[Senate Hearing 115-637]
[From the U.S. Government Publishing Office]
S. Hrg. 115-637
EXAMINING HOW HEALTHY CHOICES
CAN IMPROVE HEALTH OUTCOMES
AND REDUCE COSTS
=======================================================================
HEARING
OF THE
COMMITTEE ON HEALTH, EDUCATION,
LABOR, AND PENSIONS
UNITED STATES SENATE
ONE HUNDRED FIFTEENTH CONGRESS
FIRST SESSION
ON
EXAMINING HOW HEALTHY CHOICES CAN IMPROVE HEALTH
OUTCOMES AND REDUCE COSTS
__________
OCTOBER 19, 2017
__________
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Pensions
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COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS
LAMAR ALEXANDER, Tennessee, Chairman
MICHAEL B. ENZI, Wyoming PATTY MURRAY, Washington
RICHARD BURR, North Carolina BARBARA A. MIKULSKI, Maryland
JOHNNY ISAKSON, Georgia BERNARD SANDERS (I), Vermont
RAND PAUL, Kentucky ROBERT P. CASEY, JR., Pennsylvania
SUSAN COLLINS, Maine AL FRANKEN, Minnesota
LISA MURKOWSKI, Alaska MICHAEL F. BENNET, Colorado
SUSAN M. COLLINS, Maine SHELDON WHITEHOUSE, Rhode Island
BILL CASSIDY, M.D., Louisiana TAMMY BALDWIN, Wisconsin
TODD YOUNG, Indiana CHRISTOPHER S. MURPHY, Connecticut
ORRIN G. HATCH, Utah ELIZABETH WARREN, Massachusetts
PAT ROBERTS, Kansas TIM KAINE, Virginia
LISA MURKOWSKI, Alaska MAGGIE HASSAN, New Hampshire
TIM SCOTT, South Carolina
David P. Cleary, Republican Staff Director
Lindsey Ward Seidman, Republican Deputy Staff Director
Evan Schatz, Democratic Staff Director
John Righter, Democratic Deputy Staff Director
C O N T E N T S
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STATEMENTS
THURSDAY, OCTOBER 19, 2017
Page
Committee Members
Alexander, Hon. Lamar, Chairman, Committee on Health, Education,
Labor, and Pensions, Opening Statement......................... 1
Murray, Hon. Patty, Ranking Member, a U.S. Senator from the State
of Washington, Opening Statement............................... 3
Young, Hon. Todd, a U.S. Senator from the State of Indiana....... 32
Isakson, Hon. Johnny, a U.S. Senator from the State of Georgia... 36
Franken, Hon. Al, a U.S. Senator from the State of Minnesota..... 38
Casey, Hon. Robert P., Jr., a U.S. Senator from the State of
Pennsylvania................................................... 40
Cassidy, Hon. Bill, a U.S. Senator from the State of Louisiana... 42
Bennet, Hon. Michael F. a U.S. Senator from the State of Colorado
Warren, Hon. Elizabeth, a U.S. Senator from the State of
Massachusetts.................................................. 44
Witnesses
Statement of Steve Burd, Founder and CEO, Burd Health, Alamo, CA. 5
Prepared statement........................................... 7
Statement of Michael F. Roizen, M.D., Chief Wellness Officer,
Roizen Family Chair, The Wellness Institute of the Cleveland
Clinic, Cleveland, OH.......................................... 9
Prepared statement........................................... 12
Statement of David A. Asch, M.D., M.B.A., John Morgan Professor,
Perelman School of Medicine and the Wharton School, Executive
Director, Center for Health Care Innovation, University of
Pennsylvania, Philadelphia, PA................................. 22
Prepared statement........................................... 24
Statement of Jennifer Mathis, Director of Policy and Legal
Advocacy, Judge David L. Bazelon Center for Mental Health Law,
Washington, DC................................................. 26
Prepared statement........................................... 27
EXAMINING HOW HEALTHY CHOICES
CAN IMPROVE HEALTH OUTCOMES
AND REDUCE COSTS
----------
THURSDAY, OCTOBER 19, 2017
U.S. Senate,
Committee on Health, Education, Labor, and Pensions,
Washington, DC.
The Committee met, pursuant to notice, at 10:07 a.m. in
room SD-430, Dirksen Senate Office Building, Hon. Lamar
Alexander, Chairman of the Committee, presiding.
Present: Senators Alexander [presiding], Murray, Isakson,
Young, Cassidy, Casey, Franken, Bennet, Whitehouse, Murphy,
Warren, Kaine, and Hassan.
Opening Statement of Senator Alexander
The Chairman. The Senate Committee on Health, Education,
Labor, and Pensions will please come to order.
We have a vote at 11:45, but that should leave us an
opportunity to hear from our witnesses and to have a good
amount of time for questions.
I told our witnesses that I was delighted to be talking
about something other than the individual health insurance
market.
[Laughter.]
I am really quite serious about that because we know that
the larger issues in healthcare are much more than the 6
percent of the people, every one of whom is important, who have
to buy their insurance in the individual health insurance
market.
We are glad to have this discussion, and it is a subject on
which both Republicans and Democrats have a lot of interest,
and we look forward to your advice.
Today, we are holding a hearing to look at what can be done
to encourage people to make healthier lifestyle choices to help
prevent serious illnesses and reduce healthcare costs.
Senator Murray and I will each have an opening statement,
and then we will introduce the witnesses. After the witnesses'
testimony, Senators will each have 5 minutes of questions.
Let me say, before I begin, that I want to thank Senator
Murray for her leadership and being a straightforward, tough
negotiating partner on our efforts to present to the Senate a
limited, bipartisan bill to stabilize the insurance market
during 2018 and 2019.
She and I will go to the Senate floor today at one o'clock
and make a brief statement, and put the text of the legislation
in the Congressional Record so Senators can examine it. We will
also list a significant number of Republican and Democratic co-
sponsors for the legislation.
The hope is, now that we have put a proposal on the table,
that the Senate will consider it, that the house will consider
it, and the President will consider it.
I talked with the President last night, and he encouraged
the process, which he asked me to begin, and said he looked
forward to considering it. I said, ``If you have suggestions
for improving it, that is certainly your prerogative to do,''
and that is what we would expect to happen in the legislative
process.
I thank Senator Murray for that, and other Members of the
Committee, who have been involved in it.
Over the last 7 years, we have endured this political
stalemate over the Affordable Care Act, with most of the
disagreement being over, as I said, a very small part of the
health insurance market where 6 percent of Americans buy their
insurance.
The fact that we have had that stalemate makes this even
more refreshing to talk about an area of healthcare on which
most Americans--doctors, employers, Republicans, Democrats--
agree. That consensus is that a healthy lifestyle leads to
longer and better lives, and reduces the Nation's healthcare
costs.
According to the Centers for Medicare and Medicaid
Services, healthcare spending in the United States has grown
from consuming 9 percent of the Gross Domestic Product in 1980
to nearly 18 percent, or $3.2 trillion, in 2015 and a predicted
20 percent in 2025.
The Cleveland Clinic, which is represented by one of our
witnesses today, has said if you achieve at least four of six
normal measures of good health and two behaviors, you will
avoid chronic disease about 80 percent of the time.
The six indicators of good health are familiar: blood
pressure, cholesterol level, blood sugar, Body Mass Index,
smoking status, and your ability to fulfill the physical
requirements of your job.
The two behaviors are seeing your primary care physician
regularly and keeping immunizations up to date.
Again, if you hit four of the six indicators and keep up
the two behaviors, according to the Cleveland Clinic, you will
avoid chronic diseases 80 percent of the time.
This is important because we spend more than 84 percent of
our healthcare costs, or $2.6 trillion, treating chronic
diseases. That is something on which almost everyone agrees.
Let us add that to another obvious fact: about 60 percent
of Americans get their health insurance on the job. So if we
really want to focus on improving the quality of healthcare in
America, why not connect the consensus about wellness to the
insurance policies that 178 million Americans get from their
job? That is precisely what the Affordable Care Act sought to
do in 2010. In fact, it was one of the only parts of the ACA
that everybody seemed to agree on.
Today's hearing is about how successful wellness
initiatives have been, and what we can do to make it easier to
encourage people to lead healthier lives and reduce healthcare
costs.
Many employers have developed wellness programs to
incentivize people to make healthier choices. These programs
may reward behaviors such as exercising, eating better,
quitting smoking, or offer employees a percentage of their
insurance premiums for doing things like maintaining a healthy
weight or keeping their cholesterol levels in check.
These programs have the potential to save employers money,
and improve the health and well-being of their employees.
Steve Burd, one of our witnesses, as CEO of Safeway,
visited with many of us a few years ago, and started a
successful employee wellness program after he left Safeway,
which I hope he will talk about. That is one part of it.
I would also like to hear about what communities and the
Federal Government are doing to encourage healthy lifestyle
choices.
I know that Blue Cross Blue Shield of Tennessee partnered
with local, state, and private organizations to fund community-
level initiatives across our state, such as Fitness Zones in
Chattanooga, programs in rural counties to promote healthy
habits, and an interactive elementary school program to keep
kids moving.
An example of encouraging wellness at the Federal level is
the Medicare Diabetes Prevention Program, an intervention
program for Medicare recipients diagnosed as pre-diabetic to
prevent Type 2 diabetes. Medicare spent an estimated $42
billion more in 2016 on people with diabetes than it would have
spent if those recipients did not have diabetes.
There are other ways to encourage healthier behavior, but
it is hard to think of a better way to make a bigger impact on
the health of millions of Americans than to connect the
consensus about wellness to employer-based insurance for 178
million people.
I look forward to the hearing.
Senator Murray.
Opening Statement of Senator Murray
Senator Murray. Well, thank you very much, Chairman
Alexander.
Thank you to all of our colleagues and witnesses for
joining us today.
We often think of healthcare as something you need when you
get sick, but we should be thinking a lot more about ways we
can help prevent families from getting sick in the first place
and ending up in the doctor's office or the hospital.
I am really glad that we are having today's hearing on how
to better promote health and wellness. Because the truth is we
all have a role to play in supporting families' efforts to make
healthy choices, whether it is Government, or communities, or
hospitals, or schools; and certainly, businesses and employers
who can promote healthy behaviors in partnership with their
communities.
I look forward to a robust discussion today around wellness
and public health efforts that promote physical activity,
improve access to healthy and affordable food, especially for
our children, expand on science-based ways to reduce tobacco
use, and a lot more.
I will be focused on making sure Congress is providing the
investments needed to support local, state, and Federal efforts
to promote public health. That includes grant programs by the
Centers for Disease Control and Prevention that invest in
community health centers, as well as the Prevention and Public
Health Fund, which has made a difference for so many patients
and families nationwide.
Given our Nation's high healthcare costs, and the fact that
so many of those costs can be attributed to chronic diseases,
it is critical we do more to support public health efforts
focused on health education and promotion.
I do want to be clear on the following: while we consider
wellness programs, we have to do it in a balanced manner and
make sure that we are protecting workers' civil rights and
privacy.
For me, and I know for a lot of my colleagues, the fact
that employer wellness programs could impose significant
financial penalties on workers, who do not wish to share
protected health information, is a very serious concern.
I want to hear today more about what we need to do to make
sure we find this right balance for wellness programs that
protects workers' rights under the Americans with Disabilities
Act, and HIPAA, and the Genetic Information Non-discrimination
Act, three laws that were written and passed by this Committee.
I have to be clear: responsibility for making sure that the
rights of workers with disabilities, and those who do not wish
to share genetic information, are protected and respected in
these programs will rest with the Trump EEOC.
That is exactly one of the reasons why Democrats pushed so
hard against his recent nominees to the EEOC, nominees who, I
really am concerned, do not show they were truly committed to
protecting those workers from discrimination.
This is a balance, and we need to work on it, and figure it
out.
I really appreciate all of our witnesses who are here to
help share your information with us, and I look forward to the
discussion.
Mr. Chairman, I do have a letter from AARP that I want to
submit for the record as well.
The Chairman. Thank you. It will be submitted.
Thanks, Senator Murray.
We would ask each witness to please summarize your remarks
in about 5 minutes. That will give us more time to have
questions back and forth from Senators.
The first witness is Steve Burd, Founder and CEO of Burd
Health. He was CEO of Safeway for 20 years, and many of us met
him when he roamed the halls during the debate on the
Affordable Care Act, both the Democratic and Republican halls,
with a message about wellness.
Second, we will hear from Dr. Michael Roizen, the Chief
Wellness Officer and Founding Chair of the Wellness Institute
at the Cleveland Clinic, a program that I just described in my
opening remarks.
Dr. David Asch, is Executive Director of Penn Medicine
Center at the Health Care Innovation, and John Morgan
Professor, Perelman School of Medicine and the Wharton School
at the University of Pennsylvania. He is a Leading Behavioral
Economist with much research on healthy lifestyle choices.
