Containing Health Benefit Costs

DIVA comprehensive picture of costs in Japan's effective and efficient health care system. /div

The springboard for this sixth volume in the Industry and Health Care series was a conference sponsored by the Center for Industry and Health Care of Boston University on June 9 and 10, 1978. That conference had a gradual genesis. Over a year ago we spent some time with Kevin Stokeld of Deere and Company and heard his views on self-insurance and self-administration as one device for a corporation to achieve better management control of its health benefit. More recent discussions with representatives of American Telephone and Telegraph Company and other corporations made it increasingly clear to us that management's need for data to monitor the use of employee health benefits was emerging as a critical policy issue. Subsequent meetings with executives at John Hancock Mutual Life Insurance Company in Boston and Mobil Oil Corporation in New York, among others, convinced us that simple answers would be elusive or inadequate and that there was a need for an objective and careful look at the evolving relationships between employee health benefits, claims administration, health services utilization, and corpo rate health care cost containment programs. Since self-funding and particularly self-administration represent a fun damental change in the traditional insurance relationship, the conference was convened to explore the advantages and disadvantages of self-insurance for employee health benefits, with some attention to claims production but with special emphasis on the originating question of data for effective management of an employee health benefit.

The springboard for this sixth volume in the Industry and Health Care series was a conference sponsored by the Center for Industry and Health Care of Boston University on June 9 and 10, 1978. That conference had a gradual genesis. Over a year ago we spent some time with Kevin Stokeld of Deere and Company and heard his views on self-insurance and self-administration as one device for a corporation to achieve better management control of its health benefit. More recent discussions with representatives of American Telephone and Telegraph Company and other corporations made it increasingly clear to us that management's need for data to monitor the use of employee health benefits was emerging as a critical policy issue. Subsequent meetings with executives at John Hancock Mutual Life Insurance Company in Boston and Mobil Oil Corporation in New York, among others, convinced us that simple answers would be elusive or inadequate and that there was a need for an objective and careful look at the evolving relationships between employee health benefits, claims administration, health services utilization, and corpo rate health care cost containment programs. Since self-funding and particularly self-administration represent a fun damental change in the traditional insurance relationship, the conference was convened to explore the advantages and disadvantages of self-insurance for employee health benefits, with some attention to claims production but with special emphasis on the originating question of data for effective management of an employee health benefit.

The United States is unique among economically advanced nations in its reliance on employers to provide health benefits voluntarily for workers and their families. Although it is well known that this system fails to reach millions of these individuals as well as others who have no connection to the work place, the system has other weaknesses. It also has many advantages. Because most proposals for health care reform assume some continued role for employers, this book makes an important contribution by describing the strength and limitations of the current system of employment-based health benefits. It provides the data and analysis needed to understand the historical, social, and economic dynamics that have shaped present-day arrangements and outlines what might be done to overcome some of the access, value, and equity problems associated with current employer, insurer, and government policies and practices. Health insurance terminology is often perplexing, and this volume defines essential concepts clearly and carefully. Using an array of primary sources, it provides a store of information on who is covered for what services at what costs, on how programs vary by employer size and industry, and on what governments doâ€"and do not doâ€"to oversee employment-based health programs. A case study adapted from real organizations' experiences illustrates some of the practical challenges in designing, managing, and revising benefit programs. The sometimes unintended and unwanted consequences of employer practices for workers and health care providers are explored. Understanding the concepts of risk, biased risk selection, and risk segmentation is fundamental to sound health care reform. This volume thoroughly examines these key concepts and how they complicate efforts to achieve efficiency and equity in health coverage and health care. With health care reform at the forefront of public attention, this volume will be important to policymakers and regulators, employee benefit managers and other executives, trade associations, and decisionmakers in the health insurance industry, as well as analysts, researchers, and students of health policy.

In 2010, an estimated 50 million people were uninsured in the United States. A portion of the uninsured reflects unemployment rates; however, this rate is primarily a reflection of the fact that when most health plans meet an individual's needs, most times, those health plans are not affordable. Research shows that people without health insurance are more likely to experience financial burdens associated with the utilization of health care services. But even among the insured, underinsurance has emerged as a barrier to care. The Patient Protection and Affordable Care Act (ACA) has made the most comprehensive changes to the provision of health insurance since the development of Medicare and Medicaid by requiring all Americans to have health insurance by 2016. An estimated 30 million individuals who would otherwise be uninsured are expected to obtain insurance through the private health insurance market or state expansion of Medicaid programs. The success of the ACA depends on the design of the essential health benefits (EHB) package and its affordability. Essential Health Benefits recommends a process for defining, monitoring, and updating the EHB package. The book is of value to Assistant Secretary for Planning and Evaluation (ASPE) and other U.S. Department of Health and Human Services agencies, state insurance agencies, Congress, state governors, health care providers, and consumer advocates.

Many Americans believe that people who lack health insurance somehow get the care they really need. Care Without Coverage examines the real consequences for adults who lack health insurance. The study presents findings in the areas of prevention and screening, cancer, chronic illness, hospital-based care, and general health status. The committee looked at the consequences of being uninsured for people suffering from cancer, diabetes, HIV infection and AIDS, heart and kidney disease, mental illness, traumatic injuries, and heart attacks. It focused on the roughly 30 million-one in seven-working-age Americans without health insurance. This group does not include the population over 65 that is covered by Medicare or the nearly 10 million children who are uninsured in this country. The main findings of the report are that working-age Americans without health insurance are more likely to receive too little medical care and receive it too late; be sicker and die sooner; and receive poorer care when they are in the hospital, even for acute situations like a motor vehicle crash.

In one survey, 61 percent of employees said that workplace stress had made them sick and 7 percent said they had actually been hospitalized. Job stress costs US employers more than $300 billion annually and may cause 120,000 excess deaths each year. In China, 1 million people a year may be dying from overwork. People are literally dying for a paycheck. And it needs to stop. In this timely, provocative book, Jeffrey Pfeffer contends that many modern management commonalities such as long work hours, work-family conflict, and economic insecurity are toxic to employees—hurting engagement, increasing turnover, and destroying people’s physical and emotional health—and also inimical to company performance. He argues that human sustainability should be as important as environmental stewardship. You don’t have to do a physically dangerous job to confront a health-destroying, possibly life-threatening, workplace. Just ask the manager in a senior finance role whose immense workload, once handled by several employees, required frequent all-nighters—leading to alcohol and drug addiction. Or the dedicated news media producer whose commitment to getting the story resulted in a sixty-pound weight gain thanks to having no down time to eat properly or exercise. Or the marketing professional prescribed antidepressants a week after joining her employer. In Dying for a Paycheck, Jeffrey Pfeffer marshals a vast trove of evidence and numerous examples from all over the world to expose the infuriating truth about modern work life: even as organizations allow management practices that literally sicken and kill their employees, those policies do not enhance productivity or the bottom line, thereby creating a lose-lose situation. Exploring a range of important topics including layoffs, health insurance, work-family conflict, work hours, job autonomy, and why people remain in toxic environments, Pfeffer offers guidance and practical solutions all of us—employees, employers, and the government—can use to enhance workplace wellbeing. We must wake up to the dangers and enormous costs of today’s workplace, Pfeffer argues. Dying for a Paycheck is a clarion call for a social movement focused on human sustainability. Pfeffer makes clear that the environment we work in is just as important as the one we live in, and with this urgent book, he opens our eyes and shows how we can make our workplaces healthier and better.