inside workplace wellness

Tips & Tools to Choose the Safest Medical Care

noreply@blogger.com (jmcnichol) — Mon, 24 Aug 2020 17:12:00 +0000

We've always loved our Twisted Oak neighbors, and the pandemic has prompted us to spend even more time together--outside and six feet apart, of course. Out of one of our happy hours, the idea to hold neighborhood TwED Talks was born. We'd each pick a subject we know well and give a 20-minute presentation. We've learned about regulatory compliance, CRISPR gene editing, and behavioral economics and Nudges so far. Last weekend it was my turn, big surprise, I talked about choosing safe medical care. Some neighbors asked me to post my slides with links to the sites we discussed, so here they are. Antonia, filmed the presentation and provided this link. This Friday, we'll be learning about daily fantasy sports.

Tips & Tools to Choose the Safest Medical Care from Janet McNichol

The Path Forward for Mental Health

noreply@blogger.com (jmcnichol) — Thu, 30 Jan 2020 18:42:00 +0000

Mental Health Care is in the U.S. is in crisis. There are too few providers, too few providers in networks, widespread gaps in collaborative care, and too little evidence-based practice. Access to providers who participate in insurance networks is particularly bad in the state of Maryland, placing a heavy financial burden on patients and their families. The problem affects all of us who live and work in the state.

We've watched our colleagues at ASHA suffer. The stories we hear from parents trying to get care for their children are genuinely heartbreaking. Adults face similar challenges in finding providers. We've been searching for a way to improve access to high-quality mental healthcare for ASHA staff and jumped at the chance to support an initiative spearheaded by the Mid-Atlantic Business Group on Health.

The initiative focuses on making improvements in five key areas:

Network Access
Tele-behavioral Health
Mental Health Parity Compliance
Collaborative Care
Measurement-Based Care

The kickoff meeting on January 15 brought together an impressive group of stakeholders--the MidAtlantic Business Group on Health, the Mental Health Association of Maryland, the Maryland Primary Care Program, and the National Alliance of Healthcare Purchaser Coalitions. The people around the table have the desire, drive, and influence to do something about the problems we face. We're excited to join forces with this group.

The Cost of Hospital Care is Much Higher for those with Employer-Provided Coverage

noreply@blogger.com (jmcnichol) — Wed, 17 Apr 2019 16:28:00 +0000

When you go to the hospital, what you pay is based on what your insurance covers. This raises the question, how do insurers determine what a hospital is paid? On one end there is the chargemaster amount, the list price for services that hospitals are now required to post. On the other end, there is what Medicare pays. Traditionally insurers have negotiated discounts from the chargemaster prices, but that's starting to change. Employers are banding together to force insurers to negotiate up from Medicare instead of down from the chargemaster.

A group of self-insured employers in Indiana commissioned Rand to conduct a study that would provide useful information about the prices they are paying for health care services. The study showed that what employers paid varied wildly--200 to 600 percent over what Medicare reimburses. This is not a question of good hospitals charging more. It's poor hospitals charging too much. The amount considered appropriate as a percentage of Medicare varies. I've heard anywhere from 120 percent to 200 percent of what Medicare reimburses deemed acceptable. The Rand study was so informative that it has been expanded to include 22 states, and the results are due to be announced next month.

Ideally, this pricing information would be used in conjunction with quality data. This raises another issue where employers need to press insurance companies. I've encouraged people to use Leapfrog ratings to obtain care from the safest hospitals. I want to take the next step and build a financial incentive into the plan design for doing this, but the network contracts insurers have with hospitals prevent this. Here is the response I received from UHC.

"Contractual agreements with UHC requires contracted providers of the same service type to receive the same benefits. That is, one contracted hospital cannot fall into a higher benefit level than other contracted hospitals. All contracted hospitals must receive the highest level of member benefits."

49% of American's get their health insurance at work, and most are happy with it. The healthcare industry has a massive lobbying force. There are all kinds of special interests groups exerting their influence in health policy discussions, but employers rarely engage. I encourage organizations to join their local business coalitions and engage in the discussion. You can identify active local groups on the National Alliance of Healthcare Purchaser Coalitions website.

Related reading:

Are Hidden Fees Driving Up the Cost of Your Healthcare Coverage?

noreply@blogger.com (jmcnichol) — Sat, 23 Feb 2019 12:28:00 +0000

Every once in a while, you come across an article you wish you would have read a decade or two earlier. Propublica's Behind the Scenes, Health Insurers Use Cash and Gifts to Sway Which Benefits Employers Choose by Marshall Allen is one of those articles. For years, I compared the commission our broker was paid to what others were paying. The fees usually ranged between three and six percent. What I didn't see was the additional bonuses insurers paid our broker. I finally looked at the 5500 filings of other associations and was able to see the picture more completely. I created this scatter plot to see how what we were paying really compared. A quick look at this chart will show you how dramatically per employee per year broker fees varied among associations in the DC area in 2015. This caused us to make a change. We now work with Zack Pace at CBIZ. We pay Zack a monthly fee for his help and everything is transparent and above board.

I've run into Dave Chase and David Contorno who were interviewed in this article at various meetings in the past year. It seems like the Health Rosetta movement is gaining steam which is good for all of us who have employer-provided health care coverage. Ask your HR team how your employer's advisors are paid.

Engaging Employees in Health Care Benefit Design

noreply@blogger.com (jmcnichol) — Tue, 05 Feb 2019 02:04:00 +0000

Traditionally, benefit managers get together with an advisor or broker and a representative from a health insurance company to decide what to include in their employer-provided health care coverage. No employer can afford to pay for everything, so this small team debates the tradeoffs and decides what's best for the organization.

I asked myself what it would look like if employees had input into these decisions, and I set out to design a process to facilitate employee input. I invited ASHA employees to participate in this process, and together, we redesigned one of the health insurance plans we offer to staff and dubbed it the ASHA signature plan.

You can read about this journey in Health Affairs. If you're interested in learning more, I wrote a white paper with Len Nichols, professor of Health Economics at George Mason University (GMU), Lisabeth Buelt, and her colleagues at NPC. NPC provided funding for me to contract with GMU to analyze what insights we could draw from all the data we collected. I hope our work inspires other employers to involve their employees in decisions about their benefits.

You Must See The Bleeding Edge

noreply@blogger.com (jmcnichol) — Wed, 15 Aug 2018 16:48:00 +0000

Americans value innovation, and we built a health care system that rewards it, but at what cost? Few people understand that medical devices are not regulated as well as pharmaceuticals and patients can have untested objects implanted in their bodies.

Prescription drugs must be tested in humans, and the FDA reviews the data before they're approved to go to market. The process has its shortcomings, but nothing like what goes on with medical devices. Through a what is essentially a loophole, the 510(k) pathway, medical devices can be approved if the manufacturer demonstrates that their device is "substantially equivalent" to a device that's already on the market. Manufacturers can get approval even if the device they're using for the comparison has been recalled because it caused problems. The new device might be made from entirely different material like using cobalt in a hip replacement or used in a completely different way like mesh that was used for hernia repairs being used for gynecological repairs. Under the current administration, what little control the FDA had is eroding.

As frightening as the situation is and as horrifying as the stories you'll hear in The Bleeding Edge are, you'll be buoyed by how you see patients fighting back. Right before this film was released, Bayer announced that it would stop selling Essure, a permanent birth control implant, in the U.S. It had already been banned in other countries, but despite women suffering from persistent pain and bleeding, organ perforation, dangerous unintended pregnancies and more, it continued to be available in the U.S. 100,000 women are suing the manufacturers of gynecological mesh implants in the largest multi-district litigation since asbestos. (A story that was also covered by 60 Minutes.)

Kirby Dick, the director, sheds light on a topic we all need to know more about if we want to protect ourselves and the people we love. The film concludes with some good advice:

Research any device that will be used on or in you. New is not necessarily better.
Get a second opinion for any risky or expensive procedure.
Ask your surgeon how many procedures he or she has performed.
Have a friend or family member be your advocate while you're in the hospital.
To see if a medical device company has paid your doctor, go to openpaymentsdata.cms.gov.

