--CONSULTATION REPORT-- HARVARD PILGRIM HEALTH CARE ETHICS ADVISORY GROUP

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1 --CONSULTATION REPORT-- HARVARD PILGRIM HEALTH CARE ETHICS ADVISORY GROUP Giving Incentives to Members for Health Promoting Behavior: A Values Framework for use of Carrots and Sticks March 30, 2005 Customer: Judith Frampton, Vice President for Clinical Quality Programs. Background Earlier this month HPHC and John Hancock launched Healthy Returns a new program for Hancock employees. A brochure distributed to John Hancock employees describes Healthy Returns as follows: Healthy Returns is an exciting new program from John Hancock and Harvard Pilgrim Health Care designed to help you stay healthy or get healthier Come to a Healthy Returns event and a team of Harvard Pilgrim health professionals will help you set a few realistic health goals. Then we ll support you throughout the year and provide real incentives like gift certificates and chances to win cash to help you achieve your goals The more goals you meet and check-in sessions you attend, the more points you get. The more points you get, the better your chances are to win Employer interest in having health plans take an active role in promoting positive changes in health-relevant behavior is not new. In 1999, Dr. Mary Jane England, then president of the Washington Business Group on Health, stated increasingly, our members are looking to the health plans to play a role in primary prevention to reduce their health risks. 1 The use of external incentives (incentives other than the intrinsic reward of improved health or reduced risk), however, is just now beginning to emerge. A Boston Business Journal article on September 17, 2004 described an incentive program instituted by Mellon Financial Corporation to encourage employees to get more exercise. And, last month the Boston Globe reported on how Tufts Health Plan s Liberty program offers a range of incentives to encourage positive changes in health habits. 2 The US health system is increasingly turning to economic incentives to engage consumers in a) promoting health improvement and b) helping to constrain health care costs. Insurance products with substantial deductibles use the stick of financial risk to encourage consumers to consider the value of potential diagnostic tests and treatments. Incentives for positive health behavior change reflect the carrot approach. Insurance products that include both sticks (deductibles) and carrots (rewards for making positive changes) are increasingly common. 1 Quoted in Health Behavior Change in Managed Care: A Status Report (Purchasers Report). Center for the Advancement of Health, Available at: 2 A description of the Liberty program is available at:

2 The EAG has examined products with deductibles ( sticks ) at several meetings, most recently in May In its discussion of health coaching at its last meeting (2/17/05) the EAG noted that incentives ( carrots ) might play a helpful role by encouraging members to make use of the coaching that is provided to them. At the March 30 meeting the EAG was asked to advise about a values framework for the use of incentives. Questions for the Ethics Advisory Group 1. A health plan incentive program can serve many objectives, including helping members maintain or improve health status, creating loyalty among members, meeting purchaser demands, and attracting prevention-oriented members to enroll in the plan. What values are at stake in selecting objectives for an incentive program? 2. Similarly, employers could see a range of reasons for supporting an incentive program, including improved employee health, reduction of medical cost, reduced absenteeism/increased productivity and employee retention. What values are at stake in the objectives employers might have for an incentive program? 3. Can the same program design support values that might seem to be in conflict (e.g., helping people be more healthy & gaining advantage in the marketplace)? 4. Members, health plans, providers and employers all have an interest in encouraging positive health behavior changes. What values are most relevant to deciding on the optimal roles and responsibilities for members, providers, health plans and employers? 5. What values are at stake in deciding whether to base incentive programs on self-report compared to biometrics (weight, blood pressure, etc)? Relevant precedents On July 18, 2001, in the context of an EAG meeting focused on Ethical Issues in Low Option Coverage and Defined Contribution, in a section called ethically justifiable new financial models the minutes include this clear anticipation of some of the potential positives in the carrot approach of using positive incentives: One EAG member suggested that incentives could be aligned with healthpromoting behaviors. In Brookline children who are caught wearing helmets while riding their bicycles are given prizes. Perhaps enrollees could be rewarded for not smoking, managing their weight, and other behaviors likely to improve health and thereby reduce health care costs. Clearly such a program would be challenging to administer, but connecting financial gain to health promoting behaviors and a financial penalty to health undermining behaviors would be consistent with the original HMO concept of health promotion as well as treatment of illness. EAG DISCUSSION/RECOMMENDATIONS Jim Sabin opened the meeting by telling the group that this would be Harvey Cotton s last meeting. Harvey has been a strong supporter of and excellent contributor to the 2

