On-site workplace centers have grown in recent years from being traditional in-house occupational health clinics where someone who was injured on the job could get basic care, to more extensive total health management centers that offer acute care treatment, health and wellness programs, health coaching, behavioral health assistance and chronic disease management.

Not all on-site facilities are right for all employers, but many different-sized companies are finding models that make sense for them.

“Studies have shown that only about 25 percent of large, self-insured firms offer some type of workplace center,” said Leonard Eisenbeis, director of Clinical Health Operations for UPMC WorkPartners, an affiliated company of UPMC Health Plan. “But, studies have also shown that the number of companies planning to open a worksite center doubled between 2007 and 2011 because employers are looking for a way to lower health care costs and support their bottom line.”

Smart Business talked with Eisenbeis about on-site services and why they can make sense for some employers.

What are some of the benefits that employees receive in on-site centers? 

An on-site health management center is attractive to employees because it provides convenient and timely treatment for a set of acute conditions. It also replaces what, for the employee, would be a more costly visit to an emergency room or urgent care facility. Additionally, the center can monitor employees’ chronic conditions, which can easily be relayed to their primary care provider or medical home, improving overall total health management.

What are some of the benefits employers see with on-site centers?

Employers like the fact that on-site centers reduce employees’ lost time from work, which increases productivity. In addition, a good on-site center can help generate employee awareness through physician referrals by engaging at-risk employees in a comprehensive management of lifestyle behavior and disease management. Also, directly avoidable health care costs — such as physician visits, urgent care and emergency room use — can be diminished through on-site centers.

What are some features you can expect at an on-site center?

On-site center staff provide primary care support and on-site care for acute health care services, such as headaches, minor injuries, sore throats, sprains and strains.

You can expect the center to be a front door to occupational health services, where occupational injuries can be reviewed quickly and triaged, and occupational health exams, drug testing and OSHA reporting could take place. Good on-site total health management centers provide health and wellness education and referrals. Employers may include prescription medication services by providing a courier service to deliver prescriptions to employees.

Is there one model for on-site centers?

No. Employers can choose from several delivery methods to find the one that works best for their individual companies. For instance, they can have on-site health centers, or they can have a ‘near-site’ center within several miles of the employer’s campus to be used by employees who work at different sites. Another form of on-site services is mobile medical units, which are a cost-effective option for targeted medical services or testing.

Employers also may take advantage of telehealth technology within an on-site center to effectively service a number of worksite campuses. Telehealth is a remote health management application that links employees from an on-site health center to a physician or provider using interactive videoconferencing, voice and data systems, and embedded peripheral devices.

Telehealth is becoming more popular because this technology could allow an employer to install telehealth equipment with a nurse or medical assistant and transmit a patient encounter to a provider, greatly increasing the affordability of on-site care and financial return on investment. There are many options in the deployment of telehealth that make providing total health management care very scalable to companies of all sizes.

Leonard Eisenbeis is a director, Clinical Health Operations at UPMC WorkPartners. Reach him at (412) 454-4960 or eisenbeisl@upmc.edu.


Save the date: Join UPMC WorkPartners for an upcoming webinar, “The Next Generation Worksite Health Center,” at 10 a.m. April 24. To register, contact Lauren Formato at (412) 454-8838 or formatol@upmc.edu.


Insights Health Care is brought to you by UPMC Health Plan


Published in National

Many employers realize that their commitment to their employees doesn’t necessarily end at retirement. But wanting to deliver post-retirement health benefits and doing so in an effective and affordable manner is not always possible for all businesses.

However, employers do have several options, including outsourcing retiree billing administration to a firm that specializes in that area.

“It may make sense for many companies to outsource their retiree billing administration,” says Tammy Clay, manager for Flexible Spending Accounts and COBRA with UPMC Benefit Management Services. “It can save a company money, time and valuable resources.”

Smart Business talked with Clay about retirement billing administration and why it can work for many employers.

What is retiree billing?

Basically, it’s a Web-based service that provides coordination of enrollment and billing. For many companies, retiree billing is considered as a sort of a yolk around their necks. They need help in this area and sometimes an outside source is the best place to look for it.

What makes retiree billing difficult for some employers?

Retiree billing is generally considered to be among the most time- and paperwork-intensive assignments that a human resources department ever has to deal with.

There are a number of ‘necessary evils’ employers have to deal with where retiree billing administration is concerned. When billing the appropriate premiums and relaying timely eligibility updates to the carrier, a multi-functional billing system should be at the heart of the process.

In some cases, an employer provides credits to the retirees to apply toward Medicare supplement plans. The process used to determine if the money leaving an account matches the amount claimed, and ensuring that the correct credit is being applied for a certain time period, is account reconciliation. Account reconciliation is important because it helps with cash management and protects businesses against fraudulent activities.