Then, Jennifer Mathis is Director of Policy and Legal
Advocacy at the Judge David L. Bazelon Center for Mental Health
Law. She supervises the Center's policy work and engages in
advocacy.
Why do we not start with you, Mr. Burd?
Welcome.
STATEMENT OF STEVE BURD
Mr. Burd. All right. Well, thank you. Thank you very much.
I think the first thing I would like to say is that I very
much appreciate the opportunity to share my experience in the
wellness category with the Committee here. I really want to
applaud your willingness to work in a bipartisan fashion to
improve the health of Americans and ultimately legislation that
attaches to that.
I am going to go quickly through a little bit of background
of what I have done since I left Safeway in the CEO position
because it has impacted how I think about the subject.
Second, I want to talk about why we picked wellness as a
real important area.
Third, I am going to cover the elements of the wellness
program that we introduced at Safeway. I think it is most
instructive because we have had a 10-year run. We know what the
statistics look like after some 10 years.
I am going to speak to the results that we achieved, which
I think are extraordinary, and I think indicative of what
others can do.
Then finally, I want to talk about what I think are the
five keys to success in a company wellness plan because most
people have failed at this. I know that Michael and I, and
maybe others here that will testify, have succeeded. I think
you will find some common success elements.
After leaving Safeway, while at Safeway as the Chairman
indicated, I got very involved in healthcare and discovered
that it was a fascinating area; a great opportunity to improve
the health of Americans, opportunity to improve care without
adding to costs, and frankly, an opportunity to dramatically
lower costs. I committed to spending the next 10 years of my
life, and I have now spent four, in this space.
What I wanted to do was to tell you briefly what my company
does is we do three things that are unique.
We are able to lower a company or organization's costs,
actually 40 to 50 percent, simultaneously lower the employee's
expense about 6 to 10 percent.
We are also capable of significantly improving the care
they receive.
If they are willing, we can have a dramatic effect on the
wellness of their population, which has profound effects on the
productivity of that workforce.
I picked wellness back in 2008 because we took note that
about 70 percent of all healthcare costs are driven by
healthcare behavior. So we thought as a self-insured employer
with the right to design a plan however we chose, we could
actually affect behaviors and people would become healthier.
I want to just put into context for you, because I know you
will, at some point, want to understand how to reduce costs.
That, in the short run, there are other ways to reduce costs
more significantly. The first one I would mention would be
provider efficiency, then plan discipline, plan design, and
then wellness.
In the first 5 years, I have put wellness in the fourth
place. In the next five to 10 years, I would put it probably
close to second place or third place. So there is an
opportunity there.
On the wellness front, we put together a program at Safeway
and we made it a voluntary program, which I am not sure
everybody understood at the time. Eighty Five percent of our
employees opted-in to this plan, and 70 percent of the spouse's
opted-in to this plan.
We rewarded people for achieving certain biometric
standards with about $600 worth of reward. When we polled
people, as we did annually, about 78 percent of the
participants viewed the program as either very good or
excellent. What we measured was blood pressure, HbA1c,
cholesterol, tobacco use, and BMI.
As I said, the results were amazing, and I will give you a
2-year look after starting the program.
Of the people that failed the blood pressure standard, 2
years later, 73 percent of them passed and they maintained that
over the balance of the program.
Pre-diabetics, of those that failed initially, 45 percent
of them passed 2 years later.
Cholesterol level, 43 percent of those passed 2 years
later.
Smokers, I have a number of 35 percent. In fairness, you
can beat that test and so while we did improve the smoking, 35
percent is a bit strong.
Then we took the obesity rate of our population of 28
percent down to 21 percent. I had a goal to be, if we were a
state, we would be the lowest obesity state in the United
States. Senator Bennet, at that time, Colorado held that
position. When I left in 2013, we matched Colorado at 21
percent.
I want to just move, shift quickly, because it says I have
9 seconds left.
Why did we succeed?
First of all, we rewarded on outcomes, not participation.
The vast majority of programs, they say they are outcome-based.
They are not. They are participation-based.
We had to put a meaningful amount of money at stake. We
viewed that starting point as about $600.
We needed to provide support tools that would allow people
to actually change their behavior and enhance their state of
health.
We needed to surround it with an ecosystem that constantly
convinced the employee that we cared about their health. We can
talk more about that in the Q and A.
Then, we consciously developed a culture of health and
fitness. I did this when I was about 57 years of age, and I
understood that my fitness level down the road was going to
determine my state of health. Once you become immobile, your
health begins to decline. So we focused on health and fitness.
Then last, it needs leadership and I practice this with
clients today. If you do not have CEO leadership, it just does
not work.
I would contend, you cannot pick three of the five. In my
experience, you have to do all five.
[The prepared statement of Mr. Burd follows:]
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
The Chairman. Thank you, Mr. Burd.
Dr. Roizen, welcome.
STATEMENT OF MICHAEL F. ROIZEN
Dr. Roizen. Thank you.
Chairman Alexander, Ranking Member Murray, and Members of
the Committee.
My name is Dr. Mike Roizen, and I thank you for the
opportunity to testify today before your Committee.
Since 2007, I have served as the Chief Wellness Officer at
the Cleveland Clinic. In this capacity, I lead the Clinic's
work in preventing illness and helping people live longer,
healthier lives.
We give people more time. Keeping people well, and enabling
them to live their best lives, is not just my professional
goal, it is my passion, my life's work, and the passion of the
Cleveland Clinic.
Thank you for your leadership in holding this important
hearing. In fact, the title of the hearing encapsulates the
Cleveland Clinic's story. That is, how healthy choices can
improve health outcomes and substantially reduce medical costs.
We are hopeful that sharing the results of our efforts over
the last 9 years can demonstrate that we, as a Nation, can have
real impacts on the health of our people while resulting in
hundreds, literally hundreds of billions of dollars in savings
for both the private sector and the Federal Government.
For years, the central healthcare debate in Washington has
been about what role government should play in providing health
insurance. If leaders in Washington do not address the
skyrocketing costs of healthcare caused by the influx of
chronic disease, it will not matter whether Medicare, Medicaid,
private insurance, or individuals pay the bills.
Everyone in this room has seen the CBO estimates. Unless we
do something to bend the cost curve, we will all be bankrupt
from this influx of chronic disease that is growing five to
seven times faster than the population.
There is, however, something that both the Federal
Government and private insurers could do right now to
significantly reduce healthcare costs across the country, a
step that could save our Nation hundreds of billions over 10
years and with voluntary participation.
Nine years ago, the Cleveland Clinic began an ambitious
experiment to improve the health and wellness of its employees
and their families.
The Clinic's Rewards for Healthy Choice program provides
employees, who voluntarily choose to do so, much like Mr. Burd,
with compensation for reaching several outcomes, wellness
outcomes and medical outcomes, that you mentioned, each year.
The program is born of a few key insights about the causes
of chronic disease and the drivers of healthcare spending.
It starts with the fact that 84 percent of all healthcare
costs are due to chronic disease and 75 percent of chronic
diseases are driven by six measurable factors: your blood
pressure; your Body Mass Index; your fasting blood sugar or
hemoglobin A1c; your LDL cholesterol; whether you smoke or not,
we measure it by urine cotinine levels; and unmanaged stress.
These six predictors of chronic disease are controllable in
well over 90 percent of individuals. The Cleveland Clinic
Rewards for Healthy Choice program focuses on helping its
100,000 employees and dependents get and keep these six
measurements normal; combined with encouraging those two
additional behaviors: seeing a primary care provider regularly
and keeping immunizations up to date.
The Clinic program helps employees get these six normals.
The way we do it is we pay employees; that is, we incentivize
employees. We ended up--we started very small--but ended up by
increasing payments to about the same number as Mr. Burd to
achieve the six normals and the two behaviors.
The upshot, since the onset of the program, the Cleveland
Clinic has saved $254 million in direct medical costs
increasing yearly. This year we will save over $150 million
more versus the Milliman Benchmark as more of our employees get
and stay healthy. Further, their improved health is reflected
in substantial reductions in unscheduled sick leave.
The 62 percent of Clinic employees who voluntarily
participate in the program have seen their healthcare costs and
premiums decrease now by $600 for individuals to $2,000
annually for families for hitting these targets.
Smoking rates have decreased from 15.4 to under 5 percent
while the state of Ohio is around 23 percent.
Body Mass Index of employees, for all 100,000 employees
taken together, is decreasing 0.5 percent per year as opposed
to the Nation's increasing 0.37 percent per year.
Blood pressure, LDL cholesterol, and hemoglobin A1c levels
have improved substantially resulting in over an 11 percent
decrease in the need for illness care since 2009 rather than
the expected and projected 20 percent increase due to our aging
population.
The Cleveland Clinic model has been replicated with our
help by nine other large employers, all of whom have seen
similar impressive results. For example, Lafarge, a national
construction supply company, is saving over 46 percent of
expected medical costs as estimated by Aetna. We know that
other organizations can learn from these examples.
In short, the Cleveland Clinic Rewards for Healthy Choice
program is doable, exportable, and scalable across the country.
The Clinic has been working to educate lawmakers on this
idea, and Senators Ron Wyden and Rob Portman are collaborating
to work in the Senate Finance Committee aimed at reducing the
costs and improving health of Medicare beneficiaries.
It does not have to stop with federal programs. Private
sector programs, supported by this Committee, could benefit by
the work we have pioneered.
This program has at least three critical virtues. It has
been tested in multiple settings across different populations
and patient groups, everything from engineers to blue collar
workers. It is entirely voluntary, and it enables the Federal
Government to achieve substantial cost savings without any of
the programmatic budget cuts and without any initial costs.
Bending the cost curve through voluntary wellness and
incentive programs is a commonsense idea that both Democrats
and Republicans should be able to rally around for both the
health of our Nation's finances and the health of our people,
and it increases our competitiveness for jobs.
Thank you.
[The prepared statement of Dr. Roizen follows:]
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
The Chairman. Thank you, Dr. Roizen.
Dr. Asch, welcome.
STATEMENT OF DAVID A. ASCH
Dr. Asch. Chairman Alexander, Ranking Member Murray, and
distinguished Members of the Committee.
Thank you for the opportunity to speak with you today.
My name is David Asch, and I am a practicing physician and
a professor at the University of Pennsylvania. I am here to
talk about workplace health programs and their role in the
Nation's health.
My summary message is this: I believe that employer-
sponsored wellness programs have value to contribute.
I believe that even though the health and financial
benefits of these programs are often overstated. I believe that
even though some of these programs, and the ways they are
currently designed, risk treating some employees unfairly.
I am optimistic about these programs going forward because
we are learning how to design them to be much more effective
and much more fair.
Americans spend most of their time outside of the
healthcare system. Even those with a chronic illness spend only
a few hours a year in front of a doctor.
We spend about 5,000 waking hours a year doing everything
else in our lives. It is during those 5,000 hours when so many
of the determinants of our health unfold: how we eat, whether
we exercise, smoke, or take our prescribed medications.
We can put more and more money into healthcare, but much of
our health is determined in the 5,000 waking hours outside the
reach of doctors and hospitals.
Americans spend many of those waking hours at work and
employers have a large financial incentive to advance health,
not just because of our system of employment-based health
insurance, but also because healthier workers are more
productive.
More than three-quarters of large employers now have some
sort of workplace wellness program targeting risk factors, that
you have heard about already, that account for much of chronic
illness. Risk factors like tobacco use, high blood pressure,
obesity, and the like.
Unfortunately, it is a lot easier to know what conditions
to target than it is to know how to do so. Managing these
conditions requires substantial behavioral change.
Our Nation has invested considerably in the science of
medical treatment, as it should, but less in the science of
behavioral change. Our knowledge of how to break old habits and
develop healthier ones is rudimentary, but it is getting
better.
Behavioral economics is one example of how we are learning
more about changing behavior. Just last week, Richard Thaler,
of the University of Chicago, won the Nobel Prize in economics
for recognizing that we all succumb to irrational tendencies
that compete with our long term goals.
Increasingly, behavioral economics has been used to help
doctors and patients make better decisions. I am proud to say
that the University of Pennsylvania is a world leader in this
field.
One such irrationality is called loss aversion. We are much
more motivated to avoid $100 loss than we are to achieve $100
gain. It does not make economic sense, but it is how humans
tend to think.
We found this recently when encouraging overweight
employees at a large firm to increase their fitness. In one
group, employees were given $1.40 for each day that they walked
at least 7,000 steps. That is a standard, economic, financial
incentive.
For another group, we structured it as a loss, $1.40 a day
is $42 a month. So in that group, we gave each employee $42 at
the beginning of the month and we took away $1.40 for every day
they did not walk 7,000 steps.
An economist would see those two designs as the same. For
every day you walk 7,000 steps, you are $1.40 richer.
It turned out that those who received $1.40 were no more
likely to walk 7,000 than those who received no incentive at
all.
Those who had $1.40 taken away if they did not walk 7,000
steps were 50 percent more likely to succeed.
Mathematically and financially, these two approaches are
the same, but one worked and the other did not.
