Taking a whack at tobacco use

Inside the latest BCBS of MA newsletter for employers (which has the catchy title IAI, for “Important Administrative Information”) are several significant announcements, including information about the new state health insurance mandate, formulary changes, and a progress report on BCBS’s crackdown on rogue bariatric surgery programs. But the most interesting announcement was entitled, “Tobacco Premium Contribution Offerings.”BCBS is offering employers the opportunity to make smokers pay a higher contribution toward their premium. The rationale for the new program is phrased in a passive manner, as though no one at BCBS wants to be blamed for coming up with the idea:

It has come to our attention that you have an interest in offering premium contribution differentials to tobacco users at your worksite.

Regardless, BCBS offers to help design and implement the program in a way that “in most cases” is “cost neutral” to employers. A key question for employers will be how to verify that its employees (and presumably their family members) don’t use tobacco. BCBS implies that they have many verification options, although the only one mentioned is having employees sign an affidavit. Presumably the other options are more invasive, such as urine or blood tests.Smokers who are actively trying to quit are placed in the same category as non-smokers. They have to demonstrate their participation in a smoking cessation program (another affidavit is suggested here.)It will be interesting to see where this leads. I remember a few years ago, when efforts to ban smoking got underway, opponents of the bans used a variety of scare tactics –suggesting for example that hamburgers would be banned next—to generate opposition. At the time I thought they were overdoing it. After all, smoking has direct negative effects on people nearby because of secondhand smoke. Eating and other activities are different.Over time I’ve seen that the opponents were on to something. The movement to ban trans fats is a good example, and I have to say I’m not as opposed to such bans as I used to be.I expect we’ll see similar expansion in the workplace related to health coverage. (It’s already being tried elsewhere to some extent.) Any matter seen as personal choice –diet, exercise, drinking-- will be fair game. If those parameters gain traction, there could be expansion into other areas. For example, diabetics could be required to check their glucose levels a certain number of times a day or face higher contributions.It’s not as far-fetched as it sounds, especially as employers and health plans make personal health records available and apply pay for performance logic to patients as well as providers. The verification could be done more directly than affidavits, too. For example, the employer could monitor the number of blood glucose tests uploaded to the PHR and keep track of the number of prescription refills while they're at it.BCBS of MA pitches the program as a way to help employees improve their health. But there’s another rationale, too. Employers that single out and punish workers who are at risk of poor health or who smoke may discourage such workers from applying in the first place. For instance they may hope to benefit by reductions in absenteeism. Walmart, for one, has clearly been thinking this way.