In late June, Clarian Health, the Indianapolis-based hospital system, announced that starting in 2009, it will fine employees $10 per paycheck if their body mass index (BMI, a ratio of height to weight that measures body fat) is over 30. If their cholesterol, blood pressure, and glucose levels are too high, they'll be charged $5 for each standard they don't meet. Ditto if they smoke: Starting next year, they'll be charged another $5 in each check.
Clarian has been making headlines for its aggressive and unusual approach to covering escalating health-care costs. Rather than taking the more common step of giving employees incentives for merely participating in its wellness programs, such as joining a smoking cessation group or using a health coach, Clarian is actually measuring outcomes. And unlike most employers, it is penalizing workers for poor health instead of rewarding them for taking healthy steps.
But some employment lawyers and wellness program administrators believe Clarian's approach may not be so unusual in coming years. They see employers, already overwhelmed by rising health-care costs, getting more aggressive in mandating changes in employee behavior. Garry Mathiason, a senior partner at employment law firm Littler Mendelson, says more than 300 companies have requested its assistance on mandatory wellness initiatives since it released a study on the topic in April. "In reality, you only get a certain amount of participation with incentive and encouragement," he says. "The demand for (curtailing health-care costs) is so great that (employers) are willing to take the next step. It's tough love." As BusinessWeek chronicled in February, some outlier companies have even banned tobacco use for its employees altogether (see BusinessWeek.com, 2/26/07, "Get Healthy -- or Else").
In addition, regulations that became effective July 1 could prompt cautious employers to step off the sidelines. The federal government recently issued final rules on how wellness programs could comply with the nondiscrimination conditions of the Health Insurance Portability & Accountability Act (HIPAA). While the new regulations have been proposed for years, the final rules provide employers with some sense of security and more clarification on how much they can reward or penalize employees based on specific health results. "When you get into things that involve discrimination, employers aren't very comfortable with the words 'proposed regulation,'" says Jerry Ripperger, director of consumer health for the Principal Financial Group, a financial-services and insurance firm that offers wellness programs for large employers.
The final regulations were a major catalyst for Clarian Health's new program. Steve Wantz, Clarian's senior vice-president of administration and human resources, says his team had been considering their plan for two years, but the new regulations "gave us a lot more confidence." Another change in Indiana state law that allowed employers to offer financial incentives or surcharges to smokers in their health plans was also an impetus. After benchmarking other companies, Clarian, which had already been encouraging employees to join smoking cessation programs and take health risk tests, decided charging employees was more "transparent." Other companies "were providing what they called incentives through credits or discounts toward health premiums," says Wantz. "What we found was what those employers were doing, many times, was raising their premiums and discounting them back."
Sticks and Carrots
At Clarian, employees who have blood pressure that's above 140 over 90, blood glucose levels over 120, low-density lipoprotein cholesterol over 130, or a BMI over 29.9 could be subject to the paycheck deductions. Of the company's 13,000 employees, about 8,000 are enrolled in the company's health plan. The company estimates that as many as 34% of its employees will meet the definition of being obese, while it expects lower levels for other health measures. About 26% are tobacco users. The fines are waived for employees who can provide a doctor's note stating it's not advisable for them to try to meet the benchmark -- employees will be able to submit new notes from their doctors quarterly -- and that they are complying with the proper diet, exercise, and treatment plan.
While Clarian's plan is highly unusual, a few other employers are using the stick approach, too. Western & Southern Financial Group, a Cincinnati-based insurance and financial-services provider, has been issuing employees with high BMIs a surcharge to their premiums since 2001. Depending on their scores, employees are charged a tiered fee of between $15 and $75 a month if their self-reported BMI is high, but can have those fees refunded if their numbers go down. Preventure, a provider of fitness and wellness programs for midsize to large employers, has one client in the manufacturing industry that rewards employees when their BMI falls from their baseline score and charges them more when their number rises. "We haven't seen a lot of companies do it," says Laura Gilligan, director of business development for Preventure, "but I sense it might be a trend."
What's more likely for employers who start measuring health results is that they will provide carrots. In July, UnitedHealthcare began offering a new plan targeted at small businesses called Vital Measures, which combines a high-deductible insurance plan with a supplemental plan that provides discounts for healthy outcomes. Members who choose to participate will receive $500 discounts toward their deductible for each cholesterol, blood pressure, and BMI level they meet, along with refraining from tobacco use or taking a health risk assessment.
A reward-driven approach will surely be better received by employees, say benefits consultants. "The concept of penalizing for poor health is not well accepted, and a lot of employees would react badly to it," says Bruce Kelley, a consultant in the health-care practice of human resources advisory firm Watson Wyatt Worldwide. Clarian Health admits that its program is aggressive by design, and that employee reaction has been mixed, with much debate on its internal message boards. While some employees were supportive, there's been "the other reaction that this is very personal," says Wantz, with people asking, "'How dare you? This is my personal space.' There's been a lot of questions and confusion."
That's why some benefits consultants and health-care groups think many companies won't adopt a plan like Clarian's anytime soon. "People are not interested in making their employees unhappy," says Helen Darling, president of the National Business Group on Health, a nonprofit that represents large employers' health-care interests. "We're in a war for talent, and there are more than enough work-related challenges to manage people and performance that (penalizing) for something that is so complicated, so personal, so hard to deal with, just isn't the right thing to do at this point."
Others may steer clear of such aggressive plans until questions are ironed out about other legal issues besides HIPAA. Sharon Cohen, Watson Wyatt's group and health-care benefits counsel, says that "any time an employer tries to influence employee behavior and they start to become more aggressive, there are other laws that are implicated," including the Americans with Disabilities Act. She says it's not clear how the requirement of taking a health risk assessment to be eligible for an insurance plan, like Clarian's, would be seen by the Equal Employment Opportunity Commission under the ADA. Clarian's Wantz says their plan has been extensively reviewed by attorneys.
Still, Clarian's approach has already attracted interest. Wantz says it has received calls from several local companies, along with other hospital systems, interested in their approach. "The most common response from other employers," he says, "has been 'thank you.'"