Most large companies are using financial incentives to
encourage healthy behaviors. The vast majority of them do so by
adjusting the premiums their employees pay for their health
insurance.
Although it may seem obvious that charging higher premiums
for being a smoker or being overweight would encourage people
to modify their habits, there is little evidence that programs
designed that way often work. At best, they provide modest
financial benefits to employers and unclear health benefits to
employees.
These programs offer promise, but they also draw criticism.
I remain, nevertheless, excited about well-designed
programs that help Americans change the behaviors they want to
change: help them quit tobacco, help them lose weight, and help
them better manage their high blood pressure.
Those changes are much less likely to come from typical
premium-based financial incentives and much more likely to come
from approaches that reflect the underlying psychology of how
people make decisions encouraged by frequent rewards, emotional
engagement, contests, and social acceptance. Those are the
ingredients of successful programs and they are missing from
most of what employers currently do.
We know so much more about how to design financial and
other incentives to motivate human behavior far more now than
even 10 years ago. I have not seen much of this new knowledge
applied effectively by employers, but there is no reason why it
cannot be.
Thank you for inviting me to testify.
I look forward to your questions.
[The prepared statement of Dr. Asch follows:]
Prepared Statement of David A. Asch
I believe that employer sponsored wellness programs
have value to contribute--even though the health and financial
benefits of these programs are frequently overstated, and even
though some of these programs--in the ways they are currently
designed--risk treating some employees unfairly. I am
optimistic about these programs going forward, because we are
learning how to design them to be much more effective and much
more fair.
More than three quarters of large employers now have
some sort of workplace wellness program to eliminate the use of
tobacco, reduce obesity, or manage other risk factors for
chronic disease. Most large companies are using financial
incentives to encourage healthy behaviors. The vast majority of
them do so by adjusting the premiums their employees pay for
their health insurance.
Although it may seem obvious that charging higher
premiums for being a smoker or being overweight would encourage
people to modify their habits, there is little evidence that
programs designed that way actually work. Those that do seem to
work provide modest financial benefits to employers and unclear
health benefits to employees.
Managing these conditions requires substantial
behavioral change and behavioral change is hard. centsehavioral
economics is an example of one way we are learning more about
changing behavior, and it offers promise for how to design
better programs in the future. The Penn Center for Health
Incentives and Behavioral Economics is 1 of 2 NIH-funded
Centers on behavioral economics and health and the world's
leader in designing programs to improve consumer health
behaviors.
I'm excited about well-designed programs that help
Americans change the behaviors they want to change: help them
quit tobacco, help them lose weight, help them better manage
their high blood pressure. Those changes are much less likely
to come from typical premium-based financial incentives and
much more likely to come from approaches that reflect the
underlying psychology of how people make decisions--encouraged
by frequent rewards, emotional engagement, contests, social
acceptance. These are the ingredients of successful programs
and they are missing from most of what employers currently do.
We know so much more now about how to design financial
and other incentives to motivate human behavior--far more now
than even 10 years ago. I haven't yet seen much of this new
knowledge applied effectively by employers but there's no
reason why it can't be.
______
Summary Statement of David A. Asch
Chairman Alexander, Ranking Member Murray, and distinguished
Members of the Committee:
Thank you for the opportunity to speak with you today. My name is
David Asch. I am a physician, and a professor at the University of
Pennsylvania.
I am here to talk about workplace health programs and their role in
the nation's health. My summary message is this: I believe that
employer sponsored wellness programs have value to contribute. I
believe that even though the health and financial benefits of these
programs are often overstated. I believe that even though some of these
programs, in the ways they are currently designed, risk treating some
employees unfairly. I am optimistic about these programs going forward,
because we are learning how to design them to be much more effective
and much more fair.
Americans spend most of their time outside of the health care
system. Even those with a chronic illness spend only a few hours a year
with a doctor. We spend 5,000 waking hours each year doing everything
else in our lives. It is during those 5,000 hours when so many of the
determinants of our health unfold: how we eat, whether we exercise,
smoke, or take our prescribed medications. We can put more and more
money into health care, but much of our health is determined in the
5,000 waking hours outside the reach of doctors and hospitals.\1\
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\1\ Asch DA, Muller RW, Volpp KG. Automated hovering in health
care: watching over the 5,000 hours. N Engl J Med. 2012;367:1-3.
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Americans spend many of those waking hours at work. Employers have
a large financial incentive to advance health, not just because of our
system of employment-based health insurance, but also because healthier
workers are more productive.
More than three quarters of large employers now have some sort of
workplace wellness program, targeting risk factors that together
account for most chronic illness. These include:
Eliminating the use of tobacco
Controlling high blood pressure
Reducing obesity
Increasing exercise
Lowering cholesterol
Managing diabetes
Unfortunately, it is a lot easier to know what conditions to target
than to know how to do so. Managing these conditions requires
substantial behavioral change.
Our Nation has invested considerably in the science of medical
treatment, but less in the science of behavioral change. Our knowledge
of how to break old habits and develop healthier ones is rudimentary,
but it is getting better.
Behavioral economics is one example of how we are learning more
about changing behavior. Last week, Richard Thaler of the University of
Chicago won the Nobel Prize in economics for recognizing that we all
succumb to irrational tendencies that compete with our long term goals.
Increasingly, behavioral economics has been used to help doctors
and patients make better decisions. I'm proud to say that the
University of Pennsylvania is a world leader in this field.
One such irrationality is called loss aversion. We are much more
motivated to avoid a $100 loss than we are to achieve a $100 gain. It
doesn't make economic sense, but it is how humans tend to think.
We found this recently when encouraging overweight employees at a
large firm to increase their fitness.\2\ In one group, employees were
given $1.40 for each day they walked at least 7,000 steps. That's a
standard economic financial incentive. For another group, we structured
it as a loss. $1.40 a day is $42 a month. So, in that group, we gave
each employee $42 at the beginning of the month and we took away $1.40
for every day they didn't walk 7,000 steps. An economist would see
these two designs as the same: for every day you walk 7,000 steps, you
are $1.40 richer. It turned out that those who received $1.40 were no
more likely to walk 7,000 steps than those in a control group that
received no financial incentive. However, those who had $1.40 taken
away if they didn't walk at least 7,000 steps were 50 percent more
likely to succeed. Mathematically and financially, these two approaches
are the same, but one worked and the other didn't.
---------------------------------------------------------------------------
\2\ Patel MS, Asch DA, Rosin R, Small DS, Bellamy SL, Heuer J,
Sproat S, Hyson C, Haff N, Lee SM, Wesby L, Hoffer K, Shuttleworth D,
Taylor DH, Ulrich V, Zhu J, Yang L, Wang X, Volpp KG. Framing financial
incentives to increase physical activity among overweight and obese
adults--a randomized, controlled trial. Ann Intern Med. 2016;164:385-
94.
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Most large companies are using financial incentives to encourage
healthy behaviors. The vast majority of them do so by adjusting the
premiums their employees pay for their health insurance.
Although it may seem obvious that charging higher premiums for
being a smoker or being overweight would encourage people to modify
their habits, there is little evidence that programs designed that way
often work.\3\ At best they provide modest financial benefits to
employers and unclear health benefits to employees.
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\3\ Volpp KG, Asch DA, Galvin R, Loewenstein G. Redesigning
employee health incentives--lessons from behavioral economics. N Engl J
Med. 2011;365:388-90.
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These programs offer promise but they also draw criticism. One
criticism is that they can be seen as coercive. Programs are more
likely to be seen as coercive to the extent they put a lot of money at
risk, whether in the form of rewards or penalties. I think that problem
is avoidable. Most current employer programs are based on the idea that
the more money you put at risk, the more effective the incentive.
That's a mistake based on outdated economic thinking and it can create
unfairness. We've designed programs that trade on psychological
principles of behavioral economics that are often much more effective
than programs putting considerably larger amounts of money at risk.
Those designs can be more effective, and they can be fairer.
In general, the key fairness question is this: How much can the
behaviors we most want to target be modified through incentive programs
and how much are we just punishing the people with those behaviors?\4\
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\4\ Loewenstein G, Volpp KG, Asch DA. Incentives in health:
Different prescriptions for physicians and patients. JAMA.
2012;307:1375-6.
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To the extent these programs are not effective at changing
behavior, then all they are doing is cost-shifting. Employees who smoke
or are obese tend to be the poorest, and they will end up paying the
highest rates. That kind of cost-shifting just moves around the money,
and it is regressive.
I remain excited about well-designed programs that help Americans
change the behaviors they want to change: help them quit tobacco, help
them lose weight, help them better manage their high blood pressure.
Those changes are much less likely to come from typical premium-based
financial incentives and much more likely to come from approaches that
reflect the underlying psychology of how people make decisions--
encouraged by frequent rewards, emotional engagement, contests, social
acceptance. These are the ingredients of successful programs and they
are missing from most of what employers currently do.\5\
---------------------------------------------------------------------------
\5\ Asch DA, Rosin R. Engineering social incentives for health. N
Engl J Med.
2016;375:2511-3.
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We know so much more now about how to design financial and other
incentives to motivate human behavior--far more now than even 10 years
ago. I haven't yet seen much of this new knowledge applied effectively
by employers but there's no reason why it can't be.
Thank you for inviting me to testify today. I look forward to your
questions.
The Chairman. Thank you, Dr. Asch.
Ms. Mathis, welcome.
STATEMENT OF JENNIFER MATHIS
Ms. Mathis. Thank you.
Chairman Alexander, Ranking Member Murray, and Members of
the Committee.
I appreciate the opportunity to testify about this
important issue. My name is Jennifer Mathis and Chairman
Alexander noted my position at the Bazelon Center for Mental
Health Law.
I am here also as a representative of the Consortium for
Citizens with Disabilities, or CCD, a coalition of over 100
national disability organizations that work together to promote
public policy, ensuring the self-determination, independence,
empowerment, integration, and inclusion of adults and children
with disabilities in all aspects of society.
I appreciate the breadth of the topic for this hearing.
Obviously, there are many different ways that we can promote
healthy choices that improve health outcomes and reduce costs,
and many different stakeholders who can do so.
The primary concern that animates this hearing seems to be
the role of employer-based wellness programs. I also think it
is important to mention the role of state service systems.
Particularly those for people with disabilities and older
adults in planning and administering service systems in a way
that expands opportunities for independence, choice, and
autonomy; enabling people to exert more control and participate
actively in their own healthcare, direct their own lives, and
work.
We have seen from numerous studies over many years that
realigning service systems to offer people with disabilities
the chance to live, work, and receive services in their own
communities leads to improved health outcomes and also lowers
cost.
I am happy to answer any questions about that, but I will
focus the rest of my comments on workplace wellness programs.
CCD has supported the development of wellness programs as a
tool to improve life and health outcomes. Those programs can,
and must, operate in a way that respects longstanding and
important workplace protections, such as those provided by the
Americans with Disabilities Act, or ADA, and the Genetic
Information Nondiscrimination Act, or GINA, especially
workplace privacy protections. People with disabilities need
these protections.
The employment rate of people with disabilities is much
lower than that of any other group tracked by the Bureau of
Labor Statistics. They are employed at less than half of the
rates of people without disabilities.
Study after study that has examined why the employment rate
of people with disabilities is so low cites attitudinal
barriers as one of the chief reasons. Perceptions that people
with disabilities are incapable continue to be pervasive
including in our workplaces.
It was precisely for that reason that when Congress passed
the ADA, one of our most important civil rights laws for people
with disabilities, it created strict protections to enable
employees to keep their health and disability-related
information confidential in the workplace.
Employees could be subjected to medical exams or inquiries
only if they were job-related, or if they were voluntary
inquiries that were part of an employee health program. GINA
provided similar protections for employees' genetic information
including their spouse's health information.
Removing or weakening those hard-won protections would make
many people with disabilities vulnerable in their workplaces
and expose them to the risks that Congress meant to avoid.
Last year, the EEOC significantly rolled back the
protection that it had enforced for many years to ensure that
employers could not penalize employees for declining to provide
their health information as part of a wellness program.
The agency, instead, permitted steep financial penalties
for employees who choose to keep their health information
private and more steep penalties if their spouses chose to keep
their health information private, making this choice far from a
voluntary one for many people.
A Federal judge has now ruled that the agency violated the
law and failed to provide a reasoned justification for this
change in position.
The agency now has an opportunity to revisit its
regulations and do the right thing to afford people the rights
guaranteed by the ADA and GINA.
We believe it is not difficult for the EEOC to ensure that
wellness programs serve to promote the healthy choices and
healthy outcomes while respecting important civil rights of
people with disabilities.
The agency set out a path for doing this in its 2010
regulations implementing GINA, clarifying that financial
incentives can be used, but not for questions asking for
genetic information. The same rule should apply to questions
about seeking health information of an employee or a spouse.
The lead study on wellness programs conducted for the
Department of Labor highlighted many strategies other than
incentives that have made wellness programs more effective.
