We have a boat at 11 45 but that should leave us an opportunity to her from our witnesses and to have good time for questions. I told our witnesses that i was delighted to be talk about something other than the individual Health Insurance market. Im really quite serious about that because we know that larger issues in health care are much more than the 6 of the people i the one of whom is important not to buy the insurance on the individual Health Insurance market. So were glad to get, glad to have this discussion and that the subject in which both republicans and democrats have a lot of interest, and we look forward to your advice. Today were Holding Hearing to look at what can be done to encourage people to make healthier lifestyle choices, o prevent serious illnesses and reduce healthcare costs. Senator murray and i will each have an Opening Statement and then will introduce the witnesses. After the witnesses testimony senators will each have five minutes of questions. Let me say before begin to what you think senator murray for her leadership and being a straightforward tough negotiating partner on our efforts to present to the senate a limited a bipartisan bill to stabilize the Insurance Market during 2018 and 19. She and i will go to the Senate Floor Today at 1 00 and make a brief statement, and put the text of the legislation and congressional records. The the senators can examine it. We will also list a significant number of republicandemocratic cosponsors for the legislation and our hope is now the we put a proposal on the table that the senate will consider it, the house will consider it, the president will consider it. I talked to the president last night and he encouraged the process, which he asked me to begin and said he looks forward to considering it. I said if your suggestion for improving it, that is certainly your prerogative to do and thats what we would expect to happen in the legislative process. I think senator murray for that and other members of the committee who have been involved in it. Over the last seven years we endured this political stalemate over the Affordable Care act with most of the disagreement being over as i sit a very small part of the Health Insurance market where 6 of americans by their insurance. Our stalemate has really been over all of healthcare. The fact that weve had that stalemate makes this even more refreshing to talk about an area of healthcare on which most americans, doctors, employers, republicans, democrats agree. That consensus is that a Healthy Lifestyle leads to longer and better lives and reduces the nations healthcare costs according to the centers for medicare and medicaid services, healthcare spending in the United States has grown from consuming 9 of the Gross Domestic Product in 1980, the nearly 18 , or 3. 2 trillion, in 2015 and predicted 20 in 2025. Cleveland clinic which is represented by one of our Witnesses Today has said if you achieve at least four of six normal measures of good health, and to behaviors, you will avoid chronic disease about 80 of the time. The six indicators of good health are familiar, Blood Pressure, cholesterol level, like sugar, body mass index, smoking status and your ability to fulfill the physical requirements of your job. The two behaviors are seeing your primary care physician regularly and keeping immunizations uptodate. Again if you get four of the six indicators and keep up the two behaviors, according to the Cleveland Clinic you will avoid chronic diseases 80 of the time. This is important because we spend more than 84 of our healthcare costs, or 2. 6 trillion, treating chronic diseases. Thats something on which almost everyone agrees. So lets add to that under the obvious fact. About 60 of americans get their Health Insurance on the job. We really want to focus on improving the quality of healthcare in america, why not connect the consensus about wellness to the insurance policies that 178 million americans get from their job . Thats precisely what the Affordable Care act sought to do in 2010. Fact is one of the only parts of the aca that everybody seem to agree on. Todays hearing is about how successful wellness initiatives have been and what we can do to make it easier to encourage people to lead healthier lives and reduce healthcare costs. Many employers have developed Wellness Programs to incentivize people to make healthier choices. These programs may reward behaviors such as exercising, eating better, waiting smoking, or offer employees a percentage of their insurance premiums for doing things like maintain a healthy weight or keeping their cholesterol levels in check. These programs have the potential to save employers money and improve the health and wellbeing of their employees. Steve burd, one of our witnesses, as ceo of safeway, visited with many of us a few years ago and started a Successful Employee Wellness Program after he left safeway which ill kill talk about, thats 11 part of it. I would also like to what communities and the federal government for doing to encourage Healthy Lifestyles choice of the kind of Blue Cross Blue Shield of tennessee partner with local state and private organizations to find Community Level initiatives across our state such as fitness zones in chattanooga, programs and rowan county to promote Healthy Habits and interactive Elementary School program to keep kids moving. An example of encouraging wellness at the federal level is a medicare Diabetes Prevention program, and innovation, Intervention Program for medicare recipients diagnosed as prediabetic to prevent type two diabetes. Medicare spin estimated 42 billion more in 2016 on people with diabetes than it would expand if those recipients did not have diabetes. There are other ways to encourage healthier behavior, but its hard to think of a better way to make a bigger impact on the health of millions of americans than to connect the consensus about wellness to employerbased insurance for 178 million people. I look forward i look forward it to the hearing. Senator murray. Thank you very much, chairman alexander. Thank you to all of our colleagues and witnesses for joining us today. We often think of healthcare as something you need when you get sick, but we should be thinking about more about ways we can help prevent families from getting sick in the first place and the makeup in the Doctors Office for the hospital. Im really glad were having tradition on how to better promote health and wellness because the truth is we all have a role to play in supporting families efforts to make healthy choices whether its government for community or hospital or schools. Businesses employers who can promote Healthy Behaviors in partnership with their the com. So i look forward to a robust discussion today about wellness and Public Health efforts that promote physical activity, improve access to healthy, affordable foods especially for our kids, expand on sciencebased ways to to reduce tobacco use, and a lot more. I will be focused on making sure congress is providing the investments needed to support local, state, and federal efforts to promote Public Health, that includes Grant Programs by the centers for Disease Control and prevention that invest in Community Health centers as well as the prevention of Public Health fund which has made a difference for so many patients and families nationwide. Given our nations high healthcare costs and the fact some of those costs can be attributed to chronic diseases, it is critical we do more to support Public Health efforts focused on Health Education and promotion. I do want to be clear on the following one who consider Wellness Programs we have to do it in a balanced manner and make sure we are protecting workers, civil rights and privacy trip for me and enough a lot of my colleagues the fact that Employee Wellness program could impose significant financial penalties on workers who do not wish to share protected Health Information is a very serious concern. I want to today more about what we need to do to make sure we find this right balance for Wellness Programs that protects workers rights under