You can watch the documentary on Netflix and you'll find more resources on The Bleeding Edge website.

Many thanks to Terry Harris for pointing out this documentary to me.

Nine Actions to Mitigate Specialty Drug Costs

noreply@blogger.com (jmcnichol) — Wed, 01 Aug 2018 19:47:00 +0000

I was asked to give a presentation at the Employee Health, Benefits, & Well-Being Congress in Boston about what employers can do to manage specialty drug costs. The timing was good, ASHA's PBM contract is out to bid and I've spent the last four months learning what I need to know to evaluate our options. I was happy to share what I've learned and will summarize what I shared here as well with links to some of the things I mentioned.

In April, I attended a session on RX Challenges at the HRE conference. The session was good, but the man that sat next to me kept leaning over and asking me what the acronyms he was hearing met. What's AWP? What's WAC? What's ICP? What's CVS? The language was so unfamiliar and had him so confused, he didn't even recognize CVS as the drug store chain. As five of us stood around chatting after the session, two other people said they were just as lost in the sea of acronyms. I didn't want that to happen during my session, so I put together this reference with a little design help from my colleague Kathy. If you're looking for more, here's a nice drug benefit glossary that I found online.

There is no single agreed upon definition of a specialty drug. Characteristics typically include:

Qualities that make for costly medication delivery, such as requirements for professional administration or special handling e.g., temperature control.
Complex treatment administration e.g., infusions.
Complex molecule composition e.g., biologics.
High cost e.g., CMS uses $600 per month for Medicare. ASHA uses $1,000.

Specialty medications may be covered under the pharmacy benefit or under the medical benefit. Generally, medications that require a professional to administer them are covered under medical.

1-2% of prescriptions are for specialty drugs, but they represent 35% or more of overall pharmacy cost. There are 2,320 drugs in active development and 40 or 50 new drugs expected to be introduced in each of the next 5 years. We here about new very expensive drugs like Soliris all the time. Soliris is used to treat a rare blood disorder and it averages $18,000 a dose or $500,000 annually. As I said, it's rare and employers have stop-loss coverage to protect them if they have a member that takes it.

What worries me more is how specialty medications have become the standard of care for many common chronic conditions e.g., rheumatoid arthritis, psoriasis, multiple sclerosis, HIV/AIDS and many cancers. Employers are seeing a lot of members taking drugs like Enbrel for rheumatoid arthritis at $60,000 a year or Otezla for psoriasis at $36,000 a year. If someone starts on one of these medications when he or she is 40, you may pay for them for 25 years. Longer if you offer retiree health coverage. The average annual cost of a single specialty drug already exceeds wages.

V-BID
Value-Based Insurance Design (V-BID) is about shifting the conversation from how much to how well. Here's how the Center for Value-Based Insurance Design describes applying V-BID to specialty medication.

Impose no more than modest cost-sharing on high-value medications.
Reduce cost-sharing in accordance with patient or disease-specific characteristics
Relieve patients from high cost-sharing after failure on a different medication
Use incentives to encourage patients to select high-performing providers and settings for their care.

The headline of the July issue of Health Affairs reads V-BID Improves Medication Adherence without Increase in Total Health Spending.

Note: On February 8, 2018, the Chronic Disease Management Act of 2018 (S. 2410 and H.R. 4978) was introduced in Congress. The bipartisan bill amends IRS Section 223 (c)(2)(C), which would provide health savings account eligible high-deductible health plans (HSA-HDHPs) the flexibility to cover services and drugs used to treat chronic diseases prior to neeting the plan deductible.

I recently worked with Lauren Vela at the Pacific Business Group on Health (PBGH) on a project and here's how we described a value-based prescription drug benefit.

Waste-free formulary excludes no-added-value, high-cost drugs.
Some medications require a second opinion.
Clinical indication based on FDA approval will be enforced via pre-authorization
Infusion services must be obtained in an infusion center, doctor’s office or at home unless it is determined that it is medically necessary to administer them in a hospital setting.
Use of coupon cards is banned. Accumulator programs will be applied. Chronic care maintenance drugs for some conditions have no cost share. (E.g., diabetes, coronary artery disease, congestive heart failure, asthma, hyperlipidemia, and hypertension.)

Barriers
I believe this is what employers should strive to create, but there are barriers. When I was at the Magellan Rx meeting in May, I learned that there prior authorization (PA) process isn't built to handle genetic testing yet. Some drugs on the market require genetic testing to make sure the patient is a candidate. Unfortunately, you can't rely on physicians to have performed the genetic testing before writing the prescription. Mercer did a study that showed that many times the genetic test wasn't done. That's pretty horrifying if you think about it. Patients could wind up on a drug (a costly drug) that will harm them instead of helping them. Obviously, this is something employers should look into and press for. It's also a good idea to make sure your health benefits cover the cost of the genetic testing. The Right RX genetic test shows you how a patient processes medication. It covers 21 disease states and costs $250. When the administrative and ownership dilemmas (i.e., who owns the results of the test--the patient or the entity that paid for it) get ironed out, it will change how formularies are constructed. They'll become much more personalized.

The next step beyond plan design is outcomes-based pricing. Pricing medications based on the impact they have on a patients quality of life. Earlier this month CMS suspended a plan to pay for Norvatis’ Kymriah therapy based on how well it worked. The $475,000 gene therapy treats kids and young adults with leukemia. The arrangement would have been the first agreement with a manufacturer for outcomes-based pricing. The demise of the CMS deal illustrates how difficult it is to figure out how much government health programs should pay for expensive treatments whose long-term benefits are still unclear. CMS and Novartis discussed paying full price if Kymriah produced results in patients after one month — an unrealistically short timeline for evaluating a complex cancer treatment.

What can we do? Here are nine actions that I think are worth considering.

1 Think in terms of total costs of care. Look at pharmacy spend across PBM and medical. Only 48% of employers receive reporting on drug expenses paid under medical according to a McKinsey Report.

2 Work to integrate your pharmacy and medical data with outcomes. Complete an audit across the medical and pharmacy plans to determine their current state and identify changes to improve management. Generate insights through data aggregation and analytics that will help you prioritize what you want to work on.

3 Evaluate your contract terms. Can you get the kind of reporting that you want for your disease management vendor? Does your PBM require providers to use NDC coding for Specialty Pharmaceuticals to improve monitoring and tracking of utilization? What percent of rebates are you getting? According to McKinsey, many large employers (e.g., 5,000 employees) have been receiving 100% of the rebates. In recent years, a growing number of smaller employers have insisted on 100% pass-through arrangements as well. In 2016, 39% of smaller employers received 100% of the rebates for specialty drugs, compared with 23% in 2015. I've heard the cut-off for getting 100% of your rebates is 4 million in drug spend. I personally would not attempt this without expert help. We contract with Mike Zucarelli at CBIZ to help us with our PBM. Folks at CBIZ refer to pharmacy benefit management pricing as a dark art. If that's the case, Mike is Harry Potter.

4 Strive to improve the consumer experience.

Engage people early in the disease state
Increase transparency. Help employees use cost calculators. Integrate pricing tools like GoodRX.
Improve the mail order experience. Amazon bought PillPack and they have the capacity to set a new bar when it comes to mail-order pharmacies.

5 Implement a site of care program to administer drugs in the highest-value setting. Many specialty drugs are significantly more expensive in the hospital setting. Infusions may cost $6,000 in a doctor’s office and $36,000 in a hospital outpatient setting. Hospitals are buying physician practices and telling physicians not to handle infusions and refer patients to the hospital instead. The average mark up in a hospital setting is 252%. Magellan has a site of care management program that we use at ASHA. (To learn about Magellan's program contact Peter Lenar--plenar@magellanhealth.com or 860-507-1804 x71804)

6 Shore up your clinical utilization management. Look at:

Prior-authorization
Step therapy
Step-edits
Channel management -- limiting dispensing to specific providers
Patient adherence

7 Review your plan design. Most employers use a three-tier plan design — generic, preferred brand, non-preferred brand. A growing number of plans are using four or more tiers. Most plans with three or fewer tiers use copayments. Plans with four or more tiers are more likely to use coinsurance. High-cost sharing creates a financial burden and increases non-adherence.