Good wellness programs can be designed without eroding the
civil rights of people with disabilities and we will all be
better served if that happens.
Thank you.
[The prepared statement of Ms. Mathis follows:]
Prepared Statement of Jennifer Mathis
Thank you for inviting me to testify concerning this important
issue. My name is Jennifer Mathis. I serve as Director of Policy and
Legal Advocacy at the Bazelon Center for Mental Health Law, a national
non-profit organization that works to promote equal opportunities for
individuals with mental disabilities in all aspects of life through
litigation, policy advocacy and public education. I am here also on
behalf of the Consortium for Citizens with Disabilities (CCD), the
largest coalition of national organizations working together to
advocate for Federal public policy that ensures the self-determination,
independence, empowerment, integration and inclusion of children and
adults with disabilities in all aspects of society.
Since the Committee's topic is broad, I will address employer-
sponsored wellness programs as well as describing some ways in which
broader health service delivery systems can and have promoted healthy
choices that result in better health outcomes and reduced costs.
Workplace Wellness Programs May Hold Potential to Improve Health
Outcome and Reduce Costs, but Must Not Erode Critical Workplace
Protections for People with Disabilities
Employer-sponsored wellness programs have become increasingly
prevalent as employers look for ways to reduce employee health care
costs. According to the Kaiser Family Foundation, 90 percent of large
companies that offer health benefits offer some type of wellness
program.\1\ These programs may include health risk assessments and
biometric screenings, as well as classes or other activities to help
employees stop smoking, lose weight, or adopt healthier lifestyles or
to manage chronic diseases such as diabetes.
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\1\ Karen Pollitz & Matthew Rae, Henry J. Kaiser Family Foundation,
Changing Rules for Workplace Wellness programs: Implications for
Sensitive Health Conditions, at 2 (April 2017), http://files.kff.org/
attachment/Issue-Brief-Changing-Rules-for-Workplace-Wellness-Programs.
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While CCD believes that employer-based wellness programs have
potential to promote individuals' health and well-being, we believe it
is critical that such programs be administered in a way that does not
undermine the workplace protections that Congress provided to employees
with disabilities and their spouses in the Americans with Disabilities
Act (ADA) and the Genetic Information Non-discrimination Act (GINA).
These laws--both enacted with overwhelming bipartisan support--were
adopted in response to a long history of workplace discrimination based
on disability and on genetic information. They are important tools to
help ensure fair workplaces for people with disabilities. In
particular, they provide workplace privacy protections that enable
people with disabilities to keep their health information private if it
is not related to their ability to do their job, and to keep their
spouses' health information private.
People with disabilities need these protections. The employment
rate of people with disabilities has remained far lower than that of
any other group tracked by the Bureau of Labor Statistics. Among
working age adults, the employment rate of people with disabilities is
less than half of that for people without disabilities.\2\ This
Committee has reported about the importance of efforts to improve this
situation. In addition, the need to increase employment of people with
disabilities has been a concern and a priority for Federal agencies
including the Department of Labor, the Department of Justice, the
Department of Health and Human Services, the Equal Employment
Opportunity Commission, and others. Against this backdrop, it is
particularly important to ensure that employer-based wellness programs
are implemented in ways that promote healthy behaviors without eroding
longstanding and critical workplace protections for people with
disabilities.
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\2\ U.S. Department of Labor, Bureau of Labor Statistics, Persons
with a Disability: Labor Force Characteristics Summary (June 21, 2017)
(among persons age 16 to 64, the employment-population ratio in 2016
for people with disabilities was 27.7 percent, in contrast to 72.8
percent for people without disabilities), https://www.bls.gov/
news.release/disabl.nr0.htm.
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While the research over the last several years has consistently
shown that the early assessments of workplace wellness programs'
effectiveness in improving health outcomes and achieving cost savings
appear to have been overblown,\3\ the primary concern of the disability
community has been the need for fair treatment by these programs.
Whatever their utility, these programs should not punish people for
having disabilities or pressure people to disclose sensitive health or
disability information unrelated to their ability to do their jobs. The
Affordable Care Act (ACA) and its implementing regulations provide some
protection against wellness program incentives that punish people for
having disabilities; where a program offers financial incentives to
participants who meet a health standard or engage in an activity, the
ACA requires that the program allow a person to meet a reasonable
alternative standard if the person's medical condition makes it
``unreasonably difficult'' or ``medically inadvisable'' to meet that
health standard or engage in the activity.\4\
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\3\ See, e.g., Soeren Mattke et al., RAND Health, Workplace
Wellness Programs Study: Final Report (2013), https://www.dol.gov/ebsa/
pdf/workplacewellnessstudyfinal.pdf; Soeren Mattke et al., RAND
Corporation, Workplace Wellness Programs Services Offered,
Participation, and Incentives (2014), https://www.dol.gov/sites/
default/files/ebsa/researchers/analysis/health-and-welfare/
WellnessStudyFinal.pdf; Jill R. Horwitz et al., Wellness Incentives In
the Workplace: Cost Savings Through Cost Shifting to Unhealthy Workers,
32 Health Affairs 468 (2013); Adrianno McIntyre et al., The Dubious
Empirical and Legal Foundations of Wellness Programs, 27 Health Matrix
59 (2017).
\4\ U.S.C. 300gg-4(j)(3); 26 C.F.R. 54.9802-1, (f)(3)(iv),
(f)(4)(iv). The ADA also requires that reasonable accommodations be
provided, absent undue hardship, to enable employees with disabilities
to earn whatever financial incentive an employer offers in a wellness
program. The reasonable accommodation requirement will often be
satisfied by the provision of a reasonable alternative or waiver of the
standard or activity. 29 C.F.R. Part 1630 Appx., 1630.14(d)(3):
Limitations on Incentives.
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Concerns remain, however, about the use of wellness program
incentives that are used to pressure employees to give up their rights
to keep their own health information and their spouse's health
information private.
The ADA Requires Workplace Wellness Program Medical Inquiries and Exams
to be Voluntary
The Americans with Disabilities Act (ADA) prohibits employers from
subjecting employees to medical inquiries or exams that are not job-
related and consistent with business necessity, unless they are
``voluntary medical examinations, including voluntary medical
histories, which are part of an employee health program available to
employees at that work site.''\5\
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\5\ 42 U.S.C. 12112(d)(4)(A), (d)(4)(B). See also EEOC
Enforcement Guidance on Disability-Related Inquiries and Medical
Examinations of Employees Under the Americans with Disabilities Act
(July 27, 2000) at Question 22, http://www.eeoc.gov/policy/docs/
guidance-inquiries.html (``EEOC Guidance'').
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The ADA's medical inquiries provisions are part of a detailed
scheme that Congress enacted to limit employer access to medical
information from employees and applicants. Such limits are a core
protection of the ADA. Due to the prevalence of negative attitudes
about people with disabilities--including assumptions that they are not
capable--Congress recognized that the best way to prevent
discrimination was to ensure that employers simply did not have this
information unless it was related to someone's job performance. See S.
Rep. 101-116, at 39-40 (1989) (``An inquiry or medical examination that
is not job-related serves no legitimate employer purpose, but simply
serves to stigmatize the person with a disability. . . . As was
abundantly clear before the Committee, being identified as disabled
often carries both blatant and subtle stigma. An employer's legitimate
needs will be met by allowing the medical inquiries and examinations
which are job-related.'').
As the EEOC noted in its guidance concerning disability-related
inquiries of employees:
Historically, many employers asked applicants and employees to
provide information concerning their physical and/or mental condition.
This information often was used to exclude and otherwise discriminate
against individuals with disabilities--particularly non visible
disabilities, such as diabetes, epilepsy, heart disease, cancer, and
mental illness--despite their ability to perform the job. The ADA's
provisions concerning disability-related inquiries and medical
examinations reflect Congress's intent to protect the rights of
applicants and employees to be assessed on merit alone, while
protecting the rights of employers to ensure that individuals in the
workplace can efficiently perform the essential functions of their
jobs.\6\
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\6\ EEOC Guidance, General Principles.
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For many years, the EEOC defined ``voluntary'' wellness program
medical inquiries and examinations to mean that an employer may neither
require participation nor penalize employees who do not participate.\7\
In 2016, however, the agency abandoned that interpretation and issued
regulations providing that such inquiries and examinations are
``voluntary'' if the wellness program incentives for answering or
participating do not exceed 30 percent of the cost of employee-only
health insurance premiums. Such incentives would penalize employees who
chose to exercise their privacy rights with penalties that could in
many cases amount to thousands of dollars. At their maximum, these
penalties would approximately double the amount that employees would
have to pay for their health insurance. A Federal judge has since
concluded that the agency failed to provide any reasoned justification
for or evidence supporting its new position.\8\
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\7\ EEOC Guidance, Question 22. While the guidance speaks of
``voluntary wellness programs'' rather than ``voluntary medical
inquiries'' or ``voluntary medical examinations,'' it construes the
ADA's text relating to ``voluntary medical examinations, including
voluntary medical histories'' that are part of an employee health
program. It is clear that the guidance refers to penalties for
answering questions or undergoing medical exams.
\8\31AAARP v. EEOC, Case No. 1:16-cv-02113-JDB, Memorandum Opinion
(D.D.C. Aug. 22, 2017).
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GINA Requires that Workplace Wellness Program Medical Inquiries of
Employees' Spouses be Voluntary
GINA provides similar protections barring employers from
requesting, requiring or purchasing employees' genetic information,
including medical information of their spouses, with a similar
exception for workplace wellness program requests that are voluntary.
The EEOC's implementing regulations define voluntary to mean that an
employer may neither require employees to provide genetic information
nor penalize employees who decline to provide it.\9\ When the EEOC
changed its rules concerning the ADA's application to wellness
programs, it also changed its rules concerning GINA's application,
defining voluntary requests for the health information of an employee's
spouse to allow financial incentives of up to 30 percent of the cost of
employee-only health insurance premiums.\10\ These incentives would be
in addition to any incentives for disclosure of the employee's health
information, with the potential to create astronomical increases in the
cost of health insurance for families. The same Federal court that
concluded that the agency failed to provide a reasoned justification or
evidence supporting its new interpretation of ``voluntary'' under the
ADA reached a similar conclusion about the agency's new interpretation
of ``voluntary'' under GINA. The court remanded both rules to the
agency, which must now revise its rules or provide appropriate support
for them.
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\9\ 29 C.F.R. 1635.8(b)(2).
\10\ C.F.R. 1635.8(b)(2)(iii).
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The EEOC now has an opportunity to revamp its regulations to ensure
that employer efforts to promote employee wellness proceed without
damaging the employment prospects of people with disabilities.
Penalizing the Exercise of Health Privacy Rights Damages the Employment
Prospects of Workers with Disabilities
Such a ``wellness-or-else'' approach places significant pressures
on many employees with disabilities to make unwanted disclosures of
their health information, potentially putting their jobs at risk. Even
though employers are not supposed to receive individually identifiable
health information when a wellness program is run by a third party
vendor, that protection offers little comfort to employees in employer-
run programs, and to employees in small workplaces where it is not
difficult to connect knowledge that someone has a particular disability
with the employee in question. Furthermore, data breaches of sensitive
information are not uncommon. Given the widespread attitudinal barriers
that continue to hold people with disabilities back from securing,
maintaining, and advancing in employment, extracting steep financial
penalties for employees who exercise their right to keep health
information confidential damages the employment prospects of people
with disabilities.
Other Avenues to Improve Wellness Programs
We should be encouraging other means of improving wellness
programs' effectiveness rather than encouraging steep financial
penalties to try to force people to participate in wellness programs,
including turning over sensitive health information. Notably, the
principal author of the Federal Government-sponsored RAND study--the
lead study on wellness program effectiveness--stated:
Why do employees, and in particular those at high risk, choose
not to participate? We do not yet have the evidence or insight
to understand and convincingly answer that question. When we
do, we will be able to design attractive and accessible
programs. In the meantime, we should not penalize vulnerable
employees who are reluctant to join marginally effective
programs.\11\
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\11\ Soeren Mattke, When It Comes To the Value of Wellness, Ask
About Fairness Not Just About Effectiveness, Health Affairs Blog (Mar.
18, 2015), http://healthaffairs.org/blog/2015/03/18/when-it-comes-to-
the-value-of-wellness-ask-about-fairness-not-just-about-effectiveness/.
The RAND study, which included almost 600,000 employees at seven
employers, found that well designed wellness programs succeed in
promoting employee participation without the use of incentives. The
study notes that comprehensive programs with genuine corporate and
manager engagement in wellness, and commitment to monitoring and
evaluating programs, tend to succeed. By contrast, limited programs,
such as those that only use health risk assessments to glean
information about employees' health, tend not to inspire participation
without the use of incentive and tend not to reduce costs or improve
health.\12\
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\12\ Mattke 2013, supra note 3.