the americans with disability act and hipaa and the Genetic Information nondiscrimination act, three laws that were written and passed by this committee, and i have a clear, responsible for making sure the rights of workers with disabilities and those who do not wish to share Genetic Information protected and respected in these programs will rest with the trump eeoc which is exactly one of the reasons why democrats pushed so hard against his recent nominee to the eeoc nominees who really unconcerned dont show they were truly committed to protecting those workers from discrimination. So this is a balance we need to work on and figured out and it would appreciate all of our witnesses who are being here to help share your information with us and look forward to the discussion. Mr. Chairman, i do have a letter from aarp that a participant for the record as well. Thank you. It will be submitted. Thanks, senator murray. We would ask each witness to please summarize your remarks in about five minutes. That will give us more time to ask questions back and forth from senators. First witness is steve burd, founder and ceo of burd health or he was ceo of safeway for 20 years but many of us met him when he roam the halls during the debate on the Affordable Care act, both democratic and republican halls with a message about wellness. Secondly from dr. Michael roizen, the chief wellness officer and founding chair of the Wellness Institute at the Cleveland Clinic. A program that i just described in my opening remarks. Dr. David asch is executive director of Pain Medicine center at the Healthcare Innovation and john morgan professor, Goldman School of medicine and the Wharton School at the university of pennsylvania. Hes a leading behavioral economist with Much Research on Healthy Lifestyle choices. And then Jennifer Mathis is director of policy and legal advocacy at the judge center for Mental Health law. She supervises the Center Policy work and engages in advocacy. Why dont we start with you, mr. Berg . Welcome. Thank you. Thank thank you very much. I think the first thing id like to say is i very much appreciate the opportunity to share my experience in the wellness category with the committee here, and i would want to applaud your willingness to work in a bipartisan fashion with the health of americans and ultimately legislation that is attached to that. Im going to go quickly through a little bit of background of what ive done since i left safeway in the ceo position because its impact how i think about the subject. Secondly, i want to talk about why we picked wellness as a real important area. Third, im going to cover the elements of the Wellness Program that we introduced at safeway. I think its most instructive because we had a ten year run so we know what the statistics look like after some ten years. And then finally im going to speak to the results that we achieved which i think are extraordinary and i think indicative of what others can do. And then finally i want to talk about what you think are the five keys to success in a Company Wellness plan. Because most people have failed at this, and i know that michael and i, and maybe others here who testify have succeeded i think youll find some common success elements. After leaving safeway, while at safeway as the chairman indicated, i got very involved in healthcare. And discovered it was a fascinating area, great opportunity to improve the health of americans opportunity to improve care without adding to cost and, frankly, an opportunity to dramatically lower costs. So i committed to spending the next ten years of my life and i now spend for in this space. What i wanted to do is tell you briefly what my company does is we do three things that are unique. We are able to lower a company or organizations cost 4050 simultaneously lower the employees expense about six to 10 there were also capable of significant improving the care they receive here and if they are willing we can have a dramatic effect on the wellness of the population which has profound effects on the productivity of that workforce. I picked wellness back in 2008 because we took note that about 7 of all healthcare costs are driven by healthcare behavior. We thought as a selfinsured and point with the right to design a plan, whoever we chose we can actually affect behaviors and people would become healthier. I want to put in context for you because i know you will at some point want to understand how to reduce costs. That in the short run there are other ways to reduce costs more significantly. The first one i would mention would be provider agencies and plan discipline, plan design and then wellness. In the first five years i put wellness in the fourthplace. In the next five to ten years i would put it probably close to second place or third place. So theres an opportunity there. On the wellness front we put together a program at safeway and we made it a volunteer program, which im not sure everybody understood at the time. And 85 of our employees opted into this plan, and 70 of the spouses opted into this plan. We rewarded people for achieving certain biometric standards with about 600 worth of rewards. When we polled people as we did annually about of the participants be the program is either very good or excellent. What we measured was 78 . Blood pressure, tobacco use and bmi. As i said the results were amazing. Ill give you a tear your look after starting the program. Of the people that failed the Blood Pressure standard, two years later 73 of the past and they maintained that over the balance of the program. Prediabetic, of those a failed initially 45 of the past two years later. Cholesterol level, 43 of those past two years later. Smokers, cut a number of 35 but in fairness, you can beat that task, and so while it did improve the smoking, 35 is a bit a bit strong. Then we took the obesity rate of our population of 28 down to 21 . I had a goal to become if we were state would be the lowest obesity state in the United States. Senator bennet at the time of colorado held the positions aware that in 2013 we matched colorado at 21 . I want to just move quickly because as i have nine seconds left. Why did we succeed . First of all we rewarded outcomes in our participation, the best budget of programs, they say their outcomebased. Not their participation base. We put a meaningful amount of money at stake. We give that starting point at about 600. We needed to provide support tools that would allow people to actually change their behavior, enhance their state of health. Then we needed to surround them with an ecosystem that constantly convinced the employee that we cared about their health. We can talk more about that in the q a. And then we consciously develop a culture of health and fitness. I did this when i was about 57 7 years of age and i understood that my fitness level down the road was going to determine my state of health. Once you become a mobile, your Health Begins to decline so we focused on health and fitness. And lastly, it needs leadership and a practice this with clients today. If you dont have ceo leadership it just doesnt work. And i i would contend you cant pick three of the five in my experience you have to do all five. Thank you, mr. Berg. Dr. Roizen, welcome. Chairman alexander, Ranking Member murray, it was of the committee. My name is dr. Michael roizen edit thank you for the opportunity to testify today before your committee. Since 2007 i served us of the chief wellness officer at the Cleveland Clinic. In this capacity i leave the clinics work in preventing illness and helping people live longer, healthier lives. We give people more time. Keeping people well and enabling them to live the best life is not just my professional goal, its my passion, my lacework and passion of the Cleveland Clinic. Thank you for your leadership in building this important hearing. In fact, the title of the hearing encapsulates the Cleveland Clinic story. That is, how healthy choices can improve Health Outcomes and substantially reduce medical costs. Were hopeful the result of our efforts over the last nine