Benefits – Page 5

February 28, 2020June 29, 2023

Mental health in low-wage workers

employers mental health; Millennials and mental health

Mental illness impacts people from every demographic — be it age group, race, job type, socioeconomic group or gender. Still, despite these similarities, low-wage workers face unique challenges to addressing their mental health concerns.

The Midwest Business Group on Health held a one-day conference on mental health access and stigma in the workplace last week, and one theme that came up in a few presentations was addressing mental health in low-wage workers.

Also read: Mental illness cuts across the workplace hierarchy

Bruce Sherman — chief medical officer at the National Alliance of Healthcare Purchaser Coalitions, longtime researcher of health issues, and medical director, population health management at Conduent HR Services — did a presentation called “Do wages buy happiness?” He confirmed that, yes, wages are important in the sense that in the past 15 to 20 years, low-wage workers have gotten the smallest pay increases in relation to their income and high-wage workers have gotten the largest pay increases in relation to their income.

Needless to say, wages do matter.

The conversation goes past that, though. Sherman is currently working on a research project on this topic whose results are not public yet, but he also provided a high level overview of some the issues low-wage workers may face with mental health care and access.

Worsening income inequality is one reason these workers may face trouble. Another major reason is productivity demands, Sherman said.

Rising productivity expectations is not a surprise to me. Research for a few recent stories have led me to data points or findings that support this. For example, according to the 2018 European Agency for Safety and Health at Work report, “Managing Performance Enhancing Drugs in the Workplace: An Occupational Safety and Health Perspective,” workers in low-paid jobs that are not protected under standard labor laws may feel increased pressure to hit certain productivity levels, especially since they are increasingly being monitored by their employers. Not wanting to lose a job they rely on, they may turn to smart drugs. “Electronic means of monitoring employees are likely to be accompanied by an increase in the stresses on workers,” the article noted.

Also read: The workplace is not immune to the impact of social determinants of health

Sherman also informed the audience at MBGH’s event that the perception of mental health stigma may vary by socioeconomic status. There are two types of stigma — public stigma refers to discrimination or stereotyping from other people and private stigma refers to people internalizing stigma in a way that eats away at their self-worth. Low-wage workers often have a greater sense of personal stigma with behavioral health disorders, Sherman said.

This type of personal barrier also exists among cost issues and broader, structural barriers, like the lack of available psychiatrists in their insurance network or the the lack of nearby mental health care based on where they live.

Sherman suggested a few types of ways employers can address these issues. Through benefits design, they can consider eliminating mental health copays for employees so they can access behavioral health services. Ocean Spray is an example of a company who has done this, as of July 2019.

In an article Workforce published last March, Sherman gave more suggestions for changes in benefits design to address mental health in low-wage workers:

“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.”

Organizations can also leverage community social services that employees could take advantage of, Sherman said. Further, they can consider what workplace contributors may add to behavioral health problems and address those workplace issues.

Also read: Business group releases employer guide for managing diabetes in low-wage employees

One final suggestion to address mental health in low-wage workers relates to mental health stigma, and I found it rather interesting. Diversity programs could include information that addresses the negative stereotypes associated with mental health problems. I don’t know of any diversity programs doing this, but I’d be interested in hearing from anyone who is involved with a program like that!

Final takeaways from the MBGH conference:

1. Jeremy Nobel — the founder of The Unlonely Project who currently serves on the faculty of the Harvard Medical School in the Department of Global Health and Social Medicine — spoke about the negative impact of loneliness on people. He mentioned that LGBTQ+ employees, minorities and people with major illnesses or disabilities are especially susceptible to isolation, and mentioned some activities to help them feel connected.

This was interesting and valuable in its own way, but what I found was missing from his presentation was what external factors might make some of these groups of people feel isolated at work. These are groups of people that are likely to be discriminated against in the workplace compared to straight people, white people or people without disabilities. If your organization is pushing for these deeper connections between people but not addressing the reality that even casual discrimatation or harassment will stifle these connections, can it really address this issue?

2. What’s the actual definition of a crisis? Any time I attend a health-related conference, most every public health issue is deemed a crisis. While I understand some of this mentality, I also wonder how we as individuals, governments or organizations are supposed to pay attention to so many health crises at the same time and give them all the proper attention.

3. I wrote a little about generational stereotypes about mental health last week. My overall argument was that both older and younger employees have health issues, and only paying attention to how millennials or Generation Z “can’t handle stress” or whatever can be infantilizing. Also, it leaves older people out of a very important discussion about finally getting help for mental health issues.

I want to add one more thought. Business/health conferences tend to have an older crowd. That makes sense; they’re professionals who have a deep history in the industry. But where’s the voice of these “young people” who apparently have so many more mental health issues than generations before them?

What I think would be interesting is if there was a way for teenagers or young 20-somethings to share their perspective on the mental health of their generation versus older ones. It could be an opportunity for people in different generations to share their stories. For every “Kids these days get all their self-esteem from social media and that destroys their mental health!” from a 40-something parent, maybe a 16-year-old could clarify how common or uncommon that actually is. It could be an opportunity to address certain generational stereotypes head-on.

February 17, 2020June 29, 2023

Business group releases employer guide for managing diabetes in low-wage employees

The employer coalition Northeast Business Group on Health has released a guide for employers looking to better manage diabetes in their low-wage workers.

Low socioeconomic status doubles the risk of developing Type 2 diabetes, according to the NEBGH guide “Diabetes and Lower-Wage Workers,” released Feb. 12. Income determines what basic necessities like food, housing and education people can access, which may in turn affect people’s health. This is true for both hourly and salaried employees with low wages.

Managing Type 2 diabetes, which is typically a lifelong disease, involves a lot of coordinated care, including lifestyle changes, treatment, monitoring and periodic care.

“Even for those earning moderate or high incomes, diabetes can be a challenging disease,” the report stated. “[Low-wage employees] may have myriad financial and social pressures that for them take priority over the steps necessary to control their disease — increasing exercise, changing their diets and getting enough sleep.”

Social determinants of health have been getting increasingly more attention from employers, as those socioeconomic factors in a person’s life can lead to poor health and higher health care costs.

