文章基本信息

标题：Wellness Incentives, Equity, and the 5 Groups Problem
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作者：Harald Schmidt
期刊名称：American journal of public health
印刷版ISSN：0090-0036
出版年度：2012
卷号：102
期号：1
页码：49-54
DOI：10.2105/AJPH.2011.300348
语种：English
出版社：American Public Health Association
摘要：Wellness incentives are an increasingly popular means of encouraging participation in prevention programs, but they may not benefit all groups equally. To assist those planning, conducting, and evaluating incentive programs, I describe the impact of incentives on 5 groups: the “lucky ones,” the “yes-I-can” group, the “I'll-do-it-tomorrow” group, the “unlucky ones,” and the “leave-me-alone” group. The 5 groups problem concerns the question of when disparities in the capacity to use incentive programs constitute unfairness and how policymakers ought to respond. I outline 4 policy options: to continue to offer incentives universally, to offer them universally but with modifications, to offer targeted rather than universal programs, and to abandon incentive programs altogether. Incentives aimed at individuals increasingly play a role in the organization of health care systems. 1,2 Wellness incentives are intended to encourage uptake of prevention and health promotion programs. A recent survey also found that 56% of large US employers see wellness programs as 1 of the top 3 strategies for curbing cost. 3 Savings may result, for example, from reduced health care expenditure owing to a healthier workforce or from incentives structured in a way that shifts health care cost from employers to employees. The goals of health promotion and cost containment may come into conflict, and the fairness of wellness programs depends significantly on their implementation. Various ethical issues may arise, but a central concern is equity, because ideally, all who are offered incentive programs should enjoy equal opportunity to access them, especially when associated benefits are substantial. Regulations issued by the US Departments of Labor, Treasury, and Health and Human Services in 2006 distinguish between 2 principal forms of incentives. 4 Process incentives may offer a premium discount or rebate for participating in, for example, an exercise, weight-loss, or smoking cessation program. Outcome incentives link monetary benefits to meeting certain risk factor targets, such as body mass index (BMI) or blood pressure thresholds. The regulations impose no cap on process incentive levels, but for outcome incentives they initially specified that reimbursements must not exceed 20% of the total cost of an employee's coverage (or $965, according to the 2009 average cost of coverage of a single individual). The Patient Protection and Affordable Care Act, passed in March 2010, increased this to 30% (or $1447), with the option of 50% ($2412) in exceptional cases. 5,6 Incentives may be funded through gain sharing, but the regulations also explicitly permit cost shifting from plan sponsors to participants who do not satisfy the standards, from participants who satisfy the standards to those who do not, or some combination of these. 5 Depending on the exact implementation, wellness incentives may therefore lead to an increase in cost of coverage for some enrollees. Other countries, such as Germany, have had similar systems in place for some time, although incentive levels are usually much lower (generally < $100), no difference in amounts is specified between outcome and process incentives, and financing may come from gain sharing only and not from cost shifting. 7 Individual-level incentives have been used widely outside of health policy. For example, many airlines and supermarkets provide discounts for loyal customers, and auto insurers offer lower premiums for customers with few or no claims. Program enrollment is usually straightforward, and failure to participate or to qualify for rewards typically means losing out on some benefit. Applying this model to the health care context, however, raises some concerns.