years can demonstrate that we as a nation can have real impact on the health of our people while resulting in hundreds, literally hundreds of billions of dollars in savings for both the private sector and the federal government. For years the Central Healthcare debate in washington has been about what role of government should play in providing Health Insurance. But if leaders in washington dont address the skyrocketing cost of healthcare caused by the influx of chronic disease, it wont matter whether medicare, medicaid, private insurance or individuals pay the bills. Everyone in this room has seen the cbo estimates. And lastly do something to bend the cost curve, we will all be bankrupt from this influx of chronic disease. That is growing five to seven times faster than the population. There is, however, something both the federal government and private insurers could do right now to significantly reduce healthcare costs across the country. Regularly and keeping immunizations uptodate. The Program Helps employees get these six going. The way we do it is we pay employees, that is we incentivize employees and we ended up small but ended up increasing payments the same number as mister burd to achieve the six normal and to behaviors. The upshot since the onset of the program the Cleveland Clinic has saved 240 million and direct cost increasing yearly. This year we will save 150 million more versus the benchmark, as more of our employees get to stay healthy. Their improved health is reflected in substantial reductions in unscheduled sick leave and a 62 percent of clinic employees who voluntarily participate have seen their healthcare costs and premiumsdecrease. Now by 600. For hitting these increases from 16. 42 other four for the state of ohio, body mass employees is taken 14. 5 percent per year as opposed to the nation increasing. 7 percent per year. Blood pressure, cholesterol and a1c levels have improved substantially resulting in an 11 percent decrease in the need for illness care since 2009 rather than the expected 20 percent increase. The Cleveland Clinic has replicated health by nine other large employers, all of whom have seen similar results. Lafarge National Construction supply company is saving 60 percent of expected medical cost and we know that other organizations learn from these examples. In short, the Cleveland Clinic reward for Healthy Choice Program is doable, exportable and scalable across the country. The clinic has been working to educate lawmakers on this idea and senators rob wyden and portman are collaborating to work in the Senate Finance committee aimed at reducing the cost and improving health of Medicare Beneficiaries but it doesnt have to stop with federal programs. Private sector programs supported by this committee could benefit by the work we pioneered. This program have at least three critical virtues. Its been tested in multiple settings across different population and patient groups, everything from engineers to blue cross , bluecollar workers. Its entirely voluntary and it enables the federal government to achieve substantial cost savings without any of the program added budget cuts and without any initial cost. Ending the cost through voluntary Wellness Programs is a common sense idea that both republicans and democrats should be able to rally around for the health of our nations finances, the health of our people. It increases our competitiveness for jobs thank you dr. Roizen and doctor asch, welcome to chairman alexander and distinguished members of the committee, thank you for the opportunity to speak with you today. My name is david asch and i am a practicing pro position. Im here to talk about Workplace Health programs and their role in the nations health. My summary messages this, i believe employersponsored Wellness Programs value to contribute. I believe even though the health and financial benefits of these programs are often overstated. I believe that even though some of these programs and the ways they are designed treating some employees unfairly but im optimistic. About these programs going forward. Because we are learning how to design and be much more effective and fair. Americans spend most of their time outside the Health Care System even though those with a chronic illness spend only a few hours a year in front of a doctor that we spend about 5000 waiting hours a year doing Everything Else in our lives and its during those 5000 hours when so many of the determinants of our help unfold. How we eat, whether we exercise, smoke or take our medications. We can put more and more money into healthcare but much of our health is determined in the 5000 waiting hours outside the reach of doctors and hospitals. Americans spend many of those waking hours at work. And employers have a large financial incentive to advance health, not just because of our system of employment based Health Insurance but also because healthier workers are more productive and so more than three quarters of large employers now have some sort of workplace Wellness Program charging risk factors that youve heard about already that account for much of chronic illness risk factors like tobacco use, high Blood Pressure, obesity and the life. Unfortunately its a lot easier to know what conditions to target than it is to know how to do so. Managing these conditions requires potentialbehavior change. Our nation has invested considerably in the science of medical treatment as it should, but less in the science of behavior change. Our our knowledge how to break old habits , develop healthier ones is rudimentary. But its getting better. Behavioral economics, one example of how we are learning more about changing behavior, just last week Richard Taylor of the university of chicago won the nobel prize in economics recognizing we all succumb to irrational tendency to compete with our goals. Increasingly, behavioral economics and then used to help doctors and patients make better decisions and im proud to say the university of pennsylvania is a world leader in the field. One such irrationality is we are much more motivated to avoid a 100 loss and we are to see a 100 gain. It doesnt make economic sense. We found this recently when encouraging overweight employees in a large firm to increase their fitness. In one group, employees were given a dollar 40 for each day that they want at least 7000 steps. Thats entered economic dental incentive. For another group we structured it as a loss, a dollar 40 a day or 42 a month. We gave each employee 42 at the beginning of the month and took away a dollar 40 every day they didnt want. And in economist with would see those two designs at the same. For every day you walk 7000 steps you are a dollar 40 richer but it turned out those who received a dollar 44, were no more likely to walk 7000 steps than those who received no incentive but those who had a dollar 40 taken away and didnt want 7000 steps were 50 percent more likely to succeed. Mathematically and financially, these two approaches are the same but one work and the other didnt. Most Large Companies are using financial incentives to encourage healthy behavior, the vast majority of them do so by adjusting the premiums their employees pay for their Health Insurance. Although it may seem obvious at charging higher premiums for being a smoker or overweight would encourage people to modify their hats, there is little evidence that programs designed that way work. At best, they provide modest financial benefits to employers and unclear Health Benefits to employees. These programs offer promise but also draw criticism. I remain nevertheless excited about the welldesigned programs that help americans change the behaviors they want to change, help them quit tobacco, lose weight, help them better manage their high Blood Pressure. These changes are much less likely to come from typical premium based financial incentives and more likely to come from approaches that reflect the underlying psychology of how people make decisions encouraged by frequent lawrence and emotional engagement, contests and the social acceptance. Those are the ingredients