Ethical Guidelines For Employee Behavior Change

Steven Pearson and Sarah Lieber (May/Jun 09) have suggesteda series of ethical rules for employers to follow when designinghealth plan benefits for their employees. We agree with themthat the workplace is a good place to deliver health promotionand behavior change tools, and we have seen many examples ofemployers successfully introducing benefit designs that engagetheir beneficiaries and improve healthy behavior. We fear, however,that strict adherence to these proposed rules could preventemployers from designing incentives that might have the mostbeneficial impact on employee health and on the cost of care.

Pearson and Lieber reject employee-specific outcome goals, suchas weight loss, cigarette cessation, or cholesterol or bloodpressure control, stating that patients do not have completecontrol over attaining these goals. They instead suggest thatemployers should only provide incentives for process measures—suchas trying to quit smoking or enrolling in a weight-loss program.We believe that goals must be realistic and tailored to patientsand workplace culture, but incentives to actually quit smokingor maintain normal body mass index (BMI) will be far more valuablethan incentives to merely enroll in a program. In our experience,reasonable biometric goals should be tailored to individualpatients, since an unattainable goal will not help encourageemployees to improve their health.

The authors conclude that penalties can be acceptable only tothe extent that they seek to prevent excess costs that harmfellow employees. We disagree. Behavioral economics shows usthat economically equivalent penalties can be more effectivethan rewards, and we support continued experimentation to determinethe right mixture of "carrots" and "sticks" to encourage healthfulbehavior.

Jeff Levin-Scherz and Harlan Levine
Towers Perrin, Boston, Massachusetts, and Los Angeles, California

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Ethical Guidelines For Employee Behavior Change