The rules issued in late May did not clarify what might be reasonably expected from doctors.
At a minimum, physicians will likely be asked to sign off on health risk assessment forms for patients. Dr. Cooke said she’s noticed an uptick in patients asking for that, whereas 3 or 4 years ago she’d never encountered such a request. For now, it’s "not hugely onerous," but as requests have increased, "I began to wonder where this would go next," she said.
The regulations for programs that ask employees to participate in education programs or smoking cessation programs, or to meet particular health outcomes, may end up steering more patients to their doctors’ offices. That’s because employers are required to provide "a reasonable alternative standard." For so-called participatory programs, the alternative has to be provided for workers for whom "it is either unreasonably difficult due to a medical condition to meet the otherwise applicable standard, or for whom it is medically inadvisable to attempt to satisfy the otherwise applicable standard."
For outcomes-based programs, an alternative "must be provided to all individuals who do not meet the initial standard, to ensure that the program is reasonably designed to improve health and is not a subterfuge for underwriting or reducing benefits based on health status," according to the rules.
The rules say that an individual’s personal physician is the arbiter of what’s medically appropriate – and of coming up with a reasonable alternative that will allow the employee to be eligible for the incentive program.
Dr. Blackwelder said it’s important for physicians to be involved. For instance, he said, "For some diabetics, getting their hemoglobin A1c to a normal level might not be the best thing." Only a doctor could make that determination, he said.
Finally, there are concerns that incentives might not be enough to get people to change their lifestyle.
Ms. Horowitz and her colleagues said that "evidence is sparse that financial incentives induce behavior that improves health." They said it was not surprising, given that "powerful personal, social, and financial incentives to be healthy, nonsmoking, and thin already exist." Even so, "people often fail at efforts to lose weight and stop smoking."
Dr. Cooke agrees, noting that "from the practicing clinician’s side, it’s not news to someone who smokes or weighs twice as much as they should that they’re doing something unhealthy." She added, "I haven’t spoken to a significantly overweight person who hasn’t tried to lose weight."
In the meantime, wellness programs are expected to continue to grow – despite no clear evidence that they accomplish their stated goals of improving health and cutting costs.
Dr. Cooke said she hoped that employers look at what works and what doesn’t "before they just hand money hand over fist to programs to produce a result that we’re all interested in."
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