Your boss will weigh you now
According to Blue Cross Blue Shield of North Carolina’s Annual Report, claims in 2008 reached $10.7 Billion — half the entire budget for the state of North Carolina. Claims increased nearly three times the growth in health plan members. Claims also cost the State Health Plan more than $200 million over that budgeted. Politicians had believed that preventive wellness and managed care in the State Health Plan, administered by BCBSNC, would save the state money.
Participants in the State’s Health Plan pay more out-of-pocket expenses for medical care than those in any other major health plan in the state, and that’s about to go up even more for some of them. They believed that wellness care and healthy lifestyle benefits were free.
Employers will now perform random tests of employees for evidence that they’ve smoked outside of work and will weigh employees in the workplace and report their BMIs to the state. Employees deemed noncompliant with the State Health Plan’s employer wellness initiative, will pay one-third-more for health insurance. Employers believed that eliminating smokers and fat people would lower health costs.
Employers, politicians and participants believed the marketing. The results were easily predictable. When decisions work from false beliefs, rather than sound evidence, the end results aren’t likely to be very good.
Under the State
North Carolina State University employees, state employees, teachers, retirees and other members of the North Carolina State Health Plan received a mailing last week about changes to their benefits, effective July 1, 2009. The changes would affect their out-of-pocket expenses, deductibles and co-payments. As part of the state’s “Comprehensive Wellness Initiative” signed into law (Senate Bill 287) in April by Governor Beverly E. Perdue, everyone covered by the state plan must now complete an Attestation Form, stating that they, and their covered dependents, do not use tobacco products and that they have a BMI less than 40 or are participating in approved weight management and/or tobacco cessation programs. They must also agree to submit to random testing for the presence of nicotine and to be weighed and measured at their workplace. By July 2012, the BMI requirement will be lowered to less than 35.
The mailing included “the requirements for compliance and the consequences of noncompliance” to its weight management and smoking cessation policies. The consequences of noncompliance mean paying one-third higher insurance premiums, higher deductibles and out-of-pocket expenses, for themselves and all covered family members. Noncompliants will no longer be eligible for the 80/20 plan and will be automatically moved to a costlier 70/30 plan. Plus, “members will forfeit any coinsurance and deductibles already paid under the 80/20 Standard Plan.”
“But wait!”, a reader wrote. “This is a government health insurance, the state’s health plan. And, we were told that the State Health Plan’s Healthy Living Initiative is voluntary and free.”
It is… at a price.
This is what happens when people want something for free and to let someone else manage their health, rather than take care of themselves for regular upkeep and purchase insurance to protect themselves from unforeseen major medical expenses. Anymore, insurance is no longer actual insurance; it’s health management, because that’s where the money and politics are.
Skyrocketing claims
Years ago, the state had signed with BCBSNC for managed health care focused on wellness and prevention and “quality” measures (providers mandated to provide care that adhered to pay-for-performance measures). Like company benefit managers, politicians believed that it would not only save, but make them money. The recent audit of the State Health Plan revealed, however, that it lost $79.7 million in 2008 and that the higher number of claims and administrative expenses cost the state $200.1 million more than planned.
Why did claims rise so much? The reasons are not surprising, but admitting them goes against today’s political correctness.
The popular belief is that when people get low cost insurance benefits, they over-utilize medical services which raises costs. But, that doesn’t fully explain the growing numbers of claims filed under the State’s Health Plan and why these managed care plans actually cost employers and consumers more.
● Newly insured? No. These teachers and state employees have had health insurance, so they aren’t making up for years without medical care.
● New members? No. The surge in claims isn’t explained by more members, as claims increased three times over the increase in members, according to the 2008 BCBSNC Annual Report. In just 2008, the company processed 46 million claims, more than 10% over the previous year; while membership increased by only 130,000 members, 3.5% of the 3.7 million members.
● Cheap? No. The theory that low health insurance premiums are encouraging overuse doesn’t hold up. Premiums for an employee and family (non-Medicare) under the NC State Plan are $533 a month for the 80/20 plan and $450 for the 70/30 plan — this is well over the national average. According to the Kaiser Family Foundation and Health Research and Educational Trust study on Employer Health Benefits, the average worker paid $293 for family coverage each month.
