The field of health insurance is in the middle of significant change. Many of those changes are still evolving and their outcomes cannot be determined at this point, but others seem inevitable, such as an increase in the number of individual plans that people will purchase in the coming years.
“Most people have employer-sponsored health insurance because, for a long time, that has been the most prevalent way for them to get health insurance,” says Andrea Gioia, executive director for Product Innovation for UPMC Health Plan. “However, the number of people with individual plans is increasing, and insurance plans are responding to that.”
Smart Business spoke with Gioia about individual plans and how they are becoming a part of the changing health insurance market.
Why would someone choose an individual plan over an employer-sponsored plan?
In group coverage, by definition, you have a one-size-fits-all type of plan. Depending on your situation, you may have to pay for coverage that you do not need, or you may not have specific coverage that you do need. Also, with an employer’s plan, once you leave your job, you also leave your health insurance, but you can take an individual plan with you wherever you go with your career.
Group plans do not have the flexibility to offer a customized plan because the provisions of the policy are negotiated between the insurer and the employer, and deductible amounts and co-payment percentages are determined in advance. With an individual plan, you have the option to select different cost shares and you can choose to have certain provisions included or excluded from your policy.
Another reason for increased demand for individual plans is tied to the economy. There are more people unemployed these days, more people self-employed and an increase in the number of smaller employers that are choosing not to purchase health insurance for their employees. This situation is resulting in more interest in individual plans.
What should someone look for when purchasing individual plans?
One of the advantages of getting an individual plan is that you can have a health care policy that better fits your specific needs. To do so, however, means that you need to find the plan that makes the most sense for you and for your specific health situation. With an individual plan, you can have direct control over your policy and its benefits. You can choose to have certain provisions included or excluded, and you can choose your deductible amount and the cost of co-payments.
You should also be sure to choose a plan that enables you to choose the hospitals and doctors you want. Some individual plans do not offer maternity or behavioral health benefits, so if those things are important to you, you should look for them. In all plans, however, preventive care is covered in full.
What is the downside of individual policies?
The biggest disadvantage can be the price. Individual policies can be very expensive, especially if you have high-risk potential or pre-existing health problems. Before issuing an individual health care insurance policy, the insurance company asks you to complete an application about your personal health history.
It is possible that you could be rejected for pre-existing conditions such as congestive heart failure, Parkinson’s disease, or cystic fibrosis. Check with your insurer to see what pre-existing conditions will be denied.
How many different kinds of coverage are there?
There are normally five choices for individual health insurance coverage. They are the traditional fee-for-service, a health maintenance organization (HMO), a preferred provider organization (PPO), a point of service plan (POS) and an exclusive provider organization, or EPO.
How does a consumer know which one to choose?
A high-deductible PPO plan that is compatible with a tax-advantaged health savings account is often the best option for people who do not have many doctor visits in a year but who still want major medical coverage. For those who want more comprehensive individual health insurance coverage, a PPO, or EPO plan with a lower deductible, might be preferable. Routine doctor’s office visits and preventive care are covered, and your co-payment can vary depending on the plan you choose.
In some ways, you can shop for insurance plans much like you shop for other major purchases. Compare the types of plans available, compare the rates and compare the coverage and benefits. Doing so will allow you to find the plan that best fits your health needs.
Will individual plans replace employer group plans?
Despite the changing marketplace, it is unlikely that individual plans will supplant employer group plans anytime soon. Employer group plans continue to be the most popular, in large part because they offer the most comprehensive coverage, both because they are largely subsidized by the employer and because there are tax breaks associated with them. For the consumer, such plans are generally less expensive than individual plans, and that will continue to make them a popular choice.
ANDREA GIOIA is executive director for Product Innovation for UPMC Health Plan. Reach her at (412) 454-8293 or firstname.lastname@example.org.
Caring for a loved one is an activity that takes place outside the workplace, but its impact inside the workplace can be significant, if often overlooked. The majority of those caring for a loved one are employed, and the impact of their care commitment on their workplace productivity is usually underestimated.
MetLife, in a 2010 study in conjunction with AARP and the National Alliance for Caregiving, estimates that lost productivity in the workplace as a result of caregiving costs businesses approximately $33 billion a year. Lost productivity can come in the form of tardiness, leaving early from work, or even in the case of some employees, rejecting promotions that would force a caregiver to move far away from elderly parents.
“Providing care for a family member is an act of kindness and love,” said Annette Kolski-Andreaco, manager of account services for LifeSolutions, an employee assistance program (EAP) that is part of the UPMC Insurance Services Division. “And with increased life expectancies due to medical advances, the need for caregivers will continue to rise.”
Smart Business spoke with Kolski-Andreaco about the impact caregiving has on the workplace and on employees, as well as what employers should know about it.
What is the extent of the impact of caregiving in the workplace?
There is a hidden cost for employers when it comes to caregiving. An employer has to understand that employees are managing difficult life challenges at different stages in their lives. Employers tend to be more aware of some of these challenges, such as marriage, childbirth, day care and the responsibility of school-age children. But employers don’t think as much about the challenges their employees face later in life. And, yet, these are challenges that employers should focus on because the working population is getting older as people continue to live longer and also want to stay in the workplace longer.
