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John Commins, for HealthLeaders Media, January 18, 2010

I very much support the wellness movement.

It's needed now more than ever, as the CDC reports that 34% of adults, and 17% of kids are obese. If we want to reduce healthcare costs by any significant measure, getting people to take responsibility for their health is the single most important component.

However, when we create the incentives for healthier living that are at the heart of wellness programs, we must also understand that not everybody will be able to take full advantage of those incentives.

We have to account for people who can't afford the snazzy health club, or they work a second job, or they don't live in a nice part of town with leafy green parks and safe streets that provide for enjoyable walks, or they've got a chronic illness like arthritis that makes movement painful and difficult.

The House and Senate healthcare reform bills each contain incentives to expand workplace wellness programs. The bill that passes must ensure that the motivation for people to maintain their health does not come in the form of shame, veiled threats, or economic hardship.

A recent essay in the the New England Journal of Medicine frames those concerns succintly. The essay warns that some of the "carrots" in wellness incentives are just orange-colored sticks designed to punish and weed out employees who aren't improving personal health metrics, like weight loss, or reducing blood pressure and cholesterol levels.

"Attainment incentives provide welcome rewards for employees who manage to comply but may be unfair for those who struggle, particularly if they fail," write the essay's authors, Harald Schmidt, Kristin Voigt, and Daniel Wikler, with the Harvard School of Public Health, and the Harvard University Program in Ethics and Health.

"The law demands the provision of alternative standards for those who cannot or should not participate because of medical conditions, but those categories are narrowly defined. For all others, the implicit assumption is that they can achieve targets if they try. This assumption is hard to reconcile with what we know about lifestyle change."

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