By Jocelyn Sivalingam, M.D., F.A.C.P. | BenefitsPRO

As employers or benefits consultants, it is critical to ensure that your health plan, advocacy or decision support providers, and other partners that depend on this information to guide their practices and decisions understand and follow current, relevant guidelines.

Employees and their family members frequently face tough questions about their health care: How do I know when it’s time to get a mammogram? When does my child need a vision screening? Is thyroid screening something I should get? If I have high blood pressure or diabetes, what is the best treatment for me?

For the providers who care for them, the key question is: How do we implement appropriate, science-backed treatments for our patients, testing where needed, but avoiding potentially harmful or unnecessary (and expensive) care? The answer is to seek guidance from and use clinical guidelines —along with existing clinical skills — wisely.

Establishing clinical guidelines

Clinical guidelines are sets of science-based recommendations, designed to optimize care for patients in areas such as screening and testing, diagnosis, and treatment. They are developed after a critical review by experts of current scientific data and additional evidence to help inform clinical decisions across a spectrum of specialties.

Based upon this process, guidelines are then released by a number of sources and collaborations, including academic and non-profit health care entities, government organizations, and medical specialty organizations.

From preventive care to treatment protocols for chronic conditions, guidelines provide a framework health care providers use with patients to help guide care. However, it is important to note that clinical guidelines are not rigid substitutes for professional judgment, and not all patient care can be encompassed within guidelines.

The impact on health care and benefits

Clinical guidelines are used in myriad ways across the health care spectrum, and providers are not the only ones who utilize them. Insurers may also use guidelines to develop coverage policies for specific procedures, services, and treatment, which can affect the care your covered population receives.

To illustrate a key example of an intended impact of guidelines on health plan coverage, consider those issued by the U.S. Preventive Services Task Force (USPSTF), whose A and B level recommendations comprise the preventive services now covered at no cost under the mandate of the Affordable Care Act.

As another example, the National Committee for Quality Assurance (NCQA), which accredits health plans and improves the quality of care through its evidence-based measures, uses the American Heart Association guidelines when creating its quality rules for treating high cholesterol with statin drugs.

Other examples exist among commercial coverage policies. For example, some cancer drug reimbursement policies use components from nationally recognized guidelines for cancer care.

The importance of up-to-date guidelines

Because science is rapidly changing, guidelines are often updated, leading insurers to revisit their policies to decide if they will change how services and medications are covered for their members. Providers and health systems may modify processes of patient care in response to major changes in guidelines and/or resultant changes in payer reimbursement.

Not all guidelines are updated on a set schedule, making it even more important for providers and organizations that rely on guidelines to stay on top of changing information, as it can have a direct impact on how they work. Attending conferences, visiting the recently established ECRI Guidelines Trust™ , and regularly reviewing relevant professional association websites and journals can help ensure needed guidelines are current. Lack of current information can affect care decisions and potential outcomes for patients. Those who have access to the most up-to-date, evidence-based information are able to work together to make well-informed healthcare decisions.

The value of clinical guidelines for employers

As employers or benefits consultants, it is critical to ensure that your health plan, advocacy or decision support providers, and other partners that depend on this information to guide their practices and decisions understand and follow current, relevant guidelines.

Further, by combining information from relevant guidelines and data from biometric screenings, health risk assessments, claims and other sources, it is possible for clinical advocacy and other decision support providers to identify employees with gaps in care and generate targeted communications (through a member website and/or mobile app) to help them take action to improve their health.

Clinical guidelines are science distilled into practical recommendations meant to be applied to most patients for quality health care. By maintaining current, relevant guidelines, organizations and providers who work with your covered population can ensure that all parties have the key information they need to make the best decisions for their health.

About the author

Jocelyn Sivalingam, M.D., F.A.C.P., is a Medical Director with West’s Health Advocate Solutions, a company that provides health and well-being solutions for over 12,500 organizations using clinical guidelines to inform preventive screening recommendations as well as ongoing disease management. Dr. Sivalingam is board-certified in Infectious Diseases and leads the Clinical Guidelines working group at Health Advocate. She also serves as a key leader of clinical operations for the Chronic Care Solutions program and provides clinical expertise across a number of areas at Health Advocate.

Wellness Programs Really Do Work

Dr. Abbie Leibowitz | HR Daily Advisor

study published recently in the Journal of the American Medical Association (JAMA) has raised questions about the value of workplace wellness programs.

While the findings confirmed that employees who participate in wellness programs make positive behavior changes, the results of this study indicated that these changes did not influence health outcomes or costs.

For years, research has generated mixed reviews of workplace wellness initiatives. However, it is important to note that many of these studies, including the most recent in the JAMA, are limited in scope and do not account for the best practices successful organizations utilize to maximize their wellness programs and drive engagement, improve health outcomes, and lower costs.

A Narrow View Doesn’t Show the Full Picture

The study published in the JAMA analyzed results among employees participating in an 18-month-long, stand-alone wellness program. While this narrow focus may be necessary for a scientific study, it does not necessarily consider other factors at play in most organizations’ wellness programs. For example, participation rates were relatively low, at about 35%, which may have skewed the results. As the study authors acknowledge, employees participating in the program tended to be in good health already.

There are obviously benefits to having healthy workers engaged in a wellness program, but there is more potential impact to be made among the segment of the population in less-than-ideal health. This study did not examine some of the strategies organizations use to drive participation among this group.

Providing incentives is one way to achieve this participation. In the study, program participants received an incentive of about $250. While this is about average among most employers, higher incentives are more effective at motivating participation, which, in turn, can generate better results.

Additionally, the study did not mention what other population health initiatives the organization had in place. Enthusiastic support from management is important to the success of any program. A wellness program integrated into an overall culture of health is more likely to be more successful. This may include offering biometric screenings to help identify employees at risk or a chronic condition management program to further support their health goals.

