5,000 steps a day to avoid paying higher health insurance costs? When money talks, people walk

(Press-News.org) ANN ARBOR, Mich. — It was a controversial move when a health insurer began requiring people who were obese to literally pay the price of not doing anything about their weight – but it worked, a new study finds.

When people had to choose between paying up to 20 percent more for health insurance or exercising more, the majority of enrollees met fitness goals one step at a time via an Internet-tracked walking program, according to a joint study by the University of Michigan Health System and Stanford University.

Researchers evaluated a group of people insured by Blue Care Network who were enrolled in a pedometer-based program as a requirement to receive insurance discounts. After one year, nearly 97 percent of the enrollees had met or exceeded the average goal of 5,000 steps a day – including the most resistant participants who disagreed with the financial incentives and found the program "coercive."

"There are ethical debates around the idea of forcing someone to be personally responsible for health care costs related to not exercising, but we expect to see more of these approaches to financially motivate healthier behaviors," says senior author Caroline R. Richardson, M.D., assistant professor in the U-M Department of Family Medicine, investigator with the VA Center for Clinical Management Research and member of the U-M Institute for Healthcare Policy and Innovation.

"Our evaluation of Blue Care's incentivized program showed a surprisingly high rate of people who enrolled in the Internet-mediated walking program and stuck with it – even among those who were initially hostile to the idea. Wellness interventions like this clearly hold significant promise for encouraging physical activity among adults who are obese."

The new findings appear in Translational Behavioral Medicine.

Blue Care Network created a buzz when it implemented one of the largest-scaled financial incentive programs in the country by requiring adults who were obese and in the Healthy Blue Living program to enroll in a fitness program to qualify for lower out-of-pocket health care costs. Enrollees could choose between several programs, including Weight Watchers and WalkingSpree, which uses a digital pedometer to upload walking data on a wellness tracking web site.

For some families, the out-of-pocket cost of failing to meet the new criteria in one of the wellness programs was nearly $2,000 more per year. Those with medical conditions were exempt if they had waivers from their doctors.

Nearly half of the 12,102 enrollees who met criteria for a wellness program picked pedometer-based WalkingSpree, and the study's authors evaluated their success. The 6,548 participants were required to reach an average of 5,000 daily steps in each three month period, or 450,000 steps a quarter, to remain eligible for enhanced benefits. Just 3 percent failed to do so.

Among users who responded to a satisfaction survey about the program, a third were unhappy with the financial incentives because they felt the incentives were coercive. The remaining two-thirds of respondents, however, liked the program.

Authors note that policies under the Affordable Care Act are expected to expand the types of wellness programs offered by employers and insurance companies who ultimately save on health costs when employees and enrollees maintain healthier habits.

"Our findings suggest that incentivized wellness programs are acceptable to many individuals and that these programs encourage healthy behaviors," says lead author Donna Zulman, M.D., Instructor in the Division of General Medical Disciplines at Stanford University and research investigator at the VA Palo Alto Health Care System.

"Comprehensive evaluations are needed to determine whether participation in these programs translates to meaningful changes in health and costs of health care."

### Additional Authors: Laura J. Damschroder, M.S., M.P.H.; Ryan G. Smith, B.S.; Paul J. Resnick, Ph.D.; Ananda Sen, Ph.D.; Erin L. Krupka, Ph.D.

Disclosures: Richardson is a scientific advisor to WalkingSpree and unpaid consultant to Blue Care Network. She does not receive compensation in either of these roles.

Reference: "Implementation and evaluation of an incentivized Internet-mediated walking program for obese adults," Translational Behavioral Medicine, Doi: 10.1007/s13142-013-0211-6.