Lifestyle Behaviors and Health Benefit Costs

Transcription

1 LIFESTYLE BEHAVIORS: EVALUATING BEHAVIORS THAT JUSTIFY INCREASING THE EMPLOYEE S COST FOR EMPLOYER PROVIDED HEALTH INSURANCE R. Eugene Hughes, Department of Management, College of Business, East Carolina University; Greenville, NC 27858; hughesr@ecu.edu ABSTRACT Individuals under the age of 65 rely primarily on employers for their health insurance [9]. As the cost of this employee benefit has increased, employers have instituted a number of cost-savings efforts such as reduced benefits, limited access, increased co-payments, and increased deductibles. Of interest in the present paper are cost abatement efforts that focus on lifestyle behaviors, which adversely influence insurance premiums. If such efforts are to succeed, it will require the acceptance of all employees. The present paper will present information that identifies lifestyle behaviors that might reasonably receive support for such differential treatment. INTRODUCTION Some form of health insurance is offered to employees by approximately 60% of private organizations. While 59% of organizations with less than 100 employees offer health insurance, this benefit is offered by 93% those organizations with 100 or more employees. Approximately 24% of all employers pay the full cost of health insurance and 13% pay for the cost of family coverage [11]. The average total monthly cost of health insurance for the employee is $428 and an average of 81% is paid by the employer. The average total monthly cost for family coverage is $1078 with the employer paying approximately 71% of cost [11]. In a survey of 400 firms, it is reported [12] that the average cost of medical insurance provided by these employers was $5924. This amount represented approximately 14.5% of total payroll cost in 2005 and is an increase from the 11.9% reported in Employers began to observe increased cost associated with providing health insurance beginning in the 1970s and 1980s [9]. Such increases continue today and it is expected that these cost will increase by approximately 10% in 2008 [1]. As employers were negatively impacted by increasing health benefit costs, they pursued a number of cost control options, which allowed them to continue to provide employee health care insurance. Cost Control Efforts Risk management was a major tool for controlling cost prior to the passage and enactment of the Americans with Disabilities Act in Before ADA, risk reduction associated with the use of health benefits was pursued through pre-employment medical exams, which were, by some

2 organizations, extended to family members. By selecting low risk employees with low risk families, an organization could significantly reduce its exposure to increased insurance premiums based on employees health care utilization. After passage of the ADA, which seems to prohibit pre-employment physical, the use of this form of risk reduction has been severely limited. That is, ADA does allow pre-employment physicals when it is determined that the applicant s health is a bona fide occupational qualification for job performance. In addition, it is obvious that employers may secure health data from other sources [4]. Responding to the loss of this risk reduction tool, employers appeared to focus on cost shifting as a method of cost control. In its most direct and extreme form, the organization simply discontinues the health care benefit. Because of the unfavorable variability of premiums, this course of action appeals primarily to small employers [7]. Larger employers seldom experience wide variations in premiums and, consequently, have fewer reasons to discontinue health benefits. Because of the assumed relation between health benefits and the employer s ability to attract applicants [8], employers appear to view discontinuation of health benefits as a last resort. Many employers identified cost sharing as a reasoned approach to increased health benefit costs. Such cost-sharing efforts can take a number forms. In essence, however, they resulted in decreased health benefits. A direct reduction effort might involve limits on previously covered health events or the removal of coverage for certain health benefits. Employers often, however, simply increased the employee s deductibles and/or co-payments. In many situations, employers also began to reduce the employees choice of medical providers by requiring higher employee co-payments for providers who were not included in the employer s or insurance provider s list of preferred providers. These cost-sharing efforts often were, especially for large employers, the result of the organization s decision to self-insure or to move to a managed health care program [9]. Because of the impact of a large medical claim, self-insurance is a high-risk action for a small firm and, in fact, may jeopardize its survival. However, for large firms self-insurance has the advantage of removing its health benefits from state jurisdiction and places it under federal regulation (ERISA, Employee Retirement Income Security Act). It also allowed the organization to implement some form of individual pricing that charged employees higher premiums or deductibles for recognized unhealthy behaviors or conditions that do not fall under regulations of ADA. Efforts to charge premiums based on the employee s health were ended by HIPAA (Health Insurance Portability and Accountability Act of 1996), which requires that covered employees be charged the same premium regardless of pre-existing conditions or health. In 2007, employers received some relief from the prohibition when HIPAA rules were modified to allow financial incentives for wellness programs. These incentives or rewards can be as large as 20% of the cost of coverage for the employee [5].