Regardless of the size of the company, the retiree populations will always continue to grow. For some companies that growth might dwarf the active population. As a result, many companies find that they cannot afford to grow their HR departments to keep up with it.

What are some advantages of outsourcing retiree benefits administration?

Employers want to reduce their liability for post-retirement health benefits and can often do that by outsourcing. Retiree premium billing administered by a neutral third party can protect retiree privacy. Health and financial matters are sensitive issues that retirees may not want to share with a former employer. Moreover, there can be complications and frustrations in dealing with the complexity of retiree benefits. It is best for all involved that any frustration is not directed at the former employer.

What are some advantages for employers of outsourcing the process?

Retirees will no longer call an employer’s human resources department to ask questions that the HR department may or may not be able to answer. This can save both money and time, and increase the productivity of the HR department. When billing is outsourced, the people dealing with the retirees are specialists in this area who can answer any questions or concerns retirees might have. In many instances, retirees can access 800-number phone lines and 24/7 websites to make it easier for them to get information and answers to their questions. An employer is saved the hassle of dealing with multiple phone calls and emails to resolve these issues.

By outsourcing retiree billing to an experienced, reliable organization, employers can be confident that the service is compliant with federal, state and local laws. Employers also like the fact that by outsourcing retiree benefits administration, they have more time to focus on strategic planning that can create value for a company.

Tammy Clay is a manager, Flexible Spending Accounts and COBRA, at UPMC Benefit Management Services. Reach her at (412) 454-8739 or claytl@upmc.edu.

WEBSITE: For more information about what UPMC Health Plan has to offer employers, please go to www.upmchealthplan.com/employers/index.html.

Insights Health Care is brought to you by UPMC Health Plan

Published in National

Returning injured workers to a healthy and productive lifestyle is the goal of any workers’ compensation program, but the cost can be high for all involved. For an injured worker, there is the recovery from the injury itself, anxiety regarding the workers’ compensation system and the potential loss of the identity that he or she enjoys through work. For the employer and insurer, there are the escalating costs and complexities connected with managing claims, as well as the temporary or permanent loss of valuable employees.

All could benefit from the expertise and oversight that can only be provided by a comprehensive managed care approach.

“With workers’ compensation claims, you need to have a beginning-to-end strategy,” says Deborah Mehalik, manager of Network Services for UPMC WorkPartners, which is part of the UPMC Insurance Services Division. “The traditional managed care approach needs to be expanded to specifically target extremely vulnerable points within the workers’ compensation system for all parties involved.”

Smart Business talked with Mehalik about the advantages of having a robust managed care approach to help employers handle workers’ compensation issues.

How can a managed care approach impact a company’s workers’ compensation program?

Managed care must be expanded to include concepts such as:

  • Accessing medical expertise throughout the life of the claim.

  • Identifying quality providers who have expertise in workers’ compensation.

  • Aggressively identifying early, safe return-to-work potential.

  • Developing an in-depth understanding of cost containment strategies.

  • Measuring programmatic cost drivers through the use of data analytics.

An important new concept in managed care is integrating health and wellness resources at the time of a work injury to improve the employee’s overall risk profile.

What is the key benefit that a managed care approach brings to workers’ compensation?

The primary benefit in a comprehensive managed care approach is that it is structured to produce a win-win for all stakeholders involved.

How does managed care contain costs?

Costs can be contained in several ways. This would include the identification of medical providers who understand the importance of safe, early return to work and how it directly impacts lost time days and indemnity costs. Medical expertise can assist with causality determinations and appropriateness of treatment, and also ensure correct acceptance and payment for both.

Having a clear understanding of injury drivers assists safety personnel in making the necessary changes to process and policy in an effort to avoid similar claims.

Understanding cost drivers such as pharmacy and physical therapy allows for an evaluation of the gap between current and best practices and gives valuable insight when determining which vendor to partner with. Having knowledge of bill repricing and the network(s) being utilized on the employer/insured’s behalf assists in managing costs by maximizing preferential pricing and allows for continued evaluation of provider performance.

What can employers gain from using a workers’ compensation plan with managed care?

An employer will gain enhancements in areas such as case closure rate, causality determination and utilization review. Employers also should experience reductions in areas such as DART rate (days away/restricted/transfer), and medical and indemnity costs. Accessing sophisticated data analytics allows benchmarking of current programmatic performance and, when well structured, shows value or areas of cost shifting when new strategies are introduced.

What do employees gain?

A managed care approach that focuses on quality care and outcomes benefits employees by utilizing a best-of-the-best approach, linking them to superior providers and treatment platforms. By identifying best practices in areas such as pharmacy management and physical therapy, the employee has seamless access to a prescribed regime that maximizes the recovery effort.

