ACP Offers Ethical Guidelines for Wellness Program Incentives

The American College of Physicians has offered ethical guidelines for using incentives to promote personal responsibility for health. If you're running a wellness program at your organization, this is must reading.

While the position paper specifically examines a Medicaid pilot project in West Virginia, much of it can be applied to private sector wellness programs.

The paper—"Ethical Considerations for the Use of Patient Incentives to Promote Personal Responsibility for Health: West Virginia Medicaid and Beyond"—emphasizes that efforts to change unhealthy behaviors must be part of an overarching wellness program that uses evidence-based practices to develop nondiscriminatory programs that do not punish patients for unhealthy behaviors.

At play here is the inherent friction between personal responsibility, incentivizing healthy behaviors, and punishing people who don't or can't reach goals such as quitting smoking or weight loss. We know that many of the chronic and expensive ailments that plague this country—diabetes, arthritis, and respiratory and cardiovascular diseases, to name a few—are largely the result of self-inflicted poor health choices around bad diet, tobacco use, and sedentary lifestyle. Why shouldn't the individual be held accountable for his or her poor health decisions? Why should the rest of society be forced to pay for the poor health decisions of others? If the individual isn't responsible for his or her health, who is? These are legitimate questions.

On the other hand, the poor, the old, the undereducated, and minorities are often disproportionately affected by these bad health choices. Are we going to create a caste system that rewards the healthy and punishes the unhealthy? Won't that create a downward spiral of disincentives and discouragement that will only worsen health issues—and the cost—for this unhealthy segment of society? Those are legitimate questions, too.

ACP quite clearly opposes "negative incentives" that penalize patients who don't meet goals by withholding or cutting benefits, or by increasing health insurance premiums. Instead, ACP says incentive programs must:

• be equitable and not penalize individuals by withholding benefits.
• support a patient's right to refuse treatment without punitive consequences.
• be transparent and provide a clear explanation of the benefits and operational details.
• support the patient-physician relationship and the physician's ethical and professional obligations to care for patients.
• be designed to allocate benefits equitably.
• facilitate patient-centered care.

"Incentive programs should not discriminate against a class or category of people," said Virginia Hood, a co-author of the paper. "Age, gender, race, ethnicity, and socioeconomic status should be carefully considered in designing, implementing, and interpreting results of social and behavioral interventions."

ACP found that West Virginia's Mountain Health Choices Medicaid program—one of the first programs to use incentives—puts an emphasis on the patient's role in promoting good health. Mountain Health's evidence-based strategies increase access to prevention and treatment; support patient participation in decision-making; consider variables affecting comprehension and learning; and respect cultural, religious, and socioeconomic conditions. (It should be noted that The West Virginia University Institute for Health Policy Research in August 2009, offered a less generous assessment of Mountain Health.)

Regardless of the triumphs or shortcomings of Mountain Health, ACP's guidelines make sense for the larger wellness movement. There is no denying that we Americans are overweight and aging badly, and the costs associated with our graying, bloating population are staggering. We have to take responsibility for our own health. If we don't, who will? That's the appeal of wellness programs. We just have to make sure they appeal to everyone.