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Evidence-Based Diabetes Management March 2017

Payer-Provided Fitness Rewards: Employers Will Look At Evidence

Kenneth Snow, MD, MBA
Recommendations to interrupt long periods of sitting challenge both insurers and employers to find methods, based on evidence, to encourage physical activity throughout the day to improve health. Aetna has pursued programs with Apple with its own employees.
Type 2 diabetes (T2D) is a disease that is profoundly influenced by lifestyle. The value of exercise in helping prevent or control T2D is well recognized. As such, suggestions to add exercise to treatment have been a standard part of diabetes care. These often translate into recommendations for formal exercise programs only, which means the contributions from daily activities can be easily overlooked.  

Over the past several decades, the amount of activity performed as part of daily living has decreased. Shifts in transportation from walking to driving, shopping over the internet rather than at the mall, and home entertainment opportunities have contributed significantly to this drop in activity. The nature of the workplace also has changed for many people, with greater amounts of time spent in front of a computer screen. In addition, people who have not been participating in an exercise program for decades are often not willing to add one, such as attending a gym, on a regular basis. Those who do may not continue with it long term. As such, while exercise may be an effective therapy, the recommendation to participate in an exercise program can have limited efficacy.  

The recognition of the limits of adhering to an exercise program has led to a growing understanding that therapy may not necessarily be an exercise program, but rather that it should include an increase in the amount of aerobic activity in which someone participates each day. This activity might include walking, dancing, and even gardening. This activity should be added in throughout the day as part of activities of daily living. Walking to a store rather than driving, or driving to the mall but parking in a distant parking space, can add activity during the course of the day without the requirement to schedule formal activity. Less valuable is the type of activity; the degree of activity performed and the person’s persistence or willingness to continue the activity in the long term are more important.

A recent study by Dempsey et al1 demonstrated that brief periods of low-level activity, such as walking, can have a significant positive effect on improving insulin resistance compared with prolonged sitting.This information, combined with what is already known about the benefits of exercise,2 has led the American Diabetes Association (ADA) to recommend that adults should interrupt prolonged periods of sitting every 30 minutes, as well as participate in a regular exercise program. The recommendation was featured for the first time in the 2017 Standards of Medical Care in Diabetes.3  

Paying to be Well. Aetna, like many other payers, has recognized that encouraging healthy behaviors will improve the health and wellness of our members, which should also decrease healthcare expenditures in the future. Wellness initiatives have been developed for employers to encourage their employees to participate in health programs and screenings that can improve their well-being. Subsidies for gym memberships help encourage physical activity. Rewards for participating in screenings for metabolic syndrome are common. In addition, by identifying health issues that can be modified—such as being overweight or having high blood pressure, elevated cholesterol, or impaired glucose tolerance—the hope is that members will make positive changes to improve their health. The early identification of these types of health problems can spur visits to primary care physicians to initiate treatment.  

However, joining a gym does not necessarily translate into going to the gym, either intermittently or in any sustained fashion, and participating in a metabolic syndrome screening may uncover health issues, but there is no guarantee that the person will follow up with their healthcare provider, let alone make positive changes in their lives to address these issues. Exercise and activity levels have always been difficult to measure. Although dietary success can be assessed with weight, no simple measurement exists to assess participation in an exercise regimen. However, the advent of convenient activity tracking technology, such as the Apple Watch, Fitbit, and others, provides a way for people to track their level of activity and fitness, which was not possible in the past.

In 2016, Aetna entered into an agreement with Apple that makes the Apple Watch available to Aetna employees at a reduced cost. Financial rewards for Aetna employees participating in health-related activities, such as a metabolic screening, can be applied to the cost of the device. This program is also being offered to select Aetna customers, with plans to expand in the future. Not only does the new tracking technology provide an individual with the opportunity to better understand and track their own activity, it also enables a large employer, to understand the activity of its workforce.  

The addition to the 2017 ADA guideline3 recommending interrupting periods of prolonged sitting with activity every 30 minutes is one intervention that can now be assessed using this new technology. Data from fitness monitors can be retrieved and analyzed. At the simplest level, the information can be examined to see if certain behaviors, such as taking periodic breaks, occur. Even more exciting are the potential insights following data analysis. Behavioral activities that have been shown to be of benefit in controlled trials can be crowdsourced to see if the same benefits occur when scaled to large populations of people.

Naturally, lifestyle changes can only have an impact if they are actually implemented. The ability to reliably assess whether these changes actually occur allows employers to reward their employees for meeting activity-based metrics. These rewards for living a healthier life can be tied to ongoing and impactful health activities. They could be similar to those that are now provided for one-time health-related activities, such as contributions to health savings accounts, or they could occur for ongoing exercise participation, achieving certain levels of daily activity (such as meeting a weekly step target), or taking short breaks every 30 minutes to interrupt prolonged periods of sitting.  

The likelihood of an employer adopting a fitness-based health rewards stystem depends on the ability to easily and reliably track the needed information, the impact on the health and well-being of their employees, and the strength of the evidence to support the activity. Although the level of evidence does not need to be as rigorous as what FDA requires for a new drug or medical device, more support from clinical studies and greater recognition of value from specialty societies means the recommendation is more likely to be adopted. The recent addition to the ADA guidelines of the need to avoid prolonged periods of inactivity is the type of support that helps these activities become commonplace. Adoption by other companies will require a growing level of comfort with the technology and a broader adoption—as Aetna has done. 
Kenneth Snow, MD, MBA, is a medical director for Aetna. He has developed protocols for valuebased reimbursement plans, including those in Medicare.
References

  1. Dempsey PC, Larsen RN, Sethi P, et al. Benefits for type 2 diabetes of interrupting prolonged sitting with brief bouts of light walking or simple resistance activities. Diabetes Care. 2016;39(6):964-972. doi:10.2337/dc15-2336.

  2. Katzmarzyk PT, Church TS, Craig CL, Bouchard C. Sitting time and mortality from all causes, cardiovascular disease, and cancer. Med Sci Sports Exerc. 2009;41(5):998-1005. doi: 10.1249/MSS.0b013e3181930355.

  3. American Diabetes Association. Standards of medical care in diabetes—2017. Diabetes Care. 2017;40(suppl 1): S1-S135.
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