AlignMap

Using Cash Bonuses and Penalties To Enhance Weight Loss In Obese Employees

Employers penalize obesity
By Daniel Costello
Baltimore Sun. July 29, 2007

This article reports on an increasing number of employers using monetary incentives or disincentives to promote dieting and exercise among overweight employees with the goal of improving the employees’ health and, consequently, lowering medical costs secondary to obesity-related health problems.

Some employers penalize overweight employees if they don’t slim down while others offer fit workers lucrative incentives that may decrease their healthcare premiums by thousands of dollars a year. Examples include

• Clarian Health Partners, an Indiana-based hospital chain, will, beginning in 2009, charge employees up to $30 every two weeks unless they meet weight, cholesterol and blood pressure guidelines the company deems healthy, i.e., employees’ pay will be docked if they fail to meet certain weight ratios, cholesterol, blood pressure or if they smoke.
• UnitedHealthcare, a national insurer, introduced a plan this month that, for a typical family, includes a $5,000 yearly deductible that can be reduced to $1,000 if an employee isn’t obese and doesn’t smoke.
• County workers in Benton County, Ark., were offered, beginning last summer, a similar plan. The $2,500-a-year deductible can be reduced to $500 if a worker meets low height/weight ratios during yearly on-site physicals. Thomas Dunlap, Benton County’s benefits administrator, said the plan had witnessed a nearly 30 percent drop in claims – and led to changes in the workplace. Workers can attend free weight-reduction classes, and there are now regular competitions between departments to see who can lose the most weight. Acknowledging that it could be partially the result of the new deductible, he noted that the county didn’t have to raise its insurance premiums this year and likely won’t next year.

Some criticize this tactic, claiming that the lose-weight-or-pay plans “turn the health care system into a police state.” In addition, implicit in the strategy is the notion that people who are obese and have other health issues and change their situations with reasonable effort.

Lewis Maltby, president of the National Workrights Institute, a Princeton, N.J.-based employees rights group, called the trend

Employers reply that they are only responding to the rise in both health care premiums and the proportion of obese Americans.

In a telling statistical change, sixty-two percent of 135 executives responding to a PricewaterhouseCoopers survey this spring said unhealthy workers such as those who smoke or are obese should pay higher benefit costs, compared with 48 percent who said so in 2005.

Further, in January 2007, the U.S. Department of Labor released final clarifications on the Health Insurance Portability and Accountability Act (HIPAA) of 1996, which ruled that employers can use financial incentives in wellness programs to motivate workers to get healthy. Nonetheless, some lawyers say weight-based compensation plans might run afoul of other employment laws such as the Americans with Disabilities Act.

In recent years, companies have offered cash, merchandise and gift cards to those who lose weight or lower their blood pressure. A few have begun refusing to hire workers who smoke. The new plans are different because employers are demanding that workers participate in health exams and have their weight checked and blood taken to screen for high cholesterol or blood sugar.

Commentary

The use of mandatory monetary penalties and/or bonuses to direct lifestyle changes in the name of better health, especially when “better health” is a proxy for “lower costs,” is intriguing on several levels.

First, of course, is the question of the efficacy and efficiency of such tactics.

The ethical questions already suggested extend beyond the employers-employees contracts. Governmental agencies currently pass laws regulating the use of tobacco, alcohol, and, most recently, high-fat foods. It is hardly inconceivable that medical care provided by the state might someday come at a higher price to those citizens whose habits are deemed unhealthy.

Other, more specific issues are present in abundance. Which healthcare habits are fair game for bonuses and penalties? Should those with hereditary disorders be expected to pay more? How about those with a genetic predisposition to obesity? Are those who fall below the weight norms to be penalized? Or those who do not make it to follow-up clinical appointments? Or those who choose to see a priest for healing rather than a physician? Who sets the standards for healthy behavior? If a pregnant worker doesn’t seek adequate pre-natal care but is healthy and bears healthy children, is that family assessed extra costs? If a 32 year old former college athlete turned company VP plays in a semipro football league with its attendant risk of injury, should his behavior be considered unhealthy and efforts made to change it? What if he sky-dives on weekends? How about if his moonlighting job is serving as guinea pig for testing medication?

