Our survey of employer attitudes about health benefits told us a lot about what employers are doing, and what they want to stop doing. Here are 5 things employers want to stop doing:
1. Stop paying for bad employee lifestyles. Bad lifestyle choices are big drivers of expense. Our study shows that employers want to stop being solely responsible for those costs. More than half (54%) are adopting programs that use incentives — and penalties — to encourage employees to take responsibility for their health. A study released last week by Watson Wyatt showed similar results.
2. Stop expecting health plans to deliver customized programs. Health plan offerings are popular — there is a nearly 90% adoption rate for core health plan services. But employers increasingly turn to outside vendors for customized programs to fix bad employee health habits. Health plans are looked to for value-based insurance designs, with 40% of employers looking to implement VBID or similar programs.
3. Stop paying for programs that don’t work. Fifty-five percent of employers said they were reducing the number of health benefits they offer or focusing on those with a proven ROI. With 59% saying cost savings are their top priority, it makes sense that they cut costs where they don’t see savings.
4. Stop confusing employees with too many benefit offerings. Employers have in place 10 or more distinct health benefits, with 60% identifying at least five major programs (EAPs, nurse help lines, health coaching, wellness, etc). Employers want to implement a single point of contact to navigate their programs, with adoption rates of these services expected to triple in the next 2 years.
5. Stop thinking bad medical outcomes are because of bad luck. Sixty-five percent of employers said their employees struggle with making the right treatment decisions when sick. Thirty-five percent said making sure their employees have better quality care was a high priority, with 38% saying they wanted to do more to empower employees to make good health care decisions.
*This blog post was originally published at the See First blog.*
This article was co-authored by Elyse Chapman, who became an e-patient through the following process:
I recently became acquainted with a woman in Iowa, Elyse Chapman, who was concerned about her “fibroids”. I heard about her from a colleague whose online moniker is “e-Patient Dave”. Dave deBronkart used information from the internet to successfully steer the course of his own therapy for kidney cancer . Elyse is a friend of Dave’s who was scheduled for a hysterectomy because of a very large, mass, probably a uterine fibroid, a benign but often problematic tumor of the smooth muscle fibers of the uterus. She had problems with excessive painful cramping, bladder pressure and a sensation of swelling and bloating in her abdomen. A CT scan was ordered and showed a mass either on the ovary or uterus. The mass was so large that her doctors wanted to make sure that this was not a malignant tumor of the uterus or ovary. They had scheduled a total hysterectomy via exploratory laparotomy in 3 weeks and Dave was “consulting” with his online friends to see if anyone knew of a patient group with whom she could collaborate to see if there was an alternative to major surgery.
I volunteered to help. Shortly thereafter, I received an e-mail from Elyse and then gave her a call. I heard more details about her history, learned that she had lost her husband recently, and as a single parent, felt very shaky about the prospects of recovering from major surgery without help at home. She wondered why her doctors were so focused on performing a total hysterectomy and why she wouldn’t be a candidate for a laparoscopic approach. She also wondered if she really even needed to undergo surgery now, or could she safely wait and watch for a time.
Unable to determine for certain that an alternative approach was feasible in her case, I encouraged her, at the very least, to become more assertive about getting answers to her questions: If she wasn’t a candidate for laparoscopy, why not? I told her I’d do some further research about this and get back in touch with her. I looked this up on the internet and then sent her this e-mail:
I looked at some sites on laparoscopic hysterectomy. Here is one I thought was good:http://www.ohanlan.com/laparoscop.htmFrom what I can tell, it should be possible to remove even a large uterine mass via laparoscopy.Good luck getting an answer on this that makes sense to you. Let me know if I can help any further.
Elyse actually communicated directly with a nurse at the above site and it bolstered her belief that it may not be necessary to undergo a total abdominal hysterectomy. She communicated this to her doctors in Iowa who were still uncomfortable exploring alternative options. So, she sent me the following e-mail:
Charlie, have you heard of this — nuking the fibroid with ultrasound while using MRI to view and target the waves? Just learned of it today.Seems to me that U of I is wanting to just yank everything out even though there’s no proof that this growth is malignant. Sounds to my laywoman’s brain like at very worst there’s a 50-50 chance of malignancy, yet they do not want to do a biopsy for fear of rupturing something that might be ovarian and malignant, causing easy spread of malignant cells. What I don’t understand is how anyone can determine if its malignant without a biopsy, but obviously someone knows how to do that, because links in the above results say the ultrasound procedure works well for non malignant fibroids, which means that somehow there’s a way to determine malignancy or no without too much fuss.U of I insists that there is no better imaging method than the CT scan I had, but at least some of the above links state that MRI is better. Huh?? Who is right? Is this a case of “we only know how to use a hammer, so everything we see must be a nail” or maybe “we’re financially invested in [name your imaging method of choice], so we’re going to use and promote that”?Thoughts, please?
