Tag Archives: wellness

Paid Sick Leave Lowers Costs

An Upshot column “The High Costs of Not Offering Paid Sick Leave” argues that employees and their co-workers may be better off with an incentive to take time off when sick. About 45 percent of the American work force does not have paid sick leave; that’s about 50 million workers. Families with less ability to afford unpaid time off are more likely to lack paid sick leave. According to a study in Health Affairs, 65 percent of families with incomes below $35,000 had no paid sick leave, while the same was true of only 25 percent of families with annual incomes above $100,000. Those without sick leave were farm ore likely to go to work sick (“presenteeism”), as well as to forgo seeking medical care for themselves or for an ill family member. Although expanding health insurance helps people pay for health care, it does nothing to help them afford to take time off to get it.

Another study in Health Services Research by a Cornell economist supports the theory that paid sick leave could reduce the spread of contagion. This study found that each week, up to 3 million U.S. employees go to work sick. Females, low-income earners, and those aged 25 to 34 years have a significantly elevated risk of presenteeism behavior.

The Upshot column presents the benefits of paid sick leave for one illness, flu, although morbidity and mortality from other contagious conditions would also be reduced:

Paid sick leave slows the spread of disease. Cities and states that require employers to offer paid sick leave — Washington, D.C.; Seattle; New York City; and Philadelphia, as well as Connecticut, California, Massachusetts and Oregon — have fewer cases of seasonal flu than other comparable cities and states. Flu rates would fall 5 percent if paid sick leave were universal. According to one estimate, an additional seven million people contracted the H1N1 flu virus in 2009 because employees came to work while infected. The illnesses led to 1,500 additional deaths.

Beyond reducing flu deaths, paid sick leave is associated with

Though a few cities and states mentioned above mandate employers provide paid sick leave, the Family and Medical Leave Act requires only unpaid sick leave be provided by employers with more than 50 workers. A new Obama administration rule is extending paid sick leave to ~300,000 private-sector employees working on government contracts starting on Jan. 1.  Policy makers should consider the potential public health implications of their decisions when contemplating guaranteed sick leave benefits.

Is it ethical to incentivize “wellness”?

In an essay on medical ethics, Harald Schmidt explores the question: is it right for employers and health plans to offer incentives to employees/members to pursue health care that is not informed by evidence?  He uses as his example several large insurers paying young (younger than 50, even younger than 40 years), low-risk women to obtain mammograms.  The evidence has been recently reviewed: just last week, the United States Preventive Services Task Force again used this evidence to recommend that women at average risk for breast cancer begin getting regular mammograms at age 50, and then every other year until age 74. The American Cancer Society recommends yearly mammography from ages 45 to 54, then screenings every other year afterward.mammogram-gift-card-coupon-ucare

Mammograms are not without risk. Many women getting mammograms will receive entirely unnecessary treatment and anxiety because of false positive readings. He recommends that if incentives be used, that they incentivize use of mammogram decision aids, rather than incentivizing getting the mammogram itself.  He cites a randomized trial of decision aids for women that showed that more informed women are less inclined to have mammograms.

Incentives are not limited to mammography. An analysis by the RAND Corporation found that half of all organizations with 50 or more employees have programs that incentivize health screenings or other “wellness” activities. Workers increasingly are being told by their employers to undergo health screenings and enroll in wellness programs as a way to curb insurance costs. The programs often involves stiff financial penalties — often in the form of higher premiums — for not participating in activities such as  cholesterol screening, weight loss programs or diabetes management.

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In contrast to mammography in young women, some of these “wellness” activities are recommended by the US Preventive Services Task Force. Despite this, a New York Times Upshot review of the evidence related to workplace “wellness” programs have shown that they often do not work. Although some observational studies suggest improvements in health, more rigorous studies tend to find that wellness programs don’t save money and, with few exceptions, do not appreciably improve health. This is often because additional health screenings built into the programs encourage overuse of unnecessary care, pushing spending higher without improving health.

I recently overheard employees at a local company saying that they figured out how to game the company’s wellness program by creating unhealthy online baseline profiles, pretending to be overweight chain-smokers, and then demonstrating the incremental improvements rewarded by the wellness program’s quarterly surveys. The program did not reward participants who maintained non-smoking, non-overweight status–or those who were honest about being trim non-smokers–only those who made real or fictitious progress towards this status.  corporate-wellness-program-2

Schmidt concludes his essay by recommending that we incentivize decision-making, rather than specific decisions.  Evidence-based decision aids can help patients optimize the quality of their decision, personalizing the right decision to the right patient based on medical and value-driven considerations.  He concludes:

Incentives are not appropriate in all contexts. When it comes to breast screening, the right way forward is for all payers to offer incentives for using optimized evidence-based decision aids—irrespective of the ultimate decision in favor or against screening. Doing so promotes autonomy by minimizing regret that may result both from having and not having undergone screening. Incentivized active choice can furthermore assist with reducing disparities between income and educational groups.

Policy makers implementing the Institute of Medicine’s recommendation by making mammography completion rates a priority measure should complement this initiative with measuring the informedness of decision making. A focus on completion rates alone is ethically misguided given that the balancing of potential benefits and harms is highly preference sensitive.

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