Tinsley was so stressed that even something as simple as her co-workers at Caterpillar Financial Services bouncing stress balls off the ground would trigger her post-traumatic stress disorder.
Tinsley, who worked as a business system analyst for Caterpillar Financial, believed that the stress of her job was causing her to suffer adverse health issues. She emailed her supervisor, Paul Kaikaris, asking to be removed from a particular project, claiming that her “many [work] responsibilities … [were] causing [her] to be stressed beyond what [she was] physically able to handle,” which “negatively impact[ed her] work, sleep, and overall health.”
Kaikaris met with Tinsley and said he would see what he could do to take work off her plate. Six days later, however, Tinsey submitted a doctor’s note requesting four days off for a “confidential medical condition.” Upon her return, Kaikaris, good to his word, met with her and reassigned some of her projects.
Her job performance, however, continued to suffer. Kaikaris informed Tinsley that she was not following the prescribed methodology for completing her work, the quality of her work was subpar, and she had been leaving work early without prior approval. A poor formal mid-year review and a performance improvement plan followed.
In response, Tinsley claimed that Kaikaris rated her poorly and assigned the PIP in retaliation for her complaints that he had enabled a “hostile work environment” by permitting co-workers to bounce stress balls off the ground. Thereafter, Tinsley began submitting doctors’ notes ad seriatum requesting more time off for “mental and emotional duress brought on by an over-excessive workload, unrealistic deadlines, a hostile work environment and a manager’s reckless indifference to [her] mental and emotional well-being.” Those notes culminated in the company granting a five-week FMLA leave of absence.
At the end of Tinsley’s FMLA leave, her doctor cleared her to return to work “at full capacity.” However, because of her “post-traumatic stress disorder,” her doctor recommended that Caterpillar Financial return her “in a different work environment and specifically under a different manager.” The company refused the transfer or managerial change, but did permit her to take an additional eight weeks of medical leave (totaling 18 for the year).
At the end of that leave, and with Tinsley still insisting on a new manager, Caterpillar Financial decided that it had enough. It told her that it could not accommodate her “confidential” medical condition and that it did not believe that her request for a transfer to a different supervisor was a reasonable accommodation.
Tinsley has asserted that her impairment (PTSD) impacted only the major life activity of working.… Thus, we must now examine whether Tinsley’s PTSD sufficiently limited her ability to perform a class of jobs or a broad range of jobs. The evidence demonstrates that it did not.… [T]he record is replete with undisputed evidence showing that Tinsley’s issues stemmed directly from Kaikaris’ management style as opposed to the responsibilities of a broad range of jobs. The clearest example of this is when Tinsley told Human Resources that she would be able to continue in the same position so long as she was under the direction of a different supervisor because her disability was triggered by “the way [Kaikaris] managed … with all the balls bouncing.” … Tinsley’s diagnosis does not limit her ability to work a broad class of jobs; rather, it relates solely to her ability to work under a specific manager. Accordingly, she is not “disabled” pursuant to the ADA and was thus not entitled to a reasonable accommodation of additional time off or a transfer.
The ADA covers working as a major life activity. However, for an employee to be “substantially limited” in that major life activity, it is not enough to be unable to perform the specific job. The employee must be “significantly restricted in the ability to perform either a class of jobs or a broad range of jobs in various classes as compared to the average person having comparable training, skills, and abilities.”
This court reached the absolute correct result. It wasn’t that Tinsley couldn’t work as a business system analyst but that she just could not work under Kaikaris. Her own doctor said as much when he released her to return to work “at full capacity.”
If faced with a disabled employee claiming a substantial limitation in their ability to work, examine the request carefully. The ADA’s coverage of disabilities is broad. However, it is often difficult for an employee to establish “working” as a substantially limited major life activity. And, unless the employee cannot work in a class or broad range of jobs, the ADA does not cover them and you don’t have to offer to accommodate.
Jonathan Baum worked as a scheduler for Metro Restoration Services.
In late 2014, he began to suffer cardiac problems. Over the course of the next several months, he went to the ER fearing a heart attack, had a heart catheter implanted, had an echocardiogram and wore a heart monitor. He occasionally also missed work for medical tests and treatments and sometimes worked remotely. His boss, and the owner of Metro, Patrick Cahill, was aware of Baum’s medical issues.
Following a work day on which Baum had worked remotely from his home, Cahill fired him. The expressly stated reason: “health issues and doctors’ appointments.”
Oops.
Baum then sued for disability discrimination.
Even with all of Baum’s cardiac issues, the 6th Circuit held that he could not establish that he suffered a physical impairment that substantially limited one or more major life activities. Therefore, Baum did have a legally protected actual disability. Baum had failed to identify a medical expert to testify and establish whether his cardiac problems substantially limit his cardiovascular and circulatory functions.
So do Baum’s impairments limit his cardiovascular and circulatory functions? They might. But to conclude that they did, a jury would need to understand them—how they function, and what that means for Baum. And to understand them, jurors would need an opinion from someone with “scientific, technical, or other specialized knowledge”: expert testimony.
Because Baum failed to disclose his doctor—or anyone else with specialized medical knowledge—as an expert witness, he lacks the evidence he needs. And without that evidence, he hasn’t created a factual issue over whether he is actually disabled.
Case closed, right? Not so fast.
The ADA does not only protect actual disabilities, but also perceived disabilities. On this latter claim, Metro had a huge problem.
Unlike actual disability claims, an employee proceeding on a claim of perceived disability need not prove a limitation of a major life activity, but only that the employer took an adverse action “because of an actual or perceived physical … impairment.” Thus, the lack of a medical expert was not fatal to this claim.
Baum argues that a jury could find that Metro fired him because Cahill thought Baum was disabled. For support, he relies on Cahill’s knowledge of Baum’s catheter, CAT scan, trip to the ER, and period where he wore a heart monitor. Baum also points to Cahill’s stated reason for firing him: his “health issues and doctor’s appointments.” …
Cahill’s knowledge of Baum’s medical issues—alone—is insufficient to carry the day.… But Baum has more—he has Cahill’s stated reason for firing him: his “health issues and doctor’s appointments.” That statement is what creates a factual dispute and makes it material. Giving Baum the benefit of the doubt, a jury could find that Cahill meant what he said. And if a jury so found, it could also find that Cahill perceived Baum to have a physical impairment and fired Baum because of that perception.