Elyse
Well, truthfully, I had not heard of this technique, so I did some additional research and found that the number of sites offering the procedure were limited, but sent these to her, with some additional links from the internet. In addition, this e-mail string reminded me that an increasing number of doctors and patients are opting for uterine artery embolization. I mentioned this, and she e-mailed me back that she was unable to find links for this procedure that I mentioned.
Here is my reply to her:
Elyse,
I should have used the “correct” term: uterine artery embolization.
Here: http://www.fibroidworld.com/UAE.htm This is another very reasonable alternative for you to consider, maybe even more realistic than the ultrasound approach.
Charlie
After several more fax and phone exchanges between Elyse and the physician in California who published the web site noted above, and after phone exchanges with the physicians in Iowa, Elyse underwent an ultrasound examination that confirmed a large, single uterine fibroid about 6 or 7 cm in diameter. The Gynecologist/Oncologist in California felt that surgery was entirely optional at this point, noting that Elyse would likely experience shrinkage of the mass following menopause within a few years.
She is still in the process of finalizing her decision whether to proceed with a laparoscopic hysterectomy or take the “watch and wait” approach but is certain of one thing: she is NOT going to proceed with the scheduled total abdominal hysterectomy.
So, that is where we stand. But, what is the point? Well, the HUGE point is, Elyse is no longer content to blindly follow her doctor’s suggestions. Whereas they suggested she undergo a major surgical procedure, they didn’t even mention two significant new, less invasive procedures that might well be appropriate for her to consider, and did not give her clear information to consider the option of just watching and waiting.
The other point of the story is that a wealth of information is available on the web, but patients often need encouragement to seek it, and help interpreting it and applying it to their own situations. Peer support groups on line are one way to accomplish this and finding an interested, available physician to serve as an “e-patient advisor” is another way.
Either way, it is a good example of how patients are moving into the e-patient revolution and, through this process, the health care system is changing. In the meantime, join me in hoping Elyse soon finds the perfect solution for herself and has a great outcome.
*This blog post was written by Dr. Charlie Smith and originally published at the eDocAmerica blog.*
I have a nephew who has excess sweating of his feet which began as a child. The problem has not gone away as he got older, nor has it spread to other parts of his body. He has tried the new socks that say they will absorb sweat and keep the feet dry. None of them work for him. So this post is for him as I look for ways to help him.
Sweating is the release of a salty liquid from the body’s sweat glands. Sweating or perspiration is important in cooling the body. It is common to sweat under the arms, on the feet, and on the palms of the hands.
When the production of sweat is in excess of the amount needed for cooling the body (thermal regulation) it is call hyperhidrosis (excess sweating).
Hyperhidrosis may be primary or secondary. Primary (essential) hyperhidrosis is excess sweating in an otherwise healthy individual, like my nephew.
When excessive sweating affects the hands, feet, and armpits, it’s called primary or focal hyperhidrosis. Primary hyperhidrosis affects 2 – 3% of the population. Less than 40% of patients with this condition seek medical advice. In the majority of primary hyperhidrosis cases, no cause can be found. It appears to run in families.
Secondary hyperhidrosis is associated with any number of systemic illnesses. These including pheochromocytoma, thyrotoxicosis, diabetes mellitus, diabetes insipidus, hypopituitarism, anxiety, menopause, carcinoid syndrome, and drug withdrawal. Nocturnal sweating, in particular, may be a clue to the diagnosis of tuberculosis, lymphoma, endocarditis, diabetes, or acromegaly. Treatment of the underlying disease will decrease or cease the excess sweating in secondary hyperhidrosis.
Several common medications occasionally produce hyperhidrosis. These include tricyclic and serotonin reuptake inhibitors, opioid analgesics, acyclovir, and naproxen.
