32 October 2013 | The Self-Insurer © Self-Insurers’ Publishing Corp. All rights reserved.

A Matter of MORALS How to restore responsibility, accountability and respect by Bruce Shutan

© Self-Insurers’ Publishing Corp. All rights reserved. The Self-Insurer | October 2013 33

When critics of health care delivery in the U.S. preach from their respective

bully pulpits, any choirs within earshot of this message aren’t just nodding in agreement over how fi xing the system is good for business. They’re also shouting (or in this case, singing) from the mountaintop about the importance of establishing a moral imperative to restore responsibility, accountability and respect to multiple stakeholders, who aside from self-insured plan sponsors, also include consumers, providers, vendors and government.

That means making serious attempts to curtail wasteful spending, honor contracts, and most of all, place patient needs above all objectives. Another linchpin of this grand vision is the achievement of “true” mental health parity, which could combat a host of unintended consequences from high presenteeism and low productivity to larger societal implications associated with the rash of horrifi c shooting sprees by deranged individuals in recent years.

In post-health care environment, some thought leaders believe the task at hand will not be easy, nor will it take hold anytime soon without a massive effort among all involved parties to replace perverse practices with meaningful change. One such promising solution could be wholesale adoption of value-based purchasing, turning decades of cynicism and discouragement into hope and faith. But that could be wishful thinking if state-run insurance exchanges offered in 2014 erode employer-provided health benefi ts.

Unhealthy choicesA major problem today is that

most individuals do not act responsibly at a time when healthy behavior is needed more than ever before, observes George Pantos, the Self-

Insurance Institute of America’s former chief counsel who’s now Executive Director of the Healthcare Performance Management Institute in Washington, D.C.

Employers clearly have stepped up responsibility in this area as evidenced by industry research showing more than 75% of them now offering wellness programs, according to Pantos. “That wasn’t something employers used to do,” he says, noting the need to provide tools to help reduce the prevalence of chronic health conditions, which account for 80% of all doctor, hospital and prescription drug expenses.

Indeed, people would be hired to work, their claims would be paid and that was the end of it. But now that employers are taking greater control of their health plan expenses, Pantos says they’re able to better detect benefi ts spending patterns and predict with a high degree of accuracy where trouble spots will arise – paving the way for better health outcomes and lower costs.

An even bigger concern may be that the average consumer of health care services often gets lost in a maze of unnecessary complexity, frets Greg Scandlen, an independent health care analyst based in Hagerstown, Md., who founded Consumers for Health Care Choices.

“Physicians, hospitals and pharmaceutical companies treat consumers like they are passive recipients of services – not fully actualized human beings,” he says. “Even in the language used, physicians call them ‘patients,’ health plans call them ‘enrollees’ or ‘members,’ and drug companies even call them ‘subjects’ when it comes to clinical trials.”

He says health economics research also de-humanizes patients as statistics defi ned by age, gender, race and health status – completely ignoring that each individual has its own values, resources and preferences. “All of the evidence I have seen suggests that when

consumers are empowered to make their own decisions, they make very good and cost-conscious ones that satisfy themselves,” he adds.

Focusing on valueIf the health care system wasn’t

so fi xated on cost, then it’s quite possible that better outcomes could be unleashed, which, in turn, would lower cost.

Richard D. Quinn, III, a health care blogger who worked as a corporate benefi ts executive for 46 years at Public Service Enterprise Group in Newark, N.J., is a fan of value-based purchasing. However, he’s doubtful the concept can move the needle on outcomes and cost unless it’s implemented on a macro basis. “If there are 10 large self-insured employers in a state or geographic area, they have to be doing the same thing,” he says. “They all have to be able to change the fundamental outlook of the health care system and the providers.”

But Quinn fears that employers probably are headed in the other direction and will be tempted to abandon health care coverage, altogether, between the establishment of public health insurance exchanges and IRS defi nition of affordable care under health care reform. “I don’t think anything signifi cant is going to happen until we start seeing the transition for more and more people ending up in the exchanges under one uniform system,” he surmises.

What about several private exchanges now being set up? He dismisses them as “a money making scheme for consultants,” which, in fact, move away from self-insured coverage by transferring risk and cost accountability to insurers. Still, a recent white paper by Aon Hewitt, which offers its own corporate exchange, points out that “the more exchange participants, the greater the economies of scale that increase carriers’ ability to

34 October 2013 | The Self-Insurer © Self-Insurers’ Publishing Corp. All rights reserved.

offer competitive prices. In this insurance marketplace, as in every consumer market, the element of competition will ultimately reduce prices.”

One bright spot that Scandlen sees on the horizon involves challenges to the notion that employers are somehow responsible for health care, which he strongly believes is a hindrance to the employee-employer relationship. He envisions a future in which employers continue to earmark whatever dollars they can afford each year toward group health insurance and let employees shop for the best possible care – with proper guidance in place.

“There seems to be a lot of activity in that area combining fund contributions and private exchanges with a variety of coverages, and making money available for the employee to make their choices within that system,” he says.

Scandlen also cites the cash-and-counseling concept as a shining example of consumer empowerment on the lowest rung of society’s ladder. The effort is aimed at people on Medicaid who are primarily elderly and disabled, focusing on personal-care services rather than case management.

