CCA Comments and Recommendations to EEOC on Wellness Programs and Incentives

May 23, 2013

The Honorable Jacqueline Berrien, Chair

The Honorable Constance Barker, Commissioner

The Honorable Chai Feldblum, Commissioner

The Honorable Victoria Lipnic, Commissioner

The Honorable Jenny Yang, Commissioner

The Honorable P. David Lopez, General Counsel

U.S. Equal Employment Opportunity Commission

Re: Wellness Programs and Incentives

Dear Sir or Madam,

The Care Continuum Alliance (CCA) welcomes this opportunity to comment on the discussion at the May 8^th EEOC public meeting on “Wellness Programs Under Federal EEOC Laws” in Washington, D.C. We are a non-profit association of almost 200 companies. CCA convenes all stakeholders in the population health management industry. Our members design and provide services, programs and tools to better coordinate care for all patients along the continuum, from the healthy to those with chronic conditions. Through advocacy, research and education, we advance strategies that increase quality in the health care system while reducing costs.

CCA appreciates your thoughtful consideration and careful attention to the value of worksite wellness programs and incentives. We observed in your meeting that a significant portion of the discussion revolved around the “voluntary” aspect of workplace wellness programs. Jointly-issued 2006 final regulations on Nondiscrimination and Wellness Programs by the Department of Labor, Department of the Treasury and Department of Health and Human Services expressly identify the five-prong Health Information Portability and Accountability Act (HIPAA) standard as the appropriate metric for evaluating the “voluntary” aspect of worksite wellness programs.[1] The EEOC also referenced this standard in its 2008 final rule, acknowledging that Title II of the Genetic Information Nondiscrimination Act allows covered entities to offer incentives for participating in wellness programs.[2] 

The HIPAA five-prong test states that wellness programs offering rewards based on achieving a particular health status are voluntary if: (1) the reward does not exceed 30 percent of the cost of the individual’s health coverage or 50 percent in relation to tobacco; (2) the program is reasonably designed to promote health or prevent disease; (3) individuals have the opportunity to qualify for the reward at least once annually; (4) the reward is available to all similarly situated individuals; and (5) disclosure of a reasonable alternative standard if the terms of the program are described.[3]^,[4] Please also note the useful Wellness Program Analysis and Checklist provided by the Department of Labor to clarify application of the existing HIPAA standard.[5]

CCA supports this HIPAA standard as the appropriate metric. We encourage the EEOC to adopt this standard and issue such guidance to employers. This will alleviate confusion and concern regarding the possibility of additional regulatory hurdles for worksite wellness programs.[6] Confusion often leads employers to simply withdraw or abstain from offering even well-designed evidence-based wellness and incentive programs. The HIPAA standard aligns with CCA’s and the EEOC’s shared goal of promoting and improving health, while prohibiting discrimination in an employee’s eligibility or ability to participate in wellness programs.[7] Furthermore, applying the standard to worksite wellness programs offers compelling advantages over forging new compliance requirements. Using this standard in the context of worksite wellness programs would be a natural extension from its current application with group health plans, ensuring consistent and streamlined regulatory requirements around wellness programs in the health industry. Also, many employers with well-received and successfully implemented wellness programs currently use the five-prong HIPAA standard. This indicates that the standard operates as a strong functional basis for future EEOC guidance.

We are providing you with a current literature review and case studies that demonstrate advancements in worksite wellness programs. The literature shows that incentives can facilitate behavior change to increase patient engagement in wellness programs. It also positively indicates that appropriate incentive and wellness program design can produce cost savings for employers. Finally, the literature reinforces that the value of incentives in wellness programs extends beyond direct healthcare cost savings. As one component of an organizational culture of health, incentives in wellness programs can produce additional positive outcomes such as workforce productivity. 

We are also including a joint consensus paper by the Health Enhancement Research Organization, the American College of Occupational and Environmental Medicine, the American Cancer Society and American Cancer Society Cancer Action Network, the American Diabetes Association, and the American Heart Association entitled, “Guidance for a Reasonably Designed, Employer-Sponsored Wellness Program Using Outcomes-Based incentives”. This paper offers valuable insights on wellness program and incentives design for your consideration. It outlines elements of a reasonably designed wellness program and provides guidance on devising reasonable alternative standards.[8] The paper notes that incentives in wellness programs should be designed with flexibility to incent meaningful progress toward health goals and not just ideal targets.[9] It also advises employers to incorporate options that allow employees to earn any given incentive in multiple ways, promoting behavior change through individual choice.[10]

CCA looks forward to continuing this dialogue and would be glad to serve as a resource. Please feel free to contact us with thoughts or questions.