3 Ethics Advisory Group since its inception. Harvey is leaving the HPHC Legal Department to take a position with the benefits consulting group at Ropes and Gray. Jim introduced a guest Maria Schiff from the Massachusetts Division of Health Care Financing and Policy. As a fellow in the Harvard Medical School Medical Ethics Fellowship Program ( ) Maria wrote an excellent research paper Incentive Programs that Encourage Behavioral Change: An Ethical Perspective (circulated with these minutes with Maria s permission). To provide a basis for the discussion Judith Frampton presented an overview of the Healthy Returns program as it has been developed to date, along with data about HPHC s own piloting of the program with HPHC employees. Judith s excellent presentation was followed by an active and wide ranging discussion, which I have summarized under 3 headings, corresponding to questions 1 4 above (p 2): 1. What values are at stake for health plans and employers in selecting objectives for an incentive program? (Questions 1 & 2 from p 2.) For many people knowledge that a course of action will improve the potential for health is not enough to drive that action. The EAG agreed that human nature being what it is, incentives can increase the likelihood that behaviors that promote something as intrinsically valuable as improved health and prevention of illness will actually be carried out. From this perspective, the Healthy Returns program, which gives incentives to attain and maintain healthier weight, keep blood pressure in the normal range, avoid tobacco and improve cholesterol levels supports the HPHC mission of improv(ing) the health of the people we serve. A participant from HPHC confirmed the potential value of incentives by reporting that I got a lot of people to go to the Healthy Returns event at HPHC when I mentioned that a gift certificate would be given! I was surprised that even people working in health care were more motivated when they learned about the incentive. HPHC achieved participation levels of 36% (Quincy office) and 41% (Wellesley office) an excellent result! A broker told the group that employers are very interested in the Health Returns program. They are very concerned about the high and rapidly rising cost of health care and like the idea of combining the carrot of incentives for health promoting behaviors with the stick of deductibles. The group recognized and endorsed the possibility that an incentive program could serve multiple goals in addition to health improvement, including health plan member loyalty, employee retention and improved workplace productivity, and to some extent reduced cost of care. The EAG saw all of these as legitimate goals, and as discussed in the next section saw them as potentially compatible. The EAG did feel, however, that given HPHC s mission, health improvement goals should have primary status in shaping an incentive program. 2. Can the same program design support values that might seem to be in conflict (e.g., helping people be more healthy & gaining advantage in the marketplace)? (Question 3 from p 2.) 3