Click here to learn more about UPMC WorkPartners and its workers’ compensation program.


Deborah Mehalik is a manager of Network Services, UPMC WorkPartners, a segment of the UPMC Insurance Services Division. Reach her at (412) 454-7083 or Mehalikdl@upmc.edu.

Insights Health Care is brought to you by UPMC Health Plan

Published in National

Managing the leave process has always been complex and it is becoming even more so with recent updates in federal regulations concerning leave and accommodations. In addition to the federal requirements, state and local governments also are enacting laws to further protect an employee’s time away from work.

“Employee absence puts a strain on your organization, and survival in today’s business climate demands high productivity and a lean and efficient staff,” says Edward Mashey, senior director for Absence Management Services at UPMC WorkPartners. “Every hour an employee is out on leave adds costs to your bottom line and what you don’t know can hurt you.

“Compliance concerns, administrative errors, inconsistent tracking, under reporting, lack of accountability, limited knowledge and costs — all are reasons for putting leave administration in the hands of a trusted partner with years of experience administering leaves of all types, including family medical leave, military and employer-sponsored leaves,” he says.

Smart Business spoke with Mashey about what an employer should know when outsourcing leave administration.

What is an employer’s obligation in this area? 

The Family and Medical Leave Act of 1993 (FMLA) requires covered employers to provide employees job-protected unpaid leave for certain medical and family reasons, including personal or family illness, military service, family military leave, pregnancy, and the adoption or foster care placement of a child. The law recognizes the growing needs of balancing work with family and medical issues.

What are some reasons employers should consider outsourcing?

Tracking and managing the paperwork associated with all leave requests creates additional administrative burdens for an employer. UPMC WorkPartners’ experience with employers has shown the average time needed to effectively process a leave is three to five hours per leave. For an employer of 1,000 employees averaging 120 leaves per year, this amounts to nine weeks per year of managing just the initial leave requests.

Why is compliance in this area so important? 

Compliance with federal, state and local leave requirements is a key component in a successful leave program. According to the U.S. Department of Labor, Wage and Hour Division, the average wrongful termination verdict for an FMLA case is $350,000, not including attorney fees. Employers should seek out leave specialists who have ongoing training and education related to federal, state and local regulation changes in order to keep an employer’s program in compliance.

It’s important for employers to know that a supervisor can be individually liable for violating an employee’s FMLA rights based on the FMLA’s statement of who can be liable and its definition of who is an employer. Having a partner that can train and communicate to a staff and effectively interact with them regarding leave and disability issues is extremely important.

What are some other issues that surround leave management?

Intermittent leave time needs to be fully reviewed to ensure the leave meets the requirements of a serious health condition and each increment of time away from work is appropriate and medically necessary. Each absence needs to be reviewed for medical necessity.

Currently, the federal government has proposed changes to the FMLA that include updates to the military exigency and injured service member leaves. An expert outsourced leave administrator’s dedicated staff keeps abreast of all leave law changes whether federal, state or local changes.

And remember, the end of an employee’s leave time is not necessarily the end of the employer’s obligation. Recent court cases have shown employers how important it is that they discuss with the employee their potential ability to return to work after leave time has expired. Working with a partner that has the knowledge and skills to help identify those cases that will need extra attention from an employer is an essential element of an intelligent leave management strategy.

Edward Mashey is senior director, Absence Management Services at UPMC WorkPartners. Reach him at (412) 667-7117 or masheyet@upmc.edu.

SAVE THE DATE Wednesday, Jan. 16 , 11 a.m. to noon, UPMC WorkPartners webinar: Best Practices in Leave Administration. To register, contact Lauren Formato at formatol@upmc.edu or (412) 454-8838.

Insights Health Care is brought to you by UPMC Health Plan

Published in National

Life is full of stressful situations, be they personal or professional. Stress of some kind is often unavoidable, or, at least, a common experience for nearly everyone in the workplace.

Learning how to be resilient is a life approach that helps those who’ve developed it handle stress more effectively. For some, resilience is a way of living, but for all it’s something to learn and incorporate as they develop.

What exactly is resilience? Resilience refers to the ability to adapt, recover and grow stronger from adverse situations. Robert Brooks of Harvard Medical School calls resilience “ordinary magic” because everyone has the capacity to be more resilient.

“Managers and leaders may not realize that what they do contributes to having a more resilient work force. Their job is to create a work environment that makes it possible for each individual to contribute their competencies, to be creative,” says Annette Kolski-Andreaco, manager of Account Services for LifeSolutions, an employee assistance program and an affiliate of UPMC WorkPartners.