What does this mean? For employers, there is likely to be a large cohort of their employees who have increased caregiving responsibilities for elderly parents and other elderly loved ones. In today’s workplace environment, we have an older working population caring for an even older age group, and that is a significant hidden cost.
How extensive is the issue for employers?
An estimated 17 percent of full-time workers are also caregivers, and nearly one-third of all working caregivers are in a professional position. According to a Caregiving in America study, more than 73 percent of caregivers were employed at some time during their caregiving.
That is significant because the study also showed that 66 percent of employed caregivers have gone in to work late, left early or taken off time during the day to deal with caregiving issues. Also, 20 percent of employed caregivers have reported taking leaves of absence as a result of their duties.
In general, it is estimated that caregivers miss an average of 6.6 workdays per year as a result of caregiving activities. A majority of caregivers believe that caregiving has some impact on their work performance.
Is there a physical toll on caregivers?
Surveys conducted by the Centers for Disease Control and Prevention and the National Alliance for Caregiving showed that 17 percent of women over the age of 50 who are caregivers reported fair or poor health, about double the rate for other women in that age group. Similar results were evident among younger male and female caregivers, ages 40 to 49, who also reported poorer health.
The medical conditions for which caregivers are at increased risk include diabetes, high cholesterol, hypertension, pulmonary disease, heart disease, kidney disease and depression.
Caregivers are under a great deal of stress, which can cause a number of physical problems such as muscle tension, impaired immune system function, increased blood pressure, sleep difficulties and a lack of exercise. Essentially, the caregiver is at extreme risk healthwise. To compound the issue, when the caregiver’s health is compromised, the care receiver is put at increased risk.
What other impact is there on the workplace?
The stress felt by caregivers can adversely affect their job performance. Employees who are also caregivers are tired, distracted by worries and have less mental energy at times. This is an issue that employers need to recognize and address.
What can an employer do to help employees deal with caregiving issues?
In general, employees who are caregivers need some flexibility, if it is possible for the employer to grant it. Offering flexibility in terms of schedules, leave time, etc., and support from the workplace can help them deal with these difficult issues.
There also needs to be increased awareness of the caregiving issue and its potential impact on a work force. A company’s human resources department could provide information about helpful community resources, for example. Remember, for most employees, caregiving is a new experience and they need help in knowing where to turn for assistance.
If an employer has an EAP, it should be promoted as a source of support, information and referral to resources. EAPs also provide emotional and practical solutions to problems and can be a source of information about the legal implications and financial repercussions of caregiving.
ANNETTE KOLSKI-ANDREACO is manager of account services for LifeSolutions, part of the UPMC Insurance Services Division. Reach her at email@example.com or at (412) 647-8728.
Insights Health Care is brought to you by UPMC Health Plan
In recent years, health insurance companies have been enthusiastically deploying new tactics, sometimes linked to financial incentives, to improve health and reduce medical costs.
Many insurers are offering employer groups plans that provide monetary rewards to members who exhibit healthy behaviors and encourage them to be more involved in their health care decisions. A few have created a comprehensive, integrated and incentivized approach that is turnkey to help both employers and employees to achieve this goal.
A suite of next-generation, consumer-directed health plans powered by a health incentive account represents a cost-effective solution for directly addressing the rising cost of health care for employers while focusing on the health and productivity of employees.
“Enlightened consumer-directed health plans with funded health incentive accounts help employees and their families understand and improve their health,” says Dr. Michael Parkinson, senior medical director of health and productivity, UPMC Health Plan. “It also helps employees partner with their doctors in medical decisions and earn incentives as they do. Healthier, more engaged individuals — as both consumers and as patients — live longer, better and more productive lives, and usually save money in the process.”
Smart Business spoke with Parkinson about how to manage consumer-directed health plans and how they can benefit employers.
Why should an employer be interested in a consumer-directed health plan?
Increasingly, employers are focused on the health and productivity of their employees as an essential business investment. They understand that having healthy employees means increased productivity.
But employers need a cost-effective solution to the rising cost of health care. Chronic conditions account for 80 percent of all medical costs to employers, and that number is rising. The increase in these conditions and their costs predominantly are due to behavioral factors.
Consumer-directed health plans (CDHPs) must be done correctly to improve health and reduce unnecessary medical care costs for all members of a population, not just the young and healthy. Employers should embrace this growing trend because it focuses on the health and productivity of employees. It works because employees are better able to understand their health and their care, improve their health care and partner with their doctors to make health care decisions — with money they ‘see’ and ‘feel’ is their own.
How can employees be rewarded?
Employees can earn money for their Health Incentive Account to reduce out-of-pocket health care expenses by completing specific healthy behavior and care engagement activities. To understand their health needs, employees take a confidential personal health risk assessment that helps pinpoint their health risk factors. Based on aggregated data, this also enables the employer to offer targeted solutions for managing health conditions common in the population through wellness and disease management programs.