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The RAND study offered important guidance about factors that have
demonstrated success in wellness programs. Those include, for example:
clear communication about the goals of the particular wellness
interventions being used, ensuring that the program's activities are
convenient and easily accessible for all employees and consistent with
their schedules, ensuring that the program's activities are aligned
with employee preferences, soliciting ongoing feedback from employees,
continuous evaluation of the program, strong support from leadership,
and making full use of existing resources and relationships.
These strategies, rather than eviscerating important workplace
privacy protections, should be the focus of wellness program
development.
State Service Delivery Systems for People with Disabilities Can
Expand Opportunities for Healthy Choices that Improve Health Outcomes
and Reduce Costs
The Committee's examination of the impact of healthy choices on
health outcomes and costs implicates many more areas than employer-
based wellness programs, which play a relatively small role in this
sphere. For example, state service systems have a critical role to play
in enabling healthy choices that improve outcomes and reduce costs. The
investments that states choose to make, and the manner in which they
administer service delivery systems, have a significant impact on the
available choices for people with disabilities to improve their health,
and have significant potential to reduce health care costs.
A key example of state strategies to promote healthy choices is the
strategy of reallocating disability service system resources to
decrease reliance on costly institutional services and expand home and
community-based services, consistent with the ADA's ``integration
mandate''. Expanding availability of key community-based services that
enable people with significant disabilities to live in their own homes,
participate in their communities, secure and maintain employment, and
maintain health and well-being not only improves health outcomes but
also significantly reduces costs.
This Committee has held a number of bipartisan hearings in recent
years to explore the progress of states in implementing the ADA's
integration mandate. While those hearings demonstrated that we continue
to have a long way to go in realigning service systems to promote
independence and choice, they also underscored the importance of the
shift toward community integration. The implementation of the
integration mandate that has occurred in some states has demonstrated
the improved health outcomes, improved life outcomes, and reduced costs
realized through expanding community services and reallocating public
service system dollars from costly institutional care to support people
instead in their own homes and communities.
Below are examples of two states that achieved significant service
system transformations as a result of their efforts to implement the
integration mandate.
Delaware, through a settlement agreement entered with the U.S.
Department of Justice, expanded core community services for people who
received psychiatric inpatient care or emergency room care through
public programs, who were homeless, or had a history of arrests or
incarcerations. The development of this community capacity resulted in
a decrease in the average census of the state psychiatric hospital by
more than 55 percent--from 136 in Fiscal Year 2010 to 76 in 2016.\13\
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\13\ Tenth Report of the Court Monitor on Progress Toward
Compliance with the Agreement: U.S. v. State of Delaware, U.S. District
Court for the District of Delaware, Civil Action No: 11-591-LPS (Sept.
19, 2016), https://www.ada.gov/olmstead/documents/de_10th_report.pdf.
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In 2015, Delaware regularly diverted over 70 percent of individuals
in crisis from acute psychiatric beds into less expensive community
crisis services.\14\ Delaware also achieved a significant expansion in
the number of people with serious mental illness receiving employment
supports and working, quadrupling the percentage of individuals in the
target population who were employed.\15\ Many thousands of individuals
with serious mental illness have received needed community services and
avoided institutionalization because of the service expansions and
policy changes undertaken.
---------------------------------------------------------------------------
\14\ Id.
\15\ Id.
---------------------------------------------------------------------------
In New Jersey, an agreement between the state and the state
protection and advocacy system, Disability Rights New Jersey, was
reached in 2009 to develop community services for hundreds of people
who remained institutionalized in state psychiatric hospitals even
though they had been determined to no longer need hospital care, due to
the lack of community alternatives--as well as hundreds more who were
at risk of admission to state psychiatric hospitals. New Jersey
committed to provide these individuals with the services they need to
live independent, integrated lives in the community.
The state developed 1436 new supported housing units for
individuals waiting to be discharged from the state hospitals and for
those at risk of admission to these facilities. It successfully
discharged 294 of the 297 individuals who had been awaiting discharge
for more than 1 year. In addition, New Jersey significantly reduced the
length of time for which individuals remained hospitalized due to the
lack of community services, ensuring more prompt discharges.
As a result of the increased access to supported housing and other
services, New Jersey reduced admissions to psychiatric hospitals by one
third between 2006 and 2010, a rate that has remained steady over
subsequent years. In 2016, admissions had declined 36 percent from 2006
and the average daily census within state hospitals declined by 33.7
percent. The average daily census of the state psychiatric hospitals
also shrunk by 34 percent, from 2,122 in 2006 to 1,406 in 2016.\16\
---------------------------------------------------------------------------
\16\ New Jersey Dep't of Human Services, Division of Mental Health
& Addiction Services, Home to Recovery 2, 2017-2020, A Vision for the
Next Three Years (Jan. 2017),at 12, 13, http://www.nj.gov/
humanservices/dmhas/initiatives/olmstead/Home%20to%20Recovery%202%20Pla
%20-%20January %202017.pdf.
---------------------------------------------------------------------------
In addition, the number of individuals remaining in state
psychiatric hospitals due to the lack of community options has shrunk
by more than two-thirds since 2006. In 2006, these individuals
comprised nearly half of all state hospital residents, whereas in 2016,
they comprised only 22 percent of state hospital residents.\17\ The
reduction in hospital beds has enabled the state to achieve a very
significant expansion of community services. Over roughly the same
period, the number of individuals served in the community has grown by
almost 60,000 people.\18\ Supported housing is now the most common
setting for individuals discharged from New Jersey's state psychiatric
hospitals who need a place to live upon discharge.
---------------------------------------------------------------------------
\17\ Id.
\18\ New Jersey Dep't of Human Services, Division of Mental Health
& Addiction Services, Realignment of the NJ Mental Health System
(powerpoint, July 1, 2015).
---------------------------------------------------------------------------
Such system realignment efforts have also been undertaken to afford
individuals in nursing homes, institutions for individuals with
intellectual and developmental disabilities, and board and care homes
to live more independently in their own homes and communities. This
type of systems change allowing people to exercise greater control over
their own lives, and in many instances, to secure and maintain
employment, is an important aspect of enabling people to make healthy
choices, improve health outcomes, and reduce costs. Any examination of
efforts to advance healthy choices should include the role of state
service systems in addition to the role of employers in doing so.
The Chairman. Thank you, Ms. Mathis.
We will now have a round of 5 minute questions. We will
start with Senator Young.
Statement of Senator Young
Senator Young. Thank you, Mr. Chairman.
I am very excited about this hearing because I know a
number of our witnesses have discussed in their testimonies
behavioral economics and behavioral decisionmaking.
I think it is really important that we, as policymakers,
incorporate how people really behave, not according to an
economist per se or according to other policy experts, but
based on observed behaviors. Oftentimes, we behave in ways that
we do not intend to. It leads us to results that we do not want
to end up in.
Dr. Asch, I will start with you, with your expertise in
this area. You have indicated behavioral economics is being
used to help doctors and patients make better decisions, and
you see an opportunity for employers to help Americans change
their behaviors in ways they want; from tobacco mitigation, to
losing weight, to managing blood pressure.
You indicate those changes are much less likely to come
from typical premium-based financial incentives and much more
likely to come from approaches that reflect the underlying
psychology of how people make decisions encouraged by frequent
rewards, emotional engagement, contests, social acceptance, and
so forth.
Then you said in your verbal testimony, you have not seen
much of this new knowledge applied effectively by employers,
but there is no reason why it cannot be.
My question for you, sir, what might employers learn from
behavioral economists, just in summary fashion?
Dr. Asch. Well, thank you, Senator.
I will start by saying that there is a misunderstanding
often about behavioral economics and health. Many people
believe that if you use financial incentives to change
behavior, you are engaged in behavioral economics.
I would say no. That is just economics. It becomes
behavioral economics when you use an understanding of our
little psychological foibles and pitfalls to sort of
supercharge the incentives and make them more potent so that
you do not have to use incentives that are so large.
There are a variety of approaches that come from behavioral
economics that can be applied in the employment setting and
elsewhere.
I mentioned one, which is capitalizing on the notion that
losses loom larger than gains might be a new way to structure
financial incentives in the employment setting in ways that
might make it more potent and more palatable, and easier for
all employees to participate in programs to advance their
health.
The delivery of incentives more frequently, for example, or
using contests, or certain kinds of social norming where it is
acceptable to show people on leader boards, and contests, and
get people engaged in fun toward their health.
All of these are possibilities.
Senator Young. Thank you very much.
You really need to study these different phenomena
individually, I think, to have a sense of the growing body of
work that is behavioral economics. So we need to increase
awareness and the education of many employers about some of
these tics we have and that seems to be part of the answer.
In fact, Richard Thaler, who just won the Nobel Prize for
his groundbreaking work in this area, indicated that we, as
policymakers, ought to have on a regular basis, not just
lawyers and economists at the table as we are drafting
legislation, but we ought to have a behavioral scientist as
well.
In the U.K., they have the Behavioral Insights Team. The
United States, our previous Administration, had a similar sort
of team that did a number of experiments to figure out how
policies would actually impact individuals' health, and
wellness, and a number of other things.
Some of the ideas that I think we might incorporate into
the Government context, and tell me if any of these ``pop'' for
you, if you think they make sense.
We need to continue to have a unit or units embedded within
Government that do a lot of these experiments.
We need to have a clearinghouse of best practices that
others, employers included, might draw on. This does not have
to be governmental, but it could certainly be.
We, on Capitol Hill, might actually consider, aside from
having a Congressional Budget Office, we might have an entity
or at least some presence within the CBO of individuals who
understand how people would actually respond to given
proposals.
Do any, or all of those, make sense to you?
Dr. Asch. Well, thank you for your remarks.
I think they all make sense to me and one of the lessons
that, I guess, I have repeatedly learned is that seemingly
subtle differences in design can make a huge difference in how
effective a program can be, and how it is perceived, and that
we ultimately care about the impact of these programs.
So, I am very much in favor of a greater use of these
programs, but in addition, greater study of these programs
because, I think, we need an investment in the science. That
will help all of us get better at delivering these activities
not just in healthcare, but in other parts of society.
Senator Young. Makes a lot of sense.
I am out of time. Thank you.
The Chairman. Thank you, Senator Young.
Senator Murray.
Senator Murray. Thank you.
Dr. Roizen, I want to start with you.
We have heard a lot today about workplace wellness
programs. As I mentioned, I think it is critically important we
think about how the investments we make in our communities can
also play a critical role in making the healthy choice the easy
choice for our families in this country.
In my home State of Washington, we have seen a lot of these
really critical efforts in our schools, for example. We are
investing in physical education, and healthy food, and beverage
preparation.
In our cities and towns, we are working to make the
environment more accessible to all users: bicycles,
pedestrians, people of all ages and abilities.
Our healthcare providers are making it easier to quit
smoking and taking steps to better support breastfeeding, for
example.
Our communities of color are taking strides to ensure
strong culturally competent programs to promote the health of
people in my state.
I wanted to ask you. Do you agree, Ms. Mathis mentioned it,
in addition to these workplace-based programs, community-based
efforts where health and wellness are also important?
Dr. Roizen. The answer is I absolutely agree.
Your state and your schools are taking a leadership role
that the rest of the Nation would love to follow and hopefully
will be able to.
What I mean by that is when you get kids to be healthy and,
in fact, influence their parents to be healthy, when you get
food manufacturers to make foods for large distribution to your
schools that are healthy, you really get to change the health
of a whole generation.
We totally applaud that. We work with that. In fact, I go
and we have a network of what we call inner and outer ring
schools around Cleveland. It is very hard to get appropriate
products for the school lunches, et cetera, and breakfast.
Your state is taking a lead in that and we thank you.
Senator Murray. Well, thank you.
Ms. Mathis, I wanted to ask you. As you well know, a
Federal District Court recently held that the EEO Commission
failed to support its rules on wellness programs.
Those rules said that an employee's decision not to
participate in a wellness program was voluntary so long as the
employee did not have to pay a penalty greater than 30 percent
of the cost of health insurance; in other words, thousands of
dollars.
That high of a penalty is a problem for the millions of
employees and their spouses who do not wish to risk disclosure
of genetic information or the existence of a disability by
participating in wellness programs that do collect, of course,
sensitive health information.
It is a person's right. It is a right under the ADA. It is
a right under the Genetic Information Nondiscrimination Act,
and under HIPAA. Those are, as I said, three laws this
Committee wrote and I am proud of.
As you may well know, this Committee met yesterday and
cleared for the full Senate the Trump Administration's nominees
to now lead the EEOC. Among other things, those nominees will
now be responsible for rewriting those wellness rules.
I wanted to ask you, how should the EEOC set criteria for
when participation in a wellness program is not voluntary? What
advice would you give those five Members of the EEOC?
Ms. Mathis. I think the most important thing for the EEOC
to remember is that their job is to apply the ADA, and not to
rewrite it. To try to conform it to another law that also
applies at the same time, but did not overturn or modify the
ADA.
There are many circumstances where two laws apply at the
same time and one requires additional things beyond what the
other requires. We have a lot of experience with applying
multiple laws to the same set of circumstances.