These poor chronic health outcomes don’t just include diabetes but also obesity, depression, anxiety and more, said NEBGH Chief Executive Candice Sherman. Still, diabetes was important for NEBGH to address in a guide since it often leads to other illnesses. “If [diabetes is] left unchecked, there are a huge number of serious complications that can ensue,” she said.

Type 2 diabetes doesn’t just have a negative impact on the health and well-being of employees, it’s also a concern for employers, Sherman said. Chronic health conditions like diabetes impact employee absenteeism, presenteeism and productivity.

Lower-income jobs may come without benefits like health care or paid time off — even to address medical issues — and many people must take a second job just to manage expenses, according to the report. “These circumstances leave them little time to prepare healthy meals, exercise and educate themselves about health conditions.”

The guide listed several practical action steps employers can take to address this reality, including ensuring free access to diabetes retinopathy screening; glucometer and hemoglobin A1c testing; offering resources and health education opportunities; and reviewing the affordability of health insurance premiums for employees in each wage category.

Many employers already are doing many of the suggestions in this guide, Sherman said. These more common practices include preventive screening programs, well-being programs and financial wellness programs. One area of importance for Sherman is the impact of high deductible health plans, she said.

Lower-wage workers tend to choose HDHPs because of their lower premiums or because their employer only offers HDHPs. But these same employees are less able to finance upfront medical expenses like medications and doctors’ visits, Sherman said. Employees sometimes forgo taking their medication or resort to taking it every other day because of financial concerns or because they can’t afford medical costs after paying for essentials like food, housing and transportation.

The NEBGH guide suggests that employers should “add insulin and other glucose-lowering agents to a preventive drug list exempt from deductibles with no patient cost sharing or a low, fixed dollar co-payment.”

Employees also face transportation barriers in accessing care and making it to health care appointments, the report said.

Some forward-thinking employers are beginning to address this, Sherman said. Many large employers provide transit benefits, but other employers are looking beyond that. “Some employers are experimenting with things like discounts or vouchers for some of these transportation services for things like doctor visits or if they have a family member who has a serious illness and needs transportation,” she said.

Sherman also suggests that employers offer employees PTO during working hours. Employers that don’t offer PTO may worry about their bottom line, but Sherman said that this benefit can ultimately help employee productivity by allowing them to get the medical care they need.

“Employers always need to be thinking about the cost of certain benefits like time off and weigh the potential benefits, certainly for their employees but also for the business in terms of productivity,” she said.

February 5, 2020June 29, 2023

What is the Advancing Support for Working Families Act, and why doesn’t it go far enough?

During last night’s State of the Union Address, President Trump announced his endorsement of the Advancing Support for Working Families Act.

Whether we are Republican, Democrat, or independent, surely we must all agree that every human life is a sacred gift from God. As we support America’s moms and dads, I was recently proud to sign the law providing new parents in the federal workforce paid family leave, serving as a model for the rest of the country.

Now I call on Congress to pass the bipartisan Advancing Support for Working Families Act, extending family leave to mothers and fathers all across our nation.

It’s a bipartisan bill that would provide new parents the ability to borrow against the future tax benefit from their $5,000 federal Child Tax Credit, in the form of a $500 allowance for 10 years.

Also read: FMLA leave: Designate early and often

There is little doubt that the United States needs to do something (anything) to provide new parents with some form of paid family leave. I have serious concerns, however, over a proposal that requires parents to borrow against a future tax credit to take that benefit. I have further concerns over a proposal that does not protect parents who avail themselves of that benefit from retaliation.

It’s good that we are having a national conversation about paid parental and family leave. It will be better when we start talking about proposed laws that will provide real and actual benefits and employment protections to parents.

And it will be best when Congress and the White House get off their collective asses and pass meaningful legislation.

January 28, 2020June 29, 2023

Saying goodbye to a decade’s worth of bad wellness

Writing about workplace health and health care for the past several years has meant reading my fair share of buzzy health trends.

That’s why I’ve enjoyed reading about the worst wellness trends of the 2010s and discussing it with my friends and family. Vice even did a March Madness-style bracket, which I found to be fun.

Not surprisingly, the anti-vax movement took Gold, with the keto diet taking Silver.

I was especially happy that corporate wellness made it to Round 3! It lost to another unfortunate workplace trend, #NoDaysOff. You know, that crazy idea that people who work 90 hours a week and never take a break are superior to other employees, so they brag about it online? Woof.

Still, I’m glad workplace wellness made it as far as it did, because academic studies have shown that they’re not effective at cutting health costs or changing habits. They mostly shift health care costs to employees, hence the “cost-savings.” Here was Vice’s reasoning:

Corporate wellness is the latest iteration of workplace wellness, which has been around since the late 1800s and has always existed to increase worker productivity. The current iteration of corporate wellness is mainly focused on mindfulness, but can also include, uh, taking DNA samples from employees or harassing a double-mastectomy patient into getting a mammogram. Surprisingly, these programs don’t actually contribute to workplace wellness. Go figure!

This wonderful bracket made me think about the worst trends I’ve seen in employer health in the past several years.

Some of these relate to other parties that intersect with employers, and none of this is to throw shade at employers. A lot of good things have gone on this decade, as well! Reminiscing brings up cringe-worthy memories for everyone. For example, 10 years ago I used to crochet my own ill-fitted beanies and wear them out in public because I thought they made me look artsy. It’s not fun to revisit that one.

Here are my list of worst health trends, in no particular order.

1. The “culture of health” trend: Recently U-Haul got mixed reactions online for revealing that “it will no longer hire people who use nicotine in any form in the 21 states where such hiring policies are legal.” I’ve seen positive feedback from health advocates online, but ultimately, this is a scary, slippery slope. Are we headed in the direction of a person’s employability being increasingly more linked to their habits or their health?

Think about how the Affordable Care Act protects people with pre-existing conditions when it comes to accessing health insurance. Individuals with a health condition should have just as much of a chance at getting a job as healthy individuals. Health status shouldn’t be akin to a line on your resume.

2. Health care consumerism: One of my favorite articles in the past several years was a New York Times op-ed arguing that we have to stop referring to people paying for health services as “shoppers.”

