Coming soon to your employer wellness program — metabo

Earlier this year, we first learned that older Japanese workers were being required to undergo blood tests and ‘flab checks’ to identify people with metabo. These were people ostensibly costing the national healthcare system because of their bad diets and lifestyles, making compulsory medical interventions necessary. We heard little about the unsound medical evidence behind metabo and how it was most discriminating against workers who were older or who had certain genetic predispositions. Perhaps, it didn’t seem important since Japan was half a world away and everyone believed that something like that could never happen here…

Did you hear about the latest decisions for containing healthcare costs just unveiled from one of our country’s largest health insurers — the network that covers one in every three Americans?

These landmark initiatives came from the national board of the Blue Cross Blue Shield Association and its fourth largest provider network, Health Care Service Corporation (HCSC). These will tighten control over the management of members’ healthcare provided through employers. Both target employer wellness programs by focusing them on “obesity-related” health indices.

HCSC has just unveiled its new employee wellness program, which will call for screening for metabo and compulsory participation in employer weight loss programs to help “employees lead healthier and more productive lives.” Metabo, as you’ll remember, is the compilation of health risk factors that includes BMI, waist circumference, triglycerides, glucose, blood pressure and HDL-cholesterol.

“HCSC wants to become a leader in addressing Metabolic Syndrome,” said Dr. Paul Handel, M.D., HCSC senior vice president and chief medical officer, in a press release issued this past week. Their model, as he exampled, was the employee program in Japan which has mandated that every worker over age 40 be tested for metabo and has required that the percentage of overweight workers be reduced 25% from the workforce by the year 2015. Metabo is gaining attention as a key way to reduce healthcare costs, according to Dr. Handel, because its numbers identify people more likely to develop chronic diseases.

Of course, as we’ve seen, metabo is actually a poor predictor those who will get heart disease, diabetes, cancer or die prematurely. Even the recent Japanese study from Shiga University of Medical Science in Otsu, Japan, found no support for the use of metabo measures or lower BMI as indicative of health or lower mortality among the Japanese. These health indices are not measures of those eating right, exercising or following healthy lifestyles, but are primarily indicators of aging, as well as genetics and social disadvantage, and hence discriminatory. Achieving and maintaining the low numbers now being required by third-party payer managed care guidelines, including the quality measures issued by our federal Centers for Medicare & Medicaid Services, requires medical interventions and prescription medications for most older adults.

BCBS Association board of directors just adopted a nationwide disease prevention initiative which includes similar employer wellness interventions. Mr. Scott Serota, the Association’s president and chief executive, and a founding member of the National Business Group on Health's Institute on Healthcare Costs and Solutions, told the New York Times that it’s about “prediabetes” that was costly to ‘treat’. Interestingly, the health care costs that have been popularly attributed to ‘obese’ people are now being credited to those termed ‘prediabetic’ and diabetes is being approached as preventable. He said that their new action plan will focus on obesity, weight management, diet, exercise and health risk assessments. Of course, as we’ve seen, prediabetes doesn’t actually predict much of anything, nor is it caused by diet or behavior, either.

Mr. Serota told the New York Times that essential to successfully implementing their new initiatives, and insuring member compliance, will be the continuation of an employer-based insurance system. According to his interview, the impetus for this plan of action by BCBS Association is their goal to modify the entire healthcare delivery system for the nation. “We, the Blues, feel we should try to drive toward a vision for the health care delivery system which we can move collectively forward with our partners,” he said.

Sidebar — Sorting through confusing campaign news

By making the connection to healthcare reform, BCBS may have helped Americans make more informed decisions. Specifically, Mr. Serota said they didn’t support John McClain’s healthcare proposals which might disrupt the employer-based delivery system. For those who haven’t read the presidential candidates’ complete healthplan proposals or who’ve only heard the media soundbytes, Mr. Serota’s statement might not have been understood. Recently, independent academic analyses of each of the presidential candidates’ healthcare plans were conducted for HIS Network by University of Minnesota health policy and economics professor Roger Feldman, Ph.D. and colleagues. Their reviews [here and here] were especially careful and thorough and will be of help for anyone wanting to get past campaign talk and take critical looks.

These professors summarized the operational changes in each candidate’s proposal, identified the proposed changes that have no rigorous empirical evidence of support (e.g. performance measures, cost savings of prevention and public health, disease management, cost savings through investment in electronic health information technology systems, etc.), analyzed the effects on healthcare costs and coverage, the impact for specific subsets of consumers, and examined how each plan would technically work to identify possible (and surprising) unintended consequences.

