewards include:

Recognition
Personal challenges
A sense of accomplishment
Group competition
A sense of belonging
Acceptance and approval of peers

Group competition

Question 13

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Answer 13

Another technique for more closely aligning incentive rewards with the cost of healthcare benefits is to reduce health care premiums for deductibles and copayments.

For employers that use health care premium discounts as an incentive reward, it is important that employees perceive the premium reduction amount to be significant. One technique for boosting this perception, referred to as play or pay, involves first increasing health plan premium contributions and then forgiving a substantial part of the contribution for those who participate in the wellness program

Question 14

Based on the type of behavior is rewarded, there are three types of wellness incentives. What are the three categories?

Answer 14

1) . Activity incentives
2) . Achievement incentives
3) . Adherence incentives

Question 15

What are activity incentives?

Answer 15

Activity incentives reward employees for participating in, or completing, specific activities, including:

Attending an educational session
Participating in a contest or challenge
Completing a health risk assessment
Completing online activities
Attending a health fair
Completing a certain number of activities over a defined period (e.g., 30 minutes of physical activity four days/week for six weeks).

Question 16

What are achievement incentives?

Answer 16

Achievement incentives require more than just participation. In order to receive a reward, the individual must demonstrate achievement of specific goals or metrics, such as:

Maintaining low-cholesterol, or reducing it by 10 points if appropriate
Stopping smoking, or remaining tobacco free
Maintaining body mass index (BMI) below 25, or reducing it by one point if optimal
Maintaining healthy blood pressure, or reducing it if appropriate
Maintaining healthy blood glucose level or reducing it if appropriate

Question 17

What are adherence incentives?

Answer 17

Adherence incentives reward longer term maintenance of lifestyle goals. For example:

Remaining tobacco free for 12 months
Maintaining a target BMI for 12 months
Maintaining other biometric measures within healthy range over a defined period of time
Maintaining a target accident rate at work
Working three out of four calendar quarters without an unscheduled leave day

Question 18

What are some of the advantages and disadvantages of activity rewards?

Answer 18

One advantage of activity rewards is that it motivates incremental action toward healthier lifestyles. Also, an activity reward might be more readily achievable for all individuals.

Two key disadvantages of a reward based on activity are: (1) performing specific activities is not necessarily enough to decrease health risks; and (2) activity-based incentives are the easiest to game out of the three types of rewards presented.

Question 19

What are some of the advantages and disadvantages of achievement rewards?

Answer 19

The key advantage of achievement rewards is that they provide a clear, objective basis for measurement, thus allowing a focus on individual accountability for personal health management.

These rewards’ disadvantages include: (1) additional costs if biometric testing is used; (2) excessive employee focus on measurement techniques, accuracy, scoring methodology; and (3) considerations regarding health insurance portability and accountability act (HIPAA) requirements and limitations come into play.

Question 20

What are some of the advantages and disadvantages of inherence rewards?

Answer 20

A monkey advantages of adherence rewards are that they provide motivation to sustain long-term lifestyle improvements, they reinforce the important determinant of wellness return on investment (ROI), and they also allocate the greatest reward to those contributing the greatest value to the program.

There are disadvantages include longer time requirement before an incentive is awarded, the multiyear time frames possibly complicating the administration of the program, and finally HIPAA compliance must be considered.

Question 21

The process of determining the optimal incentive amount is an art and a science. Explain.

Answer 21

Success with incentives requires understanding the culture of the company, the related benefit structure and other aspects of the covered population. To maximize its perceived value, and incentive should be designed so that participants perceived value is high relative to the employers actual cost. Such an approach might lead one employer to offer lump sum cash rewards, another to utilize raffles for high-value prizes and another to offer highly visible discounts on health benefit premiums.