They already have a framework that they had used for 16
years under the ADA. They used the same framework to analyze
what is a voluntary question under GINA in their 2010
regulations, implementing a parallel provision of GINA allowing
requests for an employee's genetic information as part of a
voluntary wellness program.
I would just point out that that GINA regulation was done
after the Affordable Care Act. They considered the two laws--
and the fact that the Affordable Care Act had been passed with
its provisions about wellness programs--and considered those
consistent.
That framework was logical. It used the ordinary meaning of
``voluntary,'' that you cannot require a person to answer or
penalize a person for not answering a question.
That is consistent with the dictionary definition of
``voluntary,'' which is, ``Not impelled by outside influence or
unconstrained by interference, or without valuable
consideration.'' Having steep financial incentives, I think, is
actually the dictionary definition of what is ``not
voluntary.''
Having the same kind of framework, the same path that they
charted for the 2010 GINA regulations to apply also to the ADA,
which is how they interpreted the ADA before 2016 for many,
many years to allow wellness programs to have incentives, but
just not to incentivize or to have significant incentives for
people turning over health information that is not job-related.
That, I think, would allow wellness programs to proceed,
and develop, and use incentives in other ways, and use many
other strategies to engage people without eroding the civil
rights of people with disabilities.
Senator Murray. Thank you very much.
The Chairman. Thank you, Senator Murray.
Senator Isakson.
Statement of Senator Isakson
Senator Isakson. Thank you, Senator Alexander.
Mr. Burd, if I remember correctly, the Safeway program had
financial incentives for participants, by participation by
employees.
Is that right?
Mr. Burd. I am sorry. Could you repeat the question?
Senator Isakson. Did the Safeway program have financial
incentives for the employees for participating in the wellness
program?
Mr. Burd. Correct.
Senator Isakson. What have you found, in your work with
wellness programs with companies, are the best financial
incentives to put in place for your wellness program to induce
more people to participate?
Mr. Burd. Yes. I think we had extraordinary participation,
I think, even greater, Michael, than some of the numbers that
you had. We were 85 percent voluntary for employees, 70 percent
for spouses.
I am actually a big fan of both the 1996 HIPAA
regulations--I thought they were well thought out--and the
adjustments that were made with the Affordable Care Act. I
thought those were equally well thought out.
I do not want the Committee to do is get the impression
that it is all about incentives. Incentives are, I think,
necessary, but by themselves, not sufficient.
In going back to something that David, you had said
earlier. The ``secret sauce'' at Safeway was creating small
support groups. We had thousands of groups that came together
on their own, set goals and objectives, timeframes.
It might have been exercise goals. It might have been
weight loss goals. We gave them the tools to accomplish that,
the tools to attract one another. It really was a driving force
in this along with CEO leadership.
I look at Government as being an enabler in this process,
but I also think there is an opportunity for Government to
lead.
I think others have been down here over the years and one
opportunity to lead is I would love to see the Federal
Government adopt programs like this for their own employees.
I actually offered to do this for Secretary Sebelius and
the 80,000 people at HHS to do it for free. Unfortunately, that
was about 30 days before she left office, and she was excited
about that. It is not just about incentives. It is important
that----
We employed 10,000 people with disabilities at Safeway out
185,000 people; 2,000 of them were part of this program. The
HIPAA regs, when I say they are well thought out, they allow
for, and frankly require, if the standard that you have set is
judged to be too difficult that you adopt a different standard,
and even provide a waiver.
In our experience--and I would be interested in what you
have done at the Cleveland Clinic--about 3 to 4 percent would
reach for and get either a waiver or an alternative standard.
While we wanted you to get below a 30 BMI, if you had a 45
BMI and you made 10 percent progress, we gave you the reward.
At the end of the year when you measured, we gave you a
reimbursement check and we enjoyed writing those checks. So it
was all about encouraging wellness.
If you had co-morbidities, and your physician said, ``Look.
I would feel better going from 45 to 43.'' We would say,
``Fine,'' and that is the standard. Then we would change that
over time, and I am sure the Cleveland Clinic did something
very similar.
Senator Isakson. Well, I appreciate the answer because
being one who has had about every bad habit you could possibly
have to be a core contributor to your health at one time or
another, I know that what got me into health programs and
wellness programs was the desire to change a habit. What kept
me in them was the reward of that habit changing.
Mr. Burd. Yes.
Senator Isakson. I think you said something that is very
important, and that is if you give the employee or the
individual the measurements to show improvement and reinforce
that along the way, you can change what the program is doing to
induce them to be more healthy to an employee who is more
healthy.
Because I know quitting smoking, changing your eating
habits, exercising regularly, none of those things are easy.
Everybody likes to talk about them and every New Year's,
everybody practices them for about 2 days, but then they go
away because they are hard to do. If you get reinforcement in a
peer group----
Mr. Burd. Yes.
Senator Isakson [continuing]. In a positive way, you can
really sustain the practice.
Mr. Burd. If I could just add one more thing, I think that
I learned this a long time ago in business and it was helpful.
I had 1,800 stores.
Rather than just study and hypothesize things, we just did
it. We did it on scale and then we scaled it up.
For example, if I wanted to increase the sales of some
product, I put it in the ad, I would reduce the price, and I
would put it on an end cap.
At the end of the day, I did not care which of those three
contributed most to that. I did all three of them every time I
wanted to increase the sales by twentyfold. We struck upon
something over time that worked, and it worked famously, and we
had no issues with it.
If you do not know, the health statistics do not go to the
H.R. department. They do not know what somebody's BMI is. They
know there is a contribution to premium effect, but they really
do not know what somebody passed and what somebody failed. We
did not have any issues in the company and then we ultimately
begin rolling that out to all the divisions. So our initial
population was 40,000 Members.
Senator Isakson. Thank you, Mr. Chairman.
Let me just conclude with a compliment. Thank you, Dr.
Roizen, for your reference to what the Finance Committee was
doing. We have, in fact, now done at the Chronic Care Working
Group bill has actually passed the Senate Finance Committee,
and it has passed the Senate, and it s pending now in the
Energy Committee in the house.
We are close to getting that 3 year effort done and I
appreciate your reference to that.
Dr. Roizen. Let me make another comment. I think a couple
of things he said deserve reemphasis.
One is there is an absolute firewall between the health
plan and the company. They do not know why the premiums are
where they are, or what is driving, or not driving it.
Second, for every person, they interact with their primary
care physician in achieving those goals, those six goals plus
two behaviors. It is the primary care physician, and they set a
goal, and set a progress, and it is that relationship and that
progress that determines their incentive.
It is a culture change. It is multiple programs that work.
It is leadership as well. We also have a large buddy system
that we set up that really does the support system.
There are a lot of things that I did not get into the nuts
and bolts, but it is a lot of things that work.
The Chairman. Thank you, Senator Isakson.
Senator Franken.
Statement of Senator Franken
Senator Franken. Thank you, Mr. Chairman, and to the
Ranking Member, for holding this important hearing.
Before the hearing started, I spoke to all of you about
housing. These wellness programs that the employer runs are
very helpful, but what we are trying to do is to help people be
healthy, and lower the costs of their healthcare in the long
run.
Ms. Mathis, you pointed out research that shows a strong
connection between a person's health and stable housing despite
the fact that they are actually very often talked about as
completely separate issues.
In Minnesota, Hennepin Health, an accountable care
organization in the Twin Cities, saw the lack of stable housing
was a major barrier to improving the health of their Members.
So they decided to develop a program that paired healthcare,
housing, and social services.
Just 1 year after participants in the program were placed
in supportive housing, Hennepin Health saw significant
reductions in participant hospitalizations, and psychiatric
care, and imprisonment or going to jail.
The No. 1 cure for homelessness turns out to be a home. If
you can wraparound supportive services, it yields amazing
savings.
I brought this up to all of you. So Ms. Mathis and all of
you, could you speak to how a focus on housing, particularly
when it is paired with social supports, can lower healthcare
costs and improve health outcomes?
Ms. Mathis. I think that is absolutely right. That is, I
think, a recognition that has become increasingly prevalent in
state mental health service systems.
Maybe 20, 25 years ago, state mental health directors would
have said, ``We do not do housing. We are not in the business
of housing. We do mental health.'' That has changed
dramatically.
I think now most state mental health authorities would tell
you, ``We do housing because housing is a critical part of what
we do.'' Housing supports, housing subsidies, housing
assistance, housing locator assistance, all of that because all
of these things--housing stability, work, all the social
determinants of health--have been shown to have an enormous
impact on people's health.
There have been many studies done. I think some of the
interesting ones have been studies of people who are homeless
versus people who are in supportive housing, similar twin
studies of people in those two situations.
It costs us as much money to keep people homeless as it
does to have them stably housed with services.
Senator Franken. I want to hear from the others as well
because you all seemed to respond when I brought this up.
Dr. Asch. Senator Franken, thanks for the question and
comment.
I fully agree. There is certainly a movement and a
knowledge base called Housing First that recognizes the
critical, central actually, fundamental importance of housing
for those without it.
I would probably embed your question in a much larger set
of issues that reflect the importance of the social
determinants of health.
If you are a provider organization, a hospital or a health
system, and you face patients who are chronically ill, and they
are readmitted into your hospital multiple times for congestive
heart failure, or lung disease, or some chronic illness, almost
always the major determinant, in addition to their serious
illness that brings them back to the hospital, is some form of
social circumstance. Sometimes it is inadequate housing.
Sometimes it is another form of social support.
At the time when hospitals were incentivized only to
deliver healthcare, those considerations were, at least from a
financial perspective, less relevant. Now hospitals and health
systems are much more aware of their responsibility to be part
of the solution to the social factors that affect health
including housing. Some of the most progressive health systems
are targeting housing directly along with other social
determinants.
Those social determinants were always there and now we need
to think about financial incentives that will allow, at the
organizational level, the resources that we have in our society
to address them.
The Chairman. I want to give the other two witnesses a
chance to answer Senator Franken's question, but I want to stay
pretty close to the time because we have votes at 11:45.
Dr. Roizen. Well, some would say, Senator Franken, you are
a genius for bringing this up.
Senator Franken. Thank you, thank you.
Senator Bennet. Only Senator Franken might say that.
[Laughter.]
Dr. Roizen. Because it is really one of the social
determinants, and the social determinants are really important.
It is very hard to not have stress if you do not have a
home. It is very hard to get adequate sleep without housing,
and those are really key points in getting well, and in staying
well, and in lowering the costs of medical care.
Mr. Burd. First of all, I wanted you to know that if he had
not said you were a genius, I was ready to weigh in on that.
Senator Franken. I was ready to do it as well.
[Laughter.]
Mr. Burd. My wife and I have been involved for several
years in a philanthropic effort to provide housing to the
homeless.
I am also involved in another philanthropic effort with a
good friend where we take people who had been homeless and had
the capability to learn a skill. They are taught the skill and
then we find them a job, and they can succeed at that.
I think having a home is really important, and that social
environment that surrounds it is also something that we create.
Senator Franken. Thank you.
Thank you, Mr. Chairman.
The Chairman. Thank you very much, Senator Franken.
We will go to Senator Casey.
Statement of Senator Casey
Senator Casey. Thanks, Mr. Chairman.
I want to thank the panel for being here and for your
testimony on these important issues. I will direct, I think,
most of my question time to both Dr. Asch and Ms. Mathis.
I wanted to say first, Dr. Asch, we are grateful you are
here and grateful for the work you do at Penn. I guess you have
done work at both the Perelman School of Medicine and at
Wharton. I also want to thank you for the work you have done at
the V.A. Medical Center in Philadelphia as well; critically
important work.
I was not here for Senator Murray's questions, but I
believe she asked a question about the penalties and the
incentives.
Am I right about that?
Senator Murray. Yes.
Senator Casey. I just wanted to make sure.
I guess my follow-up to that line of questioning would be
with regard to you, Dr. Asch, that your research indicates the
penalty incentives may not have had the effect on individual
behaviors.
Both you and Dr. Roizen have indicated the importance of
the many hours, I guess 5,000 hours, of waking activity when we
are not interacting with the healthcare system.
Senator Murray indicated that some wellness plans use both
penalties and rewards that can be as high as thousands of
dollars a year.
We have heard that Dr. Roizen's program uses a 30 percent
penalty, the limit that the EEOC has set when issued the rule
last year.
My question is basically this.
Based upon your research, and other behavioral economic
research, is it necessary to use such large penalties or
rewards, and if not, what would you recommend such rewards or
penalties to be?
Dr. Asch. Well, thank you for your question, Senator Casey.
You have identified some critical issues at the interface
of effectiveness and voluntariness right there.
A lot of employers are under, what I would consider to be,
the mistaken impression that the way to make incentives
effective is to make them larger and larger. That naturally
leads to very large incentives, putting large amounts of money
at risk, whether they are in the form of rewards or penalties.