Providing access to expert support from wellness coaches and others can also make a positive impact versus an online program alone. Wellness in a silo is not as effective as an integrated program, which could skew the results when compared with the broader, more holistic approach many organizations are now implementing.

Finally, looking for short-term “savings” from a wellness program is a mistake. Behavior change takes time, and it is premature to anticipate sweeping shifts in cost trends and outcomes in such a short window. The 3-year results the study authors plan to revisit may be more telling, but true return and value on investment in a wellness program are long-term realities that are not accounted for in this particular study.

Strategies for Optimal Wellness Programs

In order to widen the focus of workplace wellness beyond a narrow, siloed approach, there are a number of best practices proven to drive engagement and achieve successful outcomes.

  • Utilize data to inform the design of a meaningful program. Data, such as health risk assessments, claims data, and biometric screening results, can provide a more detailed picture of the specific needs of a population and enable the employer to tailor the program accordingly.
  • Address the full spectrum of population health needs. Providing multiple touch points to meet people where they are based on their health status, risk level, and readiness to change can ensure that employees will be able to access the right support at the right time to reach their personal health and well-being goals.
  • Energize participation, and make it fun! Weave the organization’s culture into the program with unique activities, incentives, success stories, and challenges.
  • Demonstrate internal support. Build a culture of wellness, incorporating both employee input and executive participation.
  • Create visibility. Work with a wellness expert to create an effective and impactful communications strategy so employees are aware of the benefits and resources available to them.
  • Make the program easy to access via technology and personal support. This includes taking advantage of telephonic support, health coaching, an easy-to-use website and mobile app, and personalized e-mails and notifications to drive awareness and utilization.
  • Integrate health and well-being programs for greater impact and engagement. Provide a streamlined, simplified, all-inclusive program to reduce confusion and maximize participation.

Implementing one or more of these strategies into workplace wellness programs can have a major impact on both employee participation and results.

The Value of a Holistic Approach to Wellness

Integrating wellness with other related health and benefits programs is one of the most effective ways to generate measurable results. For example, biometric screenings can establish a strong starting point for employees’ wellness journeys. Oftentimes, employees learn about a potential condition like hypertension or hyperlipidemia during a screening, prompting them to seek treatment from their physician and support from a wellness program. Furthermore, a better understanding of the health of an organization’s employees can help the employer customize the wellness program to meet their needs, increasing the odds of participation and success.

A recent analysis of a cohort of nine companies utilizing Health Advocate’s wellness program demonstrates that best practices like this make a difference. Each of the participating groups offered wellness coaching and strong incentives of $300 or greater, access to online workshops, and wellness information, as well as integrated biometric screenings. The research assessed changes in high-risk participants over 3 years. Of the 16,741 employees who participated in biometric screenings, 9,689 participated all 3 years. Among this group, 1,674 members (17%) reduced their risk level from high risk to normal or borderline risk within 3 years for the following conditions:


  • 1,497 people identified as high risk for hypertension
  • 76% reduced to normal or borderline within 3 years = 1,138 people
  • Potential savings of up to $1,378 pp./y x 1,138 = $1,568,164


  • 425 people identified as high risk for diabetes
  • 49% reduced to normal or borderline within 3 years = 208 people
  • Potential savings of up to $1,653 pp./y x 208 = $343,824


  • 3,775 people identified as obese
  • 9% were no longer obese and improved their health within 3 years = 340 people
  • Potential savings of up to $1,090 pp./y x 340 = $370,600

The savings estimates are based on data looking at the cost of medical care needed by people with these conditions. As these results show, when compared with a stand-alone program, utilizing best practices, including integrating a wellness program with on-site health screenings, will amplify the effects. By incorporating best practices into workplace wellness, it is possible to realize both improved health outcomes and cost savings, as well as maximize the impact of the overall program.

By Raffi Terzian, M.D., Senior Medical Director at Health Advocate

As you’ve seen during the devastating 2018-2019 flu season, influenza (flu) can have a significant impact on the business community in terms of employee illness and loss of productivity.  (Keep reading for a special offer to help keep your employees safe from the flu this upcoming season at a discounted rate!)

Fast facts:

  • The CDC estimates annual direct costs in the US related to flu (i.e. medications and hospital and outpatient visits) to be in the billions.
  • The CDC also estimates that influenza has resulted in between 34.9 million and 40.1 million illnesses, between 482,000 and 585,000 hospitalizations and between 32,900 and 54,800 deaths during the 2018-2019 flu season alone.
  • Estimates vary, but there is a significant economic burden counted in the billions of dollars related to sick days and loss of productivity due to influenza.

It is clear that flu presents a significant public health concern which warrants the attention of employers who are concerned about employee health, productivity and overall health costs. Implementing an annual flu vaccination program is a vital component of a workplace well-being program.

Annual flu vaccination remains the single best way to prevent the flu, so it’s important to plan ahead and be prepared. The program should also include education for employees about the benefits of flu vaccination as well as important preventive measures such as regular handwashing and maintaining good health habits.

Prepare for the flu now and take advantage of a discount on flu shots!

Early bird discount details:

  • $33.00 per flu shot (Minimums Apply)
  • Offer applies to quadrivalent shots only
  • You must sign a flu shot contract with us by July 1, 2019

Contact us today to learn more:

Matt Verdecchia | The TriStater

Harassment can have a detrimental effect in the workplace, yet identifying what exactly comprises harassment and distinguishing it from unprofessional disrespect can create a challenge for organizations.

It is important to remember that we work in the environment we create and tolerate. Every employee has the right to work in a respectful workplace. Every employee therefore has the responsibility to help create and maintain that culture. This applies at every level of the organization.