The health incentive account approach can be effective because it combines a high-deductible health plan with a program that rewards healthy lifestyles and better medical decision making in partnership with one’s physician. The high-deductible component encourages employees to be active consumers of health care, while the healthy lifestyles reward component gives them the opportunity to earn financial rewards for activities that have been designed to improve their health.
These activities would include getting a flu shot, visiting a doctor for a well visit, participating in a healthy lifestyle or a disease management program, or learning more about options for back surgery. These activities will help your employees reach healthier outcomes, whether by alerting them to health issues they were unaware of, or by motivating them to address ongoing medical conditions.
What is in it for the employer?
These programs work to improve health and productivity and to reduce unnecessary medical care faster and more effectively than traditional health plans. This is particularly true when done as a full replacement with leadership commitment and communication.
A plan that rewards healthy behavior tells employees that you care about their current and future health risks. These plans are popular because employers want employees to lose fewer days to illness, and they provide employees with the tools to change poor health habits and adopt healthier ones for life. Studies of effective CDHP plans with funded accounts and incentives show greater preventive care, healthy behaviors, care engagement and lower cost than other types of plans — even for patients who are high users of health care with chronic medical conditions.
When a health incentive plan is tied with a consumer-directed health plan, it allows an employer to offer a less-expensive health plan but make up the difference in benefit coverage by giving employees a way to earn extra money to cover out-of-pocket costs.
Why have these plans become more popular?
Employers frankly are running out of effective strategies — as well as time — to address rising costs and declining health among their employees and their families. Consumer-directed health care plans reward consumers who take charge of their health and health care by promoting personal responsibility and cost-conscious decision making. Increasing employee engagement gives them ‘more skin in the game,’ but with enhanced support.
By aligning both responsibilities and rewards for healthier behaviors, more engagement in their care decisions and greater awareness of the costs of their options, employees do make better choices. And their healthier behaviors and better choices literally pay off in better living and lower costs for both them and for their employer.
DR. MICHAEL PARKINSON is senior medical director of health and productivity for UPMC Health Plan, which is part of the UPMC Insurance Services Division. Reach him at (412) 454-5643 or firstname.lastname@example.org.
Urgent care centers have been part of the health care landscape since the 1970s but only in the past decade have they begun to experience a dramatic surge in popularity.
Many reasons are behind the growth in popularity, but two stand out. First, urgent care centers deliver many services that cannot be provided in a primary care physician’s office. Second, people appreciate the fact they have access to these services outside of normal business hours and without having to make an appointment.
“Urgent care centers are not ideal for every medical situation,” says Dr. Stephen Perkins, vice president of Medical Affairs at UPMC Health Plan. “But there are times when urgent care centers have advantages that make sense for health care consumers.”
Smart Business spoke with Perkins about urgent care centers and how health care consumers can use them to their advantage.
Are there services that urgent care centers provide that may not be available in a primary care physician’s office?
Yes. These include such things as care for minor fractures and certain diagnostic tests, such as chest X-rays. Other non-emergency conditions that can be treated at an urgent care center include a twisted or sprained ankle, cuts, lacerations, general wound care, animal bites and minor skin rashes. Earaches, back pain and sore throats can also be treated at urgent care centers.
If you can go to urgent care centers, why would you need to have a primary care physician?
In terms of health care, it is always preferable to have a personal physician. It is best if that physician is someone who practices in a primary care specialty and who has a holistic approach to a patient’s medical care and needs.
Use of urgent care centers is not an alternative to having a personal physician. Urgent care centers are intended to be places where patients can get needed medical services when their personal physician is not available or unable to provide the specific service.
Because urgent care centers are more convenient than hospital emergency rooms for many clinical conditions, and because the services they provide are of high quality at a lower out-of-pocket cost, they are a smart choice in many instances.
What factors could influence making use of an urgent care center?
If you determine that an urgent care makes sense, you might appreciate some of the advantages, such as the fact that most insurance companies have lists of urgent care centers where their members can receive care as a covered benefit. In addition, going to an urgent care center rather than to an emergency room for acute non-emergency care is less expensive and frees up emergency rooms for more life-threatening cases.
Can an urgent care center sometimes be a better choice than a personal physician?
Because there is no need for an appointment and urgent care centers often have more flexible hours — including nights and weekends — than most physician offices, they often make sense. However, many physicians now offer extended office hours, so it is best to find out what hours you may be seen by your physician before making any health care choices.
Urgent care centers are also often convenient for people who are traveling or are some distance from home when an emergency arises.
By using urgent care centers, patients avoid the long lines they would encounter at emergency rooms. Urgent care centers also tend to have more locations, which makes them more convenient for many.
Some urgent care centers are affiliated with existing health care delivery systems. These centers may also have an affiliation with your primary care physician and, therefore, make it easier for your primary care physician to get a report of any action taken or medication prescribed. Ideally, an urgent care center should be an extension of your primary care physician’s office.
Are all urgent care centers the same?