It’s a tricky new world.

Ads That Work
For Treatment Adherence

An article in today’s LA Times, See ad, kick the habit?, reports on a study published in the August issue of the Journal of Political Economy that has ramifications for patient compliance.

The study’s results indicate that

Just seeing magazine advertisements for smoking-cessation products appears to make cigarette smokers more likely to try quitting — and to succeed in doing so — even if the consumers viewing the ads don’t go out and buy the products.

According to Alan Mathios, a professor of policy analysis and management at Cornell University, advertising used to sell smoking-cessation products apparently has “important spillover effects,” possibly including the reinforcement of public anti-smoking messages and enhancing the determination of individuals who have ceased tobacco use not to relapse. Mathios goes on to note that “the public-health returns to smoking-cessation product advertisements exceed the private returns to the manufacturers.”

Commentary

While the Journal of Political Economy is the first medical journal on my reading list, the study is certainly intriguing and worth following up. It is also gratifying to think that some of the same advertising techniques that led so many to begin smoking might be effective aids to stop.

Further, it would seem likely that those methodologies could support other positive healthcare changes as well.

Because my compliance with the treatment of an acute health problem is time-consuming and a hassle to boot, posts to this blog over the next six weeks will probably be sparse and sporadic. Posts that are published are likely to be brief and general in nature.

After that treatment is completed, new AlignMap blog entries should be again added on its typical, more or less daily (i.e., each business day) schedule.

Allan Showalter, MD

Health Literacy and Mortality Among Elderly Persons
David W. Baker, MD, MPH; Michael S. Wolf, PhD, MPH; Joseph Feinglass, PhD; Jason A. Thompson, BA; Julie A. Gazmararian, PhD; Jenny Huang, PhD. Arch Intern Med. 2007;167:1503-1509.

The Study

The study looked prospectively at 3260 Medicare managed-care enrollees in 4 US metropolitan areas who were interviewed in 1997 to determine their demographic characteristics, chronic conditions, self-reported physical and mental health, and health behaviors. Participants also completed the shortened version of the Test of Functional Health Literacy in Adults. Main outcome measures included all-cause and cause-specific (cardiovascular, cancer, and other) mortality using data from the National Death Index through 2003.

Results

Commentary

Adherence to treatment for chronic illnesses such as asthma, diabetes and heart disease can be difficult in the best of circumstances. For those with literacy problems, following a treatment plan that goes beyond “take the blue pill twice a day” may prove impossible without extensive and expensive assistance. And, as this study indicates, the inability to follow treatment instructions is deadly.

While campaigns to end illiteracy may be a long term solution, the immediate problem of millions of individuals who today cannot comprehend written medical information should prompt further work in alternative means of communicating this information.

Adherence to Treatment in Poorer Countries: A New Research Direction? Alison Breen, M.A., Leslie Swartz, Ph.D., John Joska, M.B.Ch.B., F.C.Psych.(S.A.), Alan J. Flisher, Ph.D., F.C.Psych.(S.A.) and Joanne Corrigall, M.B.B.Ch., D.M.H.(S.A.) Psychiatr Serv 58:567-568, April 2007

The Letter

This letter to the editor points out the obvious but often overlooked fact that “most studies of treatment adherence have been conducted in high-income countries and the question arises as to whether there are structural barriers to adherence that are particular to, but underresearched in, areas with poor resources.”

The authors looked at a qualitative study of ten cases conducted in South African households with members who were caring for a household member who had schizophrenia and living in poor urban environments. Several themes were identified indicative of the particular healthcare compliance problems that challenge the poor.

Commentary

The factors affecting compliance seem never-ending. Nonetheless, as the authors of this letter point out, poverty inflicts special problems on a large number of patients and research efforts in this area are essential – for all of us.

Health Beliefs, Disease Severity, and Patient Adherence: A Meta-Analysis. DiMatteo, M Robin PhD; Haskard, Kelly B. MA; Williams, Summer L. MA. Medical Care. 45(6):521-528, June 2007.