While easy to understand, this concept can sometimes be tough to put into practice. It is much easier to look away from inappropriate, disrespectful and potentially harassing behavior, rub a rabbit’s foot, and pray it goes away. With this approach, we do not have to get past our own barriers and can avoid confronting this behavior, setting an appropriate example, enforcing policies, and looking like the “bad guy, party pooper, goodie two-shoe leader,” etc. However, by doing so, we enable the behavior, we give it legs, essentially giving the perpetrator unspoken permission to continue.

This all may sound a tad harsh, but in today’s busy environment, it is often easier to ignore inappropriate behavior than to supportively confront and correct it. While you may disagree on this point, what remains important is reducing risk for your organization. Your organization may employ managers and supervisors who do not want to deal with this issue, or have never been trained and do not know how to deal with this issue – either way they will be held accountable for addressing potential incidents.

Although harassing behavior is obviously a major issue, for organizations, another significant problem is how leadership chooses to deal (or not deal) with the presenting behavior, person, department, or even corporate culture.

The culture of an organization can have a major impact on tolerance and treatment of harassment and other similar behaviors. Keep in mind that not everything someone does or says to someone else is “harassment.” In fact, it likely isn’t. However, it may be disrespectful. There is no law that states “I have to respect you.” This behavior may constitute bullying, and there is also no law that states “I cannot bully you.” Although neither disrespect nor bullying are technically harassment or illegal, this does not mean these behaviors should be condoned or considered appropriate in your company’s culture.

This reinforces the importance of having policies and procedures in place to maintain a safe, productive work environment, including a code of conduct or ethics policy to help manage behavior and productivity. So even though the behavior is not illegal, it likely goes against company policy and is therefore subject to discipline. Managers, supervisors, and others in leadership roles are responsible for managing employee behavior and performance, including creating, maintaining and reinforcing the company culture.

Within the workplace, diversity and our differences contribute positively to the company culture. However, these same differences can also impact individual employee behavior. Even if the behavior is not considered harassment (i.e., against protected classes), it is important to remember that people have different levels of tolerance or perspective on what is appropriate or “reasonable,” and finding a consensus can be difficult. I believe in flexibility – a willingness to bend, stretch, and lean. It is in most people’s power to choose to acclimate to an organizational environment/culture. We hire not only for skills but for cultural adaptability. When incidents arise, it is possible to professionally address these issues and behaviors. If they persist, we have policy to assist and guide us as to a reasonable course of action. But when it comes to harassment – that stepping over the line between disrespectful, out-of-bounds behavior and into the realm of illegal harassment – we must be fair, objective, consistent, prompt, and “reasonable” in the enforcement of the policy, regardless of who the offending person is and what position they hold. Appropriately addressing these incidents in a timely manner will have a positive impact on company culture while mitigating risk for the organization. Remember: a respectful work environment is a safer work environment.

By Andie Burjek | Workforce

From wellness to high-deductible health plans to pharmacy spend, experts help dispel some of the myths surrounding health care costs.

Employers are doing everything they can to curb health care costs.

Sure, and if you believe that you may also believe in unicorns, the Loch Ness monster and Bigfoot roaming the Pacific Northwest.

Cutting health care costs is the elusive white whale for many businesses. Employers indeed may be putting forth a good faith effort to cut their health spend but oftentimes the results just aren’t there. It’s like the arcade game of whack-a-mole — try one new fad and miss, and another pops up followed by the same result.

In the meantime, health care costs have soared. In 1999, the average annual premium (both employer and employee contributions included) was $2,196 for an individual and $5,791 for a family, compared to $6,896 and $19,616, respectively, in 2018, according to the Kaiser Family Foundation 2018 “Employer Health Benefits Survey.”

Among the myriad solutions employers try, there are overriding myths about cutting costs that don’t save money, provide a nonexistent ROI or are just plain ineffective.

We’ve asked several leading health care experts to offer their thoughts on what we’ve determined are four prevailing myths to cutting employer health expenses. There are others, but this is a good start at peeking behind the wizard’s curtain.


A big misconception in cutting health care costs is that employer expenditures rely on addressing what costs the most, said Jaja Okigwe, president and CEO of First Choice Health, a Seattle-based national health provider network. In fact, sometimes cost control doesn’t rely on addressing employee benefits at all. There’s a link between health costs and environmental factors like how employees are treated and how they think about their job, he said.

“Those things carry over into the potential for more serious illness. And there aren’t very many companies who have an easy time at getting at that,” Okigwe said.

There are some companies that have acknowledged the direct relationship between environmental factors and health and done something about it. It’s a positive step when employers decide that “we’re going to do things that create an environment that allows our employees to be their healthiest and most productive, and that’s going to spill over into our health care cost,” Okigwe said.

Utilization of Health Care Services

Health Advocate’s Arthur “Abbie” Leibowitz, chief medical officer, founder and president emeritus at the national health advocacy, patient advocacy and assistance company, also believes that companies can’t control costs by controlling price. Rather, health care costs are driven by utilization.

This brings up a different problem for employers: Motivating employees to use the health care system effectively and efficiently.

One thing that employers can do is help employees connect with trusted medical professionals and offer a path for employees to foster a consistent patient-doctor relationship, Leibowitz said.

This does not necessarily mean that employers should encourage employees to see the doctor for a physical every year, he added. In fact, that can be a fallacy because there’s little reason for the average person to see a doctor annually. “The likelihood of discovering a problem you didn’t know about at a visit like that is so low that it makes it almost [impossible],” he said. Instead, employers can promote getting in touch with one’s doctor when the employee actually needs help.

Promoting the idea that it is good for patients to connect with a trusted physician is smart because many plan designs now don’t require a patient to choose a primary care physician, Leibowitz said. When HMOs were more popular, a patient initially needed to select a primary care doctor in order to access the health system, but fewer models require that now.

“So, in that regard, employers can encourage people to select a doctor even though their plan design may not require it,” he said.

“It’s the attitude — people call it a culture of health — that the employer creates within the work environment that is the best trigger to getting people plugged into a physician relationship that will come in to pay dividends if not immediately then down the road,” he added.