I know, I know… This movement of encouraging individuals and employees to be smart health care consumers isn’t going away soon, probably. But I agree with the argument. Encouraging employees to be educated about health care is a good thing, but marketing health care as merely a consumer good rather than a vital service people need to survive seems misleading to me.

We should stick with “patients” instead of “health care consumers” or “shopper.” And, like this op-ed suggested, we can simplify our language and just say that patients “pick” or “choose” a health plan rather than “shop for” it.

3. Pseudoscience/misinformation: A big piece of wellness this month is “The Goop Lab with Gwyneth Paltrow” arriving on Netflix. Historically, Paltrow has received criticism from health advocates and medical professionals for spreading misleading or false health information through Goop, her wellness company. Yet Goop is still a big money-making player in the wellness industry.

Meanwhile, people also get misinformation about diets and workouts from social media wellness influencers, who may not be peddling effective or safe advice.

The bottom line is, take medical advice from professionals, not celebrities or influencers. And this doesn’t just apply to individual people. Health risk assessments, which some employers rely on, sometimes contain misinformation, according to Slate.

4. Overhyped health studies: Health journalism is infamous for the “big scary study.” A news outlet gets its hands on some research and twists a finding into something that will get attention. That’s how you get headlines about how some number of glasses of red wine a day reduces your chances of getting cancer.

According to the “How bad science can lead to bad science journalism — and bad policy” from the Washington Post, this also impacts employers’ decisions. This article gives the example of accountable care organizations, which employers may choose to offer employees. The best available evidence shows ACOs don’t work, the article cited. Still, journalists have sung their praises based on studies with deep design flaws.

I’ve written about this in more detail before, but both individuals and benefits decision makers should approach health journalism skeptically. Don’t be afraid to ask questions about how the research was conducted and what might be the limitations of the study.

Finally, my honorable mention goes to consumer-directed genetic tests — specifically the fact that individual or employer consumers may get marketing talking points rather than well-rounded information when companies try to sell these products to them.

January 23, 2020June 29, 2023

Mental illness cuts across the workplace hierarchy

Money, power and status do not protect people against mental illness.

Executives are affected by mental illness as often and as severely as other segments of the workforce, said Dr. Samuel Ball, director of psychology and executive programs at Silver Hill Hospital. He specializes in treating executives suffering from mental illness.

Alcoholism is one of the most common afflictions, Ball said, followed by personality disorders and mood disorders such as depression and anxiety. Executives struggling with depression may have difficulties with productivity and have to force themselves to perform their job due to lower energy levels and interpersonal skills, while some people afflicted with alcoholism can drink heavily while often being functional at work.

A group of high achievers may be initially reluctant to admit the problems they’re experiencing, Ball said. They feel a “different kind of shame about the problems they’re struggling with because they’re on a pedestal. So many people rely on them, [and] so many people look up to them at work and in their family.”

They need to feel secure, he added, describing a patient who felt comfortable speaking up because the CEO gave him a clear message that they wanted him back after treatment.

Home Life Versus Work Life

An executive’s spouse and family play a critical role in convincing them to get help.

“In a number of cases, the problem is not as widely known at work as it is at home. And the spouse has gotten to the end of their rope with [their] concerns,” Ball said.

At work, the executive will “put on the best face or a mask of maintaining their competency” because they’re motivated to maintain their career status. But when they get home, it’s different. Their spouse will usually be the one to convince them to get treatment.

If someone has these health issues, it can negatively impact their spouse and children, especially children in their teenage years. According to the Centers for Disease Control and Prevention, growing up in a family with mental health or substance abuse problems is considered an adverse childhood experience — a potentially traumatic event that occurs in childhood and increases people’s risk for health problems as adults.

This group of patients generally have the means to afford outpatient treatment, which is a good first step, Ball said. The patients he sees, though, are often the ones too ill for outpatient treatment. Instead of living at home and regularly seeing a psychiatrist, they need inpatient care. Ball will get a phone call from the spouse, who has done the research to find the ideal place for inpatient care — usually somewhere in a different city that’s nearby enough that family can visit.

How Peers and Employees Can Respond

When an executive’s mental health is severe, employees and peers may notice. But knowing what to do or how to express sympathy or concern is different. For those employees who report to this higher-ranking person, it can be difficult to know what to do, if anything.

Also read: The mental health parity challenge

An exception might be if an executive has a trusted assistant who has been with them for a long time, Ball said. This type of direct report may have some ability to do something about the situation, especially if they play a “work spouse” role in this person’s life. But a majority of direct reports are not in this situation.

Typically, these high-ranking people won’t go to HR or contact an employee assistance program, Ball said.

“These executives report to the most senior people in the organization. And when they do finally admit to having a problem, if they do admit it, it’s not clear to them where to go in the organization to get support,” he said.

Usually it’s the one or two people above them — usually the CEO or COO — telling them to go on leave to get treatment that finally makes them get help, Ball said.

“They’ll say something like, ‘You’re incredibly valuable to us and we want you back, but you’re not well enough to work now. Take a month, two months, but we want you to get into a treatment program,’” he said.

Still, HR has power here. Lower-level employees may bring their concerns to HR, and an HR representative can speak directly with the CEO or COO, who typically are not surprised by the information, Ball said. From there, the CEO or COO can lead the intervention with the sick executive, and the HR person can stay in the meeting as an observer, especially if there’s been any sort of wrongdoing or complaints about the executive’s behavior.

It’s especially helpful if their boss can show sympathy in this discussion, Ball said.

“When this has gone well, their boss is either someone who has struggled with depression or alcohol, or it’s in their family. And they’ll have that discussion with their affected employee and say something like, ‘I know what this is like, and you’ve got to take care of this,’” he said.

Fighting Stigma

A prime reason executives fear coming forward with mental health issues is the fear that their progress at the company will effectively stall and that people will wonder when their next relapse will be.

“Even if they don’t lose their job, the reputational fallout of people knowing they’ve gone off to rehab is significant,” he said.

Some workplace experts encourage leaders to be open about their mental health struggles in order to decrease stigma for employees. However, since even these leaders experience stigma, talking openly about mental health at work is a hard but courageous thing to do, according to Ball.