Urgent care centers should not be confused with convenient care clinics, many of which are located in retail pharmacies, do not have a physician on staff and generally provide lower-level health care services, such as administering flu shots. It is important to understand that being treated by a doctor who knows you is always the preferable choice for those who want the highest level of care. Receiving treatment from your doctor — or, when necessary, following your doctor’s advice to go to an urgent care center or emergency room— is often your best option.
When is it not a good idea to use an urgent care center?
Urgent care centers are not ideal for all situations. Emergencies that are potentially life-threatening are best treated in an emergency room. These would include a heart attack or severe chest pain, a major injury or burn, poisoning, severe bleeding, passing out, being unable to catch your breath, being unable to move limbs or a loss of feeling in them, or a head or spine injury.
Urgent care centers work best when used as a complement to primary care, providing service when a timely visit to a physician’s office is not available, or after regular office hours when the only other alternative would be an emergency room visit.
Dr. STEPHEN PERKINS is vice president, Medical Affairs at UPMC Health Plan. Reach him at email@example.com or (412) 454-7682.
End-of-life issues are, of course, intensely personal. But the personal nature of the subject does not keep it from having an impact in the workplace.
End-of-life issues affect the workplace because they impact employees, who, in increasing numbers, serve as caregivers for ailing parents, siblings, partners and even critically ill children.
“With an aging population and with people living longer, more employees are becoming caregivers for a parent or loved one,” says Karen Merrick, an account manager for LifeSolutions, an employee assistance program (EAP) and part of UPMC WorkPartners. “Many of them are providing care for someone with a terminal illness, so how to deal with end-of-life issues is certainly an issue for many workplaces.”
Smart Business spoke with Merrick about end-of-life issues and how employers are supporting employees to meet these challenges.
How do end-of-life issues affect the workplace?
End-of-life issues affect the workplace because the size and scope of the problem is greater than most people realize. It is estimated by AARP that 44 million Americans provide unpaid care to an adult relative or friend. Nearly 60 percent of those caring for someone 50 or older are working full time, which means many employees may be struggling with end-of-life issues on a daily basis.
The common misconception is that end-of-life issues are private, family matters that would only really be of interest to a company’s retired employees. This isn’t accurate. As people are delaying retirement, they are increasingly juggling the responsibilities of work and caregiving. Many employees who are caregivers are not senior citizens.
Why should an employer be concerned about end-of-life issues?
End-of-life issues impact a company’s benefits costs and employee productivity in the form of absenteeism and presenteeism. It has been estimated that American businesses lose from $17.1 billion to $33.6 billion per year in productivity for full-time employees with caregiving responsibilities.
A report by the National Alliance for Caregiving and AARP indicated that one in five caregivers has had to take a leave of absence from work. A retention study by Pitney Bowes and Tufts University noted that one in five caregivers seriously considered permanently leaving the work force to deal with health matters. Each year an estimated 630,000 working-age adults will die. So, end-of-life issues do impact the company’s bottom line.
For employers, providing support to employees makes sense because it is the right thing to do. Support that can reduce the physical/emotional stress on the employee/caregiver will result in the greater likelihood that the employee will emerge from this difficult period more resilient. That resilience will benefit the company in increased engagement and loyalty as the company has respected what matters most to the employee — their family and loved ones.
What can an employer do?
Employers can support employees in a variety of ways. Reviewing existing policies around flexible work arrangements and leave of absence, including bereavement, is one step. Finding options that work for both the company and the employee is essential.
Providing information on end-of-life planning such as palliative and hospice care and advance directives is also something employers can do. This helps employees plan ahead, before life-threatening or life-limiting situations occur for themselves and their loved ones. The information can be in the form of newsletters, webinars, seminars or online resource links. Some companies have chosen to make end-of-life education a part of employee wellness programs. Connecting end-of-life planning to wellness helps create a readiness to plan for death as a more natural part of life, like planning for retirement.
What other resources are available for employers?
The National Business Group on Health (NBGH) has developed an employer toolkit around caregiving and end-of-life issues and their impact on businesses. Also, various vendors of services to employers can offer information, which should be packaged in ways that can be easily incorporated into benefit offerings and communication vehicles.
Many organizations embrace events such as National Healthcare Decisions Day. This is designed to encourage people to have thoughtful conversations about their health care decisions and about completing reliable advance directives to make their wishes known. It’s not just about living wills; it is more important that the conversation take place.
Can an EAP help?
An employee assistance program (EAP) can be a valuable resource to both employers and employees around caregiving and end-of-life issues. An EAP supports the employer and the employee in preparing to address these issues. For the employer, the EAP can assist with policy review and links to resources. It also educates the workplace about the impact of these issues personally and in bottom-line costs to the company. Finally, EAP professionals provide consultation to leadership and managers when faced with challenging employee situations related to caregiving.