We have heard, of course, that penalties are more off-
putting than rewards, and actually sort of jacked up the
concerns about the lack of voluntariness. I think it is
potentially a mistake to think that way.
I actually think that that is old, outdated thinking that
the only way to increase the potency of an incentive is to
increase the size of an incentive.
Instead, we know from years of research now in behavioral
economics that the way we design incentives probably has much
more of an impact than the amount of an incentive.
You can imagine, for example, a $500 incentive that might
be bundled into someone's paycheck. Well, if they are paid once
a week, that is $10 a week. It looks much smaller then. It is
put alongside all sorts of other elements in a paycheck. It may
not even be seen. It is directly deposited.
You can imagine handing someone two crisp $100 dollar
bills, a much smaller incentive, and have it be much more
potent emotionally.
Another mistake that employers make often, but they do not
need to make, is setting explicit targets for goals.
If you believe that your employees should be at a BMI of
25, which is, let us say, the upper limit of normal and you set
that as the goal, that is a good way to make people whose BMI
is 26 lose a few pounds. If your BMI is 40, that is a
demoralizing goal.
What we care about is improvement, and pay for improvement
programs are going to be far more effective for the people who
we fundamentally need to help the most.
Both design elements with the structure of incentives, and
design elements wit the targets for incentives can be improved
by most employers. I am really optimistic that they can do
that.
Senator Casey. Thank you. I have more to pursue there, but
I want to move to a separate line of questioning.
Ms. Mathis, I will start with you and I will invite others
to answer as well.
The written testimony you have regarding balancing the
personal rights of individuals, especially those with
disabilities, while also pursuing the goal or encouraging
wellness, your references to the privacy protections in the
Americans with Disabilities Act, and other statutes, are
critically appreciated, I think, at this time.
We know that October is National Disability Employment
Awareness Month. As you have pointed out in your testimony, the
employment rate for those with disabilities is very low in
comparison to the general population.
Those with disabilities have the lowest rate of employment
of any sector of our population and I am concerned that
aggressive wellness programs could not only discriminate
against a person with a disability, but also create a workplace
climate that does not value people with disabilities.
Would you like to comment on that further?
Ms. Mathis. Sure. I should just clarify that I think our
primary concern about the large financial incentives is around
those privacy protections.
Folks have talked about the incentives for outcomes. As Mr.
Burd mentioned, there are built-in safeguards in the Affordable
Care Act that, I think, do address that concern. That if you
cannot meet a particular health outcome because of a
disability, that you are supposed to get a reasonable
alternative standard and there are regulations that sort of
implement that.
I do not think that, certainly, we have not heard that
there is a lot of, that that is a major concern anymore. I
think that was addressed. Our concern is really much more
around the privacy issues.
It is true that, I think, there are in many cases, the
information will not go directly to an employer. Sometimes it
will if the employer does directly run a wellness program. With
small employers, obviously, it is not that hard to figure out
who has what health condition that is identified in aggregate
data.
Frankly, I think for many people with disabilities just
having to turn over your sensitive, private health information,
wherever it is going to go to, is concerning. It is not the way
to build an environment of trust and a productive working
environment.
People with disabilities have had, in many cases, many
negative experiences in their lives stemming from the
disclosure of those disabilities. It is very understandable why
people react.
The Chairman. We need to try to stay within the time.
Ms. Mathis. That is all I have to say.
Senator Casey. Thanks very much.
I will do some follow-ups in writing.
Thank you.
The Chairman. Well, thank you, Senator Casey.
Senator Cassidy.
Statement of Senator Cassidy
Senator Cassidy. Dr. Asch, I am internist, as you, and
although this is a health Committee, which is not Medicaid and
Medicare, nonetheless I feel as if that which we are doing in
the employer based setting has a fairly mature science.
As I think of my patients, whom I used to care for in the
Louisiana public hospital system, the Medicaid patient or the
uninsured, it is a bigger problem, if you will, some of these
wellness issues. If you are in Philadelphia, you probably have
a practice that is somewhat similar to mine.
How can we translate some of this, which we have been
discussing for the workplace, into the Medicaid population,
which statistically has a higher incidence of chronic disease,
morbidity, et cetera, than the workplace?
Dr. Asch. Well, thanks for the question, Senator Cassidy.
I think in most cases, these activities can translate. I do
think that employers have a special role and a special trust
connection with employees that may be not as high as the trust
relationship people have with their doctor or with their
hospital, but might be potentially higher than people have with
their insurance carrier.
That trust is an important determinant of the success of
the programs.
Senator Cassidy. Now, let me ask you. Let me stop you for a
second.
Dr. Asch. Yes.
Senator Cassidy. Because as I think of my Medicaid patient,
there is a structure associated with an employer relationship
and that structure allows them to give you 30 minutes off to go
walk around the track if they have built one there.
Medicaid patients taking public transportation to their
clinic appointment are cigarette smoking and there is nothing
you can do on their Medicaid to incentivize them to stop
smoking.
I guess I am not seeing that it is as easily translated--
and, by the way, I am willing to open this up to anybody--
because to me, it actually seems almost an apple and an orange.
Dr. Asch. Well, so, we have run some programs that were
employer-based that were designed to reduce the burden of
tobacco on employees.
We did two studies, one at General Electric and one at CVS.
Both were highly successful interventions, published in the
``New England Journal of Medicine,'' and later adopted by those
two companies. They reflected largely positive financial
incentives delivered to workers to help them reduce the burden
of tobacco.
There is no reason why programs like that could not also be
introduced into the Medicaid population. They are incentive-
based. They were successful. We can think of translating some
of the science and the learning that we have developed from the
employer setting----
Senator Cassidy. Now, let me stop you because, again, you
would be familiar with the structure of Medicaid, which if it
is managed care, they contract with a provider to provide a
service at a certain rate. If it is fee for service, you are
just paying the bills as they come in. Typically, the patient
is not directly impacted by this.
The Indiana experiment may be a little bit different, in
which they prefunded health savings accounts. You could build
in an award for that. So are you thinking in----
When you say build in an incentive, and again, I open this
to anyone, how would you do that for the Medicaid as commonly
structured under the ACA or any other program?
Dr. Asch. Well, I am not sure I would know how to do it as
it is commonly structured, but it does not mean that it could
not be rethought, and that State Medicaid agencies might think
about waivers, or the like, that would enable them to engage in
those kinds of activities in order to achieve their mission.
I am not sure that they can do exactly what I just
described under the rules as they are now, but under changed
rules, they might be able to.
Senator Cassidy. So the state could apply for a waiver
asking for the flexibility to incentivize this sort of
behavior, trying to translate that which you have successfully
shown works for an employer, but to do it for the Medicaid
population.
Dr. Asch. Yes.
Dr. Roizen. I totally agree with that.
Senator Cassidy. Would you elaborate or accept just to
agree?
Dr. Roizen. Well, I do not want to take too much time, but
basically it is how do you get both programs that work,
leadership and incentives, into the Medicaid program? Obviously
Indiana, and even Ohio, are doing major efforts to do that, and
seem to be succeeding.
Senator Cassidy. So the prefunded Health Savings Accounts
of the Indiana experiment really seem to be quite novel, but
also quite effective. Folks who put in a little bit of money,
got a lot more put into their HSA, and that seemed to modify
behavior.
Is that what you are thinking of, along those lines, or
something even more so?
Dr. Roizen. No, thinking about that along those lines and
there are other ways of doing that as well, but that works.
Senator Cassidy. What about things such as obesity?
Cigarette smoking seems almost more tractable, if you will,
than obesity, which is more intractable, it seems.
Dr. Roizen. Well, one of the things is, again, a culture
program and multiple programs. So if one program does not work
for everyone, we have, in fact, ten weight management programs
at the Cleveland Clinic that 62 percent of participants have
the choice of participating in. Weight Watchers may work for a
group, and Curves may work for a group, and our own E-Coaching
program works for a group.
When you get ten programs together, you can find programs
that people can adopt, and in buddy systems, and in groups, if
you will, participate and succeed.
Senator Cassidy. So this might be a program employed by the
Medicaid Managed Care program----
Dr. Roizen. Exactly.
Senator Cassidy [continuing]. To lower their overall cost
burden.
Dr. Roizen. Exactly.
Senator Cassidy. I thank you.
I yield back.
The Chairman. Thank you, Senator Cassidy.
Senator Bennet.
Statement of Senator Bennet
Senator Bennet. Thank you, Mr. Chairman.
I would like to start by thanking you and the Ranking
Member for your work, and your bipartisan effort to fix the
healthcare system that we have.
On behalf of the people of Colorado, who have been waiting
forever, it seems, for a bipartisan effort here, I want to
express their gratitude to you for the work that you have done.
My hope is that the Senate, and the house, and the President
will work together to deal with an issue that confronts us
right now with respect to the CSR's.
As you pointed out, Mr. Chairman, this is a cherished 6
percent of the people that are insured, but it is only 6
percent of the people that are insured.
This hearing really is about what we need to get after,
which is the rising cost of healthcare in this country. I thank
you for that as well. Whatever any of us can do to help your
efforts, I hope you will let us know.
Dr. Roizen, could you describe briefly the bill that you
mentioned in your testimony that Senator Portman and Senator
Wyden are working on in the Finance Committee?
Dr. Roizen. It basically allows Medicare to incentivize and
to do the same type of thing that we do for our employees:
offer programs, offer incentives to get there, work with the
primary care physicians to set the trajectory to improve and to
get to the goals.
If you did that, if the Cleveland Clinic dollar number and
participation number goes to Medicare--and remember, Medicare,
0.6 percent of Medicare achieves even four of the six behaviors
and standards--if we did much more of that and got the 62
percent participation and 44-or-so percent success at getting
to goal, the Government would save over $500 billion, maybe
$1.2 trillion.
One of the things we have learned is putting stress
management in first, even for the Medicare population, is
really important at getting change.
We think this is an enormous opportunity, and Senators
Portman and Wyden are working on this.
Senator Bennet. The reason that we are here today in this
Committee is not about Medicare and Medicaid, but the 178
million Americans who are privately insured through their
employer who could also benefit from the kind of incentive
structures that you and Mr. Burd have put into place.
Dr. Roizen. Other parts of the program. It is not just
incentive. It is some leadership. It is some cultural change.
It is programs that help them. It literally changes the way
they relate to their primary care physician.
There has to be some insurance rule changes that this
Committee could work on to be able to allow the small, non-
self-insured corporation to do this in a way that allows the
employee to take the benefit as they go from one company to
another. That allows the company to benefit after they have
gotten the person healthier.
There need to be some rule changes, but those are minor and
there would not be a dollar spent. Not a Federal dollar needs
to be spent in advance or there is not an ask-for-money from
the Federal Government at all. It just a rule change.
Senator Bennet. Mr. Burd, it is nice to see you again. I
want to thank you for your leadership over many years in this
area.
This is going to sound a little bit off base, but I just
cannot resist because of what your job used to be. The question
that I have for you is what you learned about what we are
eating in this country in that job and how that is connected to
health and how it is changing, if it is changing?
Mr. Burd. Well, I think increasingly the population is
becoming more health conscious. I employee a number of
Millennials these days and they are particularly careful about
their nutrition.
When you run a supermarket chain, and you have 45,000 stock
keeping units, you have all kinds of products in there. I am a
big believer in free choice, but only if you also suffer
consequences of that free choice.
All of us should be able to enjoy a French fry now and
then, but I think those of us that are really into nutrition
and fitness understand that if we indulge, we have another half
hour to spend on the treadmill or walk after dinner.
One of the things that I wanted to mention about improving
health, in particular when you work on BMI, I find that the
Safeway number is extraordinary. The reason we started at 28
percent BMI is because all of the people, they are on their
feet all day. We are not doing that here. We could have had a
stand up meeting and gotten healthier.
The point is that when people just diet, and I think
everybody here would agree, it does not work. The reason it
does not work, if I lose 20 pounds and all I did was diet, for
every pound I lost, I lost a quarter pound of muscle. Muscle is
more efficient at burning calories.
When you finish that diet and you go back to your old
eating habits or maybe even refined eating habits, you cannot
eat as much in terms of calories because your burn rate has
slowed down.
When I talk about an ecosystem at Safeway that we created,
we stressed the importance of cardiovascular workouts. We
stressed strength training. You can, at the age of 60, have the
burn rate of somebody in their late 20's if you will do
resistance training.
I contend it is the secret to weight maintenance. I would
be shocked if you do not do resistance training.
Dr. Roizen. I do.
Mr. Burd. Okay. Thank you.
Senator Bennet. Thank you.
The Chairman. Thank you, Mr. Burd, and our next wellness
hearing will be a stand up hearing. We will see what happens.
[Laughter.]
Mr. Burd. Very good. Even if we just stand up once during
the hearing, it helps.
The Chairman. That is true.
Senator Warren.
Statement of Senator Warren
Senator Warren. Thank you, Mr. Chairman.
I want to see if I can just ask some more questions along
this line.