8 Use a center of excellence program to drive patients to high-value providers/settings. The Pacific Business Group for Health (PBGH) has an excellent program.

9 Consider contracting separately for specialty drugs. 60% of health plans use a PBM plus a specialty pharmacy with a separate contract. We can mirror that in the private sector. The specialty pharmacy essentially serves as a rebate aggregator.

Extra credit:

The Mid-Atlantic Business Group on Health publishes an excellent PBM Assessment. John Miller will be presenting an overview of the report and how to use it on August 7 from 12:00 to 1:00. You can register here. If you're not a member of your local business group on health, I highly recommend joining and getting involved.

Interview with Susan Hayes about the PBM Landscape, Challenges and Opportunities

Prescription Drug Spending in the U.S. Health Care System, provides a good overview of the issues

Policy Strategies for Aligning Price and Value for Brand-Name Pharmaceuticals describes options for value-based pricing

Mental Health Care -- Far from Equal (Part 2)

noreply@blogger.com (jmcnichol) — Mon, 28 May 2018 13:48:00 +0000

4 Helpful Actions Employers Can Take

It's been 10 years since the Mental Health Parity and Addiction Equity Act was passed, so it seems like a good time to pause and ask ourselves if access to care is now equal. Most insurers have dropped visit limits and separate deductibles and co-insurance for mental health care yet patients are still struggling to get access to treatment. A report from Milliman concluded:

The difference between medical/surgical and
behavioral health use out-of-network by state. Source: Milliman - 2017

In 2015, behavioral care was four to six times more likely to be provided out-of-network than medical or surgical care.
Insurers pay primary care providers 20 percent more for the same types of care as they pay addiction and mental health care specialists, including psychiatrists.
State statistics vary widely. In New Jersey, 45 percent of office visits for behavioral health care were out-of-network. In Washington D.C., the figure was 63 percent.6

In part, because reimbursement rates are low, mental health practitioners choose not to participate with insurance networks. Participation also means dealing with all the paperwork and bureaucracy involved in filing insurance claims. Many mental health care providers are solo practitioners and they don't have the administrative support they need to deal with insurance coverage.

Patients with mental health and substance abuse problems are often forced to go out-of-network to find care. Out-of-network care is subject to deductibles and significant co-insurance if there is any out-of-network benefit available at all. The need for mental health care seems even greater than it did 10 years ago:

One in five American adults has a mental illness.
One in 10 full-time employees has an addiction, and we are in the midst of an opioid crisis.
Mental illnesses are the leading cause of disability worldwide.
About 90% of people who die by suicide—the 10th leading cause of death in the U.S.—have an underlying mental illness.

What can employers do to ensure their employees have access to mental health care?

Push your insurance network to add mental health providers.
Promote a collaborative care model that incentivizes primary care providers to screen for mental health problems.
Support primary care doctors and patients with behavioral health navigators that help patients get access to appropriate, cost-effective care.
Maintain an insurance option with out-of-network coverage for your employees until adequate care is available in-network.

I have a feeling this could be a long series of posts. You can find the first one that includes an interesting take on the issues from Maggie McGary here. If you want to learn more, I recommend starting with these resources.

How to Support Mental Health at Work from the Mental Health Foundation in the U.K.
Action Brief: Hope and Healing for Mental Illness is Possible from the National Alliance of Healthcare Purchaser Coalitions
The High Cost of Mental Disorders” Facts for Employers from Tufts Medical Center by Debra Lerner eat al...
Campaign to dispel the stigma that surrounds mental health spearheaded by the Royals in the U.K.

Sewage Leaks in DC Hospital Operating Rooms

noreply@blogger.com (jmcnichol) — Wed, 18 Apr 2018 16:38:00 +0000

The next time you are tempted to think, "all hospitals are equally safe," stop and think of this story about sewage leaks in the operating rooms at MedStar Washington Hospital Center. These leaks are cited as a cause of patients acquiring infections while in the hospital and the cause of the death of a woman from Northern Virginia.

Leapfrog Hospital Safety Grade assigned Washington Hospital Center a safety grade of a D the last four times safety was evaluated. The results clearly show they scored below average in infections. Sibley Memorial Hospital is just six miles away and it earned a B. Knowing this, where would you choose to seek care?

I understand people put a lot of trust in their doctors and generally go wherever their doctors recommend, but it's up to you to choose where to seek care. I'm not exaggerating when I say this can be a life and death decision.

The good news is that the information you need to make a well-informed decision is easy to obtain. Just go to Leapfrog Hospital Safety Grade and search by state, city, zip code or hospital name. Leapfrog even has an app you can load onto your phone, so this information is always at your fingertips.

Mind the Gap

noreply@blogger.com (jmcnichol) — Tue, 10 Apr 2018 04:30:00 +0000

April 10 is equal pay day. It symbolizes the date when working women’s wages catch up to what men were paid the previous year--how far into 2018 women have to work (on average) to earn what men earned in the 2017 calendar year. Pew Research Center reported that in 2015, women earned 83% of what men earned. So, the gap is narrowing (you've probably seen the often sited 79 cents on the dollar statistic), but still persistent.

The wage gap compares women’s wages to men’s on a very broad scale. It’s stated as a very broad statistic, women earn 83 cents on the dollar, or used to compare women’s’ wages to men’s wages within industries. Sarah Kliff at Vox wrote this article that clearly explains the wage gap. Some of the gap is certainly due to discriminatory practices, but the preferences of women also have an impact. The Gender Pay Gap persists despite equal pay laws. This white paper from Denmark explains how gender inequality in earnings stems from women's preferences after they have children.

Pay equity compares what women earn to what men earn for doing the “same work.” States are enacting pay equity laws because pay equity is viewed as something that’s within the employers control. Last year, I laid out a 10 step process for employers to follow to eliminate pay inequities. I’m proud to say it’s worked for ASHA.

Consumer-Focused Approaches Won't Curb Health Care Spending

noreply@blogger.com (jmcnichol) — Tue, 03 Apr 2018 23:55:00 +0000

Image from https://www.ballonkunstenaarpatrick.nl

The U.S. spends roughly twice what other developed nations do on health care. With all that money, we buy the lowest life expectancy and the highest infant mortality rate. Americans don't use more services than people in other high-income countries; we pay more the services we receive.

In the fourth quarter of last year, health care surpassed retail and manufacturing to become the largest source of jobs in the United States. Health care is a huge driver in our economy, and one person's excess is another person's income. Putting pressure in one area to control costs is like squeezing a balloon--it increases the cost somewhere else. If we're going to spend more than every other country on health care, it would at least be nice to spend that money on things that improve people's health. We need greater transparency around the effectiveness and cost throughout the system, but especially with prescription drugs.

NPR put a human face on the problem in this story about a woman who's health reimbursement account was wiped out by a prescription for Kerydin--a $1,500 treatment that cures toenail fungus in 6.5% of the patients who use it.

Prescription Drug Spending in the U.S. Health Care System, provides a good overview of the issues. Policy Strategies for Aligning Price and Value for Brand-Name Pharmaceuticals describes options for value-based pricing.

What's the best approach for employers? Do you chase rebates or move toward value-based plan design. Today, employers cannot afford not to chase the rebates. If the Chronic Disease Management Act that was introduced in Congress in February becomes law, employers will have more tools at their disposal. The act would allow employers to cover some treatments without subjecting them to a deductible. This could lead to more innovative plan design. Reform is needed throughout the system though. Consumer-focused approaches won't curb spending unless we begin to align drug prices with the clinical value the drugs provide.

5 Reasons You Didn't Get a Bigger Raise This Year

noreply@blogger.com (jmcnichol) — Sat, 17 Feb 2018 16:02:00 +0000

Wage growth has been stable at 3% across the country and in Europe and Japan since we got out of the recession in 2008. Three percent doesn't allow for a lot of differentiation in salary increases across an organization, so it's likely your raises have been pretty unimpressive. It's been ten years since the economy tanked, so why aren't employers putting more money into salary increases?