On the employee side, EAPs provide assistance and resources for employees so they can be productive at work and enjoy their personal life. The EAP’s trained professionals address the stress of caregiving, coach the employee on how to start the conversation about end-of-life planning and ultimately provide grief counseling. Some EAPs may be able to provide resources for legal consultation around end-of-life issues. An EAP is a good resource for materials/information on caregiving, palliative and hospice care, and advance directives. <<
Karen Merrick is an account manager for LifeSolutions, an employee assistance program that is part of UPMC WorkPartners. Reach her at firstname.lastname@example.org or (412)-647-9294.
Normally, people are advised to stay away from cliffs. The steep vertical drop, the hard rocks, the water below — there’s too much danger if you get too close.
However, a different kind of “cliff” is looming on the horizon and for employers it doesn’t represent danger, but rather opportunity.
“They call it the ‘patent cliff,’” says Chronis Manolis, RPh, the vice president of pharmacy for UPMC Health Plan. “It refers to the years 2012 to 2014, when many pharmaceutical companies will lose patent protection on some of their most popular products.”
Smart Business talked with Manolis about the “patent cliff” and the opportunity it presents for employers.
What exactly is the ‘patent cliff’?
The term ‘cliff’ is used because pharmaceutical companies are facing a steep revenue shortfall as their blockbuster products lose patent protection. It’s estimated that drugs representing approximately $100 billion in sales will be available as generic drugs over the next several years. That loss to the pharmaceutical industry creates a significant opportunity for employers and employees alike.
When a pharmaceutical company develops and markets a new drug, it gets patent exclusivity for a specified number of years. What that means is that for that period there can be no generic equivalents to the brand-name drugs for the public to choose from. Over the next few years, a number of the most popular and biggest-selling drugs of recent years will all have their patents expire.
These include Lipitor, the top-selling anti-cholesterol drug in the world; Plavix, the top-selling antiplatelet medicine; Viagra, the most popular erectile-dysfunction drug; Singulair, an anti-asthma medicine; Lexapro, an anti-depressant; and several others. Every year, drugs have their patents expire, but there have never been so many popular drugs all losing patent exclusivity at the same time as there will be over the next two to three years.
Why is this an opportunity for an employer?
This is a truly unique time for employers. They have the opportunity to leverage the introduction of all these generic versions of top-selling drugs to help them bring down their health care costs. Employers need to work with their health insurer to ensure their pharmacy benefit design can leverage this significant opportunity. Generic drugs are a win-win for both the employer and employee. In addition to the cost savings, there is substantial evidence to suggest that cost is a barrier to medication adherence and lower co-pays for generic drugs can remove these cost barriers.
In conjunction with innovative formulary management, co-pay designs that promote generic drugs are the easiest way to leverage the patent cliff. For example, having a material difference in co-pay amounts between brand and generic drugs is a powerful incentive for employees. Additional examples include applying deductibles to only brand drugs as well as having co-insurance only for brand drugs while having flat dollar co-pays on generic drugs.
Can employers increase awareness and acceptance of generics?
It’s important to implement promotional and educational campaigns with your benefits administrator to educate employees. This can include educational materials, work-site promotional materials and pharmacist informational sessions to build employee awareness and confidence in generics.
There continues to be a general lack of confidence in generic drugs in regards to safety and effectiveness. Generic drugs save patients money without compromising quality and safety. The patent cliff will bring many ‘first-in-class’ generics to treat conditions such as diabetes, stroke, asthma and hypertension. We will have unprecedented access to high-quality generic drugs in almost all of the major therapeutic categories.
The ultimate goal is to get plan members talking to their physicians about therapeutic alternatives. This inquiry into generic drugs will provide a shift from brand name to generic drug utilization and help reduce benefit costs. For every 1 percent increase in generic drug use, employers can save approximately 1.5 percent in drug costs.
Is there a significant difference between generics and brand-name drugs?
The Food and Drug Administration requires generic drugs have the same effectiveness as the brand-name product. Generic drugs have exactly the same dosage, intended use, safety profile and side effects as the brand drug.
Brand-name drugs develop reputations with consumers, much of which is created through extensive media campaigns that raise awareness of the product and also increase its cost. Generic drugs have the same chemical make-up but are not backed by expensive advertising. That helps to make them less expensive and is the reason that insurance companies can offer these drugs to members for a much lower co-payment.
What kind of savings can be expected by going with generics?
For generics, employees pay, on average, co-pays that range from $5 to $15 compared to $20 to $40 for the brand-name drug. The average retail price plan sponsors pay for a brand-name drug is now approximately $128 compared to the average retail generic price of $18. So the savings are material for both employers and employees alike.
Will the ‘patent cliff’ help to increase the acceptance of generics?
Absolutely. With the influx of new generics, we should approach generic drug use rates greater than 80 percent. With high-cost biotech drugs projected to increase significantly in the next several years, maximizing generic drug adoption will be a key strategy to contain costs in the overall pharmacy benefit. Additionally, the savings is achieved without compromising safety and quality.
Chronis Manolis, RPh, is vice president of pharmacy for UPMC Health Plan. Contact him at email@example.com or (412) 454-7642.
Quality is something that consumers look for in almost every purchase they make. That includes both health care and health insurance.