In other words, employers, it’s not the best idea to tell your employee that you are firing them because of their medical issue. It will not end well for you.
Last week the U.S. Department of Labor announced that it’s launched a new toolkit for employers to help them understand mental health issues and create a supportive work culture.
The EARN Mental Health toolkit — created by the DOL’s Office of Disability Employment Policy and its Employee Assistance and Resource Network on Disability Inclusion, or EARN — includes an educational framework and a list of case studies of successful programs at organizations of various sizes.
Awareness: Build awareness and a supportive culture.
Accommodation: Provide accommodations to employees.
Assistance: Offer employee assistance.
Access: Ensure Access to treatment.
I want to focus on access for now, because no matter how much you try to create a disability-friendly culture, if employees can’t access or afford medication, therapy or whatever medical assistance they need to treat their mental illness on a regular basis, then a huge piece of the treatment puzzle is missing.
APA Publishing, a division of the American Psychiatric Association, recently published an informative article on this issue of access. The article covers a February 2019 panel discussion hosted by the New York Academy of Medicine, the New York County Psychiatric Society, and the New York State Psychiatric Association.
There are a lot of points I find valuable in this panel discussion of several people in the medical community. First, one of the panelists noted how Aetna recently settled a lawsuit in Massachusetts after an investigation found that the insurer violated state law with its “inaccurate and deceptive provider directories and inadequate provider networks.” Basically, this means that patients couldn’t access timely behavioral health care because listed providers weren’t accepting new patients or had retired.
This isn’t necessarily an anomaly, the article noted. For example, it cited a very comprehensive report that’s worth a read for anyone interested in this.
The 2017 research report by Milliman Inc. found that compared to medical/surgical care, people seeking behavioral health care more often have to access an out-of-network provider. While in-network care generally has lower co-pays for patients, when they must seek out-of-network care that means more out-of-pocket costs and more expensive behavioral health care.
Also, the report stated, “Some patients may want to avoid the higher costs and delay seeking needed services from behavioral health care providers, which can lead to less effective care.”
The article also stated the employer’s role in this. An excerpt:
Schwartz said that the business community is a strong ally in improving access to behavioral health care given the high cost of not addressing these issues in productivity loss, lower employee retention, high rates of disability, and higher overall employee costs. “While employers are paying for benefits, they are not getting what they paid for when employees cannot access behavioral health care,” he said. “Businesses are well positioned to ask health plans for data on provider networks and to examine disparities to improve accountability.”
Also noteworthy was a list of actionable items that presenters believe could help improve access to care. For example, a suggestion from the National Alliance and the Center for Workplace Mental Health is that “employers obtain quantitative assessments from third-party administrators on how well their employees are accessing mental health and substance use benefits.”
Again, I don’t want to suggest that environmental factors in the workplace don’t impact people’s general well-being. But offering free yoga classes in your building or teaching employees how to use mindfulness to reduce stress are NOT the medical equivalent of seeing a therapist or accessing an outpatient center.
Self-care is not medical care. If your organization has a deluge of trendy perks to help employees de-stress but doesn’t have a sufficient behavioral health provider network, how much of a difference could that really make?
MoMA PS1, a Queens, New York, art museum, has agreed to settle a pregnancy discrimination claim brought by Nikki Columbus, hired by the museum to direct its performance program.
She alleged that the museum rescinded her job offer after it learned she had recently given birth.
According to The New York Times, Columbus, five months pregnant when she applied for the job, chose not to disclose her pregnancy until after she was hired.
“I just went forward thinking that this is not their business, it’s not relevant to the job and to my abilities,” she told the Times. She added that Peter Eleey, the museum’s chief curator, told her during her interview that her predecessor had been “much less present” after she had a baby.
After being offered the job, Columbus asked Eleey for a soft transition-in period because she was recovering from just having a baby.
Eleey’s response, she alleged, “Why didn’t you tell me this two months ago?” A few days later, the museum rescinded its job offer, telling her that her conversations with Eleey “indicated that [she] would not be able to perform the job as it was structured.”
According to a museum spokesperson, “MoMA PS1 at all times has been compliant with the law and remains committed to supporting women and caregivers. We are satisfied with the agreement and are happy to put this matter behind us.”
Nevertheless, if you fire a new mom because she just had a baby, you might be the worst employer of 2019.
Vision care benefits have become a mainstay of the employer benefits package.
“Virtually all companies now offer vision,” said Peter DeBellis, head of the total rewards practice for Bersin by Deloitte in Washington, D.C. “It is table stakes, especially for companies of a certain scale.”
Vision care is listed as one of the 10 essential benefits included in the Affordable Care Act, and employees have come to expect it as part of the core employee benefits package. “Health, dental and vision are the benefits triad,” DeBellis said. These programs have a very high rate of participation, which further reinforces the value they bring to employees.
This category of benefits has evolved in recent years in the care options offered and the way these treatments are accessed and paid for. Telemedicine, for example, is a new trend in the vision benefits space, noted Paul Piechnik, senior vice president of group benefits for MetLife. A growing number of organizations now offer basic examinations to check visual acuity and the need for eyewear via do-it-yourself applications or through a physician-led online virtual exam.
“Some are even offering virtual walk-in exams with an optometrist to mirror the same comprehensive examination steps one would encounter at a standard brick-and-mortar optometrist’s office,” he said. The interest in telemedicine is being driven by the digital generation, who prefer self-service for everything, as well as addressing the needs of remote workers. “Telemedicine is just emerging for routine vision care, though it’s too soon to say whether this will become a vision care standard in the future.”
Preventive care
Companies are also offering a broader array of treatment options, including laser surgery, blue light protection on lenses to reduce the impact of light emitted from digital devices, and proactive vision exams to identify risks for glaucoma, hypertension, diabetes and high cholesterol. This last benefit is viewed as a useful preventive care intervention, particularly in an aging workforce. “Vision has a role to play in a lot of chronic health conditions,” DeBellis said. Encouraging employees to have vision exams can help them identify bigger health care risks so they can get prompt treatment.