Some experts recommend setting incentives, especially cash rewards, at as low a level as possible while still retaining their effectiveness. The optimal reward amount should be just enough to tip the scales. Individuals who have been moved to the “contemplation” stage by wellness program communications and education may look at a small incentive amount as a “token” - not really meaningful enough on its own to motivate a behavior change. However, when combined with factors such as aggressive education, that token become sufficient reason to make a change now rather than waiting for a better reason. The reward amount should be commensurate with what the individual is being asked to do in return. Finally, when designing an incentive program, the possible tax consequences for tangible rewards should be considered.

Question 22

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Answer 22

Because of a lag in health class savings from lower utilization, most programs take several years to develop a positive ROI. Therefore, employers must be willing to design their programs with a multiyear horizon, spreading incentives, program costs and expected savings over several years.

Question 23

What are the five basic requirements that wellness programs must meet under HIPAA when the wellness incentives are based on health status related factors?

Answer 23

1) . The total rewards must not exceed 20% of the cost of employee only coverage (or 20% of the total cost of coverage if dependence can participate in the program).
2) . The program must be reasonably designed to promote health and prevent disease.
3) . Individuals eligible for the program must be given the opportunity to qualify for the reward at least once per year.
4) . The reward must be available to all similarly situated individuals. The program must allow a reasonable alternative standard (or waiver of the initial standard) for obtaining the reward to any individual for whom it is unreasonably difficult due to a medical condition, or medically inadvisable, to satisfy the initial standard.
5) . The plan must disclose in all materials describing the terms of the program the availability of a reasonable alternative standard (or the possibility of a waiver of the initial standard).

NOTE: The 20% total reward limit noted above was increased to 30% (up to 50% under certain circumstances) by the patient protection and affordable care act (PPACA) effective 2014. PPACA also mandated that the department of health and human services develop criteria for a comprehensive workplace wellness program and create a five-year program to award grants to certain small employers for implementing wellness programs.

Question 24

Under the Americans With Disabilities Act (ADA), in general medical examinations and screenings of employees are prohibited. What two ADA requirements permit under a wellness program these prohibited practices?

Answer 24

The two ADA requirements that permit under a wellness program the prohibited practices are: (1) that any medical records acquired as part of the wellness program must be kept confidential and separate from personnel records; and (2) more importantly, that the program must be voluntary, defined as a program in which an employer “neither requires participation nor penalizes employees who do not participate”.

Question 25

In evaluating health risk assessments of wellness programs within the context of the Americans with disabilities act, what has been the position of the equal employment opportunity commission (EEOC)?

Answer 25

The general position of the EEOC, which administers ADA, is that a wellness program is voluntary if an employer neither requires participation nor penalizes employees who do not participate. Based on current EEOC informal guidance, if an employee refuses to participate in a health risk assessment and, as a result, does not have access to the incentives offered in connection with the health risk assessment, the EEOC may take the position that the incentive is actually a “penalty” for those employees who do not participate in the health risk assessment and may violate the ADA. This position, however, is not binding on courts and has been rejected and at least one Federal court ruling.

Question 26

The genetic information nondiscrimination act (GINA) prohibits employers and health plans from discriminating based on an individual’s or his or her family member’s genetic makeup. Under the act’s Title I, what practices are group plans and insurers specifically prohibited from engaging in?

Answer 26

Under the act’s Title I, group health plans and insurers are specifically prohibited from engaging in the practices of:

(A) restricting enrollment, or adjusting premium or contribution amounts for the group on the basis of genetic information.

(B). Requesting or requiring that individuals undergo a genetic test (subject to limited exceptions) and

(C) requesting, requiring, or purchasing genetic information prior to or in connection with Enrollment, or at any time for underwriting purposes.

Question 27

What does the term “genetic information” encompass under GINA?

Answer 27

Under GINA, “genetic information” includes information about an individual’s genetic tests or the genetic test of family members, family medical history or any request of more receipt by an individual or family member of genetic services, which includes genetic tests, genetic counseling and genetic education.

Question 28

Does the GINA prohibition against collecting genetic information for underwriting purposes impact wellness programs?

