Health Risk Assessments in the Workplace: Clarian Health, Indianapolis.

At the end of last month Clarian Health of Indianapolis announced a new direction in its wellness and health mission for its 13,000 employees. To enroll for their benefits employees will be required to complete health risk appraisals. Those who fail to meet the employer’s minimum standards for blood pressure, BMI, blood glucose, LDL cholesterol and tobacco use will be fined $5 per condition per paycheck.

Clarian joins many large employers who are attempting to cut health care expenses by offering or requiring health appraisals and incentive-based health promotion measures. As reported by Jessica Marquez in “Being healthy may be its own reward, but a little cash can also help keep works fit” companies (including Delta, Sprint and IBM) are discovering that merely offering a wellness program does not change employee behavior (Workforce Management, September 2005, pp. 66-69 [link requires login]). In fact, as of 2002, Hewitt Associates found that health risk appraisals are increasingly used to refer employees to health intervention programs and 40% of the 960 companies offered financial incentives for participation and/or progress.

Clarian’s announcement drew national attention; negative incentives (docked paychecks) are seldom reported. Coverage in the IndyStar, the La Times and on MSNBC’s TODAY prompted comments from some of the most widely read health and bioethics blogs. Some of these posts, like Kelly Hill’s “Shape Up or Pay Up” (Women’s Bioethics Blog, 30 July 2007), point to the genetic factors in many health conditions and question the fairness of financial disincentives. Hill writes:

[S]hould obesity, high blood pressure, and high cholesterol – things that can be genetic—be looked at with the same light [as smoking]? Should you have to pay $60 a month because your father gave you his high cholesterol?

Arthur Caplan, in “Privacy is the true price of healthy worker discounts” (blog.bioethics.net, 16 August 2007 and MSNBC’s Breaking Bioethics, 15 August 2007), echoes Hills concerns about genetics in the context of personal responsibility:

Who will be next? The guy who skis on the weekends? The woman who wears high heels? What about the family that decides to have a baby, knowing the child may have sickle-cell disease or cystic fibrosis? Will companies be willing to put up with that sort of personal “irresponsibility”?

Caplan’s comment points to an interesting question for the ethics of predictive health. What are the “responsibilities,” personal or social, that accompany a predictive appraisal of one’s health risks? Do individuals with a family history of heart disease have a personal obligation (for the good of the community) to eat well and exercise? If so, who will define and adjudicate these “responsibilities”? Government agencies? Employers? Physicians?