Piechnik suggested that companies offer sunglasses coverage as part of their vision plan as a way to get more employees to take advantage of these wellness visits. MetLife, for example, has a SunCare rider as part of its vision care benefits that allows members who don’t need corrective eyewear to use their frame allowance for non-prescription eyewear. “This encourages them to get their routine ‘wellness’ vision examination and spot those early issues that can become costly medical expenses for the member and employer alike.”
The other steady trend in vision care is who’s footing the bill. The rising cost of offering any health care benefits has pushed employers away from supporting fully employer-paid vision care to cost-sharing programs, or providing vision as a fully employee-paid/voluntary benefit. Piechnik said this hasn’t caused outrage among cost conscious workers.
“Employees for the most part see the value in nonmedical benefits such as vision care, so are willing to pick up some or all of the cost of these benefits.”
Regardless of the payment structure, benefits administrators should look for a comprehensive plan that provides annual vision examinations and eyewear benefit levels that employees value.
“With many employers offering vision on a voluntary basis there is no reason not to offer this benefit,” Piechnik said. “It’s a key product for creating a benefits package that truly increases employee satisfaction and loyalty.”
Once the program is in place, benefits administrators should educate employees about what the program covers, and the value of getting annual exams and keeping their glasses up to date. “It’s not just about getting a new pair of readers,” DeBellis added. When employees take care of their vision they are healthier and more productive, which benefits everyone.
Employers are doing everything they can to curb health care costs.
Sure, and if you believe that you may also believe in unicorns, the Loch Ness monster and Bigfoot roaming the Pacific Northwest.
Cutting health care costs is the elusive white whale for many businesses. Employers indeed may be putting forth a good faith effort to cut their health spend but oftentimes the results just aren’t there. It’s like the arcade game of whack-a-mole — try one new fad and miss, and another pops up followed by the same result.
In the meantime, health care costs have soared. In 1999, the average annual premium (both employer and employee contributions included) was $2,196 for an individual and $5,791 for a family, compared to $6,896 and $19,616, respectively, in 2018, according to the Kaiser Family Foundation 2018 “Employer Health Benefits Survey.”
What are the myths of health care costs?
Among the myriad solutions employers try, there are overriding myths about cutting costs that don’t save money, provide a nonexistent ROI or are just plain ineffective.
We’ve asked several leading health care experts to offer their thoughts on what we’ve determined are four prevailing myths to cutting employer health expenses. There are others, but this is a good start at peeking behind the wizard’s curtain.
MYTH 1: LOWER PRICES! SAVE MONEY!
A big misconception in cutting health care costs is that employer expenditures rely on addressing what costs the most, said Jaja Okigwe, president and CEO of First Choice Health, a Seattle-based national health provider network. In fact, sometimes cost control doesn’t rely on addressing employee benefits at all. There’s a link between health costs and environmental factors like how employees are treated and how they think about their job, he said.
“Those things carry over into the potential for more serious illness. And there aren’t very many companies who have an easy time at getting at that,” Okigwe said.
There are some companies that have acknowledged the direct relationship between environmental factors and health and done something about it. It’s a positive step when employers decide that “we’re going to do things that create an environment that allows our employees to be their healthiest and most productive, and that’s going to spill over into our health care cost,” Okigwe said.
Utilization of Health Care Services
Health Advocate’s Arthur “Abbie” Leibowitz, chief medical officer, founder and president emeritus at the national health advocacy, patient advocacy and assistance company, also believes that companies can’t control costs by controlling price. Rather, health care costs are driven by utilization.
This brings up a different problem for employers: Motivating employees to use the health care system effectively and efficiently.
One thing that employers can do is help employees connect with trusted medical professionals and offer a path for employees to foster a consistent patient-doctor relationship, Leibowitz said.
This does not necessarily mean that employers should encourage employees to see the doctor for a physical every year, he added. In fact, that can be a fallacy because there’s little reason for the average person to see a doctor annually. “The likelihood of discovering a problem you didn’t know about at a visit like that is so low that it makes it almost [impossible],” he said. Instead, employers can promote getting in touch with one’s doctor when the employee actually needs help.
Promoting the idea that it is good for patients to connect with a trusted physician is smart because many plan designs now don’t require a patient to choose a primary care physician, Leibowitz said. When HMOs were more popular, a patient initially needed to select a primary care doctor in order to access the health system, but fewer models require that now.
“So, in that regard, employers can encourage people to select a doctor even though their plan design may not require it,” he said.
“It’s the attitude — people call it a culture of health — that the employer creates within the work environment that is the best trigger to getting people plugged into a physician relationship that will come in to pay dividends if not immediately then down the road,” he added.
Okigwe offered suggestions to establish a culture of health other than promoting the doctor-patient relationship. For one, companies can have regular walking meetings, since research shows 30 to 40 minutes of walking a day changes one’s risk of heart disease over time.
“Yet sometimes employers don’t think that’s really their job,” he said. Rather, their focus is on the bottom line and employee productivity. But small investments in making the workplace healthier to work in can pay off.
Long-Term vs. Short-Term Costs
It’s hard for most employers to think long term with health care costs, Okigwe said. “I do think the vast majority are looking at the annual spend and trying to figure out how to reduce it in one year, and that’s just very difficult.”
But thinking long term is something that could help with health care costs. Employers and employees alike may have to pay short-term expenses in order not to have the shock of major medical expenses in upcoming years. “In general, we tend to think of any spend as being bad,” Okigwe said, but that’s not an accurate way to view health care costs.
It’s almost as if employers believe employees want to spend money on health care, he said, while in some cases what causes costs to skyrocket is that they don’t want to. There needs to be some sort of balance on spending a little bit on the care and activities that deter crises from happening down the line.
Employee cost concerns aren’t necessarily founded in reality in some cases, according to Leslie Michelson, chairman and CEO of Private Health Management and author of “The Patient’s Playbook,” a book about how to become an effective health care consumer.
“People are always concerned that the best care is the most expensive care, and that’s just not true,” he said.“In the rest of our economy there’s a pretty tight coupling between cost and quality. In health care there isn’t.”