Still, he said that it does have a positive effect on the workplace when leaders are honest and open about their struggles. He mentioned a patient who, upon preparing to leave soon, plans to go back to work and share broadly with the workforce that he’s been on leave treating his depression. This executive said he wanted people to take better care of themselves and recognize the signs that he did not.

“I think it’s courageous when people do that,” Ball said. “It’s helpful to employees when they send that message.”

January 22, 2020June 29, 2023

Dream on — lawsuit by Aerosmith drummer highlights the legal risk of ‘fitness for duty’ exams

Joey Kramer, Aerosmith’s founding and longtime drummer, is suing his band mates after they blocked him from joining them at upcoming high-profile events, including this weekend’s honor as the 2020 MusiCares Person of the Year and its Lifetime Achievement Award at this weekend’s Grammys.

Kramer claims that Steven Tyler, Joe Perry, Tom Hamilton and Brad Whitford are not allowing him back in the band following a temporary disability from minor injuries he suffered last year. According to TMZ, Kramer claims the band required the Aerosmith drummer to audition to prove he was “able to play at an appropriate level” before he could regain his drummer role. He further claims that this audition is unprecedented in the band’s 50-year history, during which each of other members had to step away for various reasons.

This story about the Aerosmith drummer got me thinking about an employer’s rights when an employee seeks to return to work after a medically related leave of absence. Two laws potentially apply — the Americans with Disabilities Act and the Family and Medical Leave Act.

According to the EEOC, under the ADA:

If an employer has a reasonable belief that an employee’s present ability to perform essential job functions will be impaired by a medical condition or that s/he will pose a direct threat due to a medical condition, the employer may make disability-related inquiries or require the employee to submit to a medical examination. Any inquiries or examination, however, must be limited in scope to what is needed to make an assessment of the employee’s ability to work. Usually, inquiries or examinations related to the specific medical condition for which the employee took leave will be all that is warranted. The employer may not use the employee’s leave as a justification for making far-ranging disability-related inquiries or requiring an unrelated medical examination.

The issue is more complicated if the FMLA covers the employee’s leave. According to the DOL’s FMLA regulations:

- As a precondition of restoring an employee out on FMLA leave for his or her own serious health condition, an employer can require the employee to obtain and present certification from the employee’s health care provider that the employee is able to resume work.

- The fitness-for-duty requirement must be made pursuant to a uniformly-applied policy or practice that requires it for all similarly-situated employees (i.e., same occupation, same serious health condition).

- An employer may only require a fitness-for-duty certification if it advised the employee of the requirement in the required FMLA designation notice at the outset of the leave.

- The requested fitness-for-duty certification is limited to the particular serious health condition that caused the need for the FMLA leave, must certify that the employee is able to return to work, and may also certify (if requested) that the employee is able to perform the essential functions of the job.

- Unlike medical certifications at the outset of an FMLA leave, fitness-for-duty certifications are a one-shot deal. No second or third certifications are permitted.

- Failure by an employee to submit a requested fitness-for-duty certification strips an employee of his or her job restoration rights (unless the employer failed to advise the employee of the requirement at the outset of the leave).
- The employer can require the employee to bear the cost of the fitness-for-duty certification.

Here’s where it can get really tricky. A failure by an employee’s medical provider to certify the employee as fit to return to work could trigger an employer’s obligation to engage in the ADA’s interactive process with the employee for a reasonable accommodation. If the employee’s medical provider, instead of returning the employee to work without restrictions, either asks for additional, finite unpaid time off or restrictions upon the return to work, the employer should engage with the employee to determine what accommodations are possible under the ADA. The failure to do so could result in an ADA violation.

These issues are tricky and fraught with legal risk. You should be contacting your employment counsel to help you navigate these issues when they arise.

January 17, 2020July 24, 2024

Employers Turning to Pharmacy Benefit Managers to Fight Employees’ Prescription Drug Abuse

Pharmacy Benefit Managers; Drug Cost Management

Pharmacy benefit managers opioids — Pharmacy benefit managers can help to reduce unnecessary opioid prescribing by improving coordination of care among physicians, pharmacists and patients to identify when the potential benefits of these medications outweigh the risks.

More than 10 million people in the United States misused a prescription opioid in 2018, and the opioid epidemic cost the country $179 billion including mortality, health care expenses, lost productivity, criminal justice expenses and assistance. The National Safety Council notes that the annual direct health care costs of individuals who misuse opioids are 8.7 times higher than those who do not.

The opioid epidemic offers an example of a preventable, complex public health and safety issue that has arisen due to a perfect storm of causative factors. Consequently, it requires multiple stakeholders to develop and deliver an effective solution to help lower costs and improve patient health outcomes. These stakeholders include health care providers, pharmacies, drug manufacturers and even employers.

However, the pharmacy benefit manager is one player in the opioid crisis that fills a critical role by employing clinical programs to ensure safe and appropriate utilization of medications. The PBM is a third-party administrator of prescription drug programs and primarily responsible for contracting with pharmacies for network services, negotiating discounts and rebates with drug manufacturers, developing and maintaining the plan’s list of covered drugs (a formulary), and processing and paying prescription drug claims.

PBMs have become an increasingly important part of health benefits since they first entered the market in the 1970s. Today, three pharmacy benefit managers control more than 80 percent of the American market. All are part of massive health care conglomerates that have interests in other aspects of the benefits food chain — from retail pharmacies to medical insurance.

This can create conflicts of interest, as these mega-corporations stand to profit from every stop on a patient’s journey. These conflicts of interest can in turn leave employers and patients vulnerable to increasing health care costs and crises such as the opioid epidemic.

The American public, from the employee to the executive suite and human resources professionals, as well as those who make decisions about employee-sponsored health care, seeks change in today’s profit-driven benefits industry. Here are just a few of the reasons why:

• In 2017, the average annual cost for prescription drugs used to treat chronic conditions reached $20,000, and drug prices increased at twice the rate of inflation.

• American families spent 67 percent more on health care in 2018 compared to 2008.

• Employer contributions toward health care costs rose 51 percent in the same period.

• More than 66 percent of bankruptcies are due to medical expenses or time out of work as a result of illness.

Mergers and acquisitions may answer the health care industry’s need to create new sources of revenue, but they can leave patients and plan sponsors behind. In a sector dominated by an outsized few, consumers all begin to look the same.