● Suddenly sick? There is no evidence that, over the past three years, teachers and state employees are suddenly becoming ill in greater numbers than ever.
Preventive wellness initiatives and disease management, as holistic and intuitively helpful as they may sound, have been shown to raise healthcare costs, and not just because of the additional tests, treatments, diets and lifestyle interventions. Health risk assessments, the key element in employer wellness programs, and screening tests are the gateway to identifying more people for prescription drugs (and other diets, products and interventions offered through health partnerships). These make money for insurers managing healthcare for government- and employer-offered health plans, under the guise of managing health indices (risk factors).
Opportunities for insurers to generate revenue with employer wellness programs go beyond pharmacy benefit management. The personal lifestyle information members reveal are marketing gold mines. Yet, for instance, nowhere among the member information is there a cautionary note telling participants in the State Health Plan that its commercial workplace wellness program and online health risk assessment are not covered under federal Health Insurance Portability and Accountability Act (HIPAA) privacy protection. That means participants have no protections in how their personal health information is used or sold. Nor are members likely aware of advertising content that appears to be health information. And few members likely stopped to read the more than 5,700-word privacy and terms disclaimer* on the North Carolina Workplace Wellness site.
Wellness isn’t medical care
The State Health Plan’s wellness initiative mandated by the legislature and largely enacted through employers, is “wellness care” and healthy lifestyle interventions, rather than caring for sick people. It was sold to politicians and company benefit managers as saving costs and preventing aging-related diseases. These alternative beliefs, born of the new field of “lifestyle medicine,” are increasingly finding their way into popular culture, even though few are supported by the scientific and medical literature.
BCBSNC tells prospective group plan managers that the key to controlling healthcare costs is prevention. Calling obesity the public health crisis of the 21st century, it blames “sedentary jobs, high-calorie diets and leisure time spend in front of the TV or on a computer” and claims that fat people in North Carolina are responsible for $83 million in medical costs that could be reduced by healthier lifestyles. It claims that expensive diseases - from heart disease, diabetes to cancers - can be prevented by regular check-ups, cancer and cholesterol screenings, cholesterol medications, diet and exercise counseling, blood pressure checks and treatment. It also blames fat people for raising everyone else’s health care premiums.
How many politicians and employer benefit managers do you know who go to the medical literature, let alone understand the research, to realize these claims are far from slam dunks and are not supported with good science? Employers and politicians also don’t weigh the health risks and safety concerns associated with wellness initiatives. Examinations of the scientific evidence behind employee wellness program recommendations; screenings; and diet, exercise and lifestyle behavioral interventions, find poor evidence for effectiveness, as well as numerous inconsistencies with U.S. Preventive Services Task Force recommendations, that they claim to be following.
In fact, there’s not even a link between degenerative diseases of aging or premature death and any of the health indices in preventive wellness programs.
Health discrimination
Ideal health risk indices — from BMI, blood pressure, blood sugars to cholesterol — are mostly euphemisms for thin and young. Those who believe that their own good health is because they eat “right,” exercise and have perfect numbers are often young and upper-income and not old enough to experience age-related changes. Their genetic good fortune is not evidence of good behavior, either. Evidence-based research to date has shown these health indices are primarily measures of aging, genetics and social stresses, and not significantly malleable with “healthful” diets and lifestyles. With aging, the “ideal” numbers of healthy 20-year olds cannot be achieved for most workers without taking controversial and risky prescription drugs or temporarily lowered by undergoing mostly ineffective weight loss measures.
Today’s healthism stigmatizes those who don’t follow culturally acceptable lifestyles, or look like they do. It is also accompanied by blaming victims of diseases, such as cancers, diabetes and heart disease, for having brought on their diseases themselves through bad behavior; and by growing age and class discrimination. Discrimination claims filed with the Equal Employment Opportunity Commission have jumped to the highest level since the agency opened in 1965, spokesperson David Grinberg told the media earlier this year. Just from 2007 to 2008, age discrimination claims grew nearly three times those of race and twice as fast as those of gender or religion.