The Study

The study is a meta-analysis of 116 articles published from 1948 to 2005 that dealt with “the relationship between patient adherence and patients’: (1) beliefs in disease threat; (2) rated health status (by physician, self, or parent); and (3) objective disease severity.”

Results & Conclusions Excerpted From The Abstract

The authors speculate that “patients may have doubts about the efficacy of their treatments, particularly if some have failed them, and their expectations for and interactions with their providers may be reduced in quality as they grow more severely ill. For patients in poor health with serious disease conditions, adherence may even seem futile, and patients may become depressed, pessimistic, socially withdrawn, and hopeless about surviving.”¹

Commentary

While the finding that patients with the most serious illnesses are least likely to adhere to treatment is counterintuitive to the common sense notion that those facing the greatest threat would be the group most likely to follow healthcare instructions, this result resonates with my clinical and personal experiences.

As DiMatteo and colleagues note, anxiety and depression associated withs severe disorders may play interfere with a patient’s ability to understand or execute a treatment plan or deplete a patient’s energy or motivation.

Also, however, more severe disorders may call for more rigorous, costly, and complex treatment regimens which could negatively affect compliance.

Regardless of the cause, however, this evidence that these individuals afflicted with the most serious illnesses are especially vulnerable to noncompliance should be a concern physicians automatically consider and monitor in the treatment of such patients.

Footnotes

1. Sickest Patients Less Likely to Follow Doctors’ Orders, UCR Study Finds ↩

The Study and The Real World

In Office Visits and ADHD Meds, yesterday’s post at Spotlight On ADHD, Dr. Brian Doyle points to a study¹ which he finds unsettling because of the implications its findings would have for practices treating these patients.

The only summary of the study I was able to find online this morning was in New and Emerging Data in the Management of ADHD, the source of these excerpts:

From this data, the researchers postulated “a direct relationship between the number of office visits and the number of prescriptions filled, suggesting a positive link between office follow-up and compliance” and suggested that “more frequent
office follow-up may lead to improved medication adherence among patients with ADHD.”

Dr. Doyle’s concerns are summarized in this excerpt from his post:

Commentary

First, in the spirit of full disclosure, I should clarify that

1. When I was involved in office practice, I treated batches of ADHD kids (although, I suspect, not as many as Dr. Doyle does) and my scheduling protocol for ADHD adolescents was almost precisely identical to his. Once the patients were stabilized, I would routinely see them once every three months for 15-30 minutes unless there was a specific problem that required more time or more frequent visits (this was a rarity). Almost all the ADHD patients I treated with medication were seen more often by a non-psychiatric therapist. I saw patients every three months because that’s how the psychiatrists I knew handled patients taking AHDH medication.
2. I am also the parent of an ADHD child who was on medication for several years. In treatment with four or five different pediatricians and psychiatrists over the years, he was almost always seen for medication check-ups once every three months for 15-30 minutes.

Given my clinical and family background, I may well be reacting defensively. Nonetheless, until I know some details of the study that are currently unavailable to me, I’m unable to generate much angst about my previous practices or enthusiasm to promote the idea that “more frequent office follow-up may lead to improved medication adherence among patients with ADHD.”

Some of the pertinent questions about the research, it seems to me, include the following:

• Was the frequency of patient visits a function of the specific case (i.e., did the clinicians in the study vary how often they requested visits by the difficulty of the case), the clinician (i.e., did some clinicians routinely schedule visits more often than others such that frequency of visits was a proxy for different groups of clinicians), or the patient and family (i.e., did the patients who did not show up at the office as often miss scheduled appointments)?
• Did the frequency of visits vary with the course of treatment (i.e., given that the patients were all “newly diagnosed,” did the clinicians use the same paradigm Dr. Doyle and I used, seeing the patient frequently at first and then decreasing the frequency)?
• What proportions of the patients fell in each age group and how did frequency of visits correlate to age (e.g., were young children routinely seen more frequently so compliance might have varied by age rather than frequency)?
• Did the clinicians provide prescriptions at times other than office visits?

Because such variables could clearly affect the suggestion that increased frequency of visits could increase compliance with medication, I suspect that some or all of them have been addressed, but until I review that information, I would hesitate to make further scheduling demands on the patients who are doing well (and their parents) based on these findings.