of successful programs and they are missing from most of what employers do. We know so much more about how to design financial and other incentives to motivate Human Behavior far more now that even 10 years ago. I havent seen much of this new knowledge applied effectively by employers but theres no reason it cant be. Thank you for inviting me to testify and i look forward to your questions. Thank you doctor asch, ms. Mathis, welcome. Chairman alexander, Ranking Member murray and members of the committee, i appreciate the opportunity to testify about this issue. My name is Jennifer Mathis, and chairman alexander noted in my position at the Babylon Center for Mental Health law but i am here as a representative of the consortium for citizens with disabilities or ccd, a coalition of over 100 National Disability organizations that Work Together to promote public policy, injuring determination, independence, integration and inclusion of adults and children with disabilities in all aspects of society. I appreciate the breath of the topic of this hearing, obviously there are many different ways you can promote the choices that improve Health Outcomes and many different stakeholders can do so. The primary concern that animates this hearing seems to be the role of employerbased Wellness Programs that i also think its important to mention the role of state Service Systems, particularly those for people with disabilities and older adults in planning and administering terraces in a way that expands opportunity for independence, choice and autonomy and enabling people to exert more control and participate in their own health care, direct their own lives and work. Weve seen from numerous studies over many years that realigning Service Systems to offer people with disabilities chance to live, work and receive services leads to improved Health Outcomes and lowers costs so im happy to answer questions about any questions about that but i will focus the rest of my comments on workplace wellness. Pcd has supported development of Wellness Programs as a tool to improve life and Health Outcomes but those programs can and must operate in a way that respects longstanding workplace protections shows such as those provided by the americans with disabilities act and the Genetic Information nondiscrimination act, especially workplace privacy protections. People with disabilities need these protections. The employment rate of people with disabilities is lower than that of any other group tracked by the bureau of labor statistics. They are employed at less than half of the rate of people without disabilities. Study after study has examined why the employment rate of peoplewith disabilities is so low , mobility barriers is one of the chief reasons. People are continuing to be pervasive in our workplace. It was precisely for that reason that when Congress Passed the ada, one of our most important civil rights laws for people with disabilities, it created strict protections to enable employees to keep their health, disability related information confidential in the workplace. Employees could be subjected to medical exams or inquiries only if they were jobrelated or voluntary inquiries that were part of an Employee Health program. Gina provided similar things. Removing or weakening those protections would make many people with disabilities vulnerable in their workplaces and expose them to the risk the congressman wanted to avoid. The eeoc rollback the protection they had enforced to ensure employers could not penalize employees or declining to provide their Health Information as part of a Wellness Program. The agency instead incurred deep financial penalties for employees who could choose to keep their Information Private and more penalties if their spouses chose to keep their Information Private, making this choice far from voluntary. A federal judge has now ruled the agency violated the law and failed to provide a reason justification for this change in position. The agency now has an opportunity to revisit its regulations and do the right thing to afford people the rights guaranteed by the ada and gina. We believe it is not difficult for the eeoc to ensure the Wellness Program to support the healthy outcomes while respecting important civil rights of people with disabilities. The agency set out path for doing this in its 2010 regulations implementing gina, clarifying that financial incentives can be used but not for questions asking for Genetic Information. The same rules should apply to actions seeking Health Information of a spouse. The study on Wellness Programs conducted for the department of labor highlighted many strategies other than incentives that have made Wellness Programs more effective. Good Wellness Programs can be designed without eroding the civil rights of people without disabilities and we will all be better served if that happens. Thank you ms. Mathis. Now we have a round of fiveminute questions and im going to start with senator young. Thank you mister chairman. Im excited about this hearing because i know a number of our witnesses have discussed in their testimonies behavioral economics and behavioral decisionmaking and i think its important that we as policymakers incorporate how people really behave, not according to an economist for say or according to other policy experts but based on observed behaviors. Often times we behave in ways that we dont intend to. It leads to results that we dont want to end up in so mister asch, i will start with you with your expertise in this area. Youve indicated behavioral economics is being used by doctors and patients to make better decisions and you see an opportunity for employers to help americans change their behaviors and ways they want. Tobacco mitigation, to losing weight to managing Blood Pressure. You indicate those changes are much less likely to come from typical premium based financial incentives and more likely to come from approaches that reflect the underlying psychology of how people make decisions, encouraged by frequent rewards, emotional engagement , contests, social acceptance and so forth. You said in your verbal testimony you havent seen much of this new knowledge applied effectively by employers but theres no reason it cannot be. So my question for you sir, what are employers, what might they learn from behavioral economists just in summary fashion . I think ill start by saying theres a misunderstanding often about behavioral economics and about how many people believe if you use financial incentives to change behavior, youre engaged in behavioral economics and i would say thats just economics, it becomes behavioral economics when you use an understanding of our psychological foibles to supercharge the incentives and make them more potent so you dont have to use incentives that are so large. There are a variety of approaches when it comes to behavioral economics that can be applied in that setting. One is capitalizing on the notion that losses loom larger than gains might be a new way to structure incentives and the employee setting in ways that might make it more potent and palatable and easier for oral implore employees. The delivery of incentives more frequently for example or using contest or social morning where its acceptable to show people on leaderboard and contest and get people engaged in fun towards their health, all of these are possible. Thank you very much and you really need tostudy these different phenomena individually. I think to have a sense of the growing body of work that is behavioral economics. We need to increase awareness and i guess the education of Many Employers about some of these things we have in that seems to be part of the answer. Richard taylor who won the nobel prize for his round breaking work in this area, indicated that we as policymakers ought to have on a regular basis not just lawyers and economists at the table as we are tracking legislation but we ought to have a behavioral science scientist as well. In the uk they have the Behavioral Insights team, the United States or previous ministration had a similar team that did a