Data from Quatt Associates

With every employer setting salary increase budgets at 3%, employers are under no pressure to do more than that. Matter-of-fact, you look pretty irresponsible to your board if you set a much larger budget. How would you justify it?
There is evidence that companies have shifted money into bonuses rather than base pay increases. Bonuses are much more nimble than base pay. It’s easier to forgo bonuses if profits are not meeting expectations than to cut salaries or lay people off.
I suspect you will see an increase in the budgets for promotions and an increase in starting salaries (to attract workers) before organizations will increase the salaries for people in their current jobs. Also, employers generally increase the salaries of top performers before they increase salaries for the masses.
I’ve also been wondering how the gig economy would impact employment. I’ve read Americans work fewer hours than we used to. Maybe before we see an uptake in raises, we’ll see an increase in the hours people work.
There is a theory that intuitively makes sense that there is an inverse relationship between unemployment and inflation. It’s called the Phillips Curve. An economist at the federal reserve wrote a paper theorizing that there is a sharp bend in the curve and that we’ll see wage increases soon—when unemployment falls below 4%. It seems plausible. Here's a link – don’t ask me to explain it. (I’ve read the Phillips Curve is dead too, so who knows.)

The Disconnect Between Unemployment and Wages

Tackling Health Spending

noreply@blogger.com (jmcnichol) — Sun, 04 Feb 2018 03:12:00 +0000

On Thursday, the National Pharmaceutical Council (NPC) and Health Affairs launched a new initiative to address health spending called Going Below the Surface. It's is a "research-first endeavor dedicated to unearthing and examining the drivers of health care spending in the United States, and convening a multiple-stakeholder discussion to better understand what we receive for these investments." The U.S. spends 18% of GDP on health care which is far more than any other country. And, despite all that money, we have worse outcomes.

David Cutler from Havard University shared a few shocking comparisons. The one that has stuck with me is Duke University Hospital has 900 hospital beds and 1,300 billing clerks. Do you think maybe we could save some money by streamlining how we pay for care?

Amitabh Chandra from Havard University showed this cost curve to illustrate how the first health care dollars spent extend life significantly, but you quickly reach a point where we're spending half a million dollars to extend a person's life by a matter of days. This leads to the tough questions. Who decides where the time isn't worth the expense? Is there one answer for everyone in the country or could individuals choose the coverage they want?

There are strong incentives in our system to produce low-value innovations. To date, we have not been able to say "no" to low-value care. There is no public support for rationing care, so the government can't put the breaks on, at least not at the federal level. Every other country has figured out that their government is responsible for controlling costs, but there was widespread agreement that we can't look to our government to solve this problem given the current state of affairs.

Patients rarely have the information they need about cost, outcomes and value to make informed decisions and who among us makes great decisions when we are seriously ill? Even if we had the information hope is engrained in Americans. We believe we or our loved ones will be the excpetional responder to a treatment. To think otherwise is to give up.

By a show of hands, people seemed split between looking to health care providers and employers to really make some progress. At the moment, my vote goes to the employers. I think Amazon-Buffet-JPMorgan Chase could really do some creative things by joining forces. (Note to self: update resume.) Mollyann Brodie from the Kaiser Family Foundation stated their research shows that people trust their employers.

I'm particularly interested in how people can be brought together to make value-laden decisions. Craig Mitton touched on this in his presentation and mentioned deliberative polling practices developed by Daniel Yankelovich. I'll share the group decision-making process I developed to allocate health care resources soon.

Corinna Sorenson talked about her work evaluating the effectiveness of the Choosing Wisely Campaign. Less than half of the recommendations reduced low-value care and those reductions had limited impact in the 3-5% range. I've been following this initiative for years and thought it had a ton of potential, so the results are discouraging. I heard yesterday that Consumer Reports is pulling out of the initiative and that the National Alliance of Healthcare Purchaser Coalitions is going to step in to fill the void.

Leslie Greenwald pointed out that our unsustainable spending has been sustained for many years. The healthcare sector employs a lot of people--12% of the population. I heard that at one point Massachussetts wanted to try to curb health care spending and then realized that it would displace so many workers if they were successful that they decided to leave it alone. From an economic standpoint, I think it would be ideal to retrain those billing clerks at Duke to do something that has a greater social value. The one point during this full day of presentations about health care that the audience erupted into spontaneous applause was when it was suggested that we'd be better off taking money out of health care and investing upstream in the social determinants of health.

This was the kick-off to a two-year initiative so there are understandably more questions than answers at this point. You may have heard that health care is complicated, but that just means we need to allocate more resources to finding solutions. I look forward to seeing what we learn. You can follow along on the Going Below the Surface website and a Health Affairs blog that's dedicated to health spending.

We're Dying Earlier in the U.S. While People in Other Countries are Living Longer

noreply@blogger.com (jmcnichol) — Wed, 24 Jan 2018 21:54:00 +0000

Our life expectancy in the U.S. decreased for the second year in a row in 2016 to 78.6 years. The drop looks small at first blush -0.1 years, but it's alarming. Life expectancy in the United States is lower than in most other OECD countries and the gap is getting wider--we're dying earlier in the U.S. while people in other countries are living longer. I could not do as good a job of explaining why as Bill Gardner did in this post, so I recommend you read his explanation.

How are people dying? These are the leading causes of death according to the CDC.

Heart Disease
Cancer
Accidents
Chronic lower respiratory disease
Stroke
Alzheimer's
Diabetes
Flu and pneumonia
Kidney disease
Suicide

The rate of death decreased for seven of these 10, but increased for accidents, Alzheimer's and suicide. We also know drug overdose deaths rose an appalling 21% from 2015 to 2016.

It bears mentioning that it's not too late to get a flu shot. The deaths from flu are largely preventable if we could get enough people vaccinated. If you're not inclined to get a flu shot for your own benefit, do it for the people around you.

Please excuse the public service announcement. Now, back to our regularly scheduled programming.

Where the death rate declined for infants and older American's, it increased for people age 15 to 64 and increased for men more than women. (Life expectancy for women was the same this year as it was last, 81.1 years. However, for men it declined from 76.3 to 76.1.)

The rich have always lived longer than the poor, but here the gap is widening too. The top 1% of male wage earners now live 15 years longer than men in the bottom 1%. (For women, the gap is 10 years.) This shocking chart ran in an article on Vox I recommend reading.

They're evidently doing something right in California, but the rest of this news is bleak. Surely, we can do better.

Mental Health Care -- Far From Equal

noreply@blogger.com (jmcnichol) — Sat, 14 Oct 2017 03:45:00 +0000

I'm reposting this with permission from Maggie McGary. She shares an interesting perspective on mental health care in this post. You can learn more about Maggie on her blog Mizz Information. I also recommend taking a look at 10+ Photos that Prove Depression Has No Face.

MENTAL HEALTH STIGMA WHEN YOU’RE NOT A CELEBRITY OR A TEEN

08.25.2017 by MAGGIELMCG // 1 COMMENT

Mental health has had a banner few weeks in the news and across the internet–at least when the news centers around celebrities or teens. Sinead O’Connor and Justin Bieber made headlines about their battles with depression and mental illness and Diply applauded a list of celebrities who have shared their struggles with mental illness. Two teens were lauded for documentaries about mental illness: one praised for his film raising awareness about mental illness and another whose documentary about suicide won the top prize at a film festival. Headlines like “Young People On ‘Brink Of The Worst Mental Health Crisis In Decades,’” and “Teen suicides now outnumber homicides,” and “Suicide Rate for Teen Girls Hits 40-Year High” are just a few of the too-many-to-list recent news items showcasing how teens are battling depression that make it feel–at least to me–that somehow the world is getting the message that teens are the only ones impacted by mental health issues…well, teens and celebrities.