Footnotes

1. Hodgkins P, Boken M, Capone NM, et al: Office visits and prescription fill rates in patients with ADHD. Poster 119, presented at the 19th Annual US Psychiatric and Mental Health Congress; November 16, 2006; New Orleans, LA.↩

Improving Antipsychotic Adherence in Schizophrenia Using Cognitive Behavioral Therapy: Expert Interview with Peter J. Weiden, MD Medscape. Posted 06/28/2007

The Interview

The Medscape interview with Peter Weiden, MD,¹ addresses a question that has puzzled me for years: why, when there is good evidence that CBT can enhance compliance, isn’t this modality more available and more often used. Perhaps it’s as simple as the marketing of any service or merchandise. Until there is a demand for an item, few will offer it; and, until it is offered, few will request it.

In any case, the interview begins with Dr. Weiden’s poster entitled “Improving Antipsychotic Adherence in Schizophrenia: A Randomized Pilot Study of a Brief CBT [Cognitive Behavioral Therapy] Intervention” and extends to a discussion compliance problems that are especially striking in although not unique to schizophrenics, Dr. Weiden’s educational trip to England where CBT is far more commonly used, the theoretical and pragmatic issues involved with using CBT to deal with noncompliance, and more.

It’s well worth the read.

This article can be found at

Footnotes

1. Dr. Weiden is Director of the Psychosis Program, in the Department of Psychiatry, at the University of Illinois Medical Center, Chicago, Illinois↩

Different Ways to Describe the Benefits of Risk-Reducing Treatments Peder A. Halvorsen, MD; Randi Selmer, PhD; and Ivar Sonbo Kristiansen, MD, PhD, MPH. Ann Intern Med, June 19, 2007; 146(12): 848-856

Knowing Number Needed to Treat May Help Patients Consent to Treatment Interventions News Author: Laurie Barclay, MD; CME Author: Charles Vega, MD; Medscape: June 20, 2007. CME¹

The Study

Excerpted from abstract:

Commentary

Summarizing their results, the study’s authors write

While the difficulty of communicating statistically valid information about possible outcomes to medical professionals as well as patients has long been recognized, this study is valuable for its emphasis on the impact this process has on treatment decisions made by the patient.

On the other hand, I am not convinced that the specific results (e.g., that using the number needed to treat results in higher consent rates than postponement of events) has been proven by this study’s use of hypothetical scenarios rather than actual clinical situations, especially when the patients’ understanding of the scenarios is unclear.

I do agree with the editorial by Harold C. Sox, MD, in the same issue of Annals of Internal Medicine,

Because it is beyond the legitimate scope of the article, an important issue on which this editorial statement touches but does not elaborate is the ethics of framing information. It is by no means certain, for example, that increasing the proportion of patients agreeing to treatment is necessarily the “good outcome.”

Footnotes

1. CME Valid for credit through June 20, 2008. Credits Available: Physicians – maximum of 0.25 AMA PRA Category 1 Credit(s) for physicians; Family Physicians – up to 0.25 AAFP Prescribed credit(s) for physicians. See CME Information↩

Portion Control Plate for Weight Loss in Obese Patients With Type 2 Diabetes Mellitus – A Controlled Clinical Trial
Sue D. Pedersen, MD, FRCPC; Jian Kang, MSc; Gregory A. Kline, MD, FRCPC, Arch Intern Med. 2007;167:1277-1283.

The Study

The trial was undertaken to evaluate the efficacy of portion control tools to induce weight loss and improve glycemic control in patients with type 2 diabetes mellitus. 130 obese patients with type 2 diabetes mellitus (including 55 patients taking insulin) were randomly assigned to the daily use of a commercially available portion control plate¹ for 6 months (intervention group) vs to usual care in the form of dietary teaching (usual care control group).

Results:

Commentary

While this clinical trial focused directly on compliance, i.e., the impact of portion control plates on the implementation of weight reduction diets and glycemic controls by diabetic patients, it also

• Reinforces the notion that education alone many be insufficient for compliance but, at least for some patients, education supplemented by aids (e.g., in this case, the portion control plates) leads to successful adherence
• Raises the possibility that other, non-medical psychological knowledge, whether about eating or other activities, could be useful in enhancing compliance.