Currently, the tax code gives a preferential tax credit for insurance premiums paid by employers — credits that aren’t given to people who buy their insurance independently or choose to self-insure and pay for their health care directly. Most working Americans today not on government assistance are, of course, locked to their employers for their health insurance, which provides added incentives for workers to comply with insurer health management that comes through those employer wellness programs — and those are the biggest money makers for insurers, through pharmacy benefit managers (PBMs) and a prescription for every metabo number. Employees ultimately pay for the health insurance they get through their employers, of course, through trade-offs in their salaries and benefits. But when employers write the checks, they can call the shots over workers’ health management and lifestyles.

Just claim it’s based on reducing healthcare costs, like metabo.

Barack Obama’s plan, according to the HIS Network review, initially “includes a $179 billion a year employer mandate” and will strengthen ties of workers to their employers for health insurance.

In contrast, McCain’s plan will change the current tax incentives in the healthcare system, the HIS Network analysis explains. Instead of employers getting the tax credits for providing insurance, under McCain’s proposals, the tax credits will go through each individual towards wherever he/she chooses to get insurance, and wherever he/she works. [It is not a tax on health insurance, it’s a tax credit. Based on his proposed $5,000 tax credit for each family, a middleclass family in the 25% income tax bracket with a $12,000/year plan, would have their tax covered with $2,000 left over for a Health Savings Account to cover deductibles or copays, explained Peter Ferrara, general counsel for the American Civil Rights Union and a director at the Institute for Policy Innovation.]

Looking at it from the viewpoint of insurers, the open marketplace diminishes any one's control over members. People would be free to buy insurance independently, from wherever they wish. McCain’s plan also allows people to purchase insurance across state lines and to shop for whatever types of plans that might best meet their needs. Plans would also be freed from thousands of cost-raising state mandates, which are often based more on lobbying than good science, and be able to bring costs down. Health plans would be forced to compete for people’s business by offering better services, mix of benefits and value — and competition drives innovative plans to meet consumer demands.

More importantly to Mr. Serota’s point, people wouldn’t feel compelled to comply with insurer managed care in order to keep a job. As BCBS noted, insurers would lose a powerful tool for motivating people to participate in employer wellness programs and insurer disease management. People would have more control over their bodies and health choices, not their bosses.

In fact, if you’re comparing the candidate’s plans based on which one leaves you with the best shot at sovereignty over your body and lifestyle, the main way the two plans differ might be most important to you. That is one way to look at them, too, given that neither differs much when it comes to things like understanding health risk factors, obesity, and preventive health and wellness. Obama’s proposal creates a new National Health Insurance Exchange, through which people who don’t get their insurance through their employer or from the new public plan, must go through. As professor Feldman and colleagues explained, through this Exchange, the government will determine and regulate the standards for all private insurance plans, what benefits must be covered and what interventions would be required (i.e. managed care with preventive health and wellness screening, disease management, etc.), and “will require that all the plans offered are at least as generous as the new public plan.”

This Exchange is basically the model that’s been tested in Massachusetts, and we’ve seen the financial problems, expanded bureaucracy, reduction in benefits and provider compensations that it’s been struggling with, without improvements in access and quality of care being realized. Earlier this month, the New York Times reported that the Massachusetts public plan had just negotiated an increase of federal funding to help subsidize it of $4.3 billion over and above the initial three-year funding. A nationwide version of this plan would be left to taxpayers to bail out on an even larger scale.

Forced through the employer mandate to offer the same plans and benefits as the new National Health Plan, private plans would quickly be undercut on price, according to analyses published last month in Health Affairs. Employers’ only other option under the employer mandate is to pay towards the public plan for their employees, so employees with the costliest healthcare needs would be dumped from employers’ plans and onto the public option rather quickly, concluded the Wall Street Journal, and private coverage will in time be replaced completely with the single-payer government managed National Health Plan.

There are trade-offs with any proposal to reform healthcare delivery, and how individuals weigh them is driven as much by philosophical and political values, as much as economics, said Harvard professors Katherine Baicher and Amitabh Chandra. “Well-intentioned prescriptions with a ‘no pain, all gain’ outlook are easy to sell, particularly in a political climate shy of nuanced discussion, but they are unlikely to produce miraculous cures,” they wrote. In a paper just published this morning in Health Affairs, “Myths and Misconceptions about U.S. Health Insurance,” they examined in more detail the most repeated and feared myths and confusions surrounding healthcare reform, with pros and cons on all sides to consider.

As they noted, myths about health insurance make it impossible to accurately diagnose the problems in our current system and move towards productive reforms. “Although many [of the myths] are build on a kernel of truth, complicated issues are often simplified to the point of being false or misleading.”

Metabo coming to employer wellness programs reminds us of the importance of understanding unsound science used to compel supervision of our bodies, diets and lifestyles in the name of reducing healthcare costs to society.