When looking for underlying health issues, it is important to know if there are any triggers (stress, anxiety, food, etc), if the sweating occurs mostly at night or during the day, which areas of the body are involved, is there an elevated body temperature, or any other problems.
You should see your doctor, if:
You sweat a lot or if sweating lasts for a long time or can’t be explained.
Sweating occurs with or is followed by chest pain or pressure.
Sweating is accompanied by weight loss or most often occurs during sleep and associated with a fever.
Treatments may include:
Antiperspirants. Excessive sweating may be controlled with strong anti-perspirants, which plug the sweat ducts. Products containing 10% to 15% aluminum chloride hexahydrate are the first line of treatment for underarm sweating. Antiperspirants can cause skin irritation. The strong doses of aluminum chloride can damage clothing.
Medication. Anticholinergics drugs, such as glycopyrrolate (Robinul, Robinul-Forte) are rarely helpful. Beta-blockers or benzodiazepines may help reduce stress-related sweating.
Iontophoresis. This FDA-approved procedure uses electricity to temporarily turn off the sweat gland. It is most effective for sweating of the hands and feet. The hands or feet are placed into water, and then a gentle current of electricity is passed through it. The electricity is gradually increased until the patient feels a light tingling sensation. The therapy lasts about 10-20 minutes and requires several sessions. Side effects include skin cracking and blisters, although rare.
Botox. Botulinum toxin type A (Botox) was approved by the FDA in 2004 for the treatment of severe underarm sweating, a condition called primary axillary hyperhidrosis. Small doses of purified botulinum toxin injected into the underarm temporarily block the nerves that stimulate sweating. Side effects include injection-site pain and flu-like symptoms.
Endoscopic thoracic sympathectomy (ETS). In severe cases, a minimally-invasive surgical procedure called sympathectomy may be recommended. The procedure is usually performed on patients with excessively sweaty palms. It is not as effective on those with excessive armpit sweating. This surgery turns off the signal which tells the body to sweat excessively. ETS surgery is done while the patient is asleep under general anesthesia. The surgery takes about a half hour. Patients usually go home the next day, but may experience pain for about a week. ETS requires special training so make sure your doctor is properly trained. Risks include artery damage, nerve damage, and increased sweating. New sweating occurs in about 50% of patients.
References
Goldman L, Ausiello D. Cecil Textbook of Medicine, 22nd ed. Philadelphia, Pa: WB Saunders; 2004:2365, 2446-2447.
Hyperhidrosis; eMedicine, May 2, 2008; Robert A Schwartz, MD, MPH, Rachel Altman, MD, George Kihiczak, MD
An assumption of my new web show, CBSDOC.COM, is that people are aching for mature discussions about health. This week I went to Central Park in New York City to talk to passersby about their sexuality, hoping to strike the right tone. I brought along two female gynecologists – Dr. Lori Warren and Dr. Rebecca Booth – experts who flew all the way from Louisville, Kentucky to help me out. Dr. Booth has written a book called “The Venus Week: Discover the Powerful Secret of Your Cycle At Any Age” that explains how hormones affect women from adolescence to menopause. Each has an active clinical practice and extensive experience talking to their patients about everything from memory loss following pregnancy (“my memory went out with the placenta”) to plummeting libido. And as luck would have it, total strangers we met at Columbus Circle talked to us quite openly about those very problems, eager to hear some practical advice. I hope we accomplished our goal of talking about a sensitive subject in a grown-up manner.
**Better Health readers: please let us know what you think of this new video series with Dr. LaPook. Leave a comment below. Thanks!**
Thanks to Andrew Sullivan who cited my post on the uninsured, I’ve gotten a lot of new comments on that subject. While my post was just a gripe about the problem, the comments were mainly focused on solutions. How do you fix the problem? I even got an e-mail specifically asking me what I would do to deal with the problem of the uninsured.
You have to realize that I’m basically chicken (as are most doctors). I like to point the finger and avoid the fingers of others. It’s much easier to gripe than to fix things. It’s much easier to criticize than it is to say things that can be criticized. But I will break from the safe position of critic and give some thoughts on what I think needs doing on the problem of the uninsured/underinsured. Those who doubt the reality of this problem have only to spend a few days in primary care physician’s office to realize that it a huge problem that is getting worse.