About 80 percent of the U.S. population lives within an hour’s drive of at least one large city where there is at least one major medical academic center. Virtually all of these centers are in-network for most carriers. Patients could access specialists on complex conditions here, and care at these facilities is likely to cost less than going to an out-of-network provider.
Michelson’s organization works with patients who have medical problems and identifies for these patients the most advanced doctors with promising and cost-effective interventions.
“If you want to address the cost bar, what you need to do is sweep in a supportive way to help people who are going to become expensive cases, identify the top experts for their care, educate them about the treatment options available, and provide a coordinated, integrated support system to channel them to the best doctors and to ensure they’re getting the care they need,” he said.
The key to controlling health care costs is addressing this small subset of patients with the most expensive cases, he said. Ten percent of patients represent 65 percent of health care costs, and 1 percent represent 25 percent, he said.
“If you aren’t doing something that meaningfully addresses that very small portion of the cases, you’re not going to have a significant impact on the costs,” he said.
Bad Incentives
One health care myth related to costs is that quality and prices aren’t improving because of cheaters in the system, according to Rob Andrews, CEO of the Health Transformation Alliance, a nonprofit group made up of 47 companies whose goal is to fundamentally transform the corporate health care benefits marketplace.
Of course, he said, there are some in the health care system who have committed wrongdoings, but they are rare.
“The problem isn’t that insurance companies are bad, or that drug manufacturers are bad, or that hospital systems are bad or that government regulations are bad. Some of all that is true. But the main problem is that incentives are bad,” Andrews said.
Over the past 60 years or so, he said, a system has been built where incentives aren’t aligned with what’s best for people’s health, giving the example of two hypothetical practices. If there are two radiology practices — one that does 1,000 images a week and produces wrong results 5 percent of the time, and the other that does 500 images a week and only gets incorrect results 1 percent of the time — the first practice would make more money under Medicare. That’s because Medicare rewards are based on the number of procedures done, not how well they’re doing.
Not to say that medical practices or insurers are incompetent, he said. This problem exists because the incentives aren’t aligned correctly in the health care system.
“What we aim to do in the HTA is align the $27 billion a year our members spend on health care with value.” Andrews said. “We want to identify and reward the producers who produce the best value.”
“We chase the shiny object — the price — but we need to be focused on the real issue of value,” he added.
MYTH 2: WELLNESS WORKS
Creating a successful wellness program isn’t as simple as offering one and watching the savings roll in, said Gary Kushner, president and CEO of benefits consultancy Kushner & Co.
Workplace wellness programs have gone through numerous iterations in the past severaldecades. While there have been health-related work programs dating back to the 1920s, it wasn’t until the 1980s and ’90s that wellness programs took off on a much larger scale. The first iteration of this more recent workplace wellness boom is what Kushner called “An Apple a Day” wellness. If an employee eats right and exercises, health care costs will drop. This was not successful, Kushner said.
The second iteration took the original idea a step further, with organizations subsidizing health club memberships and contracting with nutritionists to show employees how to prepare healthy meals. This also didn’t work to reduce costs because the types of employees taking advantage of these subsidies were the ones who already worked out regularly and had healthy lifestyles, Kushner said. The habits of employees who didn’t go to the gym remained the same.
The third iteration of wellness features employers who target their own workforce based on the health needs of that specific population. An employer with a large population of employees with type 2 diabetes may track things diabetics should be doing — like A1C testing and eye exams — through their health plan and encourage at-risk employees to get appropriate testing done.
This type of program, which is more altruistic in nature, has slightly better results. Still, “Every CFO I’ve talked to with these employers keeps coming back to wanting to see savings in the health plan. And they’re having trouble quantifying those. They’re not seeing the difference,” Kushner said.
Where Art Thou, ROI?
Investing in employee wellness is a good thing, but it’s not a short-term policy, said David Henka, president and CEO of ActiveRadar, a health care analytics and patient education company based in Gold River, California.
Although there’s value in wellness programs, he said, that value is not a financial return on investment. Wellness companies often cite huge ROIs for their programs. But academic research reveals that wellness programs do little to reduce health care costs.
A University of Illinois at Urbana-Champaign study published in June 2018 found that workplace wellness programs don’t change employee behavior much or save money on health care costs. Similarly, a University of Pittsburgh clinical trial whose results were published in JAMA in 2016 found that the use of monitoring devices and wearables — often a hallmark of corporate weight loss programs — may have no advantage over traditional weight loss strategies.
“As an employer, if you go into the wellness space thinking you’re going to get an ROI, then you’re going to be greatly disappointed,” Henka said. “But if you go into it by saying it’s the right thing to do for my employees because I want them to maintain healthier habits or lifestyles, then I think you’re tracking along the right frame of mind.”
The realistic value of wellness is more cultural, he said. Wellness companies claiming big returns are not accurate, but it is the right thing for employers to do. It lets employees know that the company values them, he said.
Many employers are not holding wellness providers accountable for the results of their programs, said Cheryl Larson, president and CEO of Midwest Business Group on Health. There are reliable wellness programs on the market, but unfortunately the average employer only pays attention to what the vendor tells them, Larson said.
Employers need to know the right questions to ask wellness vendors and the best way to research their options. Simply asking fellow employers about their programs is one way to conduct research.
Another way to improve vendor services is only agreeing to terms that suit both parties, Larson said.
“I would say if you ask [the vendor] for things, and they say, ‘We’re not going to do that’ — and you’re being fair, you’re doing industry standards, yet they still won’t do it — maybe that’s not the right vendor for you,” Larson said.
Henka suggested providing flu shots as a clear way to show ROI since the flu accounts for lost productivity and absenteeism in the workplace. As last year’s flu season showed, it can be deadly. According to the Centers for Disease Control and Prevention, 80,000 Americans died of the flu and its complications in the winter of 2017-18.
Wellness Done Right
First Choice Health’s Jaja Okigwe addressed potential issues with health screenings — a common component of wellness programs.
One staple of preventive care is annual health screenings and checkups. But the younger a person is, the less likely they are to need regular screenings, according to Okigwe. It’s not until they get older that they need annual screenings.
