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PPACA Rules on Wellness Programs Could Push Participation

 |  By John Commins  
   November 26, 2012

New proposed rules for wellness programs that were released last week under the Patient Protection and Affordable Care Act don't break much new ground, but they will likely provide the framework and clarity that will encourage more employers to participate, observers say.

"It's a good starting point," says Stephanie A. Mills, MD, president and CEO of Baton Rouge, LA–based Franciscan Health and Wellness Services, Inc. "It's the floor, and maybe a few walls, [and] some more structure and definition. I believe that it can be instrumental in providing clarity for the path forward for employers and decreasing that anxiety to jump into this by addressing the top concerns that employers have."

Within the overall framework of the wellness program guidelines, Mills says she has so far found "no major surprises."

"Overall, for those of us who are supporting wellness programs, this is well in line with the best-practice approach," she says. "There are pros and cons, as there are with any new regulations, and we will learn more as we go into the details, but at first glance it seems to be a positive for employers and individuals."

The new rules create guidelines for health-contingent wellness programs that couple financial and other incentives with biometric targets such as weight loss, tobacco use cessation, and lower cholesterol.

In particular, Mills supports the clarity around the outcomes-based incentives for metrics. "That will be very welcomed by employers and will drive participation. It diminishes a lot of the anxiety that employers are feeling around discrimination and what sorts of limits should we have around the incentives and what parameters."

For employers, the proposed rules increase from 20% to 30% the maximum permissible reward for the cost of health coverage, and increase the maximum reward to up to 50% for tobacco cessation programs.

"I don't expect a lot of employers will rush to impose 50% penalties on smokers or 30% penalties on somebody who doesn't get their cholesterol under control," says Roger Reed, senior vice president, clinical services at wellness services provider Health to You, a subsidiary of HCA. "It's just another way to say to the consumer, 'Look, we are going to let your employer impose incentives but we are going to cap it so this is as far as they can go.' In working with employers across the country, we aren't seeing a lot of people saying, 'Boy, when these rules come out, we are going to hammer our employees with these incentives.'"

For individuals, the proposed rules require that the wellness programs and their incentives be laid out simply so that participants can understand them, and that protections and appeals processes are in place for individuals who have legitimate reasons for failing to meet specific metrics.

"They have to accommodate the consumers who can't meet the standards," Reed says.

Brenda L. Rooney, medical director for Community and Preventive Care Services at Gundersen Lutheran Health in La Crosse, WI, says the federal government was smart to require no baseline incentives for wellness programs and to impose a reasonable ceiling for those incentives.

"Incentives are good but they are not the be-all and end-all. Incentives can backfire on you as well," she says. "That there is a limit is probably good. People start to expect incentives and then they tend to use the incentives to reward a behavior change. Pretty soon, if you to pull the incentive away, will the behavior change go back to the beginning?"

Rather than relying too heavily upon incentives, Rooney says wellness programs should focus on changing the environment so that it supports positive outcomes, such as banning smoking in public places.

Mills called the proposed guidelines "a big deal" and a watershed moment in the wellness movement.

"When you break it down and look at the statistics of the many chronic diseases and risk factors America is facing, we really do need to shift the focus to prevention and awareness," she says. "It's a new role for providers as we take off our acute care hats and ask, 'How do we get ahead of this curve?' It is important when we look at the health of this country with the aging population and limited resources across the board to ask how do we implement new and innovative care programs to stop this progression of chronic diseases? It's getting back to the basics of good primary care, working on prevention and lifestyle and changing behaviors."

Reed is less sanguine. "My personal opinion is it will have no real influence. The only thing it will do is add clarity and guardrails."

John Commins is a content specialist and online news editor for HealthLeaders, a Simplify Compliance brand.

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