“It isn’t that resilient people are extraordinary people,” she says. “It’s that they’ve been tested and learned that they are adaptable.”

Smart Business spoke with Kolski-Andreaco about resilience in the workplace and why it matters to employers.

Why should the resilience of the work force matter to an employer? 

The workplace can be a challenging environment for employees for a variety of reasons. They need to navigate complex networks of relationships and continuously adapt to changing work processes to keep up with the relentless competition in the marketplace.

Many employees today can easily feel overwhelmed, fatigued and disengaged due to their work environment. They may come to question whether what they do really matters, and if they can find professional fulfillment and meaning in their work.

To succeed on the job, employees need to acquire cognitive skills through training and education. But equally important for success is the establishment of a solid work/life balance with families, social networks and leisure pursuits. It is that support that enables employees to have a solid foundation from which to better handle stress in the workplace and expand their capacity for change and resilience.

Recent surveys from Gallup polls show that less than 30 percent of employees are actively engaged in their work, while 56 percent are disengaged and 15 percent are actively disengaged. When people are able to change their mindset toward being more hopeful and optimistic, the result is healthier, happier and more productive employees.

Research also supports the idea that when employees and employers actively cultivate a positive attitude, the work environment becomes more optimistic and creative.

How can an employer create an environment that encourages resilience?

The capacity for resilience is there in all people, but there are things that can be done to nurture or reward resilience.

What that means for employers and managers is that they need to realize that their employees respond far more flexibly and readily when they have supervisors who connect with them in an authentic and personal way. When managers are able to see their employees as whole persons with a desire to contribute their talents, if given an opportunity, then both parties will benefit.

Employers need to identify their employees’ positive traits and then work with them to improve and strengthen those positives. Engaged employees who believe their contributions have value are able to be more resilient and are less vulnerable to workplace stress.

Most employees want an opportunity to shine. They also want their employer to be fair, and to give them some control over what happens to them. They want their employers to be respectful and they want to connect with their manager on a human-to-human, personal level.

What are the advantages of having a resilient work force?

A more confident, challenged and interested work force is what every employer wants. The simple truth is that for this objective to be realized, managers need to spend the time and make the effort to know each of their employees as an individual contributor to the overall mission and vision of the organization.

Employees are far more motivated by flexibility, fairness, opportunities to learn and develop themselves, and acknowledgement of their accomplishments, than we realize. Stressful work environments are a fact of life, but a more resilient response by employees and their managers makes all the difference in whether they’ll be overwhelmed and burned out.

Creating an atmosphere for resilience to emerge is something that comes from leadership at all levels. An employer can turn to an employee assistance program to learn different ways to develop resilience in their managers and for their staff.

Annette Kolski-Andreaco is manager of Account Services for LifeSolutions, an affiliate of UPMC WorkPartners. Reach her at (412) 647-8728 or kolskiandreacoa@upmc.edu.

Insights Health Care is brought to you by UPMC Health Plan

Published in National

As companies grow, the demands on human resources departments also increase. To satisfy demands, employers have to be aware of the advances in self-service technology in HR that can increase productivity and create real cost savings.

HR departments can see tremendous benefits from technological innovations such as online HR/Benefits administration.

“Online automated HR/Benefits administration is attractive to companies with a sizable work force — generally 200 or more employees — because at this size, HR departments can become bogged down with daily administrative activities,” says John Galley, president of EBenefits Solutions, which is part of the UPMC Insurance Services Division. “Automation of these activities via the Web can eliminate these daily tasks for HR departments so that they can focus more of their time and energy on strategic initiatives that have a greater business impact. Online HR/Benefits administration also saves companies money, while increasing efficiency and security.”

Smart Business spoke with Galley about the benefits of online HR/Benefits administration and why it matters to employers.

Why would an employer want to make use of online HR/Benefits administration?

For many companies, the HR function has become more complex, difficult and time consuming. Oftentimes, more strategic initiatives can be squeezed out by the daily demands and volumes of administrative issues that must be addressed because they affect the work force every day. Fortunately, solutions are available.

The advantages of online HR/Benefits administration to an employer are many. Massive amounts of paperwork associated with benefits and payroll can overwhelm an HR department. There is a need to handle a number of documents that need to be filled out, signed, dated, reviewed, entered into various internal and external systems, such as carrier databases and the employer’s payroll/HRIS (Human Resource Information System) platform, and then filed. But online HR/Benefits administration can automate much of that process for employers.

Online HR/Benefits administration frees staff from duplicate paperwork, prevents errors and places all employees’ files in the same system, making it easier to access and retrieve. Other databases, such as a carrier system or payroll/HRIS platform can then be securely updated in an automated fashion via an electronic exchange.