number of experience to figure out how policies impact individuals health and wellness and a number of other things. Some of the ideas that i think we might incorporate into the government context and tell me if any of these pop for you, or they may make sense, we need to continue to have unit or units embedded within government that do a lot of these experiments. We need to have a clearinghouse of best practices that others employers included might draw on. This doesnt have to be governmental but it could. We on capitol hill might consider a aside from having a Congressional Budget Office , we might have an entity or at least some presence within the cbo of individuals who understand how people would actually respond to a given proposal. Do any or all those make sense . Thank you for your remarks, they all make sense to me and one of the lessons that i guess i have repeatedly learned is that seemingly subtle differences in design can make a huge difference in how effective a program can be and how its perceived and that ultimately is who cares about the impact of these programs so im in favor of a greater use of these programs but in addition, greater study of these programs so i think we need an investment in the science that will all of us better at delivering these activities not just in healthcare and other parts of society. Makes a lot of sense, im out of time, thank you. Thank you, i will start with you and weve heard a lot today about workplace Wellness Programs but as i mentioned i think its critically important we think about how the investments are made in our communities can also play a Critical Role in making the healthy choice the easy choice for our families in this country. Do you mind in washington we have seen a lot of these really critical efforts in our school for example. We are investing in physical education and healthy food and beverage preparation in our cities and towns are working to make the environment more accessible to all users, bicycles, pedestrians, people of all ages and abilities. Our Healthcare Providers are making it easier to quit smoking and taking steps to better support the feeding for example and our communities of color are taking strides to ensure cultural competence programs to promote the health of people in my state so i want to ask you, do you agree from in addition to these workplace based programs, communitybased efforts from what health and wellness are also important . The answer is absolutely agree. In your state, in your school, in a leadership role, the rest of the nation is, would love to file and hopefully we will be able to, what i mean by that is we need kids to be healthy and influence their parents to be healthy. When you get food manufacturers to make food for large distribution your schools, you really get to change the health of a whole generation so we totally applaud that. We work with that and in fact, i would go and give a network of what we call interim and outer ring schools in and around cleveland. And its very hard to get appropriate products for the school lunches, etc. And breakfast. Your state is taking the lead in that and we thank you. I was going to ask you as you well know Federal District court held that the eeo commission failed to support its rules on Wellness Programs. Those rules and employees decision not to participate in a wellnessprogram was voluntary so long as the employee did not have to pay a penalty greater than 30 percent. In other words, thousands of dollars. That high of a penalty is a problem, for the millions of employees and their spouses who did not wish to seek disclosure of Genetic Information or the assistance of a disability by participating in Wellness Programs that do collect sensitive Health Information. The person has a right under the ada, the right under the nondiscrimination act, under hi pda and those are three im proud of. As you may well know, this committee met yesterday and cleared for the full senate and trusted ministration nominees now lead the eeoc and among other things, those nominees will now be responsible for rewriting those rules. So i wanted to ask you , how should the eeoc criteria set criteria for when participation in a Wellness Program is not voluntary and what advice would you give those members. The most important thing to remember is that their job is to apply the ada and not to rewrite it, to try to conform it to another law that also applies for the same time but did not overturn or modify the ada, there are many circumstances where two laws apply at the same time and one that requires additional things beyond what the other requires and we have a lot of experience at calling multiple laws to the same set of circumstances. They already have a framework that they use for 16 years under the ada and they use the same to analyze what involuntary question under gina and their 2010 regulations, implementing a parallel provision. Allowing requests for employees Genetic Information as part of a voluntary Wellness Program and i would point out that the gina regulation was done after the Affordable Care act and they considered the two laws and the fact that the Affordable Care act has been passed with its provisions about Wellness Programs and considered those consistent. That framework was logical, use the ordinary meaning of a voluntary, that you can acquire a person to answer or penalize a person for not answering a question. Thats consistent with a dictionary definition of voluntary which is not upheld by outside influence or unconstrained by interference or valuable consideration and having received financial incentives, it seems the dictionary definition of what is not voluntary. So having the same kind of framework and impact that they charted for the 2010 regulations, to apply also to the ada which is how they interpreted the ada before 2016 for many years, to allow the program to have incentives but just not to incentivize or to have significant incentives for people turning over Health Information thats not jobrelated. That i think would allow Wellness Programs to proceed and develop and use incentives in other ways and use many other strategies to engage people without eroding the civil rights of people with disabilities. Thank you senator murray, senator isakson. I dont remember correctly the financial incentives of these participation by employees separately. Security . Financial incentives for the employees in their Wellness Program . Have you found in your work with Wellness Programs, the best financial incentives to put into place for your Wellness Programs and inducing more people. I think we had extraordinary anticipation even in greater that something you had, we were 85 percent voluntary, 70 percent for spouses. Im a big fan of both the 96 race, i thought they were well thought out and the adjustments that were made to the Affordable Care act, those were equally well thought out. What i dont want the committee to do is get the impression that its all about incentives. Incentives are i think necessary but by themselves not sufficient. Going back to something that david said earlier, the secret sauce at safeway was creating small workgroups. We have thousands of groups that came together on their own, set goals and objectives, time frames, they might exercise goals are weightloss goals, we give them the tools to accomplish that to attract one another and it really was a driving force along with ceo leadership. So i look at government as being in an enabler in this process but i also think theres an opportunity for government to lead. And i think ill just been down there over the years and one opportunity to lead is i would love to see the federal government about programs like this for their own employees. I offered to do this for secretary sibelius in the 80,000 people at hhs to do it for free. Unfortunately, that was about 30 days before she left office and she was excited about that. But not just about incentives, and its important that we employed 10,000 people with disabilities out of 185,000 people. 