Okigwe offered suggestions to establish a culture of health other than promoting the doctor-patient relationship. For one, companies can have regular walking meetings, since research shows 30 to 40 minutes of walking a day changes one’s risk of heart disease over time.

“Yet sometimes employers don’t think that’s really their job,” he said. Rather, their focus is on the bottom line and employee productivity. But small investments in making the workplace healthier to work in can pay off. 

Long-Term vs. Short-Term Costs

It’s hard for most employers to think long term with health care costs, Okigwe said. “I do think the vast majority are looking at the annual spend and trying to figure out how to reduce it in one year, and that’s just very difficult.”

But thinking long term is something that could help with heath care costs. Employers and employees alike may have to pay short-term expenses in order not to have the shock of major medical expenses in upcoming years. “In general, we tend to think of any spend as being bad,” Okigwe said, but that’s not an accurate way to view health care costs.

It’s almost as if employers believe employees want to spend money on health care, he said, while in some cases what causes costs to skyrocket is that they don’t want to. There needs to be some sort of balance on spending a little bit on the care and activities that deter crises from happening down the line.

Employee cost concerns aren’t necessarily founded in reality in some cases, according to Leslie Michelson, chairman and CEO of Private Health Management and author of “The Patient’s Playbook,” a book about how to become an effective health care consumer. 

“People are always concerned that the best care is the most expensive care, and that’s just not true,” he said.  “In the rest of our economy there’s a pretty tight coupling between cost and quality. In health care there isn’t.”

About 80 percent of the U.S. population lives within an hour drive of at least one large city where there is at least one major medical academic center. Virtually all of these centers are in-network for most carriers. Patients could access specialists on complex conditions here, and care at these facilities is likely to cost less than going to an out-of-network provider.

Michelson’s organization works with patients who have medical problems and identifies for these patients the most advanced doctors with promising and cost-effective interventions.

“If you want to address the cost bar, what  you need to do is sweep in a supportive way to help people who are going to become expensive cases, identify the top experts for their care, educate them about the treatment options available, and provide a coordinated, integrated support system to channel them to the best doctors and to ensure they’re getting the care they need,” he said.

The key to control health care costs is addressing this small subset of patients with the most expensive cases, he said. Ten percent of patients represent 65 percent of health care costs, and 1 percent represent 25 percent, he said.

“If you aren’t doing something that meaningfully addresses that very small portion of the cases, you’re not going to have a significant impact on the costs,” he said.

Bad Incentives

One health care myth related to costs is that quality and prices aren’t improving because of cheaters in the system, according to Rob Andrews, CEO of the Health Transformation Alliance, a nonprofit group made up of 47 companies whose goal is to fundamentally transform the corporate health care benefits marketplace.

Of course, he said, there are some in the health care system who have committed wrongdoings, but they are rare.

“The problem isn’t that insurance companies are bad, or that drug manufacturers are bad, or that hospital systems are bad or that government regulations are bad. Some of all that is true. But the main problem is that incentives are bad,” Andrews said.

Over the past 60 years or so, he said, a system has been built where incentives aren’t aligned with what’s best for people’s health, giving the example of two hypothetical practices. If there are two radiology practices — one that does 1,000 images a week and produces wrong results 5 percent of the time, and the other that does 500 images a week and only gets incorrect results 1 percent of the time — the first practice would make more money under Medicare. That’s because Medicare rewards are based on the number of procedures done, not how well they’re doing.

Not to say that medical practices or insurers are incompetent, he said. This problem exists because the incentives aren’t aligned correctly in the health care system.

“What we aim to do in the HTA is align the $27 billion a year our members spend on health care with value.” Andrews said. “We want to identify and reward the producers who produce the best value.”

“We chase the shiny object — the price — but we need to be focused on the real issue of value,” he added.


Creating a successful wellness program isn’t as simple as offering one and watching the savings roll in, said Gary Kushner, president and CEO of benefits consultancy Kushner & Co.

Workplace wellness programs have gone through numerous iterations in the past several decades. While there have been health-related work programs dating back to the 1920s, it wasn’t until the 1980s and ’90s that wellness programs took off on a much larger scale. The first iteration of this more recent workplace wellness boom is what Kushner called “An Apple a Day” wellness. If an employee eats right and exercises, health care costs will drop. This was not successful, Kushner said.

The second iteration took the original idea a step further, with organizations subsidizing health club memberships and contracting with nutritionists to show employees how to prepare healthy meals. This also didn’t work to reduce costs because the types of employees taking advantage of these subsidies were the ones who already worked out regularly and had healthy lifestyles, Kushner said. The habits of employees who didn’t go to the gym remained the same.

The third iteration of wellness features employers who target their own workforce based on the health needs of that specific population. An employer with a large population of employees with type 2 diabetes may track things diabetics should be doing — like A1C testing and eye exams — through their health plan and encourage at-risk employees to get appropriate testing done.

This type of program, which is more altruistic in nature, has slightly better results. Still, “Every CFO I’ve talked to with these employers keeps coming back to wanting to see savings in the health plan. And they’re having trouble quantifying those. They’re not seeing the difference,” Kushner said.

Where Art Thou, ROI?

Investing in employee wellness is a good thing, but it’s not a short-term policy, said David Henka, president and CEO of ActiveRadar, a health care analytics and patient education company based in Gold River, California.

Although there’s value in wellness programs, he said, that value is not a financial return on investment. Wellness companies often cite huge ROIs for their programs. But academic research reveals that wellness programs do little to reduce health care costs.

A University of Illinois at Urbana-Champaign study published in June 2018 found that workplace wellness programs don’t change employee behavior much or save money on health care costs. Similarly, a University of Pittsburgh clinical trial whose results were published in JAMA in 2016 found that the use of monitoring devices and wearables — often a hallmark of corporate weight loss programs — may have no advantage over traditional weight loss strategies.

