"Strap on the feed bag"

In the constant battle to control health care costs, there has been lots of experimentation with controlling the supply-side (eg, certificates of need, cutting back reimbursement levels to providers, etc) and the demand-side (eg, coverage limits, tiering, co-pays, co-insurance, etc). Health care costs continue to rise rapidly, but that doesn't mean that these methods have failed -- we don't know what cost growth would have been like without them.

There's been a lot of emphasis recently on digging further into the nature of demand -- rather than just cutting back patient choice, why not cut back on patient need by getting patients to be healthier in the first place. Employers pressure health insurers to curb cost growth, but the insurers argue that employers don't do enough to get employees to be healthy in the first place. Physicians and hospitals, pressured to improve quality and efficiency, complain that patient adherance is a large barrier to improved care -- if patients don't take simple measures to be healthy, and/or refuse to follow prescribed treatments, what is a provider to do?

This seems like a win-win-win; people shouldn't need that much encouragement to become healthier, and the results will be beneficial to all. Well, a large employer that is also a very savvy health care business has been experimenting with direct patient incentives to encourage healthier lifestyles, and they're finding that it's not quite as easy as it sounds (see Employers experiment with tough get-healthy regimes).

Clarian Health Partners of Indianapolis is an integrated delivery network that employees 13,000 people. They tried to segment their employee risk pool by setting higher premiums for employees who don't attempt to improve their health in certain ways, such as smoking, obesity, and high cholestorol. We as a society already allow this type of risk segmentation in other areas of insurance, and indeed, it's the very basis of preventing moral hazard incentives that undermine the efficiency gains of insurance to begin with! For example, bad drivers, and those assumed to be bad drivers (like teenagers), pay a lot more for insurance. Seems like a slam dunk, right?

Clarian ran into a buzz-saw and never rolled out the program. Some critics saw it as an intrusion of privacy -- an employer shouldn't be allowed to dictate what employees do outside of work. Others saw it as discrimination -- an employer shouldn't be able to single out certain groups of people based on health history or habits.

One bizarre quote in the article points out how weird this conversation can get. Commenting on why his company doesn't raise premiums for overweight employees, an auto-parts supplier stated that:

"We're a little bit reluctant to go down that path. It's not really the fear of litigation as much as the lack of evidence that it works," he said. "I look at my own reaction and if I were going to be penalized for my weight I'd say, 'If for an extra $15 a month I can strap the feed bag on I'm going to do that and I'm going to make sure I get my money's worth.'"

I can't think of a better summary of the depth of the problems that we face.