Online HR/Benefits administration can also include a host of special features, such as embedded communications tools that allow HR departments to customize messages to various employee populations. The most advanced technologies do much more than handle open enrollment — they handle new hires, life events such as marriages, birth of a child, divorce, etc., as well as employment events such as a promotion or a move from part-time to full-time employment. Each of these has benefits and other HR implications that may be automated by a single solution.

And, because HR/Benefits administration virtually eliminates mailing costs and reduces time and other third-party related costs from operations, most companies realize a return on investment of 200 to 300 percent in the first year. In short, employers can receive better service at lower costs.

What advantages are there for employers with an online HR/Benefits system in place?

Most employers are thinking about strategies to help advance their work force so they are better equipped to handle change and move more swiftly. What is their communications strategy? What is their portal strategy? How can they move wellness initiatives forward to provide meaningful impact on medical trends and other lost productivity costs?

An online HR/Benefits system can provide answers to these key questions — the most advanced and state-of-the-art technologies in the market can create an integrated and seamless experience for employees, one that allows them to easily navigate a single system to accomplish their daily HR/Benefit activities.

These technologies also provide a gateway into other platforms such that wellness, absence, and other key initiatives can be easily and seamlessly managed through the same integrated portal. Because employees could perform all of these tasks without contacting HR or leaving their desks, this saves time for employees and HR staff, thus increasing productivity for the employer.

The right online HR/Benefits system ensures greater security and privacy of information for employees. Electronic exchanges are secure and data is protected via various levels of security. For example, HR administrator access can be limited to HR administrators only, and the information they have access to can be further limited by role, department and location.

What strategic advantages can an employer gain?

We have found that getting the work force onboard with online communications can help to make the organization more nimble and quick. Key messages can be communicated instantly to the work force, and these messages are actually heard and, when needed, responded to.  Our work force has been given online tools to help them make decisions about which medical plan option might be best for themselves and their families. This saves them time and money and helps them make better decisions and better use of their pay, which increases employee satisfaction.

Lastly, because we have a fully integrated HR/Benefits portal, our employees can easily navigate among sites without having to remember separate Web addresses, user names or user IDs, and passwords. This integration helps employees quickly and easily get where they need to go and is one of the key reasons that we achieve more than 90 percent participation in our wellness program each year.

Employers need to think beyond just employee benefits when developing their Web strategy. They should think about all aspects of online self-service for employees and if they are looking for a strategic partner, find one that has the ability to offer additional services when they are ready.

John Galley is president of EBenefits Solutions, part of the UPMC Insurance Services Division. Reach him at (412) 647-3393 or galleyjl@upmc.edu.

Insights Health Care is brought to you by UPMC Health Plan

Published in Pittsburgh

Many myths surround alcohol and alcohol abuse, and those myths can often affect attitudes in the workplace, as well.

The most common myth may be that people who abuse alcohol are easily identifiable as “bums,” or “losers,” and that they are unlikely to be employed. The truth is that only a small percentage of alcoholics could be so categorized and that 90 percent of alcohol abusers are employed.

“There are hidden costs with alcohol abuse that employers don’t always see,” says Albert Moore, account representative for LifeSolutions, a division of the UPMC Insurance Services Division. “Its effect shows up in absenteeism, lower productivity, workplace injuries and accidents, increased health care costs and even workplace morale.”

Smart Business spoke with Moore about alcohol abuse in the workplace and how employers can address it.

Is there a reliable estimate as to how much alcohol abuse costs businesses each year?

The National Institute on Alcohol Abuse and Alcoholism estimates that untreated cases of alcohol abuse costs businesses $185 billion a year. For an individual company, it is estimated that alcohol abuse costs a company about $7,000 a year per employee, and that affects in some way 15 percent of the work force. That means that a company with 500 employees is probably spending more than $500,000 a year on the effects of alcohol abuse.

How should an employer react when there is a suspicion that an employee has an alcohol problem?

Supervisors and managers often lack confidence that they can effectively address problems that appear to be the result of alcohol abuse.  But each potential situation provides an opportunity to demonstrate leadership. The employee’s peers will gain respect for a supervisor’s problem-solving ability and appreciate the concern expressed for a co-worker. Untreated abuse always gets worse. The sooner the intervention, the better the result for the employee, the employer, and the workplace.

Are there specific things a supervisor can do?

Many factors can complicate a supervisor’s ability to take action, including the fact that alcohol consumption is legal and employers have no way to control the behavior of employees away from work.  However, employers can do what is necessary to ensure that their employees perform their duties effectively and safely, which includes banning alcohol on a work site. An employer has the right to set rules that can discourage or eliminate alcohol in the workplace.