“As an employer, if you go into the wellness space thinking you’re going to get an ROI, then you’re going to be greatly disappointed,” Henka said. “But if you go into it by saying it’s the right thing to do for my employees because I want them to maintain healthier habits or lifestyles, then I think you’re tracking along the right frame of mind.”

The realistic value of wellness is more cultural, he said. Wellness companies claiming big returns are not accurate, but it is the right thing for employers to do. It lets employees know that the company values them, he said.

Many employers are not holding wellness providers accountable for the results of their programs, said Cheryl Larson, president and CEO of Midwest Business Group on Health. There are reliable wellness programs on the market, but unfortunately the average employer only pays attention to what the vendor tells them, Larson said.

Employers need to know the right questions to ask wellness vendors and the best way to research their options. Simply asking fellow employers about their programs is one way to conduct research.

Another way to improve vendor services is only agreeing to terms that suit both parties, Larson said.

“I would say if you ask [the vendor] for things, and they say, ‘We’re not going to do that’ — and you’re being fair, you’re doing industry standards, yet they still won’t do it — maybe that’s not the right vendor for you,” Larson said.

Henka suggested providing flu shots as a clear way to show ROI since the flu accounts for lost productivity and absenteeism in the workplace. As last year’s flu season showed, it can be deadly. According to the Centers for Disease Control and Prevention, 80,000 Americans died of the flu and its complications in the winter of 2017-18.

Wellness Done Right

First Choice Health’s Jaja Okigwe addressed potential issues with health screenings — a common component of wellness programs.

One staple of preventive care is annual health screenings and checkups. But the younger a person is, the less likely they are to need regular screenings, according to Okigwe. It’s not until they get older that they need annual screenings.

“It’s a big production to take off time from work and do your screenings,” he said, especially if a patient also has to do something additional like fast for a certain amount of time before the screening. “From a person’s [point of view], there’s a barrier to do it, and then in the end you get this set of information that you probably already knew.”

Companies such as Chicago-based Visibly and Tel Aviv-based 6over6 Vision allow people to get an eye exam using the camera in their phone. The process only takes about 15 minutes, and with results that are 95 to 98 percent as effective as the results they’d get at the optometrist’s office, it’s beneficial for employees who simply need a new prescription for glasses, Okigwe said. While a virtual test can’t diagnose glaucoma, it has a clear benefit for a specific need. A patient who doesn’t need a glaucoma test won’t need to take an hour out of their day to see an optometrist.

“I’m at the age where I wear two pairs of glasses. And sometimes when I’m in that in-between zone I get headaches. Updating the prescription becomes very important and allows me to be more productive,” Okigwe said.


Employers often turn to the consumer-directed health care plan — commonly referred to as a high-deductible health plan — in part to make their employees smarter health care shoppers.

These organizations have a lofty goal when they seek to turn employees into sophisticated health care consumers. Although the goal itself is admirable, the reality is that the health care delivery system is too complex and patients don’t touch it with enough frequency, said Brian Marcotte, president and CEO of the National Business Group of Health.

An employer might have a comprehensive program that gives employees treatment options and resources when they face a surgical decision. But that may be a decision a person has to make once a year or lifetime. “It ends up being a resource that’s out of sight, out of mind,” Marcotte said.

The idea that giving employees more resources and price transparency information would make them more sophisticated consumers did not pan out like employers thought it would, he added. Employers started rolling out HDHPs in the early 2000s and ramped up the strategy when the Affordable Care Act was passed with the Cadillac tax provision. Since health care is generally not part of most people’s regular spending routine like grocery shopping, organizations need to find a way to fit it into employees’ everyday lives.

The Growth of Virtual Solutions

One way organizations are trying to make health care more a part of employees’ routines is through virtual solutions. While people today can find basically any product or service on demand, what is lacking in health care is the ability to get on-demand service, Marcotte said.

The promise of virtual solutions is that they open up avenues to access, convenience and quicker response times from medical professionals.

Virtual care covers a lot of bases including chronic disease management for conditions like diabetes, lifestyle coaching and virtual second opinion services.

However, virtual care can create complicated issues when a patient has to rely on an outside care team rather than the primary care physician with whom they might already have a strong relationship. “The challenge for all these virtual solutions as well is, ‘How do I integrate them back into care and get it within the delivery system itself?’ ” Marcotte said.

Barriers to Health Care Navigation

One reason for the “rampant confusion on how these plans work” — which unfortunately sometimes leads to employees avoiding care — is that “the industry has never done a good job teaching people how to shop for coverage,” said Kim Buckey, a health compliance expert and vice president of client services with benefits compliance company DirectPath.

A person can’t be a good consumer if they don’t know the prices of services, and there’s no easy-to-read or readily available price list, said Buckey’s colleague, Bridget Lipezker, senior vice president and general manager of advocacy and transparency at DirectPath. She referenced what she called the “myth of transparency.” 

“The lack of control the consumer has over what they’re paying for something, or even understanding what they’re paying for and what their level of responsibility is — to me, consumerism becomes a myth because of the that. Because you don’t have choice,” Lipezker said.

Another barrier to employees is time.

Patients can call their doctor and ask for options and prices, Lipezker said, but finding this information is a difficult and time-consuming process, and, as Buckey pointed out, most doctors are only available during business hours, so employees need to find the information they need while at work, adding to their stress and cutting into their productivity.

“Some employers are taking the bull by the horns and are offering advocacy and transparency services to their employees to give them a source of support where they can turn over these issues to someone else to fight on their behalf,” Buckey said.

Socioeconomic Issues With HDHPs

Socioeconomics also is an important factor that employers must consider in health care strategies. One problem that HR has, according to technology-led business process services company Conduent’s Bruce Sherman, is that “we design benefits for people like us,” thus isolating people with different benefits needs and life experiences.