All this buzz about mental health issues is great, but to me it just highlights a disparity I’ve already written about: the what-feels-like-a-growing-chasm between mental health stigma among celebrities and teens and then among GenX and older generations. While teens and millennials are doing a great job of being open about mental illness in an effort to stop the stigma that surrounds the subject, those of us who grew up being told that mental illness is a shameful secret that you better never tell anyone about or you’ll be labeled crazy, ostracized and probably lose your job…for us, it’s not that simple.

If you’re a celebrity and confess to battling depression or mental illness, you’re hailed as a hero. If you’re a teen, ditto. However, if you’re neither a celebrity, a teen who is either financially supported by parents or a twenty-something who has turned his/her mental health advocacy into a career and are, instead, just a regular non-millennial, non-celebrity with a day job and bills to pay, being open about mental illness isn’t as glamorous or non-risky.

This New York Times article “Deciding Whether to Disclose Mental Disorders to the Boss” states the unfortunate reality facing the 43.7 million adults who suffer from a mental, behavioral or emotional disorder and worry that letting bosses or coworkers know about their illness could cost them their job: “[T]here is reason to worry.”

The article goes on to detail that “…while celebrities and others who have publicized their mental health problems have to some extent reduced the stigma, that is not true in the place people spend most of their waking hours — on the job.” “We’re seeing changes in the broader culture, but we’re not seeing it in the workplace.” A psychologist who has spent years studied the issue of the risk/benefit of disclosing mental illness in the workplace suggests that people weigh these five factors before deciding to make a psychiatric condition known on the job:

How supportive is the person you are disclosing to likely to be?
What type of culture does the company have?
Do you have a proven track record?
What is happening in the society as a whole? “You probably don’t want to disclose after a mass shooting,” she said, when people tend to connect mental illness with violence. (this is literally a quote…TF?)
Do you need to disclose everything about the condition, or would it be better to be selective?

This Scientific American article also points out the potential risks of being open about mental illness in the workplace. “Historically, people who have revealed their mental illness at work have faced discrimination. For instance, in a 2010 survey of U.K. employers, about 40 percent said they considered hiring someone with a mental illness to be a “significant risk” to the company. Many employers believe that people with mental illnesses are difficult to get along with and unreliable. People with mental illness may be denied promotions and other opportunities for advancement. Even in supportive office environments, employees with mental illness sometimes feel increased scrutiny from their co-workers.”

Even outside the workplace–say, like, writing about it on your personal blog–there’s still more risk being open about mental illness if you’re of a certain age/generation where mental illness wasn’t something to be talked about openly. I struggle with it writing this now, and in terms of figuring out the balance between sharing openly to do my part to fight stigma and potentially damaging future job prospects. Because let’s face it–for as much “you go, girl” as there is about living out loud in this day and age of oversharing and being real–stigma and discrimination about people being “crazy” is still a fact of life, just as is the reality that potential employers routinely comb the social media profiles/postings of job candidates or current employees.

So what are those of us who are neither millionaire celebrities or teens who have yet to worry about workplace discrimination to do if we want to be open about living with mental illness? Just do it and hope that our employers are fine with it and that we won’t face any negative ramifications either in future business endeavors or by parents who don’t want their kids socializing with kids of a “crazy” person or whatever? Or decide that it’s not worth the potential loss of professional stature or, worst case, a job, and continue to perpetuate the very stigma that has put us in this situation to begin with by pretending that mental illness is something that only impacts teens or celebrities and that the rest of us are JUST FINE, all the time?

I guess like all things in life, the answer is probably “it depends.” But also–a lot depends on more of us “older” folks sharing our stories if we ever want to live in a time when not only the young or the rich enough feel safe/empowered enough to get be real about mental illness.

Critical Illness Insurance—Let the Buyer Beware

noreply@blogger.com (jmcnichol) — Mon, 10 Jul 2017 18:28:00 +0000

I am constantly getting calls from AFLAC representatives that want us to offer their critical illness coverage to our staff. Usually, they try to bribe their way in the door with one of those silly ducks—that's a great marketing approach if your target audience is three years old or a canine. (I hear dogs love the stuffed ducks.) Recently, a rep tried a different approach. She tried to guilt me into offering ASHA employees the opportunity to choose. Choice is a fundamental American value. Why was I denying ASHA staff the right to choose for themselves?

It's true, ASHA staff value the opportunity to choose, but they want to choose between good options. They trust me to vet what we put in front of them and I'm not going to let someone sell my colleagues swamp land.

I did a little research online and talked to a source who shall remain nameless. The average annual AFLAC premium is $780/year. The seller makes 47% commission in the first year or over $366. Stock bonuses can be earned on top of that. In other words, half of what you're paying goes in the sales reps' pocket.

No wonder the sales reps are so persistent. You'd think they'd be trying to get their foot in the door with a nice bottle of wine though. They can afford it.

In general, I'm not a fan of critical illness insurance because the policies pay out only if you get sick or injured the "right way." Some policies only cover a cancer diagnosis for example. If you have a heart attack, you're out of luck. (In more ways than one.) However, I am a big believer in protecting your income with disability insurance. I wrote about our recent efforts in that regard in this post. But, don't just take my word for it.

Critical Illness Insurance Might Not Be Worth It. More employers are offering this insurance as a benefit, but consumer advocates question its value. Consumer Reports, September 27, 2016
Insurance for Critical Illness May Add Security, but at a Cost, The New York Times, March 18 2016

The coverage is surprisingly common. SHRM reported that 9 out of 10 critical illness policies are sold through the workplace. 45 percent of employers with more than 500 employees offer the coverage. Critical illness coverage has expanded as high deductible health plans have become more popular. These plans are marketed as a way to protect yourself against the deductible. I just don't think they are the best tool. I believe your money is better spent purchasing disability coverage and funding a health savings account.

There are less expensive policies than the Aflac example I shared; and I'm sure there are some employers that are carefully vetting the options. However, I've also heard that there are employers that do offer the coverage don't handle it properly. If an employer allows the coverage to be paid for pre tax, it's an ERISA plan and you have to offer COBRA, File 5500, Report it on W2s, etc...

Because I have the utmost respect for Carol Harnett and think it's always worth considering another point of view, especially a well informed one, take a moment to read Survival Entails a Price.

I like this quote from an article in the Economist on choice.

As options multiply, there may be a point at which the effort required to obtain enough information to be able to distinguish sensibly between alternatives outweighs the benefit to the consumer of the extra choice. “At this point”, writes Barry Schwartz in “The Paradox of Choice”, “choice no longer liberates, but debilitates. It might even be said to tyrannise.” In other words, as Mr Schwartz puts it, “the fact that some choice is good doesn't necessarily mean that more choice is better.”

What happens when we don't see health as a common endeavor?

noreply@blogger.com (jmcnichol) — Fri, 30 Jun 2017 20:55:00 +0000

How much you believe in a need for universal health care is largely dependent on how much you see health as a common endeavor. The national policy debate we've been having lately and the health economics class I just completed have me giving it some thought.

Respecting people's preferences is an important tenet of economics. So, if you like to spend your leisure time watching football, smoking, drinking beer and eating pizza; we can presume that you know best what makes you happy and you alone suffer the consequences. If however, other people pay the price for your choices, then there is a social cost, and it is reasonable to consider some intervention.

What happens when we don't see health as a common endeavor?

We suffer the negative effects of exposure to secondhand smoke.

We pick up extra work because a colleague is out sick.

We accept the risk of catching an infectious disease from the people around us.

We loose revenue from tourism in regions that people avoid traveling to because a disease is prevalent like the Zika virus.

We share the costs when medical problems lead to home foreclosures--medical problems contributed to half of all home foreclosure filings in 2006

We share costs when medical problems lead to bankruptcy--medical problems contributed to 62% of all personal bankruptcies filed in 2007

We share the costs of medical divorces

We pay higher rates for medical care to make up for the uncompensated care provided in emergency rooms and other settings.

We pay higher ticket prices for airline tickets because fuel is required to move weight and more people are obese.

We suffer the negative consequences of the opioid crisis.