But trying to define what quality means in terms of health insurance and what quality should mean to an employer trying to make choices for his or her company’s health coverage is not an easy thing to do.
“There are many aspects of health care quality and health insurance, but the simplest way to define quality in health insurance terms would be access to quality care,” says Sandra McAnallen, the vice president of network and provider relations for UPMC Health Plan. “Providing that access is what helps people to get the right care in the right place and at the right time as well as providing them with an excellent experience in terms of member service.”
Smart Business spoke with McAnallen about understanding what quality means in health insurance terms and its importance to employers.
How can an employer determine quality in health insurance plans?
Quality is a difficult thing to measure accurately, but there are certain measures that employers should look for and specific questions an employer can ask to determine if a health plan can deliver it.
For instance, for any health insurance plan you are considering, you need to research that plan’s network of hospitals and physicians for broader geographic coverage and specialty services. In many instances, a health plan’s directory of providers is available online.
A second thing to look for is accreditation. An accredited provider organization such as a hospital or a health plan is one that has met the standards of an independent organization. There are many national organizations that review and accredit health insurance plans and institutions. For hospitals, the Joint Commission accredits and certifies more than 18,000 health care organizations and programs in the U.S. Accreditation and certification from the Joint Commission is given to organizations that meet certain performance standards. The National Committee for Quality Assurance (NCQA) is an independent, not-for-profit organization that regularly measures the quality of care delivered by the nation’s health plans.
Is there any way to compare plans?
The NCQA provides information on health insurance plans that can be viewed at its website. You can see if a plan is accredited and compare its quality of care and member satisfaction scores with other plans. The NCQA’s website is: www.ncqa.org/tabid/1243/Default.aspx.
You could also look for state-specific reports to find out the rate of complaints for a health plan and the hospitals it uses. Also, you can look for stories about the health plan in various publications, such as magazines and newspapers.
How does a health plan demonstrate quality?
A high-quality health plan promotes effective and efficient care in a timely fashion with no disparity among social economic groups and a satisfactory experience with member services. A health plan should enhance its members’ experiences with its care and services and by promoting effective and efficient care. Members should be assured that they would receive the recommended care for all of their health needs including preventive services and care management for heart disease, diabetes, respiratory conditions, pediatric care, women’s health and behavioral health. The recommended care will lead to improved health and eventually lower costs.
For health plans, quality is a concept that is not limited to the delivery of health care services. Quality goals are focusing on improving population health, enhancing customer experience and managing appropriate medical utilizations and cost containment by applying evidence-based medicine and avoiding unwarranted variations.
What are other quality measures that an employer should look for in a health plan?
You need to investigate how the health plan ensures good medical care. Are doctors’ qualifications reviewed before they are added to the plan’s network? Is the care provided by a health plan’s doctors and hospitals reviewed on a regular basis? Does the health plan review its own services and make the changes needed to correct the problems? How are member complaints handled? Those are all questions that should be asked and answered.
Talking with current members of the plan to learn of their experiences also can be helpful. They may know if the health plan offers specific programs designed to deal with certain conditions. Specifically, a wellness program to promote a healthy workplace would be an important quality from an employer’s perspective.
Sandra McAnallen is the vice president of network and provider relations for UPMC Health Plan. Reach her at (412) 454-8770 or firstname.lastname@example.org.
Partner violence — also known as domestic violence — is most commonly viewed as a personal issue and is associated with someone’s home life. While it’s true that partner violence often occurs in and around a home, it doesn’t stay at home when the victim and the abuser go to work.
Smart Business spoke with Caffo about partner violence and the impact it has on the workplace, employers and employees.
How would you define partner violence?
Partner violence is a pattern of abusive behavior that is done by one person to control a partner. It’s not about being angry. It’s not an over-reaction to a partner making a mistake. The goal is for the abuser to let the partner know who’s in charge. This behavior can be physical, sexual, psychological or emotional. Most often the abuser is a man and the person being abused is a woman, but there are female abusers as well. And, partner violence happens in all types of relationships — married, unmarried, heterosexual, gay, lesbian, bisexual, transgendered — and it touches all economic groups.
What is the scope of partner violence in the workplace?
According to statistics from Standing Firm, an organization in Southwest Pennsylvania that is dedicated to addressing partner violence as a workplace issue, more than one in five full-time employed adults have been victims of partner violence and 64 percent of those say that their work performance has been significantly impacted as a result. This includes receiving harassing phone calls, e-mails and text messages at work to having the abuser come to the partner’s worksite and verbally or physically assault that employee.
Abusers are also employees. Employed abusers have told researchers that they have misused company time and resources — such as phones, computers, e-mail and automobiles — to remind the partner that they are always present. Each and every workplace, regardless of size, can be impacted by partner violence.
How does partner violence impact the workplace?
First, partner violence is costly to employers. There are the direct costs, such as the hospital visits required by the abused individual and the cost of ongoing care. In addition, there is the problem with absenteeism and presenteeism. Many times, abused employees are not productive at work because they may have been up all night protecting themselves from or being harassed by the abuser. They also arrive at work late as the abuser may hide their clothes, hide the keys to the car and/or threaten not to take care of the children.