Low-income workers have been especially impacted by employers’ attempt at cost containment through HDHPs. According to the February 2017 Health Affairs article “Health Care Use and Spending Patterns Vary By Wage Level in Employer-Sponsored Plans”— which Sherman co-authored with Teresa B. Gibson, Wendy D. Lynch and Carol Addy — cost shifting in benefits plans has meant a 67 percent increase in deductibles since 2010. That’s six times more than the rise in workers’ wages (10 percent) and inflation (9 percent).

The article explored patterns of health care usage relative to employee wages and found that workers in the lowest wage group ($24,000 or less a year) were the most likely to have (had) an avoidable emergency visit, while the highest earners ($70,001 or more a year) were the least likely.

“It may be helpful to ask employees in different socioeconomic groups what benefits they’d like to have,” said Sherman, a longtime researcher of health issues. “This opens the door for information sharing and doesn’t obligate the employer to provide what employees request.” 

While more employers are talking about establishing a “culture of health,” oftentimes they also fail to address social and economic determinants in that culture of health, he said, suggesting that employers review organizational policies and practices and keep that perspective in mind to give themselves a broader understanding of where there’s opportunity to improve workplace health for different groups of people.

Some employers offer hourly employees a half day every year specifically to see their doctor for preventive care services, he said. Other employers offer paid sick leave to all employees, including hourly workers. And other employers have ditched “just-in-time” scheduling practices and opted for fixed work hours for all employees — a perk for hourly employees since variable scheduling limits predictable income for employees living paycheck to paycheck.

Some organizations are utilizing wage-based cost-sharing arrangements to address socioeconomic disparities, according to the National Business Group on Health’s 2019 “Large Employers’ Health Care Strategy and Design Survey.” According to the survey, 34 percent of employers offered a wage-based premium contribution in 2018, with 32 percent of employers planning to do the same in 2019. Similarly, 8 percent of employers offered a wage-based cost-sharing arrangement through deductibles or out of pocket costs in 2018, compared to 7 percent planning to do that in 2019.


Many employers are doing a lot to help employees with health care costs. But in actuality they demand more from insurance companies and other providers, said DirectPath’s Bridget Lipezker.

Employers comprise the largest group of payers for health care in the United States. According to 2017 National Health Expenditure data, private health insurance accounted for 34 percent of health spending, beating out Medicare (20 percent), Medicaid (12 percent) and out-of-pocket (10 percent).

Employers have a responsibility to do more and they carry a lot of clout. But there are many barriers hindering that influence, she said. It takes a lot of time, energy and focus, and most organizations don’t have the luxury of hiring a person solely focused on benefits.

A majority of small- and midsized businesses only have one person managing HR, and oftentimes HR isn’t even their primary responsibility, according to HR platform BerniePortal’s 2019 “HR Today and Tomorrow” report.

“I think that employers do try to act in the best interests of their employees, at least in my experience. But they don’t always have the expertise in-house or the dollars to hire consultants to help them figure it out,” Lipezker said.

Disruption Will Cut Costs … Not

Counting on disruption to save on health care spend (think major policy changes like the Affordable Care Act) is a strategy, but it’s a poor one for plan sponsors, said ActiveRadar’s David Henka. Employers need to be proactive.

There’s only so many levers employers can pull to affect cost, Henka said. With trends like the consolidation of health systems and influential health care industries like pharmacy benefit managers clashing with employers, organizations have limited options to influence costs.

The most valuable and accessible lever is at the pharmacy, Henka said. Pharmacy costs and formularies are decided on a national scope, unlike hospital and provider networks, which are often decided on locally or regionally. This adds an additional challenge for an employer with offices or employees in multiple states to trim costs.

The lack of transparency in pharmacy benefits is noteworthy, Henka said, and the reality is that for many drugs, there are alternatives that have the same therapeutic benefit for a fraction of the cost. For example, the brand name drug Lipitor has an average cost $184 while Atorvastatin, the generic version with the same active ingredients, has an average cost of $36, according to Henka.

He suggested reference pricing programs, with which costs go down in the short term and, in the long term, patients became more compliant with drug treatments. Reference-based pricing uses complex algorithms to identify the most expensive drugs used by the employee population, highlights more cost-effective alternatives and then encourages members to switch to the most affordable drug.

While reference pricing is trending in parts of Europe, it’s mostly gaining traction in the U.S. among large employer groups, Henka said. He added that many employers think that by switching to a generic-mandated program, they’re doing enough — but they can do more. They could save money by switching from one generic to a different, more cost-effective one.

The types of U.S. organizations mostly adopting these programs are union trust funds and private employers, he said. 

The second largest health care purchaser in the country, CalPERS, is also a proponent of reference pricing, he added. Second only to Medicaid, CalPERS purchases health care benefits for employees in the state of California that work for school districts and other public agencies and covers about 1.2 million lives. They have “already implemented reference pricing for a number of medical procedures and are in serious discussion of implementing it for their pharmacy program as well,” Henka said.

Enter the Chief Medical Officer

A conversation that is gaining traction among employers is working to get more control of health care costs in unique ways, said of First Choice Health’s Jaja Okigwe.

Cable and internet provider Comcast was among the first companies to hire a chief medical officer. In 2005, it hired Tanya Benenson to have an expert solely focused on health care outcomes. Similarly, Google hired David Feinberg, former CEO of Geisinger Health, in November 2018 to lead its health strategy, and banking giant Morgan Stanley hired David Stark as its first chief medical officer in October 2018.

“The novelty of Comcast’s situation was that they were taking charge of crafting the whole benefit program and experience for their employees,” Okigwe said. “This is typically done by carriers and benefit consultants.”

The role of the chief medical officer varies by industry, said DirectPath’s Kim Buckey. In a hospital, that role likely will oversee clinical outcomes, while at an insurance company the position is responsible for decisions on what should be covered, or to help develop health and wellness programs. For organizations like Comcast, a CMO will identify opportunities for savings, oversee the organization’s health vendors to control costs, lead negotiations with providers and analyze claims data.