We all know that the Affordable Care Act allows employers
to offer financial incentives to their employees in order to
encourage participation in these programs.
One thing the ACA does not do is eliminate the protections
already in Federal law for employers, so that they cannot
discriminate against their employees on the basis of genetic
information, health status, or disability.
These protections were put in place by two very important
pieces of legislation, the Americans with Disabilities Act and
the Genetic Information Nondiscrimination Act, or GINA.
This was a bipartisan bill. Senator Ted Kennedy worked with
a number of folks on this Committee. Last year, Senator Enzi
and I wrote and passed new legislation strengthening GINA
protections so that personally identifiable genetic information
collected through Federal research can never be made public.
In short, our Nation's nondiscrimination laws say that
employers can collect sensitive medical information from their
employees only if providing that information is voluntary.
Meaning, the employee can decide to say no.
I just want to start by asking Ms. Mathis.
What types of personal health information do employers
typically ask for as part of wellness programs?
Ms. Mathis. I have seen these health risk assessments ask
about all manner of health and medical information on a variety
of levels of detail. I can give you some examples.
Specific cancer diagnoses such as breast cancer, cervical
cancer, prostate cancer, weight, height, BMI, whether you are
being treated for depression or bipolar disorder.
Specifics about your depression such as how many times you
felt depressed in the last week, whether you had crying spells
in the last week, how often you felt like people disliked you,
how often you feel happy.
Whether you have been diagnosed with heart disease, stroke,
high blood pressure, high cholesterol, angina, bronchitis,
COPD, hepatitis B, obesity, high blood sugar, diabetes, or
sexually transmitted diseases, to name a few.
Whether you are pregnant, whether you are trying to become
pregnant, how old you were when you first became pregnant.
Those are some of the medical things that they ask about;
lots of other questions about all sorts of other life habits.
Senator Warren. So this is some really sensitive
information, and it is supposed to be voluntary to hand it
over.
Ms. Mathis. That is right.
Senator Warren. So let me ask about that.
Mr. Burd, when you were the CEO at Safeway, you set up a
wellness program that you called completely voluntary. At the
same time that families were charged $1,500 more in healthcare
premiums if they did not participate in the program.
In fact, I think you said that you thought the penalty was
not high enough. You lobbied hard to get the limits relaxed.
The quote is, ``Legislation needs to raise the Federal legal
limits on the size of these penalties.'' I know that today you
run a business that designs these kinds of penalties for other
companies.
My question is when it costs an employee $1,500 or maybe
more a year to get healthcare coverage because they do not want
to have to share this kind of confidential medical information
with their boss or because they cannot pass a biometric test, I
do not understand how that connects, then, with the rules on
discrimination. It sounds a lot like discrimination.
Mr. Burd. Well, we have been tested on that numerous times
and were never accused of discrimination during the 10-year
life of the program.
What you are referring to about my desire to raise those
limitations that were in HIPAA, HIPAA originally in 1996
allowed a 20 percent premium differential based on behavior. If
you look at something like smoking, the impact that smoking
would have----Toby Cosgrove used to say that smoking alone
would cost about $3,000 more.
I did not say in my direct testimony, but I will say now
that in our experience, about two-thirds, on average, two-
thirds of that comes immediately back to the employees as a
reward for making those standards.
It is not like they were charged $1,500. The $1,500 one,
that would be if there was a spouse and an employee. So we
think that we----I was questioned by the EEOC, I was questioned
by the Labor Department. At the end of a 45 minute interview, I
was told that I had properly followed the letter and the spirit
of the law. We had not been accused of discrimination during
that time period.
The person that was interviewing me actually wrote the
HIPAA regs in 1996, or had a role in that, and said that if I
ever opened up a Washington, DC office, they would love come to
work for me.
Senator Warren. Well, I am glad that is the case, and I am
now over time. So I want to be respectful of the time here.
I have to say when you charge differentially, $1,500 or
sometimes more, and that can happen because people do not want
to reveal very sensitive, personal medical information. That is
a penalty.
Paying a penalty may be legally all right, although as I
understand it, the courts have now said that the EEOC is going
to have to go back to the drawing board on the latest iteration
of what the rules are.
We have not repealed our laws on discrimination and I just
want to raise the issue that I think the question about what
constitutes voluntary on this kind of sensitive information is
one that we have also got to keep on the table, and maybe do
some pushing in the other direction as well.
I apologize for going over, Mr. Chairman.
Dr. Roizen. May I make a quick comment?
This information is not revealed with a company. It is
revealed with the health plan. There is an absolute firewall
between the health plan and the company. In fact, we fire
people who break that health plan because we have a tracking
system. Every other health plan I know has a tracking system.
If you break that firewall, you get fired.
Senator Warren. Now, Dr. Roizen, all I want to say is what
the law says is that the revealing of information has to be
voluntary.
Dr. Roizen. It is, but it is voluntary with the health
plan.
Senator Warren. Telling people it will cost you $1,500 if
you do not reveal very sensitive medical information, I think,
stretches the bounds of what constitutes voluntary.
Thank you, Mr. Chairman.
The Chairman. Thanks, Senator Warren.
Let me pursue that a little bit because my interest in this
hearing, while there are several possibilities, is to take this
remarkable consensus we have, and the Cleveland Clinic is
certainly not the only one to suggest it. The Mayo Clinic says
the same. Lots of people say it.
There are relatively few things that we could do that
dramatically affect, about lifestyle, that dramatically affect
chronic disease. Chronic disease is 84 percent of our
healthcare costs and then we are talking about hundreds of
billions of dollars to make a difference.
Then you go to the obvious point, and Mr. Burd has pointed
out, it is not only wellness that you look at when you are
looking at an employer plan, but insurance is clearly an
obvious opportunity to take wellness and use employer insurance
as a method of helping 178 million Americans have an
opportunity to be healthier and save a lot of money for the
country at the same time.
Mr. Burd and Dr. Roizen, how big a problem has it been for
you in your employer plans to successfully deal with the
concerns that Ms. Mathis has talked about, and that Senator
Warren talked about, and that others have asked about? Is that
a major impediment or do you think you can deal with those and
treat employees fairly?
Dr. Roizen. We deal with it. We have 1,000 roughly
exceptions requested by physicians who say, ``This person, no
matter what we do with them, cannot get to that normal.'' Those
are accepted and they get a different plan.
In fact, in some of the extreme examples, someone just
counts the amount of water they drink, bottles or glasses of
water they drink a day to hit the health plan target and get
the premium reduction.
The Chairman. So to get a premium reduction, you have the
opportunity to say, ``I need a different standard.''
Dr. Roizen. The primary care physician.
The Chairman. Or, ``I need an exception.''
Dr. Roizen. That is exactly right.
The Chairman. That you, therefore, try to provide a fair
process to meet that objective.
Ms. Mathis, does that work? I think I heard you say it
probably did, that you were more concerned about the privacy.
Ms. Mathis. Right. That is not the primary concern that we
have. The primary concern is the incentive for disclosure of
information.
The Chairman. Right.
Mr. Burd, what would your comment be on the kinds of
impediment? Actually, you have talked some about it, but the
reward or penalty for a healthier lifestyle.
Mr. Burd. Sure.
The Chairman. Has that been a problem for you?
Mr. Burd. I would say it has not been a problem and just
consider the fact that 85 percent of the people did opt-in.
One of the reasons why I think we had such a high
participation rate is I put enormous effort into communicating
why this was a good idea. I reported my public earnings
quarterly in a town hall meeting and in a broadcast, and I
reported on the health of the organization.
People would catch me individually and ask me some
questions about it, and when they really understood it, they
quickly opted-in to the program because to Michael's point,
there is a firewall there.
When you have a premium differential, you are just risk-
adjusting the premium for individuals, but then giving them an
opportunity to change their risk profile. We do that in life
insurance, and we do that in automobile insurance, and behavior
really matters.
What I would like the Committee to really focus on is that
we have two practitioners here, maybe three, and there are very
few people, I would say less than 1 percent of the companies in
this Nation that have turned back obesity, that have improved
the results on blood pressure, and cholesterol, and smoking.
These programs--and Michael and I have not had a chance to
put them out in all of their glory--they work and nothing else
has. I mean, a 21 percent obesity rate versus a Nation now
close to 40.
The Chairman. Thank you, Mr. Burd. We are close to the time
that we are going to be voting in a few minutes.
Dr. Asch, I would assume based on your behavioral research
that if we wanted to incentivize United State Senators to pass
an appropriation bill on time, that you would subtract from our
salary instead of giving us a bonus.
Dr. Asch. Maybe so, but I think you all deserve a raise.
The Chairman. Well, thank you for that.
[Laughter.]
Senator Murray. Take it under advisement.
The Chairman. Yes, take it under advisement.
Senator Murray, do you have additional questions?
Senator Murray. I do not. I know that Senator Franken, I
think, had an additional question.
Senator Franken. Yes.
Senator Murray. Correct.
I will just say--I know we are getting close to votes and
we need to go--this has been a really good hearing, and we have
a lot of work making sure we do this right.
I think it is critically important and, of course,
balancing workers' civil rights and privacy. This has been a
really important hearing and I appreciate everybody being here.
The Chairman. Thank you, Senator.
Senator Franken.
Senator Franken. Thank you, again, both for this hearing.
It is very refreshing to be talking about keeping people
healthy, and having a healthcare discussion that is not all
about structures of insurance, although this has something to
do with that.
I do want to talk about the National Diabetes Prevention
program, which has been very successful. Before that, I just
want to return one thing on the housing, which is on the opioid
crisis.
I had a visit yesterday from Bois Forte, which is a band of
Ojibwe in Minnesota. In Minnesota, we have just had an
explosion in opioid use by, especially in Indian country. In
Indian country, housing is an enormous issue.
As we go into this opioid, as it is being declared a crisis
and an emergency, I would really like to see a pilot program
where people who come back for treatment, especially in Indian
country, have a place to go.
I was in Rochester, Minnesota a couple of breaks ago. We
did an opioid roundtable and a woman whose daughter died, she
had gotten treatment, got sober, but she went back with her old
crowd, and she was gone.
We just need, I believe, to give people the opportunity to
go to sober living facilities that are good sober living
facilities. There is probably a distinction to be made here.
I would love to be able to pilot a program in Minnesota. I
would love to do it in Minnesota where we actually, this is
national, as bad as it could be in Minnesota in Indian country
because there are housing shortages there where people coming
back from rehab can go into a sober living setting.
They have secure housing, and that they have people that
are in their same boat, and in recovery. Instead of a peer
group, which is the other--a peer group that has a high drug
use--they are having a peer group of people in their own
fellowship.
That is just something I want to bring up.
Yes.
Mr. Burd. Senator, just to elaborate on what I said
earlier, that is exactly what we do in this philanthropic
effort. In other words, they have to be sober before they come
in. They get tested while they are in that safe environment.
Senator Franken. They have to be tested.
Mr. Burd. They get constantly reinforced. The program
works. So if there is a way to expand that, I think it has
great value.
Senator Franken. Now on the National Diabetes Prevention
program, this is something that Senator Lugar and I put in the
ACA. Senator Grassley and Senator Collins have been very
helpful in getting CMS to do, the Medicare.
What we learned is that this is a 16-week program and was
piloted at the YMCA in St. Paul and in Indianapolis. This is by
NIH and CDC. This is why it was me and Senator Lugar who put it
in.
What it turned out that it is 16 weeks of both nutritional
training and exercise. After 5 years, this is people who have
high levels of sugar in their blood, glucose, and they were 58
percent less likely after 5 years to become diabetic, 70
percent less likely, if they were over sixty, which is why CMS
is now in the process of implementing this.
So that any one in Medicare who wants to get the diabetes
prevention program will be able to take this 16 week program
and have it paid for by Medicare.
Can anyone speak to why this has been successful?
The Chairman. We have about 20 seconds.
Dr. Roizen. You get behavioral change, which is consistent.
You also get buddy, it is a group, so you get buddy support.
You get everything that a wellness program should be and you
are targeting one of the specific high cost things; hemoglobin
A1c or diabetes.
It is a great program.
Dr. Asch. I agree. I think the diabetes prevention program
is a great example of the importance of behavioral change.
The fact that this can be done without medication, without
financial incentives speaks to a strong program and it has
outcomes that you have mentioned are incredible, and they are
persistent.
This, I think, is an incredibly optimistic light at the end
of the tunnel there.
Senator Franken. Thank you.
The Chairman. Thank you, Senator Franken.
Thanks to the witnesses for coming. I agree with Senator
Murray, it has been a terrific hearing. We have learned a lot.
The hearing record will remain open for 10 days. Members
may submit additional information within that time, if they
would like.
The Chairman. The HELP Committee will meet again at 10 a.m.
on Thursday, October 26 for a hearing entitled, ``Exploring
Free Speech on College Campuses.''
Thank you for being here today.
The Committee will stand adjourned.
[Whereupon, at 11:43 a.m., the hearing was adjourned.]
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