“It’s a big production to take off time from work and do your screenings,” he said, especially if a patient also has to do something additional like fast for a certain amount of time before the screening. “From a person’s [point of view], there’s a barrier to do it, and then in the end you get this set of information that you probably already knew.”
Companies such as Chicago-based Visibly and Tel Aviv-based 6over6 Vision allow people to get an eye exam using the camera in their phone. The process only takes about 15 minutes, and with results that are 95 to 98 percent as effective as the results they’d get at the optometrist’s office, it’s beneficial for employees who simply need a new prescription for glasses, Okigwe said. While a virtual test can’t diagnose glaucoma, it has a clear benefit for a specific need. A patient who doesn’t need a glaucoma test won’t need to take an hour out of their day to see an optometrist.
“I’m at the age where I wear two pairs of glasses. And sometimes when I’m in that in-between zone I get headaches. Updating the prescription becomes very important and allows me to be more productive,” Okigwe said.
MYTH 3: THE CONSUMER RUMOR
Employers often turn to the consumer-directed health care plan — commonly referred to as a high-deductible health plan — in part to make their employees smarter health care shoppers.
These organizations have a lofty goal when they seek to turn employees into sophisticated health care consumers. Although the goal itself is admirable, the reality is that the health care delivery system is too complex and patients don’t touch it with enough frequency, said Brian Marcotte, president and CEO of the National Business Group of Health.
An employer might have a comprehensive program that gives employees treatment options and resources when they face a surgical decision. But that may be a decision a person has to make once a year or lifetime. “It ends up being a resource that’s out of sight, out of mind,” Marcotte said.
The idea that giving employees more resources and price transparency information would make them more sophisticated consumers did not pan out like employers thought it would, he added. Employers started rolling out HDHPs in the early 2000s and ramped up the strategy when the Affordable Care Act was passed with the Cadillac tax provision. Since health care is generally not part of most people’s regular spending routine like grocery shopping, organizations need to find a way to fit it into employees’ everyday lives.
The Growth of Virtual Solutions
One way organizations are trying to make health care more a part of employees’ routines is through virtual solutions. While people today can find basically any product or service on demand, what is lacking in health care is the ability to get on-demand service, Marcotte said.
The promise of virtual solutions is that they open up avenues to access, convenience and quicker response times from medical professionals.
Virtual care covers a lot of bases including chronic disease management for conditions like diabetes, lifestyle coaching and virtual second opinion services.
However, virtual care can create complicated issues when a patient has to rely on an outside care team rather than the primary care physician with whom they might already have a strong relationship. “The challenge for all these virtual solutions as well is, ‘How do I integrate them back into care and get it within the delivery system itself?’ ” Marcotte said.
Barriers to Health Care Navigation
One reason for the “rampant confusion on how these plans work” — which unfortunately sometimes leads to employees avoiding care — is that “the industry has never done a good job teaching people how to shop for coverage,” said Kim Buckey, a health compliance expert and vice president of client services with benefits compliance company DirectPath.
A person can’t be a good consumer if they don’t know the prices of services, and there’s no easy-to-read or readily available price list, said Buckey’s colleague, Bridget Lipezker, senior vice president and general manager of advocacy and transparency at DirectPath. She referenced what she called the “myth of transparency.”
“The lack of control the consumer has over what they’re paying for something, or even understanding what they’re paying for and what their level of responsibility is — to me, consumerism becomes a myth because of the that. Because you don’t have choice,” Lipezker said.
Another barrier to employees is time.
Patients can call their doctor and ask for options and prices, Lipezker said, but finding this information is a difficult and time-consuming process, and, as Buckey pointed out, most doctors are only available during business hours, so employees need to find the information they need while at work, adding to their stress and cutting into their productivity.
“Some employers are taking the bull by the horns and are offering advocacy and transparency services to their employees to give them a source of support where they can turn over these issues to someone else to fight on their behalf,” Buckey said.
Socioeconomic Issues With HDHPs
Socioeconomics also is an important factor that employers must consider in health care strategies. One problem that HR has, according to technology-led business process services company Conduent’s Bruce Sherman, is that “we design benefits for people like us,” thus isolating people with different benefits needs and life experiences.
Low-income workers have been especially impacted by employers’ attempt at cost containment through HDHPs. According to the February 2017 Health Affairs article “Health Care Use and Spending Patterns Vary By Wage Level in Employer-Sponsored Plans”— which Sherman co-authored with Teresa B. Gibson, Wendy D. Lynch and Carol Addy — cost shifting in benefits plans has meant a 67 percent increase in deductibles since 2010. That’s six times more than the rise in workers’ wages (10 percent) and inflation (9 percent).
The article explored patterns of health care usage relative to employee wages and found that workers in the lowest wage group ($24,000 or less a year) were the most likely to have (had) an avoidable emergency visit, while the highest earners ($70,001 or more a year) were the least likely.
“It may be helpful to ask employees in different socioeconomic groups what benefits they’d like to have,” said Sherman, a longtime researcher of health issues. “This opens the door for information sharing and doesn’t obligate the employer to provide what employees request.”
While more employers are talking about establishing a “culture of health,” oftentimes they also fail to address social and economic determinants in that culture of health, he said, suggesting that employers review organizational policies and practices and keep that perspective in mind to give themselves a broader understanding of where there’s opportunity to improve workplace health for different groups of people.
Some employers offer hourly employees a half day every year specifically to see their doctor for preventive care services, he said. Other employers offer paid sick leave to all employees, including hourly workers. And other employers have ditched “just-in-time” scheduling practices and opted for fixed work hours for all employees — a perk for hourly employees since variable scheduling limits predictable income for employees living paycheck to paycheck.
Some organizations are utilizing wage-based cost-sharing arrangements to address socioeconomic disparities, according to the National Business Group on Health’s 2019 “Large Employers’ Health Care Strategy and Design Survey.” According to the survey, 34 percent of employers offered a wage-based premium contribution in 2018, with 32 percent of employers planning to do the same in 2019. Similarly, 8 percent of employers offered a wage-based cost-sharing arrangement through deductibles or out of pocket costs in 2018, compared to 7 percent planning to do that in 2019.