Large employers can afford to have someone in this position, Buckey said, but most are “a ways away” from the chief medical officer being a common corporate title.

Our goal is to make the entire healthcare experience easier for members and their families. Our personalized second opinion service includes researching and locating providers, scheduling appointments, transferring medical records, care coordination, decision support and empowering members to become more educated about and involved in their care.

New Expert Medical Opinion Program

When it comes to second opinions or healthcare in general, there is no “one size fits all” solution.

In response to organizations who are seeking even more in-depth support around second opinions, the new Expert Medical Opinion (EMO) Program takes our existing second opinion service several steps further, promoting measurably improved health outcomes and medical cost savings.

In addition to helping to ensure the accuracy of diagnoses and proposed treatments and accessing best-in-class care, the program has a special focus on helping individuals with complex conditions and potentially life-altering diagnoses.

Next-level support for second opinions

The Expert Medical Opinion Program supports both in-person and remote (chart-based) second opinions. Using our existing Perfect MatchSM physician locator process, our clinical team will research and locate the right specialists, academic centers and Centers of Excellence nationwide to meet each individual’s specific needs. The program is supported by a live, in-house team who can also collaborate with treating physicians, coordinate ongoing care and testing and provide end-to-end follow-up and treatment decision support. We also leverage advanced data analytics and employ multi-channel communications to address member health risks and care gaps, and provide enhanced reporting on health outcomes, ROI and medical cost savings on EMO cases.

Another key advantage is that all of our services are fully integrated and provided by experienced clinicians and Personal Health Advocates, who can also do the work to resolve any other challenges such as time-consuming administrative and related care and insurance-related issues.

No matter what level of clinical support your organization is seeking, Health Advocate can help design and implement a solution to meet your unique needs. Please contact us today to start the conversation.


Next Story >> Clinical Corner: The Value of Second Opinions

Clinical Corner: The Value of Second Opinions

By Raffi Terzian, M.D.
Senior Medical Director and
Senior Vice President of Clinical Operations
Health Advocate

Obtaining a second opinion can help patients make better informed decisions about their care. While some patients may be uneasy, providers should reassure their patients that it is acceptable to pursue a second opinion if they elect to do so. The American Medical Association Code of Medical Ethics provides guidance to providers regarding consultation, referral and second opinions and asserts that “Physicians’ fiduciary obligation to promote patients’ best interests and welfare can include consulting other physicians for advice.”

In some cases, second opinions can shed light on diagnostic uncertainty. Researchers from the Mayo Clinic published a study in April 2017 which explored the impact of second opinions on changes in diagnosis. They found that final diagnoses were better defined or refined in sixty-six percent of cases. Furthermore, the researchers found that in twenty-one percent of cases, final diagnoses were different from the initial diagnosis. Clarifying diagnostic uncertainty can also lead to more cost-effective care.

The value of second opinions can be viewed through the broader context of care coordination and making sure that patients are accessing the appropriate care in a timely and efficient manner. If a patient decides to pursue a second opinion, it is helpful to be prepared in advance with questions to ask the provider. Second opinions may be sought as in-person consultations or remotely/online by submitting medical records for review by an expert in a given field. The in-person consultation is typically covered by most health insurance plans, though it’s a good idea to confirm benefit coverage in advance. Medicare Part B also allows coverage of second opinions in some circumstances. Centers that provide remote or chart review second opinions will charge for the consultation as well as any medical record collection that may be required. These types of consultations are typically not covered by insurance.

Overall, second opinions can be valuable in bringing clarity to patients facing a diagnostic dilemma, or to those seeking confidence in a proposed treatment plan, further empowering them to take an active role in their ongoing care.


Next Story >> Product Spotlight: Expert Medical Opinions

Bert Alicea | BenefitsPRO

Domestic violence may frequently occur behind closed doors, but the repercussions of abuse have the potential to spill over into the workplace. October is Domestic Violence Awareness Month, an opportunity to raise awareness of this important and difficult topic. For organizations who may employ either victims or perpetrators, domestic violence can impact the individuals involved as well as those around them, leading to a ripple effect of lost productivity, legal concerns, and other costs, not to mention the risk of an incident occurring at work.

Unfortunately, no business is immune to the issue of domestic violence. According to the most recent National Intimate Partner and Sexual Violence Survey, approximately a third of women and a quarter of men report being the victim of violence by a partner at some point in their lives. This means the likelihood of an employee being either a victim or perpetrator is higher than many may realize.

It is important to note that domestic violence is not limited to physical abuse. It can include any range of assaultive and coercive behaviors used by an individual to hurt, dominate or control and intimate a partner or family member, such as stalking, emotional or verbal abuse, financial control and more.

While this is a difficult subject matter to tackle within the workplace, taking a proactive approach to domestic violence can help organizations simultaneously protect their employees while minimizing their risk. Brokers and business leaders can work together to create an action plan and implement prevention and intervention strategies to address domestic violence within their workforce.

The impact on the workplace

Domestic violence impacts people of all ages, races and backgrounds, including employed adults. Although domestic violence is not always physical, tragically, 78 percent of women killed in the workplace between 2003 and 2008 were murdered by their abuser. While alarming, the effects on the workplace begin much sooner, and everyone pays the toll.

Consider that each year, domestic violence victims miss about eight million days of work, the equivalent of 32,000 full-time jobs. Because of this and other factors, the Centers for Disease Control and Prevention estimates that businesses lose $729 million each year in lost productivity related to domestic violence. Employee turnover is also a contributing factor; up to 60 percent of employees experiencing domestic violence reported losing their job as a result, either because they were fired or had to quit.

In addition to indirect costs, health care costs related to domestic violence can also add up for organizations. Domestic violence victims frequently require medical attention and support as a result of abuse, leading to combined medical and mental healthcare costs of more than $4 billion a year.