How does a supervisor know when it’s time to act?

It helps if a supervisor is both aware and available. Listen to employees and take note of problem behaviors. Sometimes employees might confide in a manager or supervisor, sharing the fact that they are struggling with an alcohol problem or admitting that they are worried about their drinking.

In such instances, a recommendation that they contact an Employee Assistance Program (EAP) is often all the motivation and direction they need. A manager should always refer to company policy and/or speak with a human resources representative regarding self-disclosures to assure confidentiality.

How can EAPs be of assistance?

EAPs are a good place to turn to for help if you have an alcohol problem because these programs can recommend very specific things you can do to start to address the problem. The service that EAPs provide is confidential, and because most EAPs are independent of the employer, they are trusted by employees. EAP representatives are experts in this area and have the experience to steer employees in the right direction.

An EAP health or alcohol addiction coach is a great place to start. Many people are hesitant about asking for help because they are embarrassed, or in denial, or worried they might not like what they hear. However, even the best athletes in the world need a coach, someone who can take an objective view and provide that fresh look at things that you may be missing. This is what alcohol abusers need.

EAP coaches will often refer someone with an alcohol problem to other experts who can help, depending on what they need. In this way, EAP coaches are like brokers. They know the business and can help find the best deal in terms of care and counseling.

What are some signs employers can look for that may be indicative of alcohol problems?

An impaired employee may be the last to recognize the problem. It is essential for a supervisor to focus on job performance, documenting specific examples of behaviors that are unacceptable or substandard per company policy.

Again, it is recommended that the manager consult HR before speaking to the employee. Focusing on behaviors, instead of opinions or diagnoses, allows a supervisor to avoid potentially inflammatory reactions. EAP consultation can help identify signs of deteriorating performance.

There are times when a supervisor or manager may have to deal with an employee who is impaired on the job. This requires prompt action to ensure the safety of the employee and others in the workplace. EAPs can offer guidance on making a referral and on handling the employee.

Albert Moore, MPM, CEAP, SAP, is an account representative for LifeSolutions, a division of the UPMC Insurance Services Division. Reach him at (412) 647-8124 or mooreal@upmc.edu.

Insights Health Care is brought to you by UPMC Health Plan

Published in Pittsburgh

Transparency in health care means allowing consumers to have both cost and quality information for services delivered by health care service providers. In health care, this kind of information has been largely invisible and unknown to consumers, including employer groups. Many believe this lack of information is a factor in high health care costs.

In recent years, both health plans and employer groups have been supportive of the concept that directly engaging consumers in decision-making can help to reduce costs. And, in order to engage consumers, they must be informed about costs and quality of services.

“Transparency enables consumers to compare both the cost and the quality of health care treatments,” says Dr. Stephen Perkins, vice president of Medical Affairs for UPMC Health Plan. “Those two pieces of information are essential. That is the only way they can truly make informed choices among doctors and hospitals.”

Smart Business spoke with Perkins about transparency and its possible effects on health care and health care costs in the future.

Why is transparency important?

First, for providers, it benchmarks their performance, thereby giving them a way to measure their performance against others and, consequently, make improvements. For insurers, it provides a way to recognize and reward quality and efficiency in the delivery of health care. And, finally, it provides a way to help patients make more informed decisions about their care.

In addition, the cost of procedures can vary dramatically by facility, and often the consumer has no idea of the price differences. At present, health care may be the only industry in which consumers are expected to purchase a service without fully knowing the cost or quality of what they are getting. Most consumers who are part of an employer’s health plan have no idea about the cost drivers that determine the premiums they pay.

How can transparency affect health care costs?

At present, consumers are largely unaware of the price differences that exist for the same services from different providers. They have little idea about the cost of just about anything connected to health care, with the possible exception of co-payments. Consumers certainly have a right to know the quality and cost of their health care. Through health care transparency, consumers can get the information necessary to be able to make choices based on value. Reliable cost and quality information is essential to making choices. In theory, consumer choice should create incentives at all levels and motivate the health care system to provide better care for less money. When providers compare themselves to one another, this can begin a process that could lead to improvements in care and reductions in costs.

For almost all other purchases, consumers can readily get information about price and quality. This has always been presumed to be the basis for making intelligent choices that make sense economically. It would seem logical to assume that will be the case with health care as well.

Certainly, it makes sense that engaging individuals to be more responsible in managing their health and in purchasing health care services is a necessary first step to curbing costs in health care.

What about the differences between health care purchases and other purchases?

There are certainly differences. For one thing, consumers might be inclined to automatically associate cost with quality, when that may not necessarily be the case. In addition, it is not always possible for health care decisions to be made following a slow and deliberative process. These decisions are often made under emergency conditions and at times of high emotional stress.