MYTH 4: WE’RE DOING ALL WE CAN ALREADY
Many employers are doing a lot to help employees with health care costs. But in actuality they demand more from insurance companies and other providers, said DirectPath’s Bridget Lipezker.
Employers comprise the largest group of payers for health care in the United States. According to 2017 National Health Expenditure data, private health insurance accounted for 34 percent of health spending, beating out Medicare (20 percent), Medicaid (12 percent) and out-of-pocket (10 percent).
Employers have a responsibility to do more and they carry a lot of clout. But there are many barriers hindering that influence, she said. It takes a lot of time, energy and focus, and most organizations don’t have the luxury of hiring a person solely focused on benefits.
A majority of small- and midsized businesses only have one person managing HR, and oftentimes HR isn’t even their primary responsibility, according to HR platform BerniePortal’s 2019 “HR Today and Tomorrow” report.
“I think that employers do try to act in the best interests of their employees, at least in my experience. But they don’t always have the expertise in-house or the dollars to hire consultants to help them figure it out,” Lipezker said.
Disruption Will Cut Costs … Not
Counting on disruption to save on health care spend (think major policy changes like the Affordable Care Act) is a strategy, but it’s a poor one for plan sponsors, said ActiveRadar’s David Henka. Employers need to be proactive.
There’s only so many levers employers can pull to affect cost, Henka said. With trends like the consolidation of health systems and influential health care industries like pharmacy benefit managers clashing with employers, organizations have limited options to influence costs.
The most valuable and accessible lever is at the pharmacy, Henka said. Pharmacy costs and formularies are decided on a national scope, unlike hospital and provider networks, which are often decided on locally or regionally. This adds an additional challenge for an employer with offices or employees in multiple states to trim costs.
The lack of transparency in pharmacy benefits is noteworthy, Henka said, and the reality is that for many drugs, there are alternatives that have the same therapeutic benefit for a fraction of the cost. For example, the brand name drug Lipitor has an average cost $184 while Atorvastatin, the generic version with the same active ingredients, has an average cost of $36, according to Henka.
He suggested reference pricing programs, with which costs go down in the short term and, in the long term, patients became more compliant with drug treatments. Reference-based pricing uses complex algorithms to identify the most expensive drugs used by the employee population, highlights more cost-effective alternatives and then encourages members to switch to the most affordable drug.
While reference pricing is trending in parts of Europe, it’s mostly gaining traction in the U.S. among large employer groups, Henka said. He added that many employers think that by switching to a generic-mandated program, they’re doing enough — but they can do more. They could save money by switching from one generic to a different, more cost-effective one.
The types of U.S. organizations mostly adopting these programs are union trust funds and private employers, he said.
The second largest health care purchaser in the country, CalPERS, is also a proponent of reference pricing, he added. Second only to Medicaid, CalPERS purchases health care benefits for employees in the state of California that work for school districts and other public agencies and covers about 1.2 million lives. They have “already implemented reference pricing for a number of medical procedures and are in serious discussion of implementing it for their pharmacy program as well,” Henka said.
Enter the Chief Medical Officer
A conversation that is gaining traction among employers is working to get more control of health care costs in unique ways, said of First Choice Health’s Jaja Okigwe.
Cable and internet provider Comcast was among the first companies to hire a chief medical officer. In 2005, it hired Tanya Benenson to have an expert solely focused on health care outcomes. Similarly, Google hired David Feinberg, former CEO of Geisinger Health, in November 2018 to lead its health strategy, and banking giant Morgan Stanley hired David Stark as its first chief medical officer in October 2018.
“The novelty of Comcast’s situation was that they were taking charge of crafting the whole benefit program and experience for their employees,” Okigwe said. “This is typically done by carriers and benefit consultants.”
The role of the chief medical officer varies by industry, said DirectPath’s Kim Buckey. In a hospital, that role likely will oversee clinical outcomes, while at an insurance company the position is responsible for decisions on what should be covered, or to help develop health and wellness programs. For organizations like Comcast, a CMO will identify opportunities for savings, oversee the organization’s health vendors to control costs, lead negotiations with providers and analyze claims data.
Large employers can afford to have someone in this position, Buckey said, but most are “a ways away” from the chief medical officer being a common corporate title.
National Basketball Association Commissioner Adam Silver made an important comment this week at the MIT Sloan Sports Analytics Conference in Boston, saying that a lot of players are “unhappy” and acknowledging the very real impact of mental health problems on people, no matter how much fame or money they have.
As a benefits writer who occasionally covers mental health, I think it’s genuinely positive when a powerful figure makes a straightforward, sympathetic comment about mental health issues.
Still, I don’t agree with everything Silver said. According to CBS Sports, Silver said, “We are living in a time of anxiety. I think it’s a direct result of social media. A lot of players are unhappy.”
I contend that this argument is too simplistic. I’ve seen this argument before in research and reading, this concern that technology or social media is making people more depressed or anxious.
I prefer a more nuanced approach. Yes, social media has become increasingly ubiquitous over recent years and so has this trend of people being more open about mental health problems, but this sounds more like correlation than causation. That’s a topic worthy of more research.
Mental illness isn’t as simple as X caused Y. Being too focused on social media and technology’s impacts could blind you from other factors that could influence mental health, like personal or professional problems, going through a traumatic event or something physical like brain chemistry. In the context of the NBA, there are understandably some stressors specific to being a professional athlete.
I also don’t believe that mental illnesses are any more or less common than they have been historically. At least I haven’t seen or heard any convincing evidence of that. We need to acknowledge the very real fact that because of stigma, this wasn’t something that people talked about for a long time.
The lack of public acknowledgement doesn’t mean it did not exist. Whenever someone makes the “technology/social media causes mental problems” argument, I wonder if they’ve ever stopped to consider historical context. I wonder if they truly think depression, anxiety, bipolar disorder, borderline personality disorder and panic attacks just didn’t happen before. That sounds naïve to me.
Regardless of my preference for a more nuanced take on the causes of mental health problems, I love seeing that the league commissioner is talking about it. This also led to me read about the NBA’s mental wellness program and the organization’s decision to hire a director of mental health and wellness.
