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Wellness

An Ounce of Prevention
By Haydn Bush
The wellness movement gains momentum as a way to contain medical costs and improve Americans, health—though not everyone's a fan.

Proponents of wellness—the adoption of healthier diets, increased exercise and better adherence to treatment regimens for chronic diseases—say the concept holds the power to both improve the daily lives of Americans and stanch skyrocketing health care costs. For instance, Centers for Disease Control & Prevention reports that the percentage of obese adults rose from 15 percent in 1980 to 32.9 percent in 2004, increasing risk factors for Type 2 diabetes, strokes, heart disease and other chronic illnesses. The American Diabetes Association says that 7 percent of Americans suffer from the disease. And the CDC is not optimistic about the future; a recent report warns that “although one of the national health objectives for the year 2010 is to reduce the prevalence of obesity among adults to less than 15 percent, current data indicate that the situation is worsening rather than improving.”

The costs associated with treating and preventing chronic diseases like diabetes represent a major challenge to the health care system.

“What’s really breaking us in terms of cost and poor quality is chronic illness care,” says Carolyn Clancy, M.D., director of the federal Agency for Healthcare Research and Quality. “Life expectancy increased dramatically over the last century. It’s not about stamping out disease anymore. It’s about helping people with established chronic illness, and it has to be a partnership.”

Employers eager to rein in health care costs are taking the lead in the wellness debate, with a variety of programs aimed at improving employee health.

The American Hospital Association includes the concept of wellness in the broader health reform conversation, using it in the context of issues like access to primary care physicians and proper nutrition for school-aged children. “We thought wellness needed to be en-couraged in all environments—home, schools, workplaces and communities,” says John Bluford, president and CEO of Truman Medical Centers in Kansas City, Mo., and an AHA board member who is championing a wellness program for his own employees.

The idea of wellness to reduce health care costs is gaining traction on the political level. Former Arkansas Gov. Mike Huckabee, who lost 100 pounds with a diet and exercise regimen and wrote the self-help book “Quit Digging Your Grave with a Knife and Fork,” promoted wellness as a central component of his health care platform in his bid for the Republican presidential nomination. The Healthy Americans Act, a health care reform bill currently under consideration by the U.S. Senate, includes a provision that would reduce Medicare Part B premiums for beneficiaries who participate in “weight management, exercise, nutrition counseling, refraining from tobacco use, designating a health home, and other behaviors determined appropriate.”

The wellness movement is not without its detractors, however. Employer-based programs that offer discounts on premiums for participating in wellness steps, along with a growing number of companies that refuse to hire smokers, have come under fire from both civil libertarians and from some policy-makers who are unconvinced that wellness programs are effective.

And while primary care physicians are seen by wellness proponents as essential to chronic disease management, their ranks are expected to thin in coming years as baby boomers retire, with the threat of decreased federal funding for primary care education also on the horizon.

'T-shirts and Mugs Don't Work'

As health insurance costs rise, employers are looking at ways to reach out to workers suffering from chronic disease, who typically use more health care resources than the general population.

“The research is showing that 15 percent of the population drives 85 percent of the cost,” says Larry Boress, president of the Midwest Business Group on Health.

A pilot wellness program that began this year at Truman Medical Centers is directly aimed at that population. Sixty to 90 employees deemed high-risk for chronic disease have been selected for attention from fitness managers and chronic illness care programs. Very few employees have dropped out of the program so far, says CEO Bluford, who is considering expanding the program to include a larger population. Participation is largely voluntary, with a few “very minor” incentives that are not financial in nature, including clothing and other hospital promotional items.

Employers do have more potent options, though. The U.S. Department of Labor allows companies to reduce up to 20 percent of the cost of health insurance premiums for employees who enroll in wellness programs and achieve specific health indicators, including smoking cessation and lowered cholesterol scores. Incentive-based health insurance plans are a successful way of convincing employees to take wellness seriously, says Thomas Parry, president of the Integrated Benefits Institute, which analyzes health insurance policies.

“Financial incentives tend to work,” Parry says. “T-shirts and mugs don’t work.”

Also popular, says Boress, are two-tiered programs that offer a regular insurance rate for all employees, along with a discounted plan that often requires employees to take a health risk assessment and then enroll in a program to improve various health indicators, like cholesterol rates. “Employers are providing the orange-colored stick,” Boress says, referring to programs that combine the carrot-and-stick approaches. “If you don’t participate in the program, you don’t get the discount.”

The Department of Labor allows those programs as long as employees are given “reasonable alternate standards.” For instance, if a smoker is having trouble quitting, the employer could give her credit for taking a cessation program or using a treatment program.

A growing number of high-profile employers, including Scott’s Miracle Gro, are taking their wellness initiatives one step further by refusing to hire smokers.