Secondly, partner violence doesn’t just impact the person being abused. It also affects that person’s co-workers. Because so many people work in cubicles rather than offices, many times co-workers overhear threatening phone calls to a person near them. They don’t know what to do to help and may even be fearful for their safety, as well as the safety of the co-worker, and worried that the abuser might come to the workplace and harm them as well. This raises the stress level for everyone and interferes with workplace focus and productivity.
What kinds of things should an employer do about partner violence?
It’s a concern that only about 5 percent of all employers have a policy in place to deal with partner violence. Most employers still view this as a personal issue to be handled outside of work.
So the first thing employers can do is recognize the ways that their workplace and work force are being affected by partner violence. Step two is to build on that recognition by putting a plan in place to address the issue. This includes developing a policy and should involve human resources staff, managers, security and an Employee Assistance Program (EAP), if you have one. The policy formalizes the company’s commitment and outlines the responsibilities for all parties to ensure safety.
How can an EAP work to make the situation better?
The EAP will assist the employer to develop a plan of action, including a policy. It helps both the employee being abused as well as the employee who is the abuser get help, thereby making it a worthwhile and effective company investment.
The EAP is an important internal resource to confidentially enable the employee being abused to develop a safety plan and get access to needed community resources. Abused employees are often ashamed even though they don’t cause this, and may be fearful to tell the employer about what’s going on. The EAP does not share information without written permission, so it is a trusted source to go to.
EAPs can also help an abuser get help. It is possible to learn new and safe ways of interacting with loved ones.
Finally, the EAP supports co-workers who are impacted. Figuring out how to approach an employee when concerned or addressing fears about safety are examples.
For information about resources in Southwestern Pennsylvania that deal with this issue, visit Standing Firm’s website at www.standingfirmswpa.com.
Sandra Caffo is the senior director of LifeSolutions, a UPMC WorkPartners affiliate. Reach her at email@example.com or (412) 647-9480.
Substance abuse and addiction are serious problems throughout society, so it only makes sense that the problem carries over into the workplace. According to labor statistics, vast majorities of the people who are drug users, heavy or binge drinkers or have other substance abuse problems, are employed.
A 2007 survey indicated that 8.4 percent of all full-time workers used illicit drugs and 8.8 percent reported heavy alcohol use.
“There is a cost to addiction that impacts the workplace and should be of concern to all employers,” says James Schuster, MD, MBA, the chief medical officer for Community Care, a behavioral health organization that is part of the UPMC Insurance Services Division. “The cost in terms of productivity can often be substantial.”
Smart Business spoke with Schuster about addiction in the workplace and what employers need to know about it.
How does addiction or substance abuse manifest itself in the workplace?
The most obvious effects are absenteeism, reduced productivity and tension between the employer and the employee. You can also see its effects in increased accidents and decreased productivity. Because addiction impacts every facet of a person’s life, the problem needs to be addressed at many different levels, including in the workplace. Dependency on drugs or alcohol can severely compromise an employee’s ability to contribute to the success of the company.
In addition, addiction does not just impact the employee. Nearly 40 percent of industrial fatalities and 47 percent of industrial injuries can be tied to alcohol consumption or alcoholism. The U.S. Department of Labor estimates that employees who abuse substances are 25 to 30 percent less productive and miss work three times more often than non-abusing employees.
How can an employer know if an employee has an addiction issue?
This is not always easy and that fact only compounds the problem. There are few explicit warning signs connected to it. Also, many addicts are almost experts in hiding their addiction from others.
Diagnosing a substance abuse problem is not something an employer should ever do, but there are signs to look for that may indicate that an employee may be a substance abuser. Extreme fluctuations in mood and productivity, for instance, can be indicative. Alcoholism is often connected with slurred speech, belligerent behavior and decreased inhibition. Frequent tardiness, unexplained absences and unusual weight loss or gain can also be signs.
What should employers do if they suspect an employee of alcohol or drug abuse?
As an employer, you should be focused on helping the employee get back on track, not offering a diagnosis for his or her condition. There is no need to form an opinion of your employee based on his or her addiction. It is important to understand that substance abuse definitely has the markers of a disease. There are clear genetic relationships and people who metabolize alcohol more quickly are more likely to have alcohol problems.
When should an employer do something about an employee’s substance abuse?
If the employee’s drug use directly affects his or her performance at work and relationships with co-workers, an employer can justify taking some kind of action. A logical first step would be to refer the employee to human resources, or, if possible, an Employee Assistance Program (EAP). An accurate assessment of the problem is possible by following this route and an EAP can assist with an evaluation of disciplinary options if needed.
Employers should also start by refusing to ‘enable’ the employee. The employee needs to be held accountable for his or her actions. He should not be permitted to continue his self-destructive behavior at work. This limitation must be communicated to supervisors and co-workers alike.
Can the workplace be an effective place to deal with substance abuse?
