WASHINGTON: Rules let personal physicians craft wellness program alternatives

ACA regulations let people recruit their own physicians to meet requirements for such plans, but employers say this might come at an additional cost.

By Jennifer Lubell amednews staff —

June 17, 2013 –

Washington Under an Affordable Care Act provision, physicians might play a key role in helping patients meet standards for certain employer wellness programs.

The Dept. of Health and Human Services, in conjunction with the Labor and Treasury departments, issued final rules on May 29 that outline standards for employment-based wellness programs under the ACA, including those for “nondiscriminatory health-contingent wellness programs.” Such programs can be activity-based, meaning they involve some type of diet or exercise program, or they may be outcomes-based, under which people receive rewards for meeting specific health standards on measures such as weight, blood pressure or cholesterol levels.

To protect consumers, the rule stipulated that health-contingent wellness programs should be designed to help prevent disease and promote health and “not be a subterfuge for discrimination or underwriting based on a health factor.” In the event an employee is unable to meet a certain health outcome — such as reaching a certain blood pressure benchmark, for example — the rule stated that employers must provide their employees with other options. It’s under these circumstances that doctors might be called upon by their patients to help craft such alternatives.

Another step to meeting criteria

Reasonable alternatives already exist under the Health Insurance Portability and Accountability Act’s rules for wellness programs, said Steve Wojcik, vice president of public policy for the National Business Group on Health. The rule includes a new step at which an employee can reject both the original incentive and the alternative the employer offers, and instead opt to involve his or her personal physician to come up with yet another approach.

According to the rule, if an alternative standard in a specific health plan complies with the recommendations of a health care professional who is an agent of that plan, but is found to be medically inappropriate by an employee’s doctor, “the plan must provide a second reasonable alternative standard that accommodates the recommendations of the individual’s personal physician with regard to medical appropriateness, and that normal cost sharing could be imposed for medical items and services furnished pursuant to the physician’s recommendations.”

This means the employer must work with the personal physician of the employee and most likely agree with whatever the physician proposes as a second alternative, Wojcik said. He clarified that for activity-based programs, an employee would have to obtain medical justification that an alternative was medically inadvisable, though such a requirement doesn’t exist for outcomes-based programs. The employee “can invoke the alternative without any clinical verification,” he said.

How the provisions of the final rule will play out for employers is unclear, Wojcik said. “We believe the existing HIPAA wellness program rules are and were working well, so this is uncharted territory. It could be that things go on as they currently do, but it certainly adds additional complexity and potential cost to the program for the employer if a lot of people opt out and say that they want an alternative, then decide they don’t want the alternative” and consult with physicians to find something else. The hope is that employers and physicians can work toward a common goal of improving patients’ health and wellness, Wojcik added.

A chance to set individualized goals

Molly Cooke, MD, president of the American College of Physicians and a practicing internist in San Francisco, said physicians are eager to find allies to improve the health of patients, “and it’s perfectly possible that the allies can be employers.”

Dr. Cooke said a physician’s input and guidance could be useful in instances in which an employer sets a body mass index threshold of 25 in a wellness program, but an employee’s BMI is close to 40. The employee’s physician could suggest that the patient aim to lose 25 pounds as a starting point. That’s not going to get him or her below a BMI of 25, but it’s a feasible goal that the employer, employee and physician could collaborate on, she said.

The American Academy of Family Physicians did not issue an official comment on the final rule by this article’s deadline. Reid B. Blackwelder, MD, the AAFP’s president-elect, said any measure to create a connection between patients, employers and personal physicians was a positive step. “Family physicians are all about health, wellness and prevention, so we really support any emphasis on helping people live healthier lives and preventing the problems of chronic disease.”

A big concern for family doctors has been the fragmentation of care, such as patients receiving vaccinations in one place and screenings in another, Dr. Blackwelder said. One of the goals of these wellness programs should be to connect people with primary care physicians, doctors who will serve as their patient-centered medical homes. Interpreting these rules to nurture and create relationships with primary care physicians will ensure good outcomes, he said.

The American Medical Association, which has developed its own health outcomes initiatives and healthier lifestyles programs, has policy supporting participation in employer-based programs on safety, health awareness and utilization of health care benefits.

One concern the rule brings up for doctors is the potential for more documentation burden, Dr. Cooke said. Physicians already field requests from their patients to help them document medical status, and to confirm with their employers that they’re being screened on measures such as blood pressure, vision and cholesterol, she said.


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