To compound the issue, PBM operations are often seen as veiled enterprises. Complex contracts and opaque business practices conceal the flow of dollars, making it difficult for plan sponsors, HR professionals and members to see what they’re paying for. It may seem impossible to demand meaningful change from such a sizable arm of the health care industry, but it doesn’t have to be.

Human resource professionals occupy a unique position in the U.S. workforce. As part of the decision-making process when it comes to employee benefits, HR leaders can demand change from the industry by learning how to spot PBMs that put member and plan sponsor interests first and move away from PBMs that don’t.

This requires understanding today’s health care landscape and how PBMs should be transforming to work for employers, not just for themselves. Here are four key indicators that demonstrate a PBM has broken from the status quo to operate in the best interests of its clients and their members:

• Pay-for-performance business model.

• Comprehensive clinical programs.

• Complete care coordination.

• Transparent contracting.

Pay for Performance

Most PBMs today operate on a fee-for-service model in which they are paid each time they perform a given function, such as a prior authorization review. While this type of business model is common, it fails to tie the PBM’s financial success to how well the company performs for consumers.

No matter how well or poorly the PBM helps the plan sponsor manage prescription spend, the PBM is paid the same. In some cases, it may even be paid more if the plan’s prescription spending grows based on profit incentives tied to per-claim fees and hidden revenue streams.

That’s why a pay-for-performance business model has so much potential in the PBM industry. Pay for performance is a relatively new model, so far only explored by a few PBMs despite its power to help tie the companies’ interests more closely to those of members and plan sponsors.

The pay-for-performance model helps to support transparent PBM operations by holding PBMs responsible for the quality of the work they do and putting dollars at risk if a plan sponsor’s prescription spending rises above a guaranteed maximum. This puts skin in the game and places people, not profits, first.

Under this type of pay-for-performance structure, the PBM is held accountable. Its success is tied directly to quality of service and whether it reduces overall drug spending through proactive clinical programs that help reduce inappropriate utilization. The plan sponsor is rewarded by performance guarantees tied directly to the PBM’s clinical programs and how well they improve health outcomes and lower costs over time.

This new approach helps encourage a straightforward pricing structure that does not benefit from unnecessary prescribing practices. It eliminates conflicts of interest and places plan sponsors and their members first.

Comprehensive Clinical Programs

Clinical programs can be easily overlooked when it comes to their importance not only in safeguarding patient health, but also in the amount patients and plan sponsors pay for health care each year. While many see programs such as step therapy and clinical reviews for prior authorization as sources of member disruption — and they can be if handled poorly — it’s important to recognize that these programs can positively impact plan sponsors and members alike.

An estimated 40 percent of opioid overdose deaths in 2016 involved a prescription opioid, highlighting the dangers that clinical programs have the chance to prevent. From 2011 to 2016, prescriptions were written for dozens of opioid tablets following surgeries, even when procedures would cause relatively little pain.

This prescribing pattern has tremendous impact, as the probability of long-term opioid use and abuse increases sharply in the early days of therapy, particularly after five days. To prevent addiction and abuse, it is vitally important to ensure patients take prescription opioids no longer than is medically necessary.

PBMs can help to reduce unnecessary opioid prescribing by improving coordination of care among physicians, pharmacists and patients to identify when the potential benefits of these medications outweigh the risks. Comprehensive clinical programs offer a strategic way to ensure medical necessity while protecting patients.

Data from the Centers for Disease Control and Prevention show that the rate of opioid addiction is relatively low if only one day of opioid therapy is prescribed initially, with just 6 percent of patients on opioids one year later. The likelihood of addiction increases sharply with eight or more days of prescription opioid therapy (13.5 percent of patients on opioids one year later). This data demonstrate just one way that clinical programs, such as starter dose and quantity limits, can help protect patients.

Starter dose programs limit the initial supply of a drug to help determine its appropriateness for the patient. In the case of opioids, my company, BeneCard PBF, found that a program limiting the initial supply to three days helped curb the number of prescription opioid claims by 67 percent as part of a comprehensive, clinically driven approach preventing opioid addiction. The starter dose program helps avoid members having excess opioids on hand when therapy is needed for just a few days. This approach also reduces the risk of opioid fraud, waste and abuse.

Quantity limits, which control how much of a medication can be dispensed at a time based on medical best practices, can provide similar protection. This helps to prevent unused medication from building up in the home, where it presents a danger not only to the patient, but to others who may be accidentally exposed to the drug (such as children and pets) or who may be at risk of using the medication without a prescription and a physician’s oversight.

Carefully designed and managed clinical programs have the power to save lives and to protect members and their employers from fraud, waste and abuse of prescription medications. There is an urgent need to do so that extends beyond controlled substance abuse. The United States spends about $21 billion on medication errors and $935 billion in overall health care waste each year. However, many PBMs rely primarily on retrospective reviews of prescription drug utilization to identify problems. This approach may represent a conflict of interest, as many PBMs charge a per-claim fee, meaning they get paid every time a prescription is filled.

Instead, look for a PBM that offers comprehensive clinical programs designed to be proactive, not reactive. These programs should include a retrospective review, but they should also work to identify potential concerns before a medication is dispensed and prevent potentially dangerous or wasteful prescription utilization instead of addressing it after the fact.

Complete Care Coordination

Since today’s health care system is so complex, a clinically driven PBM model is important in protecting patient and plan sponsor interests and helping to control prescription spending.

Unfortunately, many PBMs rely primarily on rebates and negotiated discounts to control prescription spending. While these negotiations are necessary in today’s marketplace, they focus on only one part of the equation.

As in any other industry, obtaining strong discounts is simply not enough. PBMs must also be smart about where and how money is spent. That’s why a clinical focus is key. Rebates and discounts do little good if the number of prescription claims continues to rise because patient welfare has become secondary to numbers on a spreadsheet.

But how do you put people first in this challenging environment? Select a PBM that empowers its pharmacists to coordinate care between the various members of a patient’s health care team. This team can include primary care physicians, specialists, retail pharmacists and others.