Footnotes

1. From Dishing out portion control for dieters: The dishes, sold by the Diet Plate Limited of England, are not specifically designed for people who are overweight or have diabetes. For breakfast, subjects used the bowl to measure 200 calories’ worth of cereal and milk – colored rings on the bowl correspond to different types of cereal – but only if they wanted cereal. If not, they were free to eat anything else, with no portion restrictions. The plate, which holds an approximately 800-calorie meal, was to be used during the biggest meal of the day. Its painted lines divvy out sections for grains, cheese, sauce and protein; mixed items such as lasagna were placed in the section that fit their ingredients closest. Vegetables were unlimited as long as they were not covered in oil or fried.↩

Source (except as otherwise noted):Electronic Pill Box Gets FDA Approval (CBS/AP)

Computerized Pill Dispenser Approved As Means Of Reducing Medication Errors

This (large, industrial size) bread box-sized, computerized pill dispenser, the Electronic Medication Management Assistant (AKA EMMA) manufactured by INRange Systems Inc., garnered FDA approval last week as a means of reducing errors in drug identification and dosing.

It should be on the market in early 2008.

The device, which can be programmed to dispense individual doses of up to a month’s worth of 10 different drugs, is designed for home use but requires the supervision of a health-care provider. EMMA is connected via the Internet to the patient’s clinician or pharmacist, allowing them to adjust the dosing schedules and dosages of drugs. Visual and audible alerts signal the patient whn it is time to take a pre-set dose of medication.

In addition to reducing medication errors, the dispenser is promoted as being useful to aging and forgetful patients, as well as those following a complex HIV treatment regimen.

According to Can an In-home Electronic Pillbox Solve Our Medication Error Problem? the cost of the machine will be $200 per month.

Commentary

While automated, clinically monitored medication dispensers offer obvious advantages, it seems unlikely that many patients will opt for a $200 per month pill reminder and even more unlikely that clinicians will happily take on the responsibility of monitoring the Internet feed from these machines, serving, in effect, as un-reimbursed employees of EMMA’s manufacturer.

After publishing two posts dealing with cost-sharing (More On Cost-sharing And Medication Compliance and Healthcare Cost-sharing And Medication Compliance) earlier this week, I realized I had other articles on this topic stashed for potential use in future blog entries.

Because I can’t predict when – or if – those articles will make it online on this site and because of the importance of the effects of healthcare cost-sharing on patient compliance as well as the current interest in the topic, today’s post references some of this material for the interested reader.

The Integrated Benefits Institute Report
The Integrated Benefits Institute (IBI) has issued the a report, A Broader Reach for Pharmacy Plan Design, that, according to the press release, “finds pharmaceutical cost shifting leads to increased disability and lost productivity.” Funded by IBI, the full report is available to IBI members,¹ but others can access the Executive Summary.

The American Journal of Managed Care Special Issue
In June, the American Journal of Managed Care published a special issue devoted to medication cost-sharing that included, among others, these titles:

• “Fiscally Responsible, Clinically Sensitive” Cost Sharing: Contain Costs While Preserving Quality
• Effect of Copayments on Drug Use in the Presence of Annual Payment Limits
• Effect of a Medication Copayment Increase in Veterans With Schizophrenia
• Relationship Between Generic and Preferred-brand Prescription Copayment Differentials and Generic Fill Rate
• Consumer Response to Dual Incentives Under Multitiered Prescription Drug Formularies

The complete articles are available in PDF format online at The American Journal of Managed Care (June 2007 Issue, Part 2): Prescription Drug Cost Sharing

Commentary

Both the Integrated Benefits Institute and the American Journal of Managed Care have a specific point of view that may influence their take on this topic. Of late, however, I have found it difficult to find research that it free of potential influence. These days, I am grateful when the researcher’s point of view and potential biases are at least clearly presented.

Footnotes

1. The full report is also offered to media; consequently, I have requested a copy. If that request is granted, I’ll review the report on this blog.↩