A guest column by the American College of Physicians, exclusive to KevinMD.com.
If you are a primary care physician, chances are that you’ve had patients ask you to complete forms for work as part of their employer’s wellness program. Workplace wellness programs have been around for several years, but it seems that more of my patients have been participating since the adoption of the Affordable Care Act (ACA).
Although these programs do not always follow High Value Care recommendations, as I’ll show below, their rationale makes sense to me. A healthy workforce is a more productive workforce. In addition, preventing disease or better managing it should reduce the cost of care (and as a result, insurance premiums). Both help a business’s bottom line, in addition to being good for the employee.
The types of programs in which my patients participate range from those where all they need to do is to see me and keep up with their recommended screenings, to ones where they are required to report data such as lipid profile results, to others where they also need to achieve specific goals, such as a normal BMI or quit smoking.
The rewards that they get in return for participating vary. Some of my patients get a cash payment or a contribution to their health savings accounts. Others receive a discount on their insurance premiums. A few get help with problems identified in their screenings. For example, one of my patients with high cholesterol gets coached on healthy eating and exercise through his employer’s program.
I was unaware of the many rules and regulations affecting workplace wellness programs until I came across an issue brief from the Kaiser Family Foundation (KFF) that reviewed how these programs must comply with federal laws such as the Employee Retirement Income Security Act (ERISA), the Americans with Disabilities Act (ADA), the Genetic Information Nondiscrimination Act (GINA), the Health Insurance Portability and Accountability Act (HIPAA), and the ACA. The brief also describes in greater detail the various flavors of wellness programs, their prevalence, and their effectiveness.
In theory, these programs should support my taking better care of my patients by getting them to come to the office regularly and reinforcing my recommendations that they get their screenings. In some ways, these programs are a type of “P4P4P,” or pay for performance for patients.
Two incidents last week involving workplace wellness programs troubled me and got me thinking about what I like and don’t like about them. The first involved a patient who dropped off a form that needed documentation of a lipid profile and blood glucose within the last calendar year. This was a woman whose last lipid profile and glucose tests were checked two years ago, and both were normal. She had no reason to repeat them this year. I entered the most recent results on the form with a notation that more frequent testing was not indicated under current guidelines. I hope that will suffice, but I doubt it.
The other patient needed similar information, which I had obtained within the year. However, along with the form, she brought a printout of the results of a workplace health screening that included the same tests and much more. Why would her employer perform these tests yet also require the patient to get the same tests ordered by me? Furthermore, even though she was up to date with her age-appropriate screening and seeing her doctor, her employer was giving her a hard time because she didn’t have a claim for a preventive exam in the past year. While that was true, she had been seen in the office for other reasons, and in the aggregate did not lack anything despite not having a 99396 billed to her plan.
If a goal of these programs is to reduce the cost of care, why require employees to get tested more frequently than is necessary, or encourage them to get tested by their personal physician while also testing them at the workplace?
Furthermore, if we are expected to practice evidence-based medicine, shouldn’t workplace wellness programs also be evidence-based? Given that there are often significant financial incentives at stake, these wellness programs often put employees and their physicians in awkward positions, when program requirements conflict with medical judgment.
Then there are the administrative burdens of these programs. While many of the forms can be completed by medical assistants or other members of the team, they still add to the practice’s workload. One local employer pays physicians a fee for faxing the completed forms, which lessens the impact, but that is the exception.
I also wonder how the disclosure of “biometric” data to employers affects patients. Does it motivate them to improve their lifestyles? Despite numerous regulations that limit how the information can be used, as described in the KFF brief, are they comfortable sharing this information and do they feel they really have a choice?
The American College of Physicians (ACP) commented on workplace wellness programs in a 2013 letter on a proposed rule that was part of the ACA. In the letter, the College recommended that the programs be evidence-based, minimize burden on physicians, and reward, instead of penalizing, employees.
As long as employers believe that workplace wellness programs will save them money, they will remain part of our practice lives. But they shouldn’t duplicate the care that we’re already providing, unduly increase our workload, or interfere with our relationships with our patients.
Yul Ejnes is an internal medicine physician and a past chair, board of regents, American College of Physicians. His statements do not necessarily reflect official policies of ACP.
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