2000 were part of this program and the hippa regulations, when i say they are well thought out, they require if its judged to be too difficult that you adopt a different standard and even provide a waiver. In our experience and id be interested what youve done at the Cleveland Clinic, about 3 to 4 percent would reach for and get either a lever or an alternative standard so while we wanted you to get before 830 bmi, if you had a 40 bmi and you made 10 percent progress we gave you the reward. We gave you a reimbursement check but we enjoyed writing those checks. It was about encouraging wellness and if you had orbited he and your position that i feel better at going from 45 to 43, we would say fine. Thats the standard. Then we would change thatover time and im sure the Cleveland Clinic did something very similar. I appreciate the answer because as one whos had every bad habit you could have, i know that what got me into the Health Programs and Wellness Programs was the desire to change the habit. What kept me in them was that reward of havingchanged. You said something thats important and thats that if you give the employee or the individual the measurements to show improvement, reinforce that along the way, you can change what the program induced them to be more helpful. Because i know quitting smoking, changing your eating habits, exercising regularly, none of those things are easy. Everybody likes to talk about them and everybody practices them for two years on new years but if you get reinforcement in a pure growth, in a positive way, you can sustain the practice. If i could add one more thing, i think that i learned this a long time ago in business and it was helpful. I had 1800 stores. Rather than study and hypothesize things, we did it on scale and scale it up. For example if i wanted to increase the sales of some products and reduce the price and put it on an endcap, at the end of the day. What somebody passed. What somebody failed. We didnt have any issues in the company. We ultimately began rolling that out to all divisions. So the initial population was 40,000 members. Thank you, mr. Chairman. Let me conclude with a compliment. Thank you, dr. Rose royce san what the financial is doing. Passed finance committee and pending in the committee in the house. Were close to getting effort done. I appreciate your reference to that. I think a couple things he said deserve reemphasis. There is absolute firewall between the health plan and the company. They dont know why the premiums are where they are or what is driving or not driving it. Secondly for every person that interact with their primary care physician in achieving those goals, those fixed goals plus two behaviors, they, the primary care physician and they set a goal and set a progress and it thats relationship and that progress that determines their incentive. But its a culture change. It is multiple programs that work. It is leadership. We have a large buddy system that we set up really does a support system. There are a lot of things, i didnt get into nuts and bolts but a lot of things that work. Thank you, senator isakson. Senator franken. Thank you, mr. Chairman, for holding, and to the Ranking Member for holding this important hearing. Before the hearing started i spoke to all of you about housing, and, you know, these Wellness Programs that employer run are very helpful but what were trying to do is, to help people be healthy and lower the costs of their health care in the long run and mrs. Mathis, you, you point the out research that shows a strong connection between Persons Health and stable housing, despite the fact theyre actually very often talked about as completely separate issues. In minnesota, hannafin health, an Accountable Care organization in the twin cities, saw the lack of stable housing was a major barrier to improving the health of their members. So, they decided to develop a program that paired health care, housing and social services. Just one year after participants in the program were placed in supportive housing, hannafin health saw specific reductions in psychiatric visits, prison care, going to jail. Number one cure for homelessness, turns out to be a home. If you can wraparound supportive services, it yields amazing savings. I brought this up to all of you, so mrs. Mathis, could all of you speak to how a focus on housing, particularly when it is paired with special supports, can Lower Health Care costs, to improve Health Outcomes . I think that is absolutely right. I think, that is a recognition become increasingly prevalent in state Mental Health Service Systems, 20, 25 years, female Health Directors said we dont do housing, we do Mental Health. That has changed dramatically. Most authorities would tell you we do housing, housing is a critical part of what we do, housing supports, housing subsidies, housing locator assistance, all these things, housing stability, work are all social determinants of health. They have been shown to have an enormous impact on Peoples Health and, there have been many studies done. I think some interesting ones have been studies of people who are homeless, versus people who are in supportive housing, kind of similar twin studies of people in those two situations, where it costs us as much money to keep people homeless as them staibly housed with services. I want to hear from others as well because you all seemed to respond when i brought this one up. Senator franken, thank you for comment. I certainly agree there is movement and Knowledge Base called housing first, that fundamental support of housing for those without it. I would bed your question in much larger set of issues, reflect determinants of health. If youre provider, health system, you face patients chronically ill, readmitted to hospital multiple times for congestive Heart Failure or lung disease or major determinant in the serious illness brings them back to the hospital is some form of social circumstance. Sometimes it is inadequate housing. Some social support. Hospitals were only delivering health care, those considerings from financial perspective are less relrestaurant. Hospitals and Health Systems are much more aware of responsibility to be part of the solution to social factors that affect health, including housing. Some most progressive Health Systems are targeting housing directly with a lot of other social determinants. Those social determinants were always there. We need to think of financial incentives at the organizational level, would allow sources in our society to address them. I want to give the other two witnesses a chance to answer senator fakens question. I want to stay pretty close to the time because we have votes at 11 45. Some would say, senator franken, youre a genius for bring this up. Because thank you. But the social determinants are very important. It is very hard not to have stress if you dont have home. Very hard to get adequate sleep without housing. Those are key points getting well and staying well, lowering the cost of medical care. First of all, if he hadnt said you were a genius i was ready to weigh in on that. I was ready to do it as well. My wife and i are have been involved for several years in a philanthropic effort to provide housing to the homeless. Im also involved in another philanthropic effort with a good friend, where we take people who have been homeless, had the capability to learn a skill, theyre taught the skill, then we find them a job, they can succeed at that. So i think, i think having a home is really important, and that social environment surrounds it is something we create. Thank you. Thank you, mr. Chairman. Thank you very much, senator franken. Well go to senator casey. Thanks, mr. Chairman. I want to thank the panel for being here and for your testimony on these important issues. I will direct i think most of my question time to both dr. Asch and ms. Mathis. I want to say first, dr. Asch, were grateful that youre here and grateful for the work you have done at penn. You have done work at pearlman school of medicine and at wharton. Thank you for the work that you have done at the Va Medical Center in philadelphia as well, critically important work. I