Hospital systems have also joined in; the Cleveland Clinic stopped hiring smokers last year, and Truman Medical Centers has not hired smokers since 2006, says CEO Bluford.

“We didn’t get negative pushback at all,” Bluford says. “I think it’s an attracter for good healthy employees.”

Is It Fair? Does It Work?

Jeremy Gruber, executive director of the National Workrights Institute, says wellness incentives and no-smoking policies put enormous pressure on the privacy and personal lives of workers. “They’re not incentives at all,” he says. “They’re in essence penalties.”

Instead of pressuring workers, Gruber says employers should offer voluntary wellness programs, and take steps to make their workplaces healthier. “Employers need to take responsibility,” he says. “One of the biggest contributors to obesity and smoking is stress, and workplace stress is one of the biggest contributors to stress.”

Some observers are downright doubtful that wellness programs achieve their desired outcomes. A recent AHRQ analysis found that while wellness incentives can boost participation in stop-smoking and weight-loss programs, “they generally have little lasting effect on actual smoking cessation rates or weight loss.”

AHRQ’s Clancy argues that employers should consider all options before investing in wellness and disease management programs. Hiring an on-site nurse practitioner, she says, could prove as effective for employers.

“They should have a sense of the full map of opportunities that they might take advantage of,” Clancy says.

Clancy is also skeptical of chronic disease management efforts, saying little data exists on whether they can be effectively exploited to improve health outcomes. “How do you know you’re not just helping the willing who would’ve done well without you?” she asks.

Wanted: Primary Care Physicians

Many experts view primary care as an essential component of successful wellness plans, providing patients suffering from chronic disease with the attention they need to adhere to diet and medication regimens.

“The concept of a patient’s medical home, focusing on prevention and chronic care management, has been shown in other industrialized countries,” says James King, president of the American Academy of Family Physicians.

To provide that level of care, Rick Kellerman, M.D., chair of the AAFP board of directors and chair of the Department of Family and Community Medicine at the University of Kansas School of Medicine–Wichita, argues that family physicians who regularly see patients suffering from chronic disease are essential.

“We can try to prevent gangrene through the improved treatment of diabetes, or we can invest in people to remove the gangrenous limbs,” Kellerman says.

By 2020, the AAFP projects that the United States will need nearly 140,000 family physicians, but the demand for primary care services is already outstripping supply.

A recent U.S. Government Accountability Office report found that between 1995 and 2006, the number of primary care residency programs declined by 3.2 percent. And in 2007, an AAFP analysis of the National Residency Matching Program found that the number of family medicine positions filled by graduates from U.S. medical schools declined from 70.8 percent in 1995 to 42.2 percent in 2007.

“There are shortages of doctors,” says Ashley Thompson, director of policy for the American Hospital Association. “If everyone did the lifestyle changes we advise, who knows if there are enough doctors to handle it?”

The AAFP and the AHA both advocate for more federal funding support for primary care providers, including debt relief for medical students pursuing primary care careers. However, President Bush’s proposed 2009 budget would eliminate federal funding for primary care training programs.

“What society needs is completely different from the way medical education is going,” King says.

The Whole Grain Pizza Compromise

Wellness experts tout improved school nutrition as helping to establish lifelong healthy eating habits. Schools have the power to create future generations of healthy eaters with their meal options, Thompson says.

“Part of it is that people don’t know how bad french fries are, and there’s no access to fresh fruits and vegetables,” she says.

Mary Hill, president of the School Nutrition Association, says most American schools have improved their nutrition programs since 2004, when Congress began requiring that schools receiving federal funding for school lunch programs adopt nutrition guidelines and wellness plans. Federal pressure, along with increased public awareness of improved nutrition, has had a positive impact on cafeteria fare, Hill says.

“I think there’s several factors causing all of us, not just schools, to look at what we’re serving children,” she says.

Schools have to strike a balance, Hill says, between serving healthy food and persuading students to buy and eat it, leading to compromises like pizza with whole grain crust.

“Taking pizza off the menu is not going to help us; it’s one of our favorite items,” says Hill, who is  executive director of food services for the Jackson (Miss.) Public Schools. “Participation is important to us.”

However, Hill says the federal government still delegates too many nutrition decisions to local schools, leading to wide variations in what is served. The School Nutrition Association advocates a national nutrition standard for food served in schools. The standard would encompass lunchroom fare, vending machines and even goods sold in schools for fund raising.

“Whatever a child eats in California, they ought to eat in Mississippi,” Hill says.

Health Stats

According to a U.S. Department of Agriculture study of school cafeterias in America:

90% offer fresh fruits/vegetables
80% offer cookies/snack cakes
76% sell pizza
62% sell french fries
48% offer yogurt