So here are my suggestions:
1. The government has to take on tasks that are in the best interest of the public.
Preventive healthcare should be paid for. This could be done via public health clinics, but having having some sort of preventive health insurance for the uninsured would not have much overall cost (compared to the whole of healthcare) and would potentially save money.
There certainly is debate as to what prevention is really worth it (the PSA test debate is a good example), but some prevention is clearly beneficial (immunizations, Pap Smears). Simply building a relationship between people and primary care physicians also has benefits by itself.
The overall goal is to improve the overall health of the American public. Promote behavior that deals with problems when they are still small or before they happen at all. Just visiting a PCP isn’t the solution by itself, but it is probably a necessary component to achieve a healthier public.
2. Promote proper utilization
One of the main costs to any system, public or private, is overutilization of services. Any solution that does not somehow look at utilization will automatically fail. More care costs more.
Here are areas of increased utilization:
Emergency room visits for non-emergencies.
Visits to specialty physicians for primary care problems.
Unnecessary tests ordered – more likely in a setting where the patient is not known.
Patient perception that “more care is better.”
Nonexistent communication – ER doesn’t know what PCP is doing, PCP doesn’t know what happened at specialist or in the hospital. This causes duplication of tests.
Solutions to these problems include:
Better access to primary care or other less costly care centers
Increase the ratio of primary care to specialists
Care management for high utilizing patients
Public education (not through the press but through better public health).
Promoting connections between information systems – better IT adoption would help, but that IT must communicate.
Make the malpractice environment less frightening to doctors. A large amount of questionable care is given to protect physicians from lawsuits. (A good example is PSA Testing. Even though recent studies question the benefit, many doctors fear that not ordering them will expose them to risk should the patient develop prostate cancer).
How does this help the problem of the uninsured? It reduces the overall cost of non-catastrophic care, which makes either public or private insurance focused on this more feesable.
3. Fix problems with Pharma
Medication costs are a huge problem to my uninsured and insured populations. There are many reasons for this, but some of them are simply due to a bad system. For example:
Medication discount programs cannot include Medicare patients. Why should I be able to give a discount card to my patients with private insurance, even my uninsured, but not Medicare patients?
High cost of generic drugs. When a drug goes generic, there is usually only a slight drip in the price. The system allows only limited competition for price, so the cash price remains high. Encourage cost competition.
Drug Rebates. This raises the overall cost of drugs to everyone. Rebates are sent to insurance companies by drug companies for inclusion on the formulary. It pretty much looks like extortion. The cost of these rebates is not absorbed by Pharma, it is passed on to those who aren’t covered by insurance companies getting the rebate. These need to be eliminated.
Get rid of direct to consumer marketing of drugs. This is pure capitalism that encourages over-utilization.
All of these programs would allow reduced overall cost of medications, which would make either drug coverage more possible or make the cash price of drugs more affordable.
4. Address Conflicts of Interest
Insurance companies are largely publicly-traded companies. This means that their main business goal is to maximize profits by either cutting their costs or increasing revenue. Having them the ones managing care is like putting the kid in charge of the cookie jar. Insurance companies should get back to the business of insuring. Care management is certainly important to control overutilization, but that should not be done by those who could profit from it (insurance companies, hospitals, physicians).
Insurance companies promote themselves as healthcare companies. They don’t provide care, and they shouldn’t. Perhaps there needs to be a third-party that does care management – I am not certain – but it is clear that good care management would greatly reduce overall utilization and profiteering.
How does this help the uninsured? It reduces the footprint of the insurance industry on healthcare as a whole, which should bring down the cost if insurance. It should let insurance companies compete solely on cost, not on provider pannels or other services they shouldn’t be giving in the first place. If insurance costs less, there are less uninsured.
5. Focus on the “uninsurable”
5% of Americans account for over 50% of the overall cost of care (reference). These are the uninsurable people – those who are truley expensive to treat. There needs to be very close management of these people. Leaving them uninsured doesn’t reduce cost, it just shifts it to hospitals and local government. It also leaves them unmanaged. Of the waste in healthcare, the likelihood is that a very large percent of it is in the high-utilizers (by definition). These people need management, either in a “medical home” or by some sort of care management.
There you have it. Follow these rules and everything will be fine.
Yeah, right. Alright everyone, have at it! Tell me what you think, but don’t be a chicken: criticism should be accompanied by an alternative solution.
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