Thank you,

Frederic S. Goldstein

Interim Executive Director

Care continuum Alliance

Victoria Shapiro

Director of Government Affairs

Care Continuum Alliance

Read CCA Submitted Comments to EEOC on Wellness Programs under Federal EEOC Laws, May 23, 2013

Read JOEM Joint Consensus Statement article on Workplace Wellness Programs and use of Incentives

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[1] 45 CFR Part 146 §146.121(f)(2)(i)-(v), Department of the Treasury, Department of Labor, Department of Health and Human Services, Nondiscrimination and Wellness Programs in Health Coverage in the Group Market, Federal Register vol. 71 No. 239 (Dec. 2006): 75052.

[2] 29 CFR Part 1635, Equal Employment Opportunity Commission, Regulations Under the Genetic Information Nondiscrimination Act of 2008, Federal Register vol. 75 No. 216 (Nov. 2010):68923 n.13.

[3] 45 CFR Part 146 §146.121(f)(2)(i)-(v) at 75052.

[4] §1201, Patient Protection and Affordable Care Act, H.R. 3590 (2010).

[5] Employee Benefits Security Administration, U.S. Department of Labor, Wellness Program Analysis, Field Assistance Bulletin No. 2008-02 (Feb. 2008) 1-5.

[6] 45 CFR Part 146 §146.121(f)(2)(i)-(v) at 75052.

[7] Id.

[8] Health Enhancement Research Organization, the American College of Occupational and Environmental Medicine, the American Cancer Society and American Cancer Society Cancer Action Network, the American Diabetes Association, and the American Heart Association, Guidance for a Reasonably Designed, Employer-Sponsored Wellness Program Using Outcomes-Based Incentives, Journal of Occupational and Environmental Medicine, Vol. 54 (July 2012).

[9] Id. at 894

[10] Id.

 

Beacon Community: Population Health Industry Innovators Hold Key to HIT Transformation

Attention, population health management innovators, you may have answers in your toolbox to health information technology problems that are plaguing communities around the nation, as they look to transform their HIT infrastructure.

A group of organizations that are part of the Beacon Community Cooperative Agreement Program participated at a Public Meeting Day on Wednesday, May 22. They shared their experiences lessons learned, and pointed to existing opportunities for health care stakeholders to engage.

The HHS office of the National Coordinator for Health IT (ONC) provided $250 million in funding through the American Recovery and Reinvestment Act of 2009 over three years (2010-2013) to 17 select Beacon Communities throughout the US for local improvement.

We thought CCA members and population health management stakeholders would be well served by a quick recap of this insightful discussion.  

The top themes of the meeting can be summarized as follows:

• Population Health Management Services Are Essential To Transformation
• Payment Reform Policies Must Be Addressed To Incorporate and Encourage Health Technology Innovations
• Organizations Need A Robust Data Sharing and Communications Infrastructure
• Technology Tools that Solve Community and Primary Care Level Challenges Are Paramount
• Organizations Need To Adopt Continuous Measurement And Program Evaluation To Create Learning Opportunities And Drive Value

As you can see, these are all areas where CCA members excel and have resources to offer to help communities transform their health technology infrastructures.

The panelists provided very timely advice to the Beacon Communities.

Carol Beasley, Vice President of Business Development at the Institute for Healthcare Improvement:

Share your stories and experience.

Consolidate lessons to generate the next layer of innovation.

Dr. Asaf Bitton, Division of General Medicine, Brigham and Women’s Hospital, Harvard Medical School Center for Primary Care:

Relationships and governance structures are an important foundation.

Keep focusing on the big tough issues because they are the critical dynamics of practice transformation.

Be ready to spring to new opportunities.

Susan Dentzer, Senior Policy Advisor at the Robert Wood Johnson Foundation, and On-Air Analyst on Health Policy, PBS NewsHour: 

For communities looking to transform, state innovation grants will be big receptor sites for new opportunities. 