Often, these individuals are spread across multiple practices, and communication between them can be difficult. However, the PBM’s pharmacists have a unique perspective, with insight into the prescriptions written and filled by multiple providers. This puts them in an ideal position to facilitate more effective communications between all parties involved in a patient’s care.

PBMs should understand a patient’s condition, symptoms, medical history and any other medications they use to help ensure each prescription dispensed is medically appropriate. They must know each drug’s manufacturer recommendations and FDA guidelines to understand if it offers the most effective course of treatment for that particular individual. PBMs also must take into account industry best practices, which constantly evolve as new medications and new clinical data become available.

All of this helps to support better health outcomes by reducing the risk of side effects and adverse drug reactions, improving treatment efficacy and supporting a better quality of life. This, in turn, can reduce the need for repeat visits to the doctor and lower the risk of hospitalization. It can also lower the risk of patients taking a medication that offers little or no benefit. All of this helps to lower overall health care costs, improve member satisfaction and support a stronger workforce.

Health care must be a coordinated team effort to achieve positive results for both the patients and the PBM.

Transparent Contracting

The ongoing conversation regarding PBMs and their role in controlling costs often focuses on transparency, and it must continue to do so. In many cases, PBMs practice selective transparency, allowing consumers to see only what’s favorable to the PBM and its revenue streams.

Complicated contracts help to conceal revenue streams in an industry where conflicts of interest have become increasingly common. This creates an environment in which human resource professionals and their companies are not fully informed regarding how their money is being spent and where PBMs may be profiting at consumers’ expense.

Convoluted business practices and hidden revenue streams make accurate PBM comparisons virtually impossible. This means that there is a greater chance companies and their employees could be spending more to get less from their PBM.

The traditional PBM business model masks several revenue streams, including rebates and spread pricing, which pharmacy benefit managers enjoy at the expense of plan sponsors and members. To avoid these and other conflicts, it is vital to select a PBM that offers clear contract terms.

Clinically driven pharmacy benefit management works, and because it works so well, there’s no need for complicated contracts that conceal exactly what the plan sponsor and their members are paying for. Another method of avoiding hidden revenue streams and conflicts of interest is to work with an independent or privately owned PBM not beholden to shareholders and not driven by the needs of larger health care ventures. This allows the PBM to focus closely on providing superior service with less emphasis on profit margins. Typically, working with these PBMs means carving out the pharmacy benefit from the medical benefit, which offers further advantages and transparency.

There are several small to midsize privately held PBMs that are advancing clinical care, transparency and innovation — outperforming the industry giants for customer satisfaction in numerous categories. The PBMI “PBM Customer Satisfaction Report” is an annual survey of pharmacy benefit managers’ customers to show client satisfaction in multiple categories such as delivery of promised savings; meets financial guarantees; effective tools to manage prescription costs; no conflicts of interest issues; and other important factors.

Let the Past Inform Our Future

To effectively manage a benefits program and protect its members as well as its financial viability, it is essential to understand the issues inherent in the pharmacy benefit management system, as well as the steps necessary to create meaningful and lasting change. This entails exploring smarter, more strategic PBM clinical programs designed to promote clinical efficacy and reduce wasteful and inappropriate prescription utilization. It also involves resisting the traditional per-claim fee structure, which can be prone to fraud, waste, and abuse.

Addressing the underlying issues in the PBM industry requires persistence and tenacity. Armed with proper knowledge, employers can begin asking their PBM the tough questions and start demanding more for their plan and for their members.

January 14, 2020June 29, 2023

Workplace Initiatives Helping to Fight Opioid Epidemic

In the months after John Hindman lost his son to a heroin overdose in 2016, he discovered that he was not alone in his grief. As word of the tragedy spread among his colleagues at Leidos, a defense, aviation and health tech firm, many came forward to share their stories of loved ones struggling with addiction. He was so overwhelmed by the breadth of the problem that he wrote to his CEO challenging him to do something about it.

In a lengthy email titled “A Father’s Request” Hindman told Leidos CEO Roger Krone about his son Sean, who died at age 30, and his struggles with opioid addiction and later, heroin. He wrote of his grief and explained that many other employees face similar challenges, either dealing with their own addictions or those of loved ones. A few weeks later Krone replied. Hindman said his exact words were, “You broke me down. We’re all in.”

“I’ve worked here since 1985 and I never knew how many people were impacted by this epidemic,” Hindman said. “I felt that Leidos’ leadership had no idea of what was happening within the company. I realized that I needed to communicate this within Leidos, not with criticism but with honesty.”

The email launched not only a companywide initiative to combat the opioid epidemic, but also a national movement among business leaders to raise awareness and provide resources to their workforces and communities. The Reston, Virginia-based company distributed a CEO pledge to end opioid addiction that 60 corporate leaders around the country have signed so far.

Leidos, which employs 33,000 people worldwide, also held town hall meetings to gauge the extent of the problem and launched an internal public awareness initiative. It also reexamined its benefits and began looking at ways to better control the prescribing of opioids.

Opioid addiction has ravaged communities across the country. The misuse of these drugs is also a contributing factor in heroin addiction. In 2017, more than 70,000 people in the U.S. died from a drug overdose, a record, according to the Centers for Disease Control and Prevention.

Opioids, which are a risk factor for heroin use, were involved in the majority of those deaths. This has a direct effect on the workplace, impacting health care costs, productivity, absenteeism and recruiting. Employers in states such as West Virginia, Pennsylvania, Ohio and Kentucky have been particularly hard hit, as have those in the construction, trucking and manufacturing industries.

Given that two-thirds of those who are addicted to opioids are in the workforce and that many get their prescriptions through their employers, corporate leaders have found themselves on the front lines of a public health crisis. According to a report by the Society of Actuaries, the prescription opioid epidemic cost the economy $179.4 billion in 2018. This includes $60.4 billion in health care costs and $26.5 billion in lost productivity.

Many employers are finding innovative ways to fight the problem, from public awareness campaigns to offering treatment programs to managing prescription opioids to seeking alternatives to pain pills.

“This is something we’re all coming to grips with,” said Lorraine M. Martin, president and CEO of the National Safety Council. “Issues in our community will end up in the workplace. This is the first year that opioid deaths eclipsed deaths by car crashes. That’s a big alarm bell. It’s tricky because most people become addicted to drugs that have been prescribed to them and many get those prescriptions through their employer.”