3 Federal and state regulation of differential premiums and/or incentives is insufficiently precise that legal assistance is required prior to implementation of any premium/incentive programs [5] [14]. However, single company examples of successful efforts to decrease health benefit costs (e.g. [1] [2] [3] [10] [13]) suggest that incentive programs have the potential to reduce health care benefit costs. None of the above examples suggests, however, that all employees are willing to participate in offered wellness programs. In fact, Dow Chemical [10] has instituted a bonus system for it health staff that is based on their ability to enroll employees in the company s wellness program. To some extent, the lower level of participation may be a function of whether employees agree with the list of unhealthy behaviors that are eligible for incentives. As would be expected, organizations choose the unhealthy behaviors based on health cost. However, employees may choose not to participate in company sponsored wellness programs because of their attitudes toward the unhealthy behaviors. METHOD Participation in wellness programs can vary from approximately 75% for intensive intervention programs to not more than 20% for a simple program [13]. A number of explanations may be provided for the low participation rates, but employees attitudes regarding the lifestyle behaviors may be an important consideration. As part of a larger study, a questionnaire was developed to investigate this question. The questionnaire described 12 lifestyle behaviors (Appendix A) that are similar to factors for which health risk has been established by epidemiology [6]. The instructions provided information as to how premiums for group health are determined. It then raised the question as to whether it is rational that the premium for each member is the same regardless of their health behavior. The questionnaire then asked the respondent whether it was rational or irrational to consider the individual s health behavior in determining that person s premium. While, as noted above, most programs that differentially price health insurance do so on the basis of incentives, it was thought that this approach would best measure respondents attitudes regarding the identified lifestyle behavior. The questionnaire was distributed in both undergraduate (BSBA) and graduate (MBA) classes at a regional state-supported university. The sample (N=106) consisted of 50 females and 56 males with an average age of 25.6 years. Sixty-nine percent indicated management experience of one year or less for an average of 2.63 years. Twenty-six were married and 80 were single. Analysis of the 12 lifestyle behaviors (MANOVA, Wilks Lamba) showed no significant overall effect associated with these variables (i.e., education, gender, age, management experience, and marital status). RESULTS The means and standard deviations for the 12 lifestyle behaviors are shown in Table 1. Table 2 shows the results of factor analysis (principal components, varimax rotation), which identified

4 three underlying dimensions (eigen values 1.0) of the 12 lifestyle behaviors. The three factors are defined, respectively, by four, two, and two lifestyle behaviors (underlined and bold). The remaining four lifestyle behaviors exhibited cross loadings that prevent their inclusion in any one of the three factors. Lifestyle scales were named based on the lifestyle behaviors that compose the factors and scale values were computed (average responses for the included lifestyle behaviors). The means, standard deviations, and reliabilities for the Risky Behavior, Prevention, and Tobacco Usage are shown in Table 3. Table 1 Means and Standard Deviations Measuring the Rationality of Recognizing Individual Behavior in Setting Health Insurance Premiums for 12 Lifestyle Behaviors Lifestyle Behavior M S.D. Smoking Other Uses of Tobacco Drinking (Liquor, Wine, etc.) Unsafe Sex Not Following Doctor s Orders Unhealthy Eating Habits Unsafe Driving Not Using Seat Belts Lack of Exercise Risky Recreational Behavior (skydiving, auto racing, etc.) Not Maintaining Healthy Weight Not Getting Annual Physical Exam

5 Table 2 Factor Analysis of the Rationality of Recognizing Individual Behavior in Setting Health Insurance Premiums for 12 Lifestyle Behaviors Factors Lifestyle Behavior I II III_ Smoking Other Uses of Tobacco Drinking Unsafe Sex Not Following Doctor s Orders Unhealthy Eating Habits Unsafe Driving Not Using Seat Belts Lack of Exercise Risky Recreational Behavior Not Maintaining Healthy Weight Not Getting Annual Physical Exam

6 Table 3 Means, Standard Deviations, and Reliability for Three Factors Representing the Rationality of Recognizing Individual Behavior in Setting Health Insurance Premiums for 12 Lifestyle Behaviors Factor M S.D. Alpha I. Risky Behavior II. Prevention III. Tobacco Usage DISCUSSION For discussion purposes, it is reasonable to recognize the response scale values as representing respondents support or the lack of support for including individuals lifestyle behavior in determining health insurance premiums. Support is defined here as values less than the midpoint of the response scale (3.5), while greater values indicate no support for considering the lifestyle behavior in rate setting. With this definition, only six (bold in Table 1) of the 12 items suggest support for recognizing individual behavior in pricing health insurance. The strongest support is provided for Smoking and Other Uses of Tobacco. Drinking and Unsafe Sex receive modest support, but Not Maintaining a Healthy Weight and Not Getting Annual Physical Exams reflect only very weak support. With one exception, these results are consistent with the cost savings pursued by many employer sponsored wellness programs. The major difference is the low level of support for recognizing weight control. As expected, data for the three identified factors, Table 2 and Table 3, are consistent with the above discussion. An import difference is that Risky Behavior receives no support for inclusions in the rate setting decision. A review of the lifestyle behaviors included in the factor suggests that respondents may feel that these are, for the most part, off-the-job behaviors. As private lifestyle behavior, it might be assumed that they should not be considered as a part of the employer/employee relation.

