Employer-sponsored wellness programs that link the cost of health insurance to an individual’s compliance with healthcare recommendations can put physicians in a difficult position, according to an opinion piece published in the New England Journal of Medicine.

More than 85% of large employers and 58% of smaller ones offer some kind of program aimed at reducing healthcare costs by improving the health of their employees. Some organizations offer discounted gym memberships or smoking cessation programs to motivate employees to improve their health, but nearly 20% of large employers’ wellness programs tie the cost of employees’ insurance contributions to their compliance with health recommendations. Incentives are often given in the form of discounts to employees who comply with physician recommendations, and those who do not comply may end up paying more for their insurance.

Some programs measure employees’ compliance directly through the use of wearable devices or biometric screening. However, when these programs require a physician to report a patient’s noncompliance to an insurer, physicians are placed in an untenable position. A physician’s primary duty is to promote patient health and well-being; this can be compromised when healthcare costs are tied to physician certification of a patient’s compliance. Physicians cannot falsely certify compliance without compromising their ethics. Physicians may be able to modify treatment plans to align better with the likelihood of a patient complying or target more achievable goals, but this may put the patient in the awkward position of getting the physician to consent to such a plan.

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Using physicians to report on patient compliance can also have deleterious effects on trust within the patient-physician relationship. Furthermore, patients may be more likely to lie about their level of compliance or may be less likely to report symptoms.

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Matt Lamkin, JD, of the University of Tulsa College of Law in Tulsa, Oklahoma, suggested that such intrusion into the patient-physician relationship might be of benefit if it produced improvements in employee health and lowered the costs of premiums. However, he noted, the evidence to date is mixed at best. A 2013 literature review found that although there were statistically significant effects on smoking, exercise, and weight loss, there was no effect on cholesterol levels. In addition, there was the potential for harm to vulnerable individuals. Those with lower incomes are more likely to have the conditions targeted by wellness programs. By shifting more healthcare costs to less healthy employees, these programs may place a greater economic burden on those least able to afford it.

Mr Lamkin called on physicians to oppose programs that penalize those with poorer health by restricting access to health care.


Lamkin M. The physician as double agent—conflicting duties arising from employer-sponsored wellness programs. N Engl J Med. 2018;379:1297-1299.