Dr. Mark McClellan, Director of the Engelberg Center for Health Care Reform, Senior Fellow, Economic Studies, Leonard D Schaeffer Chair in Health Policy Studies, Brookings Institution:

Distill the specific areas where communities can start.

The Beacon leanings can be foundations that are relevant for communities elsewhere.

We will get to a day where data moves with patients. Share key information needed by patients and providers in other communities that can be provided reliably and confidently.

 

A Must Read: Article on Population Health and Health Care Consumerism

The latest issue of the Health Care Consumerism Outlook 2013 includes an article by members of the Care Continuum Alliance’s team discussing how population health management and health care consumerism have a symbiotic relationship.

“The Future for Population Health Relies on Three Key Consumer-Centric Features: Health Data, Care Coordination, and mHealth” is an excellent read, if we may say so ourselves.

Consumerism and its impact on health often move faster than the health care industry. At CCA we have worked to keep pace with this market movement and respond appropriately. In 2013 our research and advocacy priorities, which are driven by our members through their participation in our Quality and Research committees, focus on the understanding of how incentives work, not merely to move consumers into wellness programs, but to engage them in community wellness, that is, incentives that inspire the consumer to transcend the health of self to move into a community health mindset.

Improving the health of populations starts by building a healthy shield around one individual consumer at a time. CCA’s population health framework, an outcome of our committees’ work puts the consumer at its very center.  We use the term consumer, not patient, because the health continuum encompasses services beyond those of “health care” and being a “patient” to include wellness and prevention, and the engagement of the individual. Lifestyle issues such as exercise and diet have been one of the initial foci of consumerism as it entered the health care space.

Read the article the full article, “The Future for Population Health Relies on Three Key Consumer-Centric Features: Health Data, Care Coordination, and mHealth”, on the magazine HealthCare Consumerism Outlook 2013.

Action Alert: Attend EEOC Meeting to Discuss Wellness Programs, Federal Law

The Wednesday May 8 meeting of the Equal Employment Opportunity Commission (EEOC) will be a discussion on wellness programs and federal law. It is open to the public and CCA members are strongly encouraged to attend and make their voices heard.

CCA Government Affairs Director will be at the meeting, and will report back, but the input of many informed voices is required to influence the discussion.

The panelists will discuss the federal law treatment of wellness programs. It will devote particular attention to the ways in which the Americans with Disabilities Act, the Genetic Information Nondiscrimination Act and other laws the EEOC enforces “may be implicated by these programs,” according to an EEOC statement.

Among the panelists will be Christopher Kuczynski, Acting Associate Legal Counsel, EEOC, who has also agreed to participate on a Washington Representatives meeting with CCA members on May 23, in Washington DC. Make sure you RSVP.

Read the announcement and full list of panelists here.

More information can be found here.

What: EEOC Meeting on Wellness Programs

Who: Equal Employment Opportunity Commission

Where: Commission Meeting Room

First Floor

EEOC Office Building

131 “M” Street, NE

Washington, D.C. 20507

When: Wednesday, May 8, 2013, 9:00 A.M. Eastern Time

CCA Featured Member: April 2013

Enrollment in HealthSciences Institute’s CCP Health Coach Learning and Certification Program continues to expand nationally and the organization is making inroads in Asia and the Middle East as well. HealthSciences is the largest chronic care and evidence-based health coaching training and performance improvement organization. Our fifth edition of the CCP program was released in February.

Our faculty includes NIH-funded specialists in health behavior change and engagement who have quadrupled engagement rates for employer purchasers in joint projects with Mercer, and assisted others in delivering measurable gains in patient-level outcomes by improving the proficiency of health care professionals to deliver evidence-based health behavior change solutions.

HealthSciences values the CCA partnership and continues to promote CCA membership as an avenue for a 25% reduction on the CCP Health Coach Learning and Certification Program tuition.

National Population Health Improvement Learning Collaborative

Since 2010 with the not-for-profit Partners In Improvement Alliance we have built a community of over 15,000 health care professionals from health plans, providers, federal and state units of health, among others. Each month our free learning collaborative webinar sessions are attended by 800 to 1,000 individuals. Learn more.