We pay the costs of a measles outbreak that occurs because people choose not to vaccinate their children.

We accept that more children will be raised in poverty and need social support--unplanned pregnancies cost taxpayers $21 billion dollars each year.

Each of these externalities imposes a social cost in dollars, pain and suffering, and lost opportunity. If we acknowledge this and see health as a common endeavor, then we have an opportunity to address the issues together.

The attitudes of American's are evolving. According to a Pew Research polling data,

Currently, 60% of Americans say the government should be responsible for ensuring health care coverage for all Americans, compared with 38% who say this should not be the government’s responsibility. The share saying it is the government’s responsibility has increased from 51% last year and now stands at its highest point in nearly a decade.

One argument against universal health care is that health insurance does not improve health. The NEJM just published an article by Benjamin Sommers, Atul Gawande, and Katherine Baicker that reviews recent experimental and quasi-experimental studies of the ACA and other expansions of public or private insurance titled Health Insurance Coverage and Health -- What the Recent Evidence Tells Us.

They conclude that "coverage expansions significantly increase patients' access to care and use of preventive care, primary care, chronic illness treatment, medications, and surgery." There is also abundant evidence that having health insurance improves financial security.

But, do these things improve people's care and not just how it's paid for? Yes, "insurance coverage increases access to care and improves a wide range of health outcomes." It comes at a cost though. You have to cover 239 to 316 adults on Medicaid to save one life.

I started with a question and I'll end with another. What's a life worth? There are current public policies that address workplace safety and environmental protections that average $7.6 million per life saved. Expanding Medicaid costs $327,000 to $867,000 per life saved. Another perspective on the value of life is Quality-Adjusted Life-Year (QALY). A ratio of $50,000 per QALY gained by a health care intervention has served as a benchmark. These measures are all a little crass, but relevant if we're considering cutting Medicaid to fund tax cuts for wealthy Americans.

Ezra Klein explores some of these issues in an interview with Avik Roy. It provides a window into the debate on health care happening within the republican party. It's worth a listen.

Three Things We Should All Know About the Opioid Crisis

noreply@blogger.com (jmcnichol) — Wed, 21 Jun 2017 20:46:00 +0000

I attended the Vox Unconference, the World Heath Care Congress and a pharmacy summit this spring. There was one topic that overlapped the three events--the opioid crisis. It's all over the news, but so frightening, I think it bears mentioning here. Here are some things you need to know--especially if you're a parent.

The risk of continued opioid use increases after 4 to 5 days. If there is a history of addiction in your family, even that amount of time may not be worth the risk.
Opioids are not effective for treating chronic pain. They may work for a month or so, but the effect is likely to diminish even at increased dosages. Eventually, you'll be left with your chronic pain and a drug dependency. Some people even experience hyperalgesia, a greater sensitivity to pain after taking narcotics for longer periods of time.
How pain came to be the fifth vital sign. The New Yorker ran through a good history in Who is Responsible for the Pain-Pill Epidemic. Vox reported, "US doctors wanted to treat pain as a serious medical problem. But when pharmaceutical companies pushed opioid painkillers with a misleading marketing campaign, they started a drug crisis."

Vox did a really great story on the crisis: How the opioid epidemic became America’s worst drug crisis ever, in 15 maps and charts. Please take a few minutes to scroll through it and watch the 4 minute video.

Things are really bad. A few weeks ago CBS News reported, "For the second time this year, a coroner's office in Ohio has run out of space for dead bodies due to the opioid epidemic." The opioid epidemic was directly responsible for 33,000 deaths in 2015. There were 52,000 drug related deaths overall. Much of the illicit drug use began with the use of legitimate prescriptions for opioid painkillers. As the government cracked down on how opioids are prescribed, people who are addicted switched to heroin. Horribly, things seem to be getting worse, not better. Take a look at this NY Times article, You Draw It: Just How Bad Is the Drug Overdose Epidemic? (Thanks for sharing this Ellen.)

There is tons of good information available. Here are some recommendations if you want to explore this topic in greater detail.

The opioid painkiller and heroin epidemic, explained, Vox
The opioid epidemic may be even deadlier than we think, Vox
The History of Opioids, The Incidental Economist
The Science of Opioids, The Incidental Economist
Death Rate for Drug Use -- US third highest in the world at 6.96 per 100,000, World Health Rankings
Drug Deaths in American Are Rising Faster Than Ever, New York Times
As Opiod Panel Meets, Some Say Action, Not Study, Is Needed, New York Times
From Opioid Epidemic's Front Lines, Filling In the Brutal Back Story, New York Times
Healthcare Triage Special: America’s Epidemic of Opioid Abuse, The Incidental Economist
Healthcare Triage Special: Opioid Addiction and Treatment, The Incidental Economist
Making pain a vital sign caused the opioid crisis. Here’s how., Kevin MD
Organ Donations Spike In The Wake Of The Opioid Epidemic, NPR

The Health Benefits of Being In the Presence of Trees

noreply@blogger.com (jmcnichol) — Tue, 20 Jun 2017 13:53:00 +0000

As I write, I'm sitting under
our silver maple tree.

Tree At My Window by Robert Frost

Tree at my window, window tree,
My sash is lowered when night comes on;
But let there never be curtain drawn
Between you and me.
Vague dream-head lifted out of the ground,
And thing next most diffuse to cloud,
Not all your light tongues talking aloud
Could be profound.
But tree, I have seen you taken and tossed,
And if you have seen me when I slept,
You have seen me when I was taken and swept
And all but lost.
That day she put our heads together,
Fate had her imagination about her,
Your head so much concerned with outer,
Mine with inner, weather.

We sleep with the curtains open because I like to fall asleep looking at our silver maple tree. I figured Robert Frost would approve, but there may be more to my peculiar trait. Simply being in the presence of trees reduces the stress hormone cortisol and increases your immune defense system. It's part of a national health program in Japan where they call it "forest bathing." You can get the gist of it in this short video from the World Economic Forum.

I don't need any convincing, but I'm still adding Your Brain on Nature to my reading list. This is yet another good example of where wellness and environmental issues intersect and it presents a unique opportunity for me to include a poem on my blog.

Life vs Disability Insurance -- Why are we far less likely to protect ourselves against the more likely event?

noreply@blogger.com (jmcnichol) — Thu, 15 Jun 2017 16:33:00 +0000

42 out of 100 ASHA staff are worried enough about protecting their families to buy life insurance, but only 25 in 100 had individual disability income insurance. These coverage choices don't reflect the actual risk. We undertook an initiative to offer supplemental disability (aka individual disability income) insurance to all our staff that had not taken it at the time they were hired. Now 53 out of 100 have individual disability income insurance. This initiative more than doubled the number of people with coverage.

People are far more likely to become disabled during their working years than to die. You hear all kinds of numbers thrown around. I looked at disability and death probability tables published by the Social Security Administration for insured workers born in 1996. Death is pretty indisputable, but disability is more subjective. The Social security Administrations standard of disability is high, so this gives us a conservative estimate of disability.

Males born in 1996 (so they attained the age of 20 in 2016) have a 26.3% probability of disability before age 65 and a 7.2% probability of death.
Females born in 1996 (so they attained the age of 20 2016) have a 24.8% probability of disability before age 65 adn a 3.6% probability of death.

You can calculate your personal likelihood of disability using this tool from the Council of Disability Awareness.

Why are we far less likely to protect ourselves against the more likely event? Most of us cannot afford to live without a paycheck. Medical problems contribute to 62% of all personal bankruptcies filed in the U.S. and half of all home foreclosures. We’re lucky that ASHA insures 60% of our income for us, but the extra 15% we have the opportunity to buy can make a huge difference if misfortune strikes. I assumed that many of my colleagues had not made a fully informed decision and worked with UNUM to offer supplemental disability (aka individual disability income) insurance to all our staff that had not taken it at the time they were hired. This was not easy. It took two years of hounding UNUM using every angle and connection I could muster to get them to agree. (A special thanks to Zack Pace at CBIZ and Carol Harnett at the Council for Disability Awareness for their help.)