4 A participant stated that helping people improve their health, saving money and retaining members are all good objectives. In themselves these goods are not in conflict, so I see no ethical problem in having multiple objectives. The EAG agreed with this perspective and added the following suggestions: The multiple objectives should be acknowledged explicitly just as Judith Frampton did at the EAG meeting by calling the program a member incentive/loyalty program. Given public distrust of health insurers and managed care, explicitly stating the range of values the incentive program serves and explaining the rationale for promoting each of the values encourages trust and support. Transparency about the full range of values the incentive program serves supports the HPHC vision of be(ing) the most trusted and respected name in health care. While the EAG endorsed the view that an incentive program could support values that might initially seem to be in conflict, it did note a potential for skepticism and misunderstanding. One participant stated I have had an epiphany in this meeting at first I had a visceral reaction against mixing health care and marketing, but as I learned about what the program is I see that there is nothing wrong with it! Among educators there is debate about the relative merits of intrinsic versus extrinsic rewards. At the extreme, some see extrinsic incentives as potentially demotivating (for example: Alfie Kohn Punished by Rewards: The Trouble with Gold Stars, Incentive Plans, A s, Praise, and Other Bribes, and The EAG, however, felt that because Healthy Returns clearly emphasizes the intrinsic value of achieving health improvement goals it does not carry the risk of demotivation. One participant commented that being part of a group pursuing the same goal is in itself an incentive, as programs like Alcoholics Anonymous and Weight Watchers demonstrate. This member encouraged HPHC incentive program design to recognize and build on the positive impact of group commitment to health improvement. 3. What values are most relevant to deciding on the optimal roles and responsibilities for health plans, providers, employers and members? (Question 4 from p 2.) The EAG felt strongly that that health improvement goals for individual enrollees/employees are best supported when health plan, employers and providers collaborate. All have a crucial role to play. Re health plans: HPHC is in the best position to coordinate the key players because it is contractually related to members, employers and providers. From its databases HPHC can do a form of public health/epidemiologic assessment of the health needs of a subpopulation of members, such as the employees of a large employer. This positions HPHC well for working with an employer to design and manage a program targeted to the employee group. Re providers: At the start of the discussion a provider commented It is our responsibility to pursue the goals Healthy Returns aims it if the program is needed that must mean that we provider aren t doing our job! Wouldn t it be better to put the money towards additional clinical resources? Judith Frampton and Tom Hawkins both reported that in their experience doing on site programs it is not uncommon to suggest that an 4

5 employee participating in the program to follow up with their doctor. Thus when an onsite program like Healthy Returns identifies a health issue that should ideally be discussed with the employee/member s clinician the HPHC staff can make that recommendation. The EAG felt that on site programs that seek to enhance health promoting behaviors can work in synergy with the care provided by network clinicians that focuses on the same goals. Unfortunately, not all members have strong and satisfying primary care relationships. An HPHC staff member reported that after the HPHC Healthy Returns event colleagues said that they got to speak at greater length to clinicians at Healthy Returns than they were able to do during their medical appointments. From the perspective of these employees, Health Returns provided opportunities they had not found in their relationship(s) with providers. Re employers: Many participants commented on the potential for large employers to take a public health-like role with reference to its employees. Public health is concerned with populations and an employee group is a population! In addition to working with HPHC to create a program like Health Returns an employer can do many things that contribute to health promotion as by offering healthy food choices in a cafeteria and providing potential opportunities for exercise. One participant imagined a dialogue between employer and employees that went We are all concerned about health and health care costs. What can we do together to move things in a positive direction? If these incentives promote health and help us reduce costs everyone s interests are served! The EAG agreed with Judith Frampton that the employer/workplace is an underutilized channel for health promotion and disease prevention, especially given the fact that for many employed people it is difficult to access care in the medical office model. The Healthy Returns model takes advantage of the potential of the workplace to advance health and health care. Re members: The group did not discuss member responsibility at length, but two distinctive viewpoints were articulated. One participant felt that Healthy Returns did not go far enough, and imagined a drill sergeant s health plan in which employee/members were essentially required to participate in activities that promote health and contribute to disease prevention. The rationale for an approach like this is that health care costs are crippling employers and if trends continue the problem will only get worse. A contrary concern was voiced that as employees better understood the connection between illness among the employee group and their own salaries and health care costs an attitude of blaming the sick might emerge. Summary 1. With regard to Judith Frampton s question about whether the same incentive program design can support values that might seem to be in conflict the EAG s perspective is that the answer is yes, providing that (a) each value is worthy in itself, (b) health improvement goals are primary in design of the program, and (c) HPHC is explicit in acknowledging and educating about each of the values. 2. Health promotion and disease prevention are best served if health plans, providers and employers work collaboratively to support positive behavior change on the part of employees/members. 5

6 3. It is possible for large employers to take a public health-like role with regard to the employee population and the workplace. HPHC can be a crucial ally in developing this approach. 4. The EAG thanked Judith Frampton for inviting it to advise about this important area of policy and practice and hoped that she would return when HPHC has accumulated further experience in the area. Jim Sabin 6