Yes. For one thing, the workplace can serve as a framework to counteract the denial and manipulation that often goes with alcoholism. An employee needs to work to make money and the risk of losing that can be strong motivation to get help for problems. The workplace is also the best place where behavior patterns can be accurately documented and that documentation can convince an employee to seek help and change behavior.
EAPs were originally created to deal specifically with alcohol problems, so it is not surprising that studies have shown that 70 to 80 percent of persons with alcoholism who are referred to EAP programs are productive employees within one year after being referred to a program.
Are small businesses affected by addiction and substance abuse?
Yes, they are. In fact, smaller businesses might be more adversely affected. Roughly half of all U.S. workers are employed by a small business — that is, a company with 500 or fewer workers — and 90 percent of small businesses employ either current illicit drug users or heavy drinkers. However, smaller firms are generally less likely to test for substance abuse and less likely to offer programs designed to combat the problem.
Can addiction problems be completely handled in the workplace?
That would be extremely rare. It is difficult to overcome an addiction without some kind of outside help. An employee needs the encouragement and support of his or her employer to make it through, but that person may need more than the workplace can provide.
James Schuster, MD, MBA, is the chief medical officer at Community Care, a behavioral health organization that is part of the UPMC Insurance Services Division. Reach him at (412) 454-2153 or firstname.lastname@example.org.
Social media, such as Facebook, Twitter and LinkedIn, has been increasing in popularity in recent years, and along with that growth has come an increased connection to the health insurance world.
Once the question was: “Why would an insurer need a Facebook page?” Now, that question is more likely to be: “Why not?”
“The modern consumer of health insurance has come to expect companies to use social media products,” says Kelly Kimberland, director of social marketing for UPMC Health Plan. “When an insurer uses social media it is providing the access that consumers value.”
Smart Business spoke to Kimberland about social media in health insurance and why it matters to employers.
Why should an employer care if his or her company’s health insurer is active on social media?
By using social media — Facebook, Twitter, and/or LinkedIn — a business, such as a health insurer, can increase awareness of the company name and its products. But more importantly, it is also a way that the insurer can actively engage with its members and provide useful information about their health plan options and about healthier lifestyles. When a health insurer has a presence on social media sites, it increases the ways that its members — and your employees — can receive information and form connections that can reinforce healthy messages.
What makes social media especially appropriate for a health insurer?
Research indicates that social media may be helpful to individuals trying to improve their lifestyles in areas such as quitting smoking and losing weight. The reason for this is that social media encourages a group dynamic. Instead of asking people to drive to a specific location to be part of a group — which still remains an option, of course — individuals with similar interests can connect online and share stories. It also provides a way for health insurers to get more feedback from and information to members who are interested in using social media.
What evidence is there that social media can be an effective means of communication?
Surveys have shown that an estimated 61 percent of American adults look online for health information and that about two-thirds of those talk with others about what they discover online. Many so-called e-patients have read about someone else’s experience on an online news group, website or blog. What social media tools do is offer a new venue and a new way for people to share stories, make healthy lifestyle changes, and affect others’ lives. Of course, not everyone on Facebook, Twitter, LinkedIn or other social media channels choose to be actively engaged in online communities or chat. But with social media, everyone will have the opportunity to participate and at least build awareness of the importance of healthier lifestyles.
What are some advantages of social media in terms of customer service?
One is access. Many times people are intimidated by forms and by the technical language sometimes connected with health insurance, and they can feel more comfortable using Twitter or Facebook. Finding companies on Facebook, for those who use it frequently, is probably easier than trying to remember a company’s e-mail address or phone number. Social media can provide answers and links to resources more quickly. If there are people out there using social media to do comparison-shopping, to find information and to communicate with others, it just makes sense that a health insurer would be there as well. Also, many employees may consider social media outlets to be friendlier than other media and that will help an insurer to get its message across as well.
What are the biggest challenges facing an insurer that uses social media?
Social media is a 24/7 proposition and demands a kind of more immediate interaction that not every company is equipped or ready to deal with. There is also the challenge of adhering to HIPAA and other regulatory guidelines. Anyone using social media must be aware of the dangers of posting private or personal health information. Visitors to a Facebook page must be mindful of the information they post. But there are advantages, too.
For instance, although not on a public-facing site, UPMC Health Plan offers a Live Chat feature through its secured member portal. Any member that has a question regarding coverage, claims, etc. can connect in real-time with a member advocate. An insurer can enhance the health insurance experience in a more personal way, which is what people are accustomed to with social media, by leveraging new technologies and tools. Social media is about making connections, providing useful information and sharing ideas. It is not all things to all people, but it can be a way to touch lives and is definitely worth offering to employees.
What advantages can an employer gain by having an insurer that uses social media?
One advantage of using social media is your employees may come to see their insurer in a more personal way because it is part of an online community. The health insurer can help to facilitate communities and conversations not only among its followers, but also gain their insight and feedback on specific questions or issues.
Kelly Kimberland is the director of social marketing for UPMC Health Plan. Reach her at email@example.com or (412) 454-5273.