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The Boss Is Watching You

Craig Klugman, Ph.D.

Do you smoke? Do you exercise? Do you have a yearly physical with your physician? Your answers to these questions could have an affect on the cost and coverage of your health insurance. The annual survey is a part of the work wellness trend that began nearly a decade ago and was an attempt to cut the cost of health care by providing incentives for employees to adopt healthier habits. The concept was that healthier habits would reduce use of medical services leading to lower insurance costs for the employer.

Thus, employers offered carrots or rewards for good behavior. If you did not smoke or enrolled in a smoking cessation program, you received a discount on your premium. If you took an annual health quiz, you got a lower annual out-of-pocket deductible. If you exercised, you often received subsidized gym memberships that could reduce copays at the doctor’s office. At the time that these incentives appeared, some critics were concerned that it was only a matter of time until these “incentives” were turned into penalties. History has proven those critics correct as carrots turned into sticks. A few years ago, the discount for not smoking became a penalty in the form of higher premiums for smokers.

In bioethics, a slippery slope argument holds that once society starts down a path, we will find ourselves at the ad absurdum end point. For example, if we start testing embryos for genetic diseases then eventually there will be required genetic designing of children. The slippery slope assumes that there are no moral breakpoints along the way. Usually slippery slope arguments are scare tactics and lack any real world reality. The passing of Roe v. Wade did not lead to abortion as birth control and legalized gay marriage in 9 states has not destroyed marriage for heterosexuals in those jurisdictions. As it turns out, humans can make rational choices and rarely find themselves on the runaway train that the slippery slope argument assumes.

The work wellness movement, however, may actually be on the slippery slope. From rewards to penalties, the next step is outright bans. As of March 12, New York City has banned large servings of sugary drinks including 32-ounce servings, the 2-liter bottle with a pizza delivery, and pitchers of carbonated beverages at restaurants. The ban does not apply to alcohol or diet drinks. In fact, any sugary drink over 16 ounces is prohibited. Of course you can buy 2, 16-oz drinks. You can get a refill. You can also drink as much sugary goodness as you wish at home. So there are ways around the ban. But the city of New York has decided that the social and health care costs of obesity related to these beverages are so high that the government is justified in controlling them. It’s a public health argument—that the state has a right to limit your liberty when you pose harm to someone else. In this case, your choices affect your use of limited health care resources including dollars as a result of preventable health problems. And if you can’t make the rational choice to restrict consumption of these goods, then the government will do it for you.

Even more extreme, if you, your spouse, or a dependent use a tobacco product, do not even think about applying for a job at the University of Pennsylvania medical enterprises after July 1. That institution is requiring all new applicants to attest that he/she has not used tobacco products for the last 6 months. They are not the first, as their website lists many other health systems including Cleveland Clinic, Geisinger Health, St. Luke’s, Baylor Health Care System and others with similar policies. The website states that there is no empirical evidence that these programs reduce costs, but that such a move is in alignment with a health care system since tobacco is a “…habit that leads to disease, disability and premature death.” In other words, employees should model the health that the institution is trying to sell. But is your employer telling you how to behave in your personal life a step too far?

Perhaps most interesting is a recent study published in Health Affairs which shows that work wellness programs decrease hospitalization but use of outpatient services and medications increase dramatically, wiping out any cost savings. If the goal is to improve health, then these extreme programs seem to be effective since fewer people presumably need hospital care. But if the goal is to reduce health care expenditures, then the programs are not effective, they simply shift cost from acute hospital care to primary outpatient care.

The ethical concerns of required work wellness policies as they slide down the slope are many: intrusion of government into personal life as well as employer control over employee behaviors outside the workplace. Not to mention whether these companies are really concerned with the health of their employees or in limiting losses to health care (insurance premiums, sick days)? The question that I am left with is, how much is too much?

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