What kind of consumer tools can be effective to ensure transparency?

In order for consumers to get information that is most useful, they would need to know data that is derived from actual claims. That way they see what actually was paid to the hospital for a certain procedure, for instance. They can use that information to determine, for example, what the cost of a certain procedure was in several different hospitals in the area. But consumers have to know not just how much a procedure costs but also the total cost of caring for a given condition.

How will health plans be involved in transparency efforts?

Health plans will be essential to transparency efforts because they have the capacity to make price and quality information available at the local level and they can offer consumer-directed plans for employers and individuals.

Health plans have the capacity to show comparisons of price, quality and efficiency. They are interested in transparency because providing quality and price information to consumers in a way they can easily access and use is also a way to build trust with members.

Why would providers support transparency?

Transparency data will allow providers to improve by benchmarking their performance against others. It encourages private insurers and public programs to reward quality and efficiency. And, it helps patients to make more informed choices about their care.

There will be concern, of course, that consumers might, at least initially, be confused by the new information, but essentially, transparency is seen as something that will certainly become a benefit to consumers.

Dr. STEPHEN PERKINS is vice president, Medical Affairs, for UPMC Health Plan. Reach him at (412) 454-7682 or perkinss@upmc.edu.

Insights Health Care is brought to you by UPMC Health Plan.

Published in Pittsburgh

The TV show, “Are You Smarter Than a Fifth Grader?” is fun because it highlights how much young students know that their parents have long forgotten or never knew.

But, measuring up to fifth-graders is equally difficult in other areas. For instance, how would most adults answer this question: “Are you as fit as a fifth-grader?”

“It’s likely that most adults don’t know how fit they are and they are probably less likely than fifth-graders to be able to find out,” says Dr. Michael Parkinson, senior medical director of Health and Productivity, for UPMC Health Plan. “Many employers do health risk assessments for their employees, but they do not realize that the absence of risk does not equal fitness.”

Smart Business spoke with Parkinson about how employers can better gauge and encourage fitness among their employees.

Why compare an employee’s fitness to that of a fifth-grader?

That is certainly an arbitrary standard, but what got me thinking about it was when my fifth-grade son came home with what was called a ‘Fitness Gram’ that showed how he scored in a number of physical tests designed to measure his fitness. What struck me most was how detailed the test was, most especially when you compare it to anything that could pass as its equivalent in the corporate world.

Employers have been measuring and promoting workplace wellness primarily through use of a health risk assessment that measures personal health behaviors and self-reported height and weight, or body mass index (BMI). Many employers add biometric screenings, which include blood pressure and lipid or blood fat levels, as well. And, of course, all employers are now required to pay for preventive care at no cost to their employees.

Are health risk assessments ineffective in measuring fitness?

They have a purpose, certainly, but they can be misleading. In health risk assessments, those whose scores indicate low risk are considered to be the most healthy. But what employers do not realize is that an absence of risk does not equal health. Absence of risk does not equal fitness. To be blunt, in the corporate world, the bar has been set too low on wellness.

How can the bar on fitness be raised?

One of the tests my fifth-grader had to take measured his aerobic capacity and is known as ‘VO2 Max.’ Aerobic testing is rarely, if ever, a part of any corporate wellness test for an adult, even though the information is vital.

Aerobic capacity shows the maximum capacity of an individual’s body to transport and use oxygen during incremental exercise. It is widely recognized as the test that best reflects the physical fitness of an individual.

It is also been shown to be the best single predictor of ‘all cause mortality,’ or how long we’ll live. Greater aerobic capacity has been associated with the ability to better perform both physical and mental work, clearly required in today’s demanding and competitive workplace.

Why should the fitness of employees matter to an employer?

Fitness tests generally assess muscle strength, endurance and flexibility, all of which are of great importance in the workplace. However, unlike elementary students, adults are rarely tested in these areas. Musculoskeletal injuries such as strains and sprains are due often to obesity, lack of core body strength and fitness.

Musculoskeletal injuries are a leading cause of lost workdays, as well as medical and disability costs. Back injuries, slips and stretching mishaps are common work-related incidents that employees face and that could be avoided with improved core body strength.

Is BMI an important measure of fitness?

Body mass index, or BMI, is a measurement test that is a common feature of most health risk assessments and it is used to determine whether an individual’s body weight differs from what is normal or desirable for a person of that height.

BMI is a measurement based on a formula that takes into account your height and weight in determining whether you have a healthy percentage of body fat. In general, BMI is an inexpensive and easy-to-perform method of screening for weight categories that have the potential to develop into health problems. But, again, it doesn’t indicate anything in terms of fitness levels and it doesn’t really say how healthy you are, just that you might be at risk for obesity.