“They actually give them a pool of money and let them hire their own personal care service providers,” he says. “It has been enormously successful, and this is not coming from a conservative Republican, right-wing kind of perspective. This is from the Robert Wood Johnson Foundation, which is considered a very liberal organization. It increases patient satisfaction and lowers costs and just makes for a happier system when the consumer is an active player in decision-making.”

Another concern about the state of the nation’s dysfunctional health care system is a dearth of education about employee health promotion and wellness. “There isn’t enough information being disseminated out there to persuade people to stop smoking or eat more nutritious foods and to exercise more in terms of how it relates to their job performance, or expenditure of funds,” Pantos says.

But sometimes businesses can go to extremes in ways that discourage healthier behaviors. Some employers, for example, push wellness programs to an unhealthy extreme. Scandlen has heard of cases where companies not only refuse to hire smokers, but also “anyone with a smoker in their family” – a candidate for consideration on the list of solutions being worse than the problems they seek to address.

© Self-Insurers’ Publishing Corp. All rights reserved. The Self-Insurer | October 2013 35

And that’s just one example.

“I remember talking to a medical director of a large company some time ago who was concerned about employees appropriately using weed whackers on the weekend at their homes,” he continues. “It seems to me that kind of attitude is going far beyond what an employee-employer relationship should be. Because they are paying for health coverage, they feel like they have a right to oversee employees’ complete activity 24 hours a day. That is a plantation mentality, and I think an outrageous overreach.”

A close watch on mental health

In order for the health care system to work, employees in both self-insured and fully insured plans

need to be content from a holistic standpoint – a goal that cannot be fully realized unless they have access to affordable and quality mental health services. Therein, lies a simmering problem that occasionally bubbles to the surface in dramatic news accounts of horrific shootings. About one-third of those responding to the American Psychological Association’s most recent annual Stress in America report reveal that they suffer from high stress, but never discuss stress-management strategies with their health care provider.

“The treatment system has been unable or unwilling to collect data on the rate of recovery and make it public,” explains Peter C. Brown, executive director of the Institute for Behavioral Health care Improvement in Castleton, N.Y. “We do know from work of individual researchers that people recover. The real question is

how fast are they recovering? Society as a whole has the feeling that behavioral health problems are permanent, but, in fact, they are not nearly as permanent as many people would believe.”

Brown says there also are gray areas to address, starting with an inability “to effectively articulate the expectations people should have when they entered care,” which serves to decrease “both the business of support and the individual consumer’s willingness in a lot of cases to invest effectively in the care.”

Quinn believes it is hard to justify a different way of paying for mental health treatment relative to physical ailments, but also realizes that costs could swirl out of control given that some mental health conditions can require indefinite treatment and may never be cured.

He predicts stronger enforcement of the Mental Health Parity Act

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(MHPA) “and maybe even regulations enhancing that [legislation] with regard to gun legislation because we’ve all heard in the press that the problem is really mental health. I think we have to look at what is causing all of this, which seems to be escalating. Is it breakdown of the family? Is it this environment people are growing up with that creates these problems? I don’t know the answer, but it seems to me it is more than just focusing on the treatment. We ought to be focused on why do we have so much? Why do we need so much treatment?

Despite efforts to improve mental health care under the Affordable Care Act and MHPA, their intersection could be in the form of a dead end. “There are some real problems apparently about getting parity in care if what you are doing is transforming the general care system into an accountable-care methodology or patients-setting, medical home methodology,” Brown says.

The system clearly requires a more comprehensive approach. “Depression and chronic heart failure will feed off of each other to the point that if we don’t deal with them at the same time, we’ll fi nd it increasingly diffi cult to help that individual cope with accommodating either one of those problems, or certainly the combination,” Brown explains.

While health care reform has sought to fi x longstanding systemic problems that have eroded the state of responsibility, accountability and respect among key stakeholders, Pantos fi rmly believes the employment-based model is still the best hope for substantive change. “For a long time, people have criticized the fact that employees are beholden to an employer for their health care and that they don’t just basically get it from other sources like the government,” he explains.

But he cites a recent Kaiser Family Foundation report estimating that 150

million Americans are covered through the private health care system, more than 60% of whom benefi t from self-insurance. The self-insured model makes it easier to apply proper algorithms for more aggressive solutions when years of claims data are amassed for apples-to-apples analyses that do not encroach on an individual’s privacy, Pantos opines.

He’s sanguine about the future, noting one-on-one health care coaching by a nurse practitioner or other health care professional serving as the newest dimension to wellness. Those efforts could involve anything from managing medication adherence to following up on doctor visits. Pantos believes this could go “a long way toward getting people to be more accountable for their health care once they have all the information and they’re educated.”

What’s still largely missing, however, is the measurement component – particularly as it relates to gauging the impact of poor health, absenteeism and presenteeism on productivity, he notes.

But be that as it may, “the fact that you have such a high level of participation in the private health care system by self-insured employers certainly indicates that the employer has taken on a greater responsibility by planning, controlling, establishing and maintaining their health plan than by just simply paying a premium and turning it over to the insurance company and having nothing more to do with it,” according to Pantos. n

Bruce Shutan is a Los Angeles freelance writer who has closely covered the employee benefi ts industry for 25 years.