Summary: Passage of a bipartisan amendment from US Senators John Ensign (R-NV) and Tom Carper (D-DE) has elevated a debate Integrator columnist Michael Levin has repeated brought to these pages. To change behavior, in Levin's view, "education rarely works, economics usually does." The Ensign-Carper amendment allow health plan costs to be cut by as much as 50% for those who engage healthy behaviors. Some unions and major disease-based organizations are opposed. Employers tend to support the direction, as Kenneth R. Pelletier, PhD, MD(hc) and Sean Sullivan, JD, each share. A tremendous discussion has been kindled on the Washington Post site. Levin lays out what he believes are significant opportunities for the integrative medicine community. Where are you on this issue of patient engagement, habit change, healthcare economics and public policy?

On the top of page 2 of 10 pages of comments on an October 16, 2009 Washington Post story on a recent US Senate move to significantly increase economic incentives for good health behavior, a respondent facetiously captured the depth of the debate this way. First, the writer noted the 10 states with the highest levels of obesity: Mississippi, Alabama, Tennessee, Louisiana, West Virginia, South Carolina, Georgia. Oklahoma and Texas. Then the writer suggested that perhaps the best way to resolve the nation's healthcare cost crisis would be to let them secede.

That might be easier than grappling with the economic-clinical-ethical issues surrounding health habits, personal responsibility, chronic disease and obesity. 

US Senator John Ensign- co-sponsor on bipartisan bill for financial incentives for wellness

Opinions run high on just what we should do, as a policy matter, to better health care through a strategy of habit shifting incentives as we do in

Sullivan: this direction makes sense

I contacted Sean Sullivan, JD, co-founder of Integrator sponsor Institute for Health and Productivity Management and Integrator adviser Kenneth R. Pelletier, PhD, MD(hc) for his perspective. Sullivan is a strong promoter of the employer-sponsored health system with employers taking the lead through values-based benefit designs which tend to support investment in wellness and potentially, in Sullivan's view, in integrative approaches. He is not typically fond of government programs. He states:

"I’m always in favor of letting employers use their own money for their own purposes without having to get a permission slip from government – this is the rare kind of legislative provision (like the Harkin bill offering tax credits for health promotion programs) that actually makes sense because it promotes intelligent private sector actions.  Regarding the potential for integrative medicine to expand its mind-share with employers, I’m all for letting employers decide on the wisdom of that for themselves!

Pelletier: "Safeway Plan" rests on positive incentives

Pelletier: productive for individuals and organizations

Pelletier is the founder of the Corporate Health Improvement Program (CHIP) which he co-directs with Andrew Weil, MD at the Arizona Center for Integrative Medicine. Pelletier responded:

"Senator John Ensign's bill is clearly in the right direction to raise the current limit of 20% of the total medical premium for employee wellness incentives to 30%. Actually, there is a provision that would give government officials the option to raise this incentive as high as 50%. Additionally the Senate Finance Committee bill would set up a trial program allowing insurers in 10 states to create wellness based incentives for individuals.

"Providing effective programs with appropriate incentives based on measurable outcomes is clearly the most productive future direction for both individuals and organizations."

"From all of the research literature, it is clear that positive (carrots are better than sticks) financial incentives elicit and sustain positive, long term behavioral changes. There is no substitute for informed, individual choice. Although some corporate programs provide incentives for participation only (these are appropriate for such conditions as diabetes), the 'Safeway' model incentivizes employees to meet specific outcome 'standards' (on BMI and other biometrics) in order to earn financial incentives. Providing effective programs with appropriate incentives based on measurable outcomes is clearly the most productive future direction for both individuals and organizations."

Levin: It's Big Brother-ish, but greed can make good things happen

I asked Levin what he meant by "siezing this opportunity." His response focused on the kinds of clinical protocols he believed integrative practitioners could offer to support significant, cost-saving habit changes:

"Great question - and creative minds much smarter than mine could offer better answers than I could, I'm sure. This may be a question to toss out to the crowd. From my limited framework involving nutritional interventions, I can envision creating cost reducing treatment & prevention programs along the lines of:

1) Depression: economically incentive folks taking antidepressants to switch to St. John's wort (SJW) for 9 months, which the Cochrane Collaboration has established is safe and effective. Offer insureds the opportunity to receive high-quality SJW at a price point below the Rx co-pay, and reduce premiums by $25/month. Presto! Depending on the product, the payor could experience direct savings up to $90/month and the patient could experience therapeutic benefit with fewer side effects. If they choose to stay on SJW past 9 months, great. If they drop-out before 9 months or choose another Rx drug after 9 months, the monthly discount disappears. This is an easy, albeit one-dimensional approach to a very expensive problem on which drug spending alone exceeds $12 billion per year.

2) Cardiovascular Disease Prevention: include omega-3 fatty acids post initial-myocardial infarction (MI), along with other modalities, eg, diet, exercise, stress reduction, etc. For a while, the UK, under NICE guidelines (National Institute for Health and Clinical Excellence), provided omega-3 FAs within 30 days of the first MI for as long at 4 years at no charge to patients (those were the numbers that worked in their economic model). This was subsequently halted for reasons that are unclear but appear to me to be related to stakeholders in the Rx industry. Economic models need to be developed. 

3) Obesity/Type II Diabetes: Let BMI and blood glucose trigger eligibility into an integrated program designed to alter lifestyle, with end-points measured by BMI, blood glucose, H5A1c. Nutrition, diet, stress management, mindbody work, exercise, might all be components in this model. Economic models need to be developed. 

"How to do? Develop and package the intervention and co-market to self-funded corporations (or the government) with an infrastructure partner (eg, insurance network, disease management company, third party administrator (TPA), etc). The complexity of the intervention will determine the ideal marketing partner(s). The secondary benefit from these programs is the continuing enrichment of a knowledge base about which interventions work, and which don't.

"This is an example where greed, properly deployed, could be very good, indeed."

"For widespread adoption, the interventions need to be standardized, safe, effective and proven. Risk sharing (ie, where the program developer/seller and buyer/payor share in the program costs and benefits) will help overcome certain barriers to entry and provide economic upside to the seller (e.g.: if your program can, on a population basis, reliably improve quality of life while reducing annual healthcare costs for disease X from $200 million to $75 million, there's nothing wrong with the developer/marketeer of the program to snag 25% of the savings; that's a huge economic incentive for cost reduction/disease prevention. This is an example where greed, properly deployed, could be very good, indeed. This is also an example of transforming healthcare economic incentives, from ones which reward disease treatment to ones which disease reward prevention, using economic incentives at the insured level to change behavior).

	"Extreme times call for extreme measures in order to avert an economic trainwreck. It's time we drove more personal accountability into healthcare."

"The thought of influencing consumer behavior through economic incentives may be difficult for some to embrace. To some, it sounds like 'healthcare hardball.' To others, it's big brother-ish. But, extreme times call for extreme measures in order to avert an economic trainwreck. It's time we drove more personal accountability into healthcare. This type of legislation may empower us to do exactly that. Caveat: All easier said than done!"