How can employees raise their fitness levels?

Fifth-graders are often more fit than adults because, generally speaking, they are more active. In order to improve fitness, people need to participate in some kind of moderate aerobic activity for 30 minutes a day, five days a week. It does not matter if the 30 minutes is broken into three 10-minute segments.

What’s important is to try to get moving. Some exercise at any level of intensity is better than none as you start to build endurance.

It’s funny to think about comparing employee fitness levels to that of fifth-graders, but the message is serious. Any company that wants to take wellness to the next level should think about measuring fitness the way fifth-graders do, and, in the process, see how their employees measure up.

Insights Health Care is brought to you by UPMC Health Plan.

Published in Pittsburgh

Shared decision making in health care can be simply defined as decisions that are shared by doctors and patients. These decisions are informed by the best evidence available and are weighted according to the specific characteristics and values of the patient.

In 2010, a study in the New England Journal of Medicine reported lower costs and fewer hospital admissions when patients were given shared decision-making tools to help understand their options and the consequences of those options.

“Shared decision making acknowledges that there is no single right answer for everyone and that medical decisions involve value judgments,” said Dr. Stephen Perkins, vice president of Medical Affairs for UPMC Health Plan. “Shared decision making doesn’t mean that the physician’s opinion does not matter in the ultimate decision. It means that the patient’s opinion will be given weight when a real choice is available.”

Smart Business spoke with Perkins about the concept of shared decision making and how it can be a force to raise quality and reduce cost in health care.

Why is shared decision making gaining acceptance?

Shared decision making encourages physicians to include, as part of their treatment routine, consultations with patients about options and outcomes. This gives the patient an opportunity to offer an opinion about those options and can result in a shared decision about treatment.

Both physicians and patients are increasingly coming to see the value of this. When decision making is shared, there is more comfort and satisfaction by the patient with the treatment decisions. This can lead to a greater acceptance of responsibility and engagement in developing and executing long-term treatment plans, which can lead to improved long-term health outcomes.  As a result, there is a reduction of wasteful spending associated with noncompliance.  Shared decision making can reduce wasteful spending because instead of physicians driven to practice ‘defensive medicine,’ ordering tests primarily to avoid potential lawsuits after the fact, physicians and patients can agree on a course of action beforehand and commit to that.

What are the barriers to shared decision making?

Shared decision making can be difficult because it balances two elements that can be in opposition to one another. One is the patient’s right to have input into treatment options, the other is a physician’s responsibility to provide the best evidence-based health care. Time is also an obstacle. Both physicians and patients may believe that they do not have the time necessary to go over all care choices.

What are some of the advantages of shared decision making?

If a decision is truly shared, there is a greater chance that it will increase patient satisfaction, which can lead to decreased anxiety and a quicker recovery because there is a greater likelihood that there will be full compliance with treatment regimens.

When shared decision making is done correctly, the treatment course will reflect what is most important to a patient who is well-informed and who fully understands all options and all of the potential outcomes of treatment. In addition, greater patient involvement in decision making often leads to lower demand for health care resources.

What does shared decision making look like?

The American Medical Association has recognized three core elements that need to be part of shared decision making: clinical information, values clarification, and guidance and communication.

Clinical information includes a synthesis of relevant scientific evidence about the patient’s medical condition, the available treatment options and the risks, benefits and outcomes associated with each option. Values clarification is a presentation of the more subjective elements of the patient’s condition and treatment options. This may require testimonials from actual patients and a questionnaire-type tool to help patients articulate their priorities.

Guidance and communication means providing the help and guidance needed in order for patients to make decisions with which they are comfortable. In short, the patient needs to be fully informed and fully engaged, and the final decision needs to involve both patient and physician.

A growing body of research indicates that both patients and physicians benefit when patients are well informed and play a significant role in deciding their treatment. Because any shared decision is more likely to match patient preferences, values and concerns, patients are more likely to stick with treatment regimens and experience better health afterward.

What is required of the patient in shared decision making?

The patient must not be too intimidated by their doctor to ask questions. The patient should not be shy about expressing personal feelings; they matter in this process. A patient must also come to grips with the idea that there are times when medical decisions need to be made, without complete assurance as to how they will turn out.

Patients can maximize the value of their physician visits by bringing a list of questions with them, by bringing a friend or family member to help them remember concerns, by taking notes, and by asking your doctor to summarize what you talked about at the end of the session.

Dr. STEPHEN PERKINS is vice president, Medical Affairs for UPMC Health Plan. Reach him at (412) 454-7682 or perkinss@upmc.edu.

Insights Health Care is brought to you by UPMC Health Plan

Published in Pittsburgh
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