While 75 percent of U.S. employers have been directly affected by opioids, only 17 percent feel extremely well prepared to deal with the issue, according to a survey by the National Safety Council. More than a third have experienced absenteeism or impaired worker performance and have had an overdose, arrest or injury because of opioid use, they survey found.

“I think we’re all at different places on this journey,” Martin said. “In areas that are hard hit employers have put in place programs that address recovery. Others still don’t understand that this is happening in their workforce or the role that they can play in fighting it. It’s important that employers understand how it affects their bottom line. The numbers are startling. Various industries and employers saw it quicker and some have taken very creative actions.”

One employer that saw firsthand how a regional opioid crisis also affected its workforce was Belden, a manufacturer in Richmond, Indiana. In 2016 the company was facing a labor shortage and having a hard time finding qualified applicants. About 1 in 10 applicants failed their drug test, so the company developed a novel approach to the problem. In 2018, Belden began offering drug treatment to those who failed their drug screening with a promise of a job if they successfully complete the program. The program, called Pathways to Employment, was so successful that the company launched it at its New York and Pennsylvania locations a year later.

“The program has grown to 30 in Richmond,” said Ellen Drazen, corporate communications manager at Belden. “Our locations in Syracuse and Washington (Pennsylvania) were chosen because they were seeing a similar impact on hiring due to the opioid epidemic.”

Belden has also signed the CEO pledge launched by Krone at Leidos.

In other parts of the country, business coalitions are taking collective action to address the problem.

In Kentucky, which has the fourth highest drug overdose rate in the country, a group of employers launched the Opioid Response Program for Businesses, which helps companies develop policies that support recovery, such as addressing the stigma around addiction. The program is run by the Kentucky Chamber Workforce Center.

“Stigma is one the most profound obstacles in dealing with this problem,” said Natalie Middaugh, a project coordinator at the Kentuckiana Health Collaborative, a nonprofit organization focused on improving health care delivery in Louisville and southern Indiana. “We need to help employers understand that addiction is a chronic disease and not a moral failing or a criminal issue.”

The collaborative joined the effort in 2017 after a significant spike in overdose deaths. In February of that year, Louisville emergency services handled 43 overdoses in one day.

“That was a huge turning point,” Middaugh said. “It’s a community health issue and a business issue, but there is also genuine concern about employees and their families.”

In the past five years, large employers have made a number of changes in their benefits plans in response to the opioid crisis, according to the Kaiser Family Foundation 2019 “Employer Health Benefits” survey. Forty percent launched or revised an employee assistance program in response to the opioid crisis, nearly a quarter modified their health plans to incorporate step therapy for opioid use, 38 percent provided additional health information to employees, 8 percent required employees with high opioid use to obtain prescriptions from only one provider, 21 percent asked their insurer or PBM to increase monitoring of opioid use, and 2 percent increased the number of substance abuse providers in their networks.

The National Business Group on Health and a number of regional employer coalitions recommend working with health plans and pharmacy benefit managers to develop benefit plans that feature safeguards such as limiting coverage for certain prescriptions to small quantities.

Managing opioid prescriptions was a top priority for Leidos, which in 2018 began restricting prescriptions on long acting opioids, such as morphine, oxycodone and fentanyl, and limiting short-acting opioids to seven days. The most common drugs involved in prescription opioid deaths are methadone, oxycodone and hydrocodone. Leidos worked with its pharmacy benefit manager ExpressScripts to implement the changes, according to Karen Kanjian, director of corporate benefits.

“Our part in this as benefits people is to look at what we’re doing in our programs, and we know that the frontline of defense is our PBM,” she said. “They see claims coming in real time and they have access to data, such as which doctors are prescribing and how much are they prescribing.”

Leidos also plans to work with dentists, who often prescribe opioids for procedures such as pulling wisdom teeth.

“My husband had a tooth pulled and got six weeks worth of pain pills that he never finished,” said Heather Misicko, a benefits consultant at Leidos.

A 2018 study in the Journal of the American Medical Association found a link between use of opioids after tooth extraction and long-term use. With 3.5 million wisdom tooth extractions performed each year, that’s a lot of pain medication sitting in people’s medicine cabinets, according to Meg Moynihan, director of strategic marketing at Stericycle. Safe disposal of medications is an important part of addressing opioid addiction, she said.

“Because these drugs are prescribed by doctors for legitimate medical conditions people don’t think of them as a risk,” Moynihan said. “I lock the liquor cabinet but I never thought of locking the medicine cabinet. Having medications lying around makes them more accessible to friends of children, housekeepers and visitors, particularly during open houses when selling a home. It takes less than 30 days to develop an addiction.”

In fact, 20 percent of Americans hold on to their prescription medications because they don’t know what to do with them, and 1 in 10 have offered or given their unused prescription drugs to friends or family members for either medical or recreational use, according to a 2019 study conducted by Stericycle. The company offers envelopes that can be mailed to the company anonymously for safe disposal.

In September, Stericycle and the National Safety Council released a free online toolkit to help employers develop and implement policies and programs that support opioid addiction recovery. It includes sample policies, employee presentations, white papers, videos and other materials designed to support a drug-free and recovery friendly workplace, according to Martin.

The toolkit recommends using the NSC substance abuse cost calculator, which takes into account location, industry and number of employees, to determine the economic impact of drug abuse. After that it lays out a 12-month plan for developing and implementing an opioid policy, from education to communication to vetting the policy with legal counsel.

The NSC also recommends working with health care plans to ensure that mental and behavioral health services are covered, encouraging annual screenings for substance abuse, making sure that alternative pain management treatments, such as non-opioid medications, acupuncture, and chiropractic and physical and occupational therapy are covered, and providing or enhancing EAP services.

“If you don’t know where to start, go to the toolkit,” Martin said. “We advise employers to look at their own health care benefits and to look into alternative medicines. Opioids are not always the best drug for managing pain. Also, make sure to have naloxone in all your facilities. It should be in every workplace and office.”