Health Coaching Performance Assessment (HCPA): Assessing the Proficiency of Health Coaches and the Quality of Population Health Services 

The first externally validated, standardized tool for measuring the quality of health coaching services delivered in wellness, disease management and care management programs. The HCPA is being used widely by BCBS affiliates, and other population health programs at Mayo Clinic, Marshfield Clinic, Stanford University Health System and the VA to benchmark and improve individual and program adherence to the evidence-based health coaching interventions demonstrated in hundreds of peer-reviewed publications to improve patient-level change. Learn more.

In an independently evaluated study by Ariel Linden, HealthSciences was the first to demonstrate a link between evidence-based health coaching proficiency (based on motivational interviewing health coaching) and member enrollment.

Registered Health Coach Program 

As you know, with lay people developing health coach training and certification programs, or wellness organizations WELLCOA offering theirs, we are proud to offer the only learning and certification programs in health coaching backed by outcomes and developed by specialists in behavioral medicine, motivational interviewing, medical psychology and health psychology. The Registered Health Coach credentials build on CCP, by offering proficiency-based training in MI health coaching. CCPs and RHCs are eligible for membership in the National Health Coach Registry http://registeredhealthcoach.org/.

CCA New Members Roll Call: April 2013

 

Accordant Health Services, a CVS Caremark company, is a recognized leader in delivering disease management and case management services for people with rare chronic conditions. We have been providing value-added services on behalf of our contracted clients such as health plans, employers, and third party administrators (TPAs) for more than 14 years.

 

Members eligible for our programs are offered our services at no cost to them through their health plan or benefit provider. This is a specialized program to help them manage their rare chronic illness. These conditions and their associated complications are managed by our registered nurses. Our programs improve the quality of life for those who are ill, their families and their caregivers, while significantly reducing overall health care costs for our clients.

 

News from CCA Quality and Research

CCA Forum Program Committee

With more than 90 proposal submissions received last month, the Program Committee has a multitude of high quality presentations from which to choose for CCA Forum 2013 in Scottsdale, AZ, on October 23-25, 2013. Through a process of online review and scoring along with an in-person meeting and conference call, the Committee is making final selections for the educational program. Themes for 2013 will include collaborative strategies for practice transformation, Big Data, and employer strategies for employee health, to name a few. And the traditional session format of the past will be transformed into more engaged presentations, working sessions, and workshops.

Walking Learning Labs and a pre-conference workshop on program evaluation are new offerings for 2013, providing additional opportunities for attendees to gain hands-on learning. The walking learning labs will guide attendees through a mini-tour of The Solutions Zone exhibit hall and demonstrate how, for example, a health care provider might use population health management strategies to better care for his patients. The half-day program evaluation workshop, on Wednesday afternoon (Oct. 23), will interest employers (HR and benefit managers) who want to better understand their wellness programs and what they should measure, resulting in “take back to the office” information. Forum attendees will need to register separately for these opportunities.

For the third year, the International Symposium on Wellness & Chronic Care will demonstrate the application and success of a variety of population health management strategies around the globe. This half-day conference will take place on Friday afternoon (Oct. 25) and will bring new perspectives from countries/regions that have not been represented at past conferences.

Our sincere appreciation goes to the Program Committee, reviewers, and their associated organizations for the commitment of time and resources: Greg Berg (McKesson Health Solutions), Suzanne Duda (Healthways), Neil Gordon (INTERVENT International), Cynthia Hallam (Blue Cross Blue Shield Louisiana), Nancy Hedstrom Wigley (Cigna), Natalie Heidrich (Ethicon), Iver Juster (ActiveHealth Management), Craig Keyes (Alere), Rose Maljanian (HealthCAWS), Michael Taylor (Accenture), and Mike Van Den Eynde (Deloitte).

Stay tuned as we begin to release more details on the CCA Forum program within the next month. Those who submitted proposals can expect to receive notification of the Committee’s decision by the end of May.

Population Health Management in Health Insurance Exchanges

A 2013 research initiative, the Population Health Management in Health Insurance Exchanges has kicked off with two work groups: HIX Assessment and Exchanges 101. We are conducting an environmental scan of the state exchanges to better understand the variety in structure, design decisions, measurement, etc. We are also using past CCA research to build the value proposition for population health management and communicate that value to the exchanges. If you have resources or expertise to share in these areas, please contact Karen Moseley, KMoseley@CareContinuumAlliance.org.