Answer 28

The prohibition on collecting genetic information at any time for underwriting purposes does impact wellness programs. The regulations provide that “underwriting purposes” include rules for and determinations of eligibility (including enrollment and continued eligibility), computation of premium or contribution amounts, and application of pre-existing condition exclusions. Notably, the rules clarify that “underwriting purposes” includes changing deductibles or other cost sharing mechanisms, for providing discounts, rebates, payments in the kind or other premium differential mechanisms in return for activities such as completing a health risk assessment for participating in a wellness program.

Question 29

Under the GINA provisions, what three options are available to plan sponsors that want to use health risk assessments?

Answer 29

A). Implement a health risk assessment that does not solicit genetic information, so that the employer may provide an incentive to participants for completing the health risk assessment, if desired.

B). Implement a health risk assessment that solicits genetic information, but does not: (I) provide an incentive for taking the health risk assessment, or (II) make the request prior to or in connection with Enrollment; or

C). Implement a variation on the programs described above by administering to health risk assessments - one that does not solicit genetic information, for the completion of which an employee may earn a reward, and one that solicits genetic information. The regulations approve this design, provided that the health risk assessment that solicits genetic information is wholly voluntary, and a participant’s completion of or failure to complete it will not affect the reward for the completion of the other health risk assessment.

Question 30

Describe the circumstances under which it would be deemed appropriate by GINA to request minimum genetic information for a disease management program.

Answer 30

While GINA prohibits genetic information contained in a health risk assessment to be used to determine whether an individual qualifies for disease management program, such a program maybe structured to limit benefits based on medical appropriateness, however. If an individual seeks to participate in a disease management program, and the plan limits the benefit only to those individuals for whom it is medically appropriate and the determination of medical appropriateness depends on genetic information, the program may condition the benefit on receipt of the minimum necessary genetic information. In application, this rule will only apply in the case of a disease management program that covers not just employees with diseases, but also those employees who are at risk for a disease that has not yet manifested.

Question 31

Which of the following is a critical decision to be made when designing and employer-sponsored wellness program?

A. Whether to make participation in the program mandatory or voluntary
B. What is the optimal amount to invest in incentives in the program for the greatest return
C. How to guarantee that no participants can “game” the system
D. How to avoid pure pressure for use as a motivator for adopting healthier behaviors.
E. In which type of trust arrangement to allocate cash rewards

Answer 31

B. What is the optimal amount to invest in incentives in the program for the greatest return.

Question 32

Which of the following statements accurately reflect(s) the concept of consumerism as it applies to employee benefits programs?

I. Employer-sponsored wellness programs are typically a key component of a consumerism strategy.
II. The principal objective of consumerism is to shift health care costs from the employer to the employee.
III. When applied effectively, consumerism can drive wellness program members to optimize receipt of incentives.

Answer 32

A. I only. Items II and III incorrectly state the concept. It is not simply about cost shifting, it is about helping members make better decisions regarding lifestyle, healthcare consumption and cost.

Question 33

All of the following fall under the genetic information nondiscrimination act’s definition of genetic information EXCEPT:

A. Employees’ tests for the presence of alcohol
B. Family medical history
C. Employees’ DNA tests
D. Employees’ request for genetic counseling
E. Payment receipts of family members for genetic education services

Answer 33

A. Employees’ tests for the presence of alcohol.

Question 34

What does title II of GINA prohibit?

Answer 34

Title II of GINA prohibits the use of genetic information in the employment context. If a wellness program is administered by an employer rather than by a health plan or insurer, title II provides an exception to the prohibition against collecting genetic information if certain requirements are met. The general requirements are: (a) The employee must provide prior knowing, voluntary and written authorization for the collection of the genetic information; (b) only the employee (or family member if the family member is receiving genetic services) and a licensed healthcare professional or board-certified genetic counselor involved in providing such services may receive individually identifiable information concerning the results of such genetic services, and; (c) any individually identifiable genetic information provided to the licensed healthcare professional or board-certified genetic counselor in connection with the wellness program cannot be disclosed to the employer except in aggregate terms that do not disclose the identity of specific employees.