know that i wasnt here for senator murrays questions, but i believe she asked a question about the penalties and incentives. Am i right about that . I want to make sure. And i guess my, kind of, my follow up to that would be, with regard to you, dr. Asch, that research indicate the penalty incentives may have not had effect on individual behaviors in both you and dr. Roizen both indicated importance of many hours, 5000 hours of waking activity when we are not interacting with the Health Care System. Senator murray, indicate the that some wellness plans use penalties and rewards can be as high as thousands of dollars a year. We have heard, that dr. Roizens program use as 30 penalty. The limit that the eeoc has set when it issued the rule last year. So, my question is basically this. Based upon your research and other behavioral economic research, is it necessary to use such large penalties or rewards, if not, what would you recommend such rewards or penalties to be . Well, thank you for your question, senator casey. I think, you have identified some Critical Issues that interface of effectiveness and voluntariness right there. So i think a lot of employers are under, what i would consider to be the mistaken impression that the way to make insenttives effective make them larger and larger. That naturally leads large incentives, putting a large amount of money at risk, whether in form of reef wards or penalties. We heard penalties are more offputting instead of rewards and jacks up the concern about lackvoluntariness. That i think is old outdated thinking. Only way to increase the potency of an incentive to increase size of an incentive. Instead we know from years of research on behavioral economics the way we design incentives has much more impact than the amount of an incentive. Imagine a 500 incentive bundled into someones paycheck f theyre paid once a week that is 10 a week, it looks much smaller then. Put alongside all sorts of other elements in the paycheck. May not be seen. Directly deposited. Imagine handing someone two crisp 100dollar bills, much smaller incentive, it is much more potent emotionally. Another mistakes employers make often but dont need to make, setting specific targets for goals. If you believe the employee should be bmi. 25, upper limit of normal, that is normal that is good way of making people at 26, lose a few pounds. If youre at 40, that is demoralizing goal. We care about improvement. Pay for improvement programs are more effective to people that fundamentally we need to help the most. Design elements with structure of incentives, Design Elements with targets of incentives can be improved by most employers. Im optimistic they can do that. Thank you. I have more to pursue there but i want to move to a separate line of questioning. Ms. Mathis, i will start with you, and i invite others to answer as well, the, written testimony you have regarding balancing the personal rights of individuals, especially those with disabilities, while also pursuing the goal or encouraging wellness, your references to the privacy protections in the americans with disabilities act, and other statutes are critically appreciated i think at this time. We know that october is National Disability employment awareness month. And as you pointed out in your testimony, the employment rate for those with disabilities is very low in comparison to the general population. Those with disabilities have the lowest rate of employment of any sector of our population. And im concerned that aggressive Wellness Programs could not only discriminate against a person with disability, but croat a create a work place environment that doesnt value people with disabilities. Would you like to comment on that further . Sure. I would like to clarify, our primary concern about the large financial insenttives is around privacy protections. Folks talked about incentives for outcomes and, as mr. Bird mentioned, there are builtin safeguards in the Affordable Care act, i think do address that concern that if you cant meet a particular Health Outcome because of a disability, the, you are supposed to get a reasonable alternative standard and there are regulations that sort of, implement that, i dont think, we certainly havent heard there are a lot of, that was a major concern anymore. That was addressed. Our concern is much more around privacy issues. It is true that, i think you know, in many cases the information will not go directly to an employer. Sometimes it will, if the employer does directly run Wellness Program, with small employers. Obviously it is, not that hard to figure out who has what health condition. I think frankly for many people with disabilities. Just having to turn over your sensitive, private Health Information, whoever it is going to go to, is concerning is not the way to build an environment of trust and productive working environment. And people with disabilities have, in many cases, had many negative experiences in their lives stemming from the disclosure of those disabilities. I think it is very understandable why people need to try to stay within the time. That is all i have to say. Thank you very much. I will do followups in writing. Thank you, senator casey. Senator cassidy. Dr. Ashe, im an internist, as you. Although this is health committee, which is not medicaid, medicare, nonetheless i feel that which were doing in employerbased setting has fairly mature science. If i look at patients i cared for in the Louisiana Public hospital system, medicaid patient or uninsured, it is bigger problem, if you will, some of these wellness issues. If youre in philadelphia you have practice somewhat similar to mine. How do we translate some of this weve been discussing this in the work place to the medicaid population, which coincidentally has higher incidence of disease than the work place population . Senator cassidy, most place these activities can translate. I do think employers have a special role, special trust connection with employees that may be not as high as the trust relationship people have with their doctor or with their hospital. But might be potentially higher than people have with their insurance carrier. And that trust is an important determinant of let me stop you for a second. I think of my medicaid patient. There is a structure associated with an employer relationship, and that structure allows them to give you 30 minutes off to go walk around the track if they have built one there. But medicaid patients taking Public Transportation to the clinic appointment, are cigarette smoking. There is nothing you can do on medicaid to incentivize them to stop smoking. Im not seeing that is easily translated. By the way im willing to open this up to anybody. Because, to me it actually seems almost an apple and an orange. So we have run programs employerbased, designed to reduce burden of toe back of employees. We did one at General Electric and cvs. They were later studied by journal of medicine and adopted by the two companies. They reflected positive financial incentives delivered to workers to reduce the burden of tobacco. There is no reason that programs like that could not be introduced to the medicaid population. They are incentivebased. We translated some science and let me stop you. You are familiar with structure of medicaid. It is managed care. Contract with provider to provide service at certain rate. If it is feeforservice, you pay bills as they come in. Typically patient is not directly impacted. Indiana experience may be different. They prefunded Health Savings accounts. You can build in reward for that. When you say build in incentive, again, i open this to anyone, how would you do that for medicaid as commonly structure under the aca or any other program. Im not sure how to do it as commonly strucked. Medicaid agencies might look at ways to engage in those kinds of activities to insure their mission. Im not sure i can do exactly described under the rules as they are now, but unchanged rules they might be able to. The state could apply for waiver asking for flexibility to incentivize this sort of behavior, translate