The details of the mental health program are interesting. This story references the league’s old policies to deal with mental health problems, often by team physicians who had no expertise in mental health.
It talks about the NBA’s decision to create a wellness program and the time and considerations that went into it. Basically, this is a comprehensive case study that also brings up some philosophical questions about wellness programs.
It also brings up a noteworthy point about privacy and transparency. The wellness program is run independently of the teams, league and players’ union. According to the article, Michele Roberts, executive director of the National Basketball Players Association said, “We don’t want players to be discouraged from getting help when they need it because they’re concerned that it will get back to the team, or it may affect their play, or it may affect their next contract.” Yet, the article continues, “even that can be debated when it comes to wellness.”
Data privacy and health privacy are topics I care about, which is why it’s intriguing to find debates like this. This story makes a point that when more people are open and transparent about mental health, there’s less stigma.
Wanting anonymity when you’re seeking mental health treatment helps “contribute to the continued stigma.” Further, one former player expressed concern that when people want anonymity, people like him are then persecuted for being up front.
I get this to a certain degree, and I understand this person’s idealized version of the world where everyone can be open about everything and there’s no judgment or consequences. But mostly I prefer to be realistic.
In any organization’s wellness program, privacy should be a clear choice. Health information is private, and no employee should feel pressured to talk publicly about something they want to keep private. HIPAA exists for a reason. And, yes, HIPAA doesn’t apply to many wellness programs, but that doesn’t mean that organizations should respect employee health privacy any less.
As employers get increasingly involved in employees’ physical, mental and financial health, it’s worth a reminder that many people want privacy, and that a respectful employer doesn’t pry into people’s personal data.
One perk of working in a city as big as Chicago is the conferences, big and small, that provide learning opportunities, ideas, and free coffee and bagels in the morning — especially the everything bagels.
The Midwest Business Group on Health held an employer-only forum on wellness, well-being, and engagement Jan. 23, giving me the chance to hear what employers had to say, chat with my table mates informally about workplace health, and listen to several experts speak on different health-related topics.
Many more ideas came up in the seven-hour forum, but here are the major takeaways that any employer should be aware of:
The Workplace Wellness Debate: Ryan Picarella, president of the Wellness Council of America, spoke about rethinking the approach to workplace wellness and building inspired organizations. Even though health care costs are going up and even though organizations are spending more money on health and wellness than before, population health is declining. Something needs to change in wellness strategy.
One topic he brought up was the debate over the value of workplace wellness. He thinks it’s fun to debate, and I agree! The reputation of workplace wellness goes up and down through phases, from something that’s celebrated to something that gets analyzed in “Workplace Wellness Programs are a Sham” articles. Where does the truth lie?
I happen to land on the more skeptical side of this (as I do with many topics), unlike Picarella who is more optimistic. That aside, one point he brought up is hard to argue: No matter what side of this debate you’re on, what we can agree about is that having happy, healthy employees is important, and something needs to be done to improve employee health.
He gave a lot of behavioral-science-based ideas for improving wellness programs, like by thinking about what motivates people, how environmental factors impact employees, and where employees’ sense of purpose lies. Workplace wellness programs need a foundation that addresses people’s basic needs like food and shelter. A program that addresses something like the importance of nutrition or going to the gym without acknowledging that some people won’t be able to focus on that if their priority is keeping the lights on or putting food on the table? That won’t do.
Another idea he shared is simple, but I find it to be strong. It’s one of those statements that’s obviously true, but I can see organizations and people not following it in practice in more areas of business than just wellness. More wellness activities and programs aren’t always better, he said. Rather than think about adding another thing, and another thing, and another, think strategically about the value add.
Persuasion Vs. Manipulation: Part of this event was a roundtable discussion about the role of trust in wellness. When someone communicates to you, the message may sound like persuasion or as manipulation, depending on how you feel about that person. Even a neutral message can read as manipulation if you do not trust the party providing the information.
Everyone in the room had discussions with their tables and then with the whole room about how to build trust in the workplace.
I love this discussion because there are so many deterrents to trust now, like with data privacy. Bring in wellness programs to that topic, and you get health data privacy, which is something people can be understandably sensitive about.
Without going into too much detail, the audience response here was interesting. One person spoke about employees worried about where their biometric data was going. The organization responded to this concern by making it crystal clear to employees what the company could see, what they couldn’t see, how the data was protected, and what they’d need to talk to the vendor about for answers.
Another audience gem: One person suggested including compassion in your messaging, and making sure your vendors do, too. At the organization, some employees had complaints about how rude a vendor was in answering questions and addressing concerns. The organization responded by reaching out to the vendor with this issue and suggesting that the call center employees go through compassion training.
In conclusion, be direct, transparent, and comprehensive.
Also, my initial big-picture reaction to this issue of trust: Isn’t a certain amount of skepticism healthy? Why should any employee blindly trust their employer? How much trust is realistic for employers to expect?
A piece of career advice that has stuck with me over the years is that even though loyalty and working hard are important, you need to look out for yourself. Don’t blindly believe that your employer always has your best interests in mind. If you feel guilty about quitting when you need to move on with your career, remember that at the end of the day if an employer comes across financial trouble, they may very likely lay you off. It’s just business as usual. Both sides can respect each other but acknowledge the reality that their employment contract is business, not personal.
The idea I’m trying to get across here — as somebody who sees that direct correlation between trust and loyalty — is that employers should want and expect employees to ask questions, be curious and even be skeptical when it comes to workplace matters that concern them. It gives both sides a chance to build a professional level of trust.
What do you think? What wellness-based conversations do you think more employers should be having with one another?
Company leadership, including the C-suite and HR managers, may first think of the bottom line when it comes to health insurance and employee benefits. But they could be missing the bigger picture.
The broader view includes the value of investment in benefits and people, and the impact on metrics such as workforce attraction, employee retention, productivity and company culture. High-value options and technologies are increasingly defining and shaping holistic employee benefit programs.
Central to these all-encompassing programs are intelligently constructed plans that consider and connect all aspects of care, including both mind and body, and that are reinforced by big data, artificial intelligence and sophisticated metrics.