Naloxone is a medication, either in the form of an injection or a nasal spray, that can stop the effects of an opioid overdose. Before implementing a workplace naloxone program Martin suggests consulting with an attorney to make sure it complies with federal, state and local regulations and training employees on how to spot and respond to an overdose.

While there are many tools and approaches to tackling opioid addiction in the workplace, Hindman said that the most important factor is having company leaders who are committed to the effort. While not every company has the resources of a Leidos, employers are in a unique position to make a difference, he said.

“A third of all addicts are functioning in society, which means that they are in the workplace,” Hindman said. “It’s very hard for the working world to come to grips with this problem. It boils down to a company’s core values. You need to commit it to paper and use it as a platform to attract talent and not treat it as rhetoric. The problem exists broadly and deeply in society and since you’re reaching into society for the employees you need, it makes sense to invest in solving it.”

January 13, 2020January 6, 2020

Social Ills Affect Both Public and Workplace Health

Public health experts have been studying for decades the role that poverty, race, environment and other external factors play in citizens’ overall health, but an increasing number of employers are seeing how social ills impact their workforce.

The concept of social determinants of health, which the World Health Organization defines as “the conditions in which people are born, grow, live, work and age,” is gaining momentum in the employer world.

In 2019, UnitedHealthcare and the American Medical Association teamed up to create medical insurance codes so that doctors can identify social factors that lead to poor health. If accepted by the Centers for Medicare and Medicaid Services, the new codes would become effective Oct. 1, 2020.

Also in 2019, bipartisan legislation called the Social Determinants Accelerator Act was introduced to provide grants and technical assistance to underserved communities. It’s considered to be the first federal proposal on social determinants.

Also read: Health Care Surveys Show Employers What to Expect in 2020

“It seems to have entered employer conversations in the past two to three years,” said Karen Moseley, president of the Health Enhancement Research Organization, a nonprofit think tank focused on workplace health. “Public health has been talking about this issue for years and years and now employers are adopting the same language. It started out as employee and employer collaboration to improve public health and has evolved into companies and communities working together.”

In a recent report on the relevance of social issues to employers, HERO outlines steps that companies can take to address community problems that affect their employees and highlight employers with innovative programs. For example, Cisco, LinkedIn and Pure Storage help fund a nonprofit in Silicon Valley that supports affordable housing initiatives, and Tom’s of Maine pays its lowest-paid workers more than 25 percent above a living wage.

The report recommends that employers create a corporate philosophy that values the needs of its employees and adopt policies and practices that support that.

Also read: The 4 Myths of Health Care Cost Reduction

“It often starts with one issue that is the greatest need in the community,” Moseley said. “Employers need to shift their focus from shareholder value to employee value. I really love this metaphor I heard at a conference about a fish tank. If we feed the fish but ignore cleaning the tank, ultimately the fish are going to die.”

January 10, 2020June 29, 2023

Unintended Costs of the Modern Workplace

A lot of conversation focuses on helping people manage the day-to-day stress that comes with modern life and the modern workplace.

Whether it is looking at financial well-being (or the lack thereof), the stress of constant change, and the greater demands placed on an always-on workforce, we know there’s a problem. Diagnosing the root cause can be difficult, and that’s why I was so struck by my friend Aaron Hurst’s summary of the six unintended consequences of the modern workplace. He presented it at Purpose 2030, his company Imperative’s annual conference that focuses on aligning people and organizations around purpose and connection. (Full disclosure: I’m on Imperative’s board.)

One of the most important insights from their recent research is that creating deeper connections among people is a vital element to the success of organizations. I left their event inspired about how to build those connections on our team and thinking a lot about the idea that a leader’s job now includes creating an environment that supports deep and meaningful connections among colleagues, whether they are sitting side by side in an office or working in various locations around the world.

But that’s hard to do if we don’t examine why work has become a place that often creates the opposite of connection — loneliness and isolation. Looking at some of the unintended consequences we’ve created gives us a path for starting to solve them.

Productivity and communication tools like Slack can increase efficiency and collaboration, promoting quicker decision-making and information sharing. But the volume of communications can be a challenge.

Also in Benefits Beat: Make Benefits and Internal Communications Inseparable

As quantity increases, stress can too, and many interactions feel transactional rather than personal. For benefits teams, these new tools can be a daunting new feedback channel to manage as well. Several of our clients use them to promote benefits in creative ways, but keeping up with employees’ dialog and questions can become a full-time job.

Questions to consider: How do we support conversations that are meaningful? And how can benefits teams with limited resources embrace new tools?

Remote work is an amazing thing. It has expanded the possibilities for the way we work and with whom. For our team, it has been a vital tool for us to bring on key talent, and I think supporting remote work is beneficial in countless ways. But, with less room for casual and face-to-face interaction, authentic connection among employees can be lost.

Questions to consider: How can we enable a sense of belonging and connection with those working remotely? How can benefits create ways for people who work remotely to feel connected and supported by their organizations?

Diversity and inclusion are key goals for most of us. The connection to benefits and the ways we build support programs for various employee groups is a hot topic.

But fully embracing a diverse and inclusive environment creates unique new challenges that require a lot of intentional new behaviors. This side of D&I is not always fully acknowledged or discussed.

As Aaron Hurst says, “The workforce is growing more diverse in every way. It is building a more inclusive society and economy as well as bringing new perspectives to work that drive innovation. When we work with people who are similar to us, the norms of communication and interaction are pretty clear, and it is easier to feel psychologically safe. When we have a diverse workforce, the old models of communication and collaboration are no longer adequate.”

Questions to consider: What does a workplace look like that can fully address the psychology of diversity? How do benefits and other programs build connections and support full inclusion?

Many modern corporations have adopted open-plan designs, hoping it will increase collaboration and productivity. In reality, workers often find that removing physical walls can decrease the quality of connection with those we work with and make focused work more challenging.

Also in Benefits Beat: A New Look at Caregiving

Questions to consider: How can we retain the benefits of open spaces while also restoring more intentional connection? Can benefits like mindfulness training or well-being challenges help individuals and teams get better connected inside and outside of the office walls?

The negative side effects of engagement as a main measurement tool and the challenges of shrinking tenure are also among the unintended consequences Aaron covered. What are the other unintended consequences of your modern workplace? And how are you going to use this year to solve them?