7 CONCLUSIONS As discussed earlier, employers are pursuing a number of wellness efforts to control their cost of employer provided health insurance. To obtain these cost savings, some employers require employees who exhibit unhealthy lifestyle behaviors to pay higher premiums and others reduce the premiums for health lifestyle behaviors. In the latter incentive system, the employer, in order to obtain the desired cost savings, must have the participation of a majority of the employees. A factor that may influence the level of participation is the extent to which employees agree that the lifestyle behavior should be included as a factor in determining premiums or incentives. Data were collected to determine whether respondents supported the inclusion of 12 lifestyle behaviors, which are consistent with those identified as health risks [6]. Scales based on the results of factor analysis provided support including Tobacco Usage and Prevention (maintaining healthy weight), which, in various forms, are included in most, if not all, wellness programs. Interestingly, respondents provided no support for the inclusion of the Risky Behavior factor. The lifestyle behaviors included in this factor appear to be a matter of private behavior. As such, respondents may be telling us that these lifestyle behaviors are out-of-bounds for inclusion in the employer s wellness programs.

8 REFERENCES 1. Covel, S. & Spors, K. K. (2008, June 26). Providing health benefits on a budget. The Wall Street Journal, p. B6. 2. Feinberg, D. (2007). Managed Care. The Journal of Child and Adolescent Psychopharmacology, 17(3), Hodge, J. (2006). Lowering healthcare premiums by increasing staff wellness. Nursing Homes, 55(11), Kapur, K. (2004). The impact of the health insurance market on small firm employment. The Journal of Risk and Insurance, 71(1), Knight, V. E. (2008, January 16). Wellness programs may face legal tests. The Wall Street Journal, p. D9. 6. Long, D. A. (2006). The cost of lifestyle health risk: Obesity. The Journal of Occupational and Environmental Medicine, 48(3), Monheit, A. C., & Schone, B. S. (2003). How has small group market reform affected employee health insurance coverage? Journal of Public Economics, 88, Monheit, A. C., & Vistnes, J. P. (1999). Health insurance availability at the workplace. The Journal of Human Resources, 34(4) Park, C. H. (2000). Prevalence of employer self-insured health benefits: National and state variation. Medical Care Research and Review, 57(3), Rubenstein, S. (2005, October 24). Keeping workers healthy pays off at Dow Chemical. The Wall Street Journal Online, ( 11. U. S. Department of Labor Statistics (2007). National compensation survey: Employee benefits in private industry in U. S. ( 12. U. S. Chamber of Commerce (2008). Chamber survey employers pay more for benefits. ( 13. Wellness; MacAllister Machinery reduces healthcare costs, Improves employee health with CareGuide s predictive modeling and health coaching program, (2007, October 13). Obesity, Fitness, and Wellness Week, p Zhang, J. (2008, June 4). Lawsuits test disabilities act. The Wall Street Journal, p. D1, 6.

9 APPENDIX A PRICING HEALTH INSURANCE In general, if you are a member of a group health insurance plan, everyone in the group is charged the same price for the insurance. When members of the group engage in unhealthy or risky behavior that results in medical costs, all members of the group share in any increase in the cost of the insurance. One might ask why all members of the group must pay for the unhealthy or risky behaviors of a few members. The following questions ask you whether you think it would be RATIONAL to consider an individual s unhealthy or risky behavior in pricing group health insurance for that person. In answering the following questions, consider only the listed behavior, do not be concerned either about the intensity or how much of the behavior would be required to initiate an additional cost or how the behavior would be detected. Very Rational Very Irrational SMOKING OTHER USES OF TOBACCO DRINKING (Liquor, Wine, etc.) UNSAFE SEX NOT FOLLOWING DOCTOR S ORDERS UNHEALTH EATING HABITS UNSAFE DRIVING NOT USING SEAT BELTS LACK OF EXERCISE RISKY RECREATIONAL BEHAVIOR (e.g., skydiving, auto racing)

10 NOT MAINTAINING A HEALTHY WEIGHT NOT GETTING ANNUAL PHSYCIAL EXAM