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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? 
  1. Push your insurance network to add mental health providers. 
  2. Promote a collaborative care model that incentivizes primary care providers to screen for mental health problems. 
  3. Support primary care doctors and patients with behavioral health navigators that help patients get access to appropriate, cost-effective care. 
  4. 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.





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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.  
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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.



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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. 
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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

  1. 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?
  2. 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.
  3. 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.
  4. 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.
  5. 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.)
Recommended Reading:
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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 a deliberative polling practice. I plan to look into Daniel Yankelovich's work on this. 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. 

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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.
  1. Heart Disease
  2. Cancer
  3. Accidents
  4. Chronic lower respiratory disease
  5. Stroke
  6. Alzheimer's
  7. Diabetes
  8. Flu and pneumonia
  9. Kidney disease
  10. 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.
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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  // 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.
  
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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. 
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. 

I'm sure there are polices out there that don't pay a 50% commission and that there are some employers that are carefully vetting the options. However, I've 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.”



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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 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.

There are many externalities associated with health that impact us all.
Each of these examples impose a social cost. 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 a question. 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. 






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