that which you successfully shown works for a employer but works for the medicaid population . Yes. I totally agree with that. Would you elaborate or just to agree . I dont want to take too much time, but basically it is, how do you get both programs that work, leadership and incentives into the Medicaid Program and obviously indiana, and even ohio are doing doing major efforts to do that. Seem to be succeeding. Prefunded Health Savings accounts of indiana experiment seem quite novel and effective. They got more money put into the hca, that seemed to modify behavior. Is that something youre thinking along those lines or something more so . No. Thinking about that along those lines. There are other ways of doing that as well but that work. What about things such as obesity . Cigarette smoking seems more trackable than obesity which is more intractable it seems. One is Culture Program and multiple programs. So one program doesnt work for everyone. We have in fact 10 Weight Management programs at the Cleveland Clinic 62 of participants have choice participating in. Weight watchers may work for a group and eecoaching Program Works but when you get together you find 10 programs people can adopt, buddy systems, groups, participate and succeed. This might be a program employed by Medicaid Managed Care program. Exactly. To lower overall cost burden . Exactly. Thank you, i yield back. Thank you, senator cassidy. Senator bennet. Thank you, mr. Chairman. I would like to start by thanking you and Ranking Member for your work on the bipartisan effort to fix the Health Care System that we have. On batch of people of colorado been waiting forever, for a bipartisan effort here, i want to express their gratitude to you for work you have done. My hope that the senate and house and president will Work Together to deal with issue that confronts us right now with respect to the csrs. As you point out, mr. Chairman, this is a cherished 6 of the people insured but only 6 of the people that are insured. This hearing is about what we need to get after, which is rising cost of health care in this country. So i thank you for that as well. And whatever any of us can do to help your efforts i have hope you let us know. Through the same type of thing, to, that we do for our employees. Offer programs, offer insend activities to get to their, work with the primary care physician to set the trajectory, to improve and to get to the goals. And if you did that, if the Cleveland Clinic dour number and participation number goes to medicare, and medicare, 0. 6 of medicare achieve even four of the six behaviors, and standards. If we did much more of that. Got 62 participation and 44 or so percent success getting to goal, the government would save over 500 billion, maybe 1. 2 trillion. One of the things we learned, putting stress management in first even for the medicare population is really important at getting change. And so, we think this is enormous opportunity. Senators portman and widen are working on this. The reason were here today in this committee is not about medicare and medicaid but the 178 million americans who are privately insured through their employer who could also benefit from the kind of insent tiff structures you and mr. Burden put in place. In other parts of the program. It is cultural change. It is programs that help them. It changes the way they relate to their primary care physician. There have to be some insurance rule changes that this committee could work on to be able to allow the small, nonselfinsured corporation to do this in a way that allows the employee to take the benefit as they go from one company to another, that allows the company to benefit after they have gotten the person healthier. So there need to be some rule changes. But, those are minor, and there wouldnt be a dollar spent, not a federal dollar needs to be spent in advance or, in fact, it, there isnt a asked for money from the federal government at all. It is just a rule change. Mr. Burd nice to see you again. I want to thank you for your leadership over the years in this area. This will sound a little off base because i cant resist what your job used to be. The question i had for you what you learned about what were eating in this country, in that job, and how that is connected to health, and how it is changing, if it is changing . Well i think increasingly the population is becoming more healthconscious. I employ a number of millenials these days. They are particularly careful about their nutrition. You know, when you run a supermarket chain, and you have 45,000 stock keeping units, you have all kinds of products in there. And im a big believer in free choice. But only if you also suffer the consequences of that free choice i think all of us should be able to enjoy a french fry, now and then. Those into nutrition and fitness but understand if we indulge, we have another half hour to spend on the treadmill, walk after dinner. One of the things that i wanted to mention about improving health, particularly when you work on bmi, i find that the safeway numbers are extraordinary. The reason we started at 28 bmi, theyre on their feet all day. Were not doing that here. We could have a standup meeting and gotten healthier. The important point, when people just diet, everybody here agrees, it doesnt work. The reason it doesnt work, if i lose 20pound, all i did for diet, every pound i lost, i lost a quarter of a pound of muscle. Muscle is more efficient of burning calories. When you finish diet, and go back to old eating habits, you cant eat as much as calories because your burn rate slows down. The ecosystem we created at safeway, we stressed cardiovascular workouts and strength training. You can at the age of 60, have the burn rate of somebody in the late 20s, if you do resistance training. I contend it is secret to weight maintenance. I would be shocked if you dont do resistance training. I do. Thank you. Thank you, mr. Burd. Our next wellness hearing will be a standup hearing. Well see what happens. Very good. Even if we stand up once, it helps. I will be sick that day. Senator warren. Thank you, mr. Chairman. So, i want to see if i can just ask some more questions along this line. We all know that the Affordable Care act allows employers to offer financial incentives to their employees in order to encourage participation in these programs. But one thing the aca doesnt do that eliminate protections in federal law for employers cant discriminate against employees based on Genetic Information, Health Status or disability. These protections were put in place by two very important pieces of legislation. The americans with disabilities act and Genetic Information nondiscrimination act or gina. This is bipartisan bill. Senator kennedy did i worked with a number of people on this committee. Senator enzi worked on gena legislation, that information collected through research could never be made public. Our nations nondiscrimination laws say employers can collect sensitive medical information from their employees only if providing the information is voluntary, meaning the employee can decide to say no. I want to start by asking, miss mathis, what types of personal Health Information in do employers typically ask for as part of Wellness Programs . Ive seen Health Risk Assessments ask about all manner of health and medical information on a variety of levels of detail. Give you some examples. Specific cancer diagnoses, breast cancer, cervical cancer, prostate cancer, weight, height, bmi. Whether youre treated for depression or bipolar disorder. Specifics about your depression. How many times you felt depressed in the last week. Whether you had crying spells in the last week. How often you felt people disliked you. How often youre happy. Whether youre diagnosed with heart disease, stroke, angina, obesity, high blood sugar or sexually transmitted diseases to. How old you were when you first became pregnant. Those are some of the medical things they ask about. A lot of other questions about all sorts of other life habits
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