A friend of mine is a physician at a local hospital, and she serves on a committee that runs programs promoting employee wellness. She described a recent meeting that discussed a competitor's use of cotinine tests (they detect nicotine in hair samples and, therefore, they also detect smoking behavior) in employment decisions. Moreover, employees are regularly screened for cotinine, in the same way that they have to annually pass a tuberculosis screen. Nicotine addiction services are available, for free, but there are consequences if you do not comply. Are we seeing the future of employee health?
The competitor hospital screens for cotinine (and, thus, smoking) because either (a) it gets them a better deal from on employee benefits from their insurer, or (b) they self-insure and they want to reduce the medical claims they need to pay. Non-smoking workers are also more productive, but I think this is just icing. In the past, employers have sought to limit health benefit costs by restricting access to health services, e.g., through managed care plans. Now, the competitor seeks to reduce the demand for services by improving employee health, a much better idea, and they seek to improve health by changing health-related behaviors. Employers have often sought to change health-related behaviors, albeit using weak interventions. Our hospital, for example, provides on-site health screening, wellness counseling, and has a fitness center; but these voluntary interventions haven't achieved much. What's interesting here is the competitor's use of much more intrusive and forceful interventions.
I think these more forcible interventions are likely to work, that is, they would provide incentives sufficiently powerful to change behavior in many employees and thereby reduce the hospital's health benefit cost. (Whether employees would accept them I'll discuss in a moment.) What might the competitor try next? Mandatory participation in Weight Watchers for obese employees? Mandatory blood lipid screening, with required treatment programs for those with excessively high cholesterol levels?
How should we feel about the prospect that employers may begin forcibly managing employees' health behaviors? Four quick thoughts.
- There's a big upside here. Forceful -- maybe coercive? -- incentives, applied to work groups, could improve health-related behaviors across the population (albeit unevenly, see #2 and #3). This would help address a fundamental cause of chronic illness, significantly improve population health, and possibly reduce the future growth of health services as a proportion of GDP. I don't have many other good ideas about how we will accomplish these goals.
- Some employees won't accept this, but others will. It's mostly the good jobs that still have health benefits, the one's where they need your skills and want to keep you for a long time. People will accept quite a lot to get those jobs.
- For that reason, it won't be offered by all or even most employers. Employers won't take on the cost of monitoring and managing employee health behaviors unless there is good ROI. This won't happen in Medicare or Medicaid. So mandatory workplace wellness would likely increase existing class disparities in health behaviors, and health.
- Mandatory wellness feels creepy. Choose your metaphor: iron cage or panopticon. We are giving control of our lives to corporate persons. But that train has already left the station.