I met with the 205 people we extended the offer to and explained how they get paid if they can't work. I drew a timeline from that date to their 65th birthday and walked them through how family and medical leave, sick leave, annual leave, short and long term disability coverage work. 92 accepted the offer of coverage. Here's some of what we discussed.

Can you live the way you want to live on 60% of your current salary? If the answer to this question is “yes,” you don’t need additional disability coverage. If the answer is “no,” keep reading. Our group policy that ASHA pays for insures 60% of our income. If you choose to purchase supplemental coverage, it raises your benefit from 60% of your salary to 75% of your salary.

What are your chances of becoming disabled? Probably higher than you might think. Just over 1 in 4 of today's 20 year-olds will become disabled before they retire.

What are the most common causes of disability? If you’re healthy, you probably think of accidents first, but they’re not usually the cause of disability. Illnesses like cancer, heart attack or diabetes cause the majority of long-term disabilities. Musculoskeletal disorders like back pain, arthritis, spine/joint disorders, and fibromytis are also significant causes. Happier circumstances can also lead to disability for example, if a woman is placed on an extended period of bed rest when pregnant.

How long does the average period of disability last? The average group long-term disability claim lasts 34.6 months, so about three years. One in eight workers will be disabled for five years or more during their working careers.

How many years do you plan to continue working? In thinking about the value of disability coverage, your age matters because the typical benefit period is until age 65. That means you’ll receive disability payments from the time you become disabled until you reach the age of 65. If you’re between 65 and 75 when you become disabled, the maximum benefit period is 24 months. If you’re over the age of 75, the plan only pays you for 12 months. Once you reach retirement age, disability coverage may not be a good value. You might want to consider additional long term care coverage instead.

It just goes to show you that people need help to make a fully informed decision. The role of disability coverage in protecting income is not well understood. We've changed our onboarding process and I now meet with every new hire to explain this coverage in particular and then we make sure that we get a decision from everyone so that they haven't set aside the information and forgotten about it. With any luck, no one will ever need it, but I'll sleep better knowing everyone who wants the coverage has it.

Trump Administration Is Proposing a Giant Step Backward for Women's Health

noreply@blogger.com (jmcnichol) — Sun, 11 Jun 2017 17:48:00 +0000

Ian and I at a pro-choice rally
April 5, 1992

Half of pregnancies in the United States are unplanned. Maternal mortality is rising and much higher in the U.S. than in comparable countries like Canada and the United Kingdom. Maternity care and childbirth cost more in the U.S. than in the rest of the developed world. Yet, we are still debating whether or not health insurance should cover birth control and maternity care.

The Trump administration recently announced plans to roll back an ACA provision requiring insurers to cover birth control and the American Health Care Act would allow states to opt out of covering maternity care. Prior to the ACA, only nine states required maternity coverage and only 12 percent of plans available in the individual market place included benefits for maternity care. [Statistics from: How Obamacare changed maternity coverage.] Similarly, the Kaiser Family Foundation reported three in four non-group health plans did not cover delivery and inpatient maternity care in 2013, before the ACA was enacted.

Instead of working to address the reasons behind appalling statistics like this, the Trump administration is trying to set us back even further.

In 2005, 23 US mothers per 100,000 live births died from complications related to pregnancy or childbirth. In 2015, that number rose to 25. In the United Kingdom, the number was less than 9. In Canada, it was less than 7. ~JAMA

There are many options for long acting reversible contraceptives available today, but some cost upwards of $500. It's a small expense in a health plan--especially when compared to maternity care and child birth which can easily hit $20,000. However, $500 out-of-pocket is out-of-reach for many young women. (Despite Tom Price suggesting all women can afford birth control.)

There is a definite link between unintended pregnancy and poverty. Medicaid paid for 68% of the births resulting from unplanned pregnancy. This makes it a public health issue that effects us all. Unplanned pregnancies cost taxpayers $21 billion dollars each year. Since the Accountable Care Act went into effect, the rate of unintended pregnancies has dropped and the abortion rate in the U.S. has fallen to the lowest level since Roe vs Wade went into effect. This progress is about to be undermined.

The proposed regulation can go into effect as soon as it's published in the federal register. Typically, there would be a notice and comment period, but the Trump administration wants to bypass that process and have it go into effect immediately. In this way, the executive branch could set us back without any help from congress and without any public involvement. Some states are beginning to take action putting birth control on the legislative agenda, but allowing employers and insurers to opt out as the Trump administration is proposing is a giant step backward.

Mom's Keys to Super-Aging

noreply@blogger.com (jmcnichol) — Wed, 19 Apr 2017 17:48:00 +0000

My mom practicing her balance
after completing 40 squats.

Meet my mom. Mom is 73 and she can out walk most of my friends. I'm always sharing exercise tips with her and Mom actually does the things I recommend. It started years ago when I suggested she stand on one foot like a stork when brushing her teeth. When that got easy, I sent her a half foam roller to challenge her balance. Balance is a key to preventing falls and broken bones according to the National Osteoporosis Foundation. Here's a simple routine anyone can follow.

Mom will be adding interval training to her routine. My friend, Carol Harnett, recently shared this NYTimes article on the best exercise for aging muscles. It describes a study that looked at the types of exercise that have the most positive impact at the cellular level. As we age, the cells in our muscles do not regenerate as quickly. Exercise can help us combat this, but interval training has the greatest positive impact.

What does this mean in practice? Mom is going to work hard on a stationary bike, elliptical or treadmill for four minutes, rest and go easy for three, and repeat three more times for a 28 minute work out. She'll throw in a few minutes to warm-up and set a goal to do this three times per week. And, because I want to be able to hike up a volcano in Iceland when I'm 72 like my mom did last year, I'll be doing the same thing.

Mom and I plan to be "super-agers" just like these women on The Today Show who defy the effects of old age. In addition to being physically active, these folks are learning new things. They routinely push through the feeling of discomfort we all feel when we're exercising or struggling to learn something new. I'm taking a Health Economics class at George Mason University this semester. Mom's looking into taking one of The Great Courses online. (Following that link will get you a free month trial thanks to Ezra Klein at Vox.)

A Day Late and 17 Cents Short

noreply@blogger.com (jmcnichol) — Wed, 05 Apr 2017 19:30:00 +0000

10 Steps to Addressing Pay Inequities

Pew Research Center
http://www.pewresearch.org/fact-tank/2017/04/03/gender-pay-gap-facts/

Yesterday was Equal Pay Day. It symbolizes the date when working women’s wages catch up to what men were paid the previous year or how far into 2017 women have to work (on average) to earn what men earned in the 2016 calendar year. Pew Research Center reported that in 2015, women earned 83% of what men earned. So, the gap is narrowing (you've probably seen the often sited 79 cents on the dollar statistic), but still persistent.

I've spent a lot of time thinking about pay equity and making sure the compensation program we have at ASHA works equally well for everyone. In 2015, I was asked to help facilitate a workshop at ASAE on Negotiation Success in Your Association Management Career and one of the things that was discussed was how to negotiate a job offer. There are plenty of studies that show women don't negotiate as aggressively and; therefore, wind up with lower starting salaries than men. Salary increases in future years compound the problem.

Since women and other people in minority groups tend to be paid less than men, basing an offer upon a candidates salary at a previous job perpetuates past discrimination. Massachusettes decided to deal with this problem by prohibiting employers from inquiring about a candidates salary history during the hiring process. The law is the first of its kind.

Addressing this problem one woman and one job offer at a time seems like a highly inefficient way to fix the problem. I think HR professionals need to fix the system--the underlying policies, procedures and practices.

It is not the candidates responsibility to tell an employer what a job is worth. HR folks have plenty of survey resources available to determine what other employers pay for similar work. At ASHA, we benchmark (market price) every job based on a carefully written position description and determine a competitive salary. When we post a job, we post a starting salary range that's from 90% to 100% of this number. It's non-negotiable and if you take a look at one of our postings, you'll see we clearly state that along with the FLSA exemption status and other facts about the job.