In today’s health care environment, holistic programs are especially vital. Behaviorally linked health issues and conditions affect almost 1 in 3 adults 18 years of age or older, but the costs are underreported in claims. Some of that cost revolves around the opioid dependency and the addiction crisis, which has cost the U.S. economy $1 trillion since 2001. Other contributors include smoking-related illnesses and complications, which still levy a toll of up to $300 billion each year, and obesity-related diseases that continue to have a tremendous economic impact.
Research has shown that people who are healthy, both mentally and physically, are more productive. For those struggling with health issues, the right support structures can make all the difference, both in quality of life and in long-term health and wellness outcomes. As an employer, an approach to health care benefits that aligns with company goals and fits the company’s culture can help keep costs in check, reduce turnover and sick leave, and even make your company more attractive to potential teammates.
For example, at Brown & Brown, we have designed a framework called the Intelligent Health Plan that encompasses an array of customizable data-driven strategies. These include plan design, clinical programs and solutions (e.g. telemedicine), and well-being and network strategies (e.g. weight reduction programs and onsite clinics, respectively).
Navigation, advocacy and education can be wrapped around these strategies to create a plan that is integrated, coordinated, and ensures members get the right care at the right time by the right provider in the right setting. A digital hub at the center can help to pull the pieces of the strategy together and enable targeted communications. Key to all of this and any employer’s strategy is the development of relevant metrics and monitoring of outcomes.
This approach to employee benefits emphasizes risk reduction and health management. Depending on the workforce and the prevalent conditions and issues found, this could mean investing in drug rehabilitation, smoking cessation, stress reduction, healthy eating, exercise and “let’s move” programs. There are also many options to leverage technology, on both the employee and delivery side, for earlier intervention.
Technology can play a significant role in an intelligent health plan, both in delivery of new services and in increased employee engagement in risk-reduction and health management programs. Research shows that while people will often pay little attention to generic messaging, buy-in is much greater when a message is customized to their individual circumstances.
Messages can be customized through wearable technology, digital platforms and coaching and clinical programs. Components of these programs may be personalized through advances in artificial intelligence and algorithmic learning. Through more sophisticated analysis of past claims and other health data, the methods and options that offer assistance when the time is right are expanding.
This can lead to both lower health care costs and better outcomes. For example, if research indicates noninvasive methods to treat lower back pain produce results as good as surgery, an employee scheduling an MRI might receive messaging about that research and assistance in obtaining appropriate care.
Prevention as part of risk reduction cannot be overstated, but there must be a deliberate approach. Immunizations, such as flu vaccinations, are crucial, but prevention also includes promoting health screening for conditions such as cancers and catching complications early if chronic diseases do arise.
While these elements may seem focused on individuals, they have a wider impact. People with similar health behaviors, such as exercising, tend to cluster together. Therefore, when one person makes healthy changes there is a trickle-down effect with friends and family that eventually impacts a community.
One size does not fit all when developing health benefit programs. Each company and its employees will have different needs. However, expanding holistic options means programs can be tailored, considering both costs and the value they can return.
Consider this: The average annual cost of health care has increased from $146 per person in 1960 to more than $10,000 per person in 2016, and care costs are expected to increase by six percent in 2019. So, while offering high-quality health care is a great way to take care of your employees, it’s becoming increasingly difficult to juggle the cost of their care with your company’s bottom line.
An option that’s become more available in recent years is the value-based health plan. In value-based health plans, payors share data and analysis to help providers improve their patient care outcomes. Through enhanced reporting and collaboration, doctors can identify areas to gain efficiencies, reduce unnecessary care, and most importantly, improve patient satisfaction and health.
Then, providers earn additional reimbursement based on their performance on cost, quality and outcomes measures. In value-based payment arrangements, health plans pay doctors more for improved patient outcomes and higher quality, and the total cost of care is better controlled.
Many companies are moving away from traditional fee-for-service agreements and toward these value-based payment arrangements. According to an analysis, the number of available alternative payment plans grew from 67 in 2011 to 823 in 2017.
Value-based payment arrangements get to the heart of the major drivers of health costs — hospital stays, ER visits, over treatment and chronic conditions like diabetes. So, when patients get the care they need at the right time, in the right setting, they have fewer complications, and require fewer hospital stays, ER visits and readmissions. These improvements help reduce costs paid by employers and insured members.
The average annual cost of health care has increased from $146 per person in 1960 to more than $10,000 per person in 2016
Nationally, the Michigan Blue Cross plan shares data and analysis with other Blue plans across the United States, so they can not only measure performance on a national scale, but use the data to create tailored, value-based health plans for companies with employees in multiple states.
For example, value-based Blue plans nationally have shown a 10 percent decline in ER visits, 2 percent decline in hospital stays, and an increase in prevention and chronic care management.
When it’s time for companies to decide on health plans for their employees, they should first ask their health plan some important questions.
Are value-based plans available where you have employees? Does your plan have enough value-based providers and programs to benefit your team? Make sure to check the geographic distribution and depth of services available, so your employees can realistically use the services of these value-based providers.
How long has your plan’s value-based program been in place? Find out if the program is mature, and whether they have a measurable trend in value. Programs that are older or more established typically have data that demonstrates the results they’ve been able to achieve.
Do the health plan and its providers collaborate? This will show whether they understand the local dynamics, and whether the plan supports the providers in achieving improved performance.
How extensive is the plan’s member base and value-based network? The larger the plan, the greater its ability to share meaningful data and influence care delivery practices.
Does the plan offer flexible options? A one-size-fits-all approach to value-based networks doesn’t necessarily fit the unique needs of your employee base. Take some time to ask your plan how it measures provider performance and how it rewards members for choosing high-performing providers.
Value-based payment arrangements and value-based network design are two trends that have been demonstrating results for companies. Health care is costly. But now, there are strategies that help companies manage health costs while improving health care for employees.
Utilization of Health Care Services 
Employers need to know the right questions to ask wellness vendors and the best way to research their options. Simply asking fellow employers about their programs is one way to conduct research.
Barriers to Health Care Navigation