Fat people and smokers are especially stigmatized and actively denormalized in our culture. Citing efforts to contain healthcare costs, it’s a short step from raising premiums on them to removing them from surgery waiting lists, denying them medical treatment, and refusing to hire them at all — all discriminatory practices that have been increasing over recent years. As Brian House, from the Dept of Sociology at the University of Washington in Seattle, and co-author Dr. Michael Siegel, M.D., Social and Behavioral Sciences Department, Boston University School of Public Health, cautioned in the January issue of Tobacco Control: “In recent years, a new trend in worksite smoking policies has emerged: a shift from ‘smoke-free’ workplace policies to what have been termed ‘smoker-free’ workplace policies.” House and Siegel found a lack of published evidence for the effectiveness of such policies, nor any evaluations of their far-reaching deleterious consequences that are putting people at increased risks.
Moreover, they wrote, “norms of other unhealthy behavior could also start to shift and socially justify barring employment to other groups.” They exampled Clarian Health in Indianapolis, which planned to begin “fining employees for smoking, having a body mass index greater than 30 and if their blood pressure, cholesterol and glucose levels are too high.” The war on obesity has become a war against the ‘obese’ and is far different than caring for them.
The State Health Plan’s healthy living initiative
The summary of the new benefit modifications that were mailed to members last week states: “NC HealthSmart, the State Health Plan’s healthy living initiative… is voluntary. Eligible members can use the program at no charge… The tools and services available through NC Health Smart include tobacco cessation and weight management programs.” The State’s healthy living initiative includes tobacco cessation support through a telephone quitline, health coaches, and smoking cessation medications; weight management in the form of nutrition counseling, weight loss medications and bariatric surgery as covered benefits, a web and telephone support line, health coaches, workplace diet and wellness initiatives, case management and personal health risk assessments.
It says its employer wellness program, called the “Eat Smart, Move More, Weigh Less,” encourages lifestyle management and “health-friendly policies” at workplaces.
The new benefits also include a Pharmacy Benefits section that’s been rewritten from last year’s plan, with new pharmacy drug exclusions for drugs not covered by the plan, prior approval requirements and quantity limits for some drugs, and a preferred drug list of drugs available through the plan with others subject to higher co-payments. Medications for chronic diseases, such as rheumatoid arthritis, multiple sclerosis, hepatitis C, and anemia, must be purchased through its contracted vendor or members will pay the total amount.
Participants in the NC State Health Plan noted that none of their wellness benefits were being reduced, even as the plan threatened to cripple employers and the state, and will cost taxpayers more than $300 million this year to keep solvent. BCBSNC saw profits of $186 million last year. In fact, in order to receive affordable health coverage, participation in preventive wellness is increasingly becoming mandatory, but not because it’s been proven to save medical costs or to be effective. According to the database on health plans kept by AthenaHealth, which manages electronic medical records and billing for more than 19,500 medical providers nationwide, BCBSNC sent out 250,000 reminders to customers last year who hadn’t complied with preventive health screenings.
While the State-provided health management comes with preventive wellness care, “free” health risk assessments and health “coaches,” and “free” case management — should recipients actually need medical care, that will cost them… increasingly more. Free isn’t really free. BCBSNC plan participants already have more out-of-pocket costs for medical expenses (12.1%) than any other major health plan in the state — 68% more than United, 60% more than Humana, 50% more than Aetna and 29% more than Cigna. This most hurts those who have real medical needs, especially older workers and those of lower socio-economic class and certain hereditary predispositions. The discriminatory aspects of preventive wellness mandates and the healthy lifestyle movement is the elephant in the room.
It is also yet to be seen if the State Health Plan will survive legal challenges for violating the Final Rules of the HIPAA, Nondiscrimination and Wellness Programs in Health Coverage in the Group Market. As ruled by the Department of Labor, these laws prohibit discrimination of employees in employee wellness programs based on hereditary features and health indices (measurements). It had also ruled that discrimination exemptions for wellness programs referred only to supplemental coverages and could not be those that are part of the primary health coverage.
Without an understanding of sound science, “for your health” can make discrimination seem acceptable … until it comes for you. Your boss will weigh you now.
© 2009 Sandy Szwarc
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