The pressure to eliminate the wage gap is ratcheting up. The Obama administration encouraged companies to sign an "Equal Pay Pledge." If employers don't fix the problem, individual states will continue to create their own pay equity laws like California, New York, Massachusetts and Maryland have. I understand New Jersey, Pennsylvania and Washington D.C. are currently working on revisions to their equal pay statutes.

Until recently, state laws typically followed the Federal Equal Pay Act of 1963. These new laws radically alter how pay equity will be determined in these states and will most certainly complicate administration for employers with employees in these states. Before other states take action or employers find themselves facing expensive and time consuming litigation, maybe HR folks should act and find out what's driving pay in their organizations.

10 steps to conducting a compensation audit:

Assure you have up-to-date position descriptions for each job
Decide what components of pay you need to review e.g., base pay, bonuses, commissions, overtime
Determine the factors you will examine e.g., gender, race/ethnicity, gender identity
If you have people working in multiple locations, decide which locations you'll start with. Obviously, you want to prioritize people working in states with pay equity laws like California, New York, Massachusetts and Maryland.
Determine what information you have that might explain differences in pay e.g., education, years of experience, special certifications
Make sure the data you are going to use is clean. If your HRIS has people in the wrong jobs, or inaccurate education information, you're going to be facing the old GIGO (garbage, in garbage out) problem.
Decide which jobs have multiple incumbents or which employees to include in comparative groups (This is where the rubber really meets the road. I suspect this is why Googles findings differ so dramatically from the governments. Be sure to look at your data in the 10 job categories that will be used in the new EEO-1 reports.)
Compare the average pay of men to the average pay of women in the same roles to determine if any statistically significant differences exist
If you find a problem, dig deeper to see what might be explained by factors you're including in your analysis like education and years of experience. You can do a regression analysis using each of these factors to determine how much of the disparity they explain.
Again, if you find a problem, develop a plan to fix it. You may need to modify your compensation program policies, procedures and practices in addition to making market adjustments to the salaries of some people.

Consider protecting confidentiality by involving an attorney. If you need a statistician to help with the analysis, you may want to have your attorney hire or contract for those services. I attended a session at a Kilpatrick Townsend seminar last week with attorneys Jim Coil and Flora Manship that was excellent. If you don't know who to call for help, you might want to start with them.

Explore more:

Why Can't Your Company Just Fix the Gender Wage Gap, Business Week June 26, 2017
Iceland Plans to Become World's First Country To Require Equal Pay for Women, NPR, March 9, 2017
Google is fighting the Labor Department about equal pay for women, and both can't be right, CNBC, April 10, 2017
The Correct Question To Ask About The Google, DoL, Spat Over Gender Inequality In Pay, Forbes, April 11, 2017
Gender quotas and the crisis of the mediocre man: theory and evidence from Sweden, LSE Research Online, February 2017
New EEO-1 Form Requires Companies to Report Pay Data, SHRM, September 30, 2016

How We Think About Stress Matters

noreply@blogger.com (jmcnichol) — Mon, 08 Aug 2016 21:51:00 +0000

What Doesn't Kill Us Makes Us Stronger

I've never been a fan of stress management programs in the workplace. For a long time, I've believed that stress comes from how we respond to events at work, not the actually events themselves. Instead of managing stress, I've tried to focus on helping people build resilience so that we can better withstand the stressful events when they occur.

Recently, I read an article in the Economist that expanded my thinking. It suggests that stress makes us stronger in the same way weight baring exercise makes our bones stronger. How we think about stress matters. And, knowing this gives us a few more ounces of control.

The Student Debt Crisis: What Role Should Employers and Professional Associations Play?

noreply@blogger.com (jmcnichol) — Fri, 22 Jul 2016 15:26:00 +0000

Generations of Americans have been raised to think that money spent on education is always a good investment. If you study hard and get decent grades, the rest is supposed to work itself out. You'll get job, pay off your loans and live the American dream. Unfortunately, many students are lent more than they can pay back in the years after graduation. The rule of thumb I've read is that you shouldn't borrow more than what you expect to earn annually when you graduate. Years after earning their degrees, today's graduates can't buy a home or start a family because they can't dig out from under their student loan debt. The statistics are startling:

Almost 71% of 2015 bachelor's degree recipients had student loan debt.
The average loan amount for those graduates was $35,000.
45% of people with student loan debt say college was not worth the cost.
One in four borrowers are behind on their loan payments.
The government is getting one heck of a return on the money it lends--20 percent on the loans that were made in 2013.
In 1975, state schools received 58% of their funding from the states. Today the funding has fallen to 37%.

A quick poll of ASHA staff showed that 25% are paying off a student loan for themselves and another 15% are paying on a loan for a spouse or child. I was contemplating this when I sat down next to Mike Muller from Common Bond at the Health and Benefits Leadership Conference in Las Vegas a few months ago. Mike started telling me about student loan refinancing. He expanded my thinking from a benefit we might put together for our staff to something that might make a great membership benefit for associations.

When I got back to the office, I learned that our membership team was out ahead of me and already exploring options. We looped Common Bond into our discussions and just met again last week. In our last meeting, Mike described two new services that they're offering that really differentiate Common Bond from their competitors. First, they just added a clean and simple student loan assessment tool. It clearly presents people with their options for student loan forgiveness programs, loan consolidation and loan refinancing. We certainly wouldn't want someone steered toward refinancing without being aware that they were eligible for a student loan forgiveness program. Right now you can find this educational tool on the Gradible site, but it will all be integrated soon. If you have a loan, check it out.

Employers are starting to take note of this crisis and a few progressively thinking workplaces are offering student loan benefits. A Towers Watson survey indicated 4% of employers offered student loan repayment programs in 2015. That number is expected to rise to 26% by 2018. Carol Harnett shares what the Consumer Technology Association is doing to help their staff in her latest column. Common Bonds other new offering provides a tool to employers to administer such a program.

I'm really impressed with what Common Bond is offering. I had the opportunity to meet with them in their offices in New York City and I was also impressed with the culture of the company. Most of their employees have student loans and understand their clients/members needs. With every loan they fund, they also fund the education of a child in need. I had a friend refinance through Common Bond and she had a good experience.

This is how Common Bond describes their programs.

Our approach is to address the student loan debt challenge with 3 distinct solutions, that are integrated into one seamless, easy-to-use online platform.

Student Loan Assessment tool - We know that awareness and education are absolutely critical elements to a successful student loan benefits program. Most individuals want help to understand their options based on their specific debt situation. Our assessment tool was developed to do just that, to make recommendations about the best approach to manage their loan debt – either through consolidation or income-based repayment, loan forgiveness programs if applicable, and refinancing.

Student Loan Refinancing Benefits - Most students graduate with student loan rates that are at 7% or higher, with typically more than $75K in debt. CommonBond’s web-based loan refinancing platform offers a simplified refinancing process to borrowers that yields an average of $14,000 in savings over the life of their loans, with zero fees. There is no cost for associations to implement this benefit offering.

Loan Contribution Management – Increasingly, U.S. employers are considering the ,implementation of company-paid contribution benefits to accelerate the payoff of their employees’ student debt. Our platform simplifies the management of this benefit, creating a cost-effective recruiting & retention tool in a very competitive labor market. This offering is primarily geared towards the corporate market but available to member organizations as well.

Organizations can choose to offer all 3 benefits, or pick and choose what works best for their workforce. Some solutions are offered cost-free, and are designed for easy implementation with little time and effort on the part of the member association.

If you're interested in this topic, be sure and take a look at the August issue of Consumer Reports, The Student Debt Crisis -- Lives on Hold. You may also be interested in:

Relieving the Student-Loan Burden in HRE
Congratulations, Class of 2015. You’re the Most Indebted Ever (For Now) in the WSJ
Why the Student Loan Crisis is Even Worse Than People Think in Time
Millennial-Friendly Benefits Worth Considering in Associations Now

The statistics I quoted came from these sources unless otherwise noted.

I enjoyed a fictional take on the issue in The Assistants by Camille Perri. It's a little less predictable than the typical summer beach read, but still light.