文章基本信息

标题：Workplace Wellness Programs: How Regulatory Flexibility Might Undermine Success
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作者：Jennifer L. Pomeranz
期刊名称：American journal of public health
印刷版ISSN：0090-0036
出版年度：2014
卷号：104
期号：11
页码：2052-2056
DOI：10.2105/AJPH.2014.302149
语种：English
出版社：American Public Health Association
摘要：The Patient Protection and Affordable Care Act revised the law related to workplace wellness programs, which have become part of the nation’s broader health strategy. Health-contingent programs are required to be reasonably designed. However, the regulatory requirements are lax and might undermine program efficacy in terms of both health gains and financial return. I propose a method for the government to support a best-practices approach by considering an accreditation or certification process. Additionally I discuss the need for program evaluation and the potential for employers to be subject to litigation if programs are not carefully implemented. As part of the Patient Protection and Affordable Care Act (ACA), Congress revised the law related to workplace wellness programs. 1 The government supports these programs as a method to promote healthy behaviors, improve employees’ health knowledge and skills, and help employees get necessary health screenings, immunizations, and follow-up care. 2 But there is a growing consensus that workplace health promotion programs could more widely prevent and control chronic disease and health care costs. 2–6 Employer health initiatives are now considered part of the nation’s broader health strategy, 7 but much debate ensues regarding efficacy, ethics, and costs. 5 ^, 8 ^, 9 A directly related but thus far largely unexamined issue in this context is the requirement that health-contingent wellness programs must be “reasonably designed to promote health or prevent disease.” 1 The government sought to provide employers flexibility by enacting this permissive standard rather than requiring a more rigorous approach, but this authorization could undermine the health and financial goals of health-contingent programs. Work sites represent a targeted location to reach a large population of working-age adults within a potentially supportive setting. Employers typically expect health promotion programs to counteract trends of increasing health care costs and declining productivity, but they may also seek to improve worker satisfaction and reduce turnover and absenteeism. 2 ^, 5 ^, 10 However, commentators expressed concern that workplace health programs focus on behavior change through a personal responsibility framework, 11 ^, 12 with the potential to discriminate against employees based on health factors. 8 ^, 13 ^, 14 To alleviate these concerns, I urge the adoption of workplace health programs that are practice- or evidence-based, equitably promote health or prevent disease, and are cost-effective. The focus of such a program goes beyond “wellness” to seek actual health gains to encourage the allocation of resources to benefit both employers and employees. Congress delegated authority to 3 administrative agencies, the Departments of Treasury, Labor, and Health and Human Services (HHS; collectively “the Departments”), to pass regulations to carry out the intent of the legislation. In June 2013, the Departments finalized regulations that provided exceptions to the Health Insurance Portability and Accountability Act of 1996 (HIPAA) for nondiscriminatory wellness programs in group health coverage. 4 This revised the 2006 regulations on the same topic and amended the agencies’ respective regulations on Pension Excise Taxes, the Employee Retirement Income Security Act (ERISA), and the Public Health Services Act. The regulations pertain to programs operated by group health plans, as well as group health insurance coverage beginning January 2014. Workplace wellness programs are divided into 2 categories. First, “participatory wellness programs,” which make up the majority of programs, do not offer a reward or do not require an individual to satisfy a health-related standard to qualify for a reward. 4 Examples of such programs include providing incentives to employees for attending health seminars or reimbursing employees for gym membership fees. 15 The second type is “health-contingent wellness programs.” These programs require an individual to satisfy a health-related standard to obtain a reward and can be activity-only or outcome-based. 15 The reward in this context may be a positive incentive or negative penalty. 15 Activity-only programs require the performance of an activity related to a health factor, such as walking or dieting, but do not require the achievement of a specific health outcome to obtain a reward. 15 Outcome-based programs require the individual to attain or maintain a specific health outcome, such as not smoking or maintaining a healthy body mass index, to obtain a reward. 15 Health-contingent programs must satisfy 5 distinct requirements to be lawful. 15 The requirement analyzed herein is that they must be “reasonably designed to promote health or prevent disease.” 15 The Departments sought to clarify regulatory standards through the revised regulations. 4 However, as explored here, the permissive reasonable design standard is not compatible with addressing the nation’s critical health problems and increasing health care costs, and is additionally counter to businesses' expectation to realize a cost savings by investing in them. 16 The government’s role in this context could be better served by fostering a best-practices approach. 9 ^, 17 In this article, I evaluate outstanding issues related to a lack of a best practice requirement and argue for a more robust approach. Given that the Departments acknowledge that future modification to the regulations or subregulatory guidance may be necessary, 4 I propose a method for the Departments to better support optimal programs by utilizing a certification or accreditation method to foster practice- and evidence-based programs. I discuss the need for program evaluation and potential for employers to be subject to litigation if programs are not carefully implemented.