The effects of domestic violence are not limited to victims; a survey conducted by the Corporate Alliance to End Partner Violence found that at least 44 percent of those who worked with a victim of domestic violence reported feeling personally impacted, including concern for their own safety. This can also have a devastating effect on workplace morale.

Recognizing instances of domestic violence

In order to effectively support employees experiencing domestic violence, it is critical to understand some of the common signs that may indicate a problem:

  • Unexplained bruises
  • Unusually quiet/withdrawn
  • Frequent absences
  • Lack of concentration
  • Wearing concealing clothing, even in warm weather
  • Depression and/or anxiety
  • Change in performance attitude
  • Frequent breaks or appointments with friends/family
  • Receipt of harassing phone calls

If an employee demonstrates any of these red flags, intervening in a sensitive and private manner can make a difference and encourage them to seek help before the problem escalates. In order to be most effective, it is beneficial for managers and other employees to be prepared to handle this important yet personal matter. Yet surprisingly, 65 percent of respondents to a survey from the Society for Human Resource Management reported that their organization does not have a policy or program in place to prevent or address domestic violence.

It is important for organizations to realize that domestic violence does not solely happen outside working hours – a survey from the National Safe Workplace Institute found that 94 percent of corporate security directors reported domestic violence as a high security issue at their organization. Keep in mind the workplace is somewhere perpetrators know they can locate their victim. This increases risk and liability for businesses, which can also lead to additional costs, especially without a plan in place to address this issue.

A proactive approach

Many organizations may be hesitant to get involved in instances of domestic abuse or violence. Yet organizations and their partners have the potential to make a big difference by stepping in early and supporting employees, making it critical to have a comprehensive prevention and response plan ready.

  1. Assess current plans (or lack thereof). The first step is to analyze past incidents, assess the potential for issues and determine current preparedness. Taking the time to review this information will help create a plan that meets the organization’s unique needs.
  2. Develop comprehensive policy. Based on the results of the assessment, this should include internal reporting procedures, support mechanisms for victims, including enhanced security measures, and disciplinary procedures for perpetrators.
  3. Implement company-wide training. In order for the policy to be effective, it is important to raise awareness of the issue and educate both managers and employees on how to identify potential situations, follow reporting procedures and respond appropriately. This may also include what to do if an incident happens at work.

Ensure employees are in the know – Get the message out to the workforce through a variety of channels, including newsletters, posters in break rooms or restrooms, the intranet and more. This can include information about the company’s program as well as how to access available resources, such as the Employee Assistance Program (EAP), community organizations or even local law enforcement.

Benefits professionals play an important role in this process by helping organizations proactively implement the right programs to help should the need arise. Waiting until something happens might be too late. By raising awareness of this important issue and connecting businesses with EAPs and other resources, brokers, consultants and others can ensure employers are prepared to address issues related to domestic violence should they arise, reducing liability while ensuring the safety of the workforce.

Norbert “Bert” Alicea, MA, CEAP, is executive vice president of EAP+Work/Life Services at Health Advocate. Alicea is a licensed psychologist and premier trainer with over 29 years of experience in the EAP field. He has a specialization with executive coaching and management consultations in assisting with difficult workplace situations and also conducts corporate training locally and on a national level.

Keep health care costs in check

By Melissa Erickson | Healthy Living

The average American spends more than $10,000 a year on personal health care, according to the most recent estimates from the Centers for Medicare & Medicaid Services, but there are ways to keep health care expenses down.

Be healthy

While staying healthy is the most straightforward way to minimize health care expenses, that’s easier said than done. Chronic health problems cost Americans big bucks, and many of them are the result of poor health choices, said Angela Snyder, director of health policy and financing at the Georgia Health Policy Center and associate professor at Georgia State University.

Diet and nutrition matter in the prevention of chronic diseases so follow these tips: Eat healthfully and get moderate exercise, regular checkups and adequate sleep. Doing those simple things can go a long way to minimize long-term health expenditures, Snyder said.

Be a smart shopper

“Shopping around for the lowest cost is an important part of being a health care consumer,” said Dr. Raffi Terzian, senior medical director at HealthAdvocate Solutions, which works with companies and organizations to communicate insurance benefits to employees. To avoid surprise bills, find out how much procedures will cost before having them done, Terzian said.

Price-shopping can pay off big when it comes to medications. Request generics, which are required to have the same active ingredients and must work the same as their brand-name counterparts to obtain FDA approval.

“Other ways to defray costs include taking advantage of drugstore discounts and manufacturers’ coupons,” Terzian said.

Stay in-network

While how much you pay depends on your health plan, it’s always better to stay within your health insurance network. It’s also in your best interest to know what your plan covers, Terzian said.

“Certain fixed amounts are set, but out-of-pocket costs may be independent. Find out how much (a procedure or test) will cost, and have a conversation with your provider,” Terzian said.

The best time to ask for a discount on a noncovered procedure is before service is rendered.

“You have a better opportunity to negotiate on the front end,” Terzian said.

Be proactive

If your health plan offers preventative services, be sure to use them, Terzian said. For example, the Affordable Care Act requires that most health plans cover blood pressure, colorectal cancer and cholesterol screenings and flu and tetanus shots for free. If you’re taking advantage of these screenings, it’s more likely a physician will notice a serious condition earlier, which may help reduce health care costs long-term.

Use a health spending account

Health spending accounts allow a person to put money aside for future health care costs, Terzian said.

“You need to anticipate what expenses will be ahead of time and put money aside to cover them. It’s good for a whole host of medical, dental and vision expenses,” Terzian said.

For people with high-deductible health plans, a health savings account is a great way to save for medical expenses and reduce taxable income, but a user must qualify for the program, Terzian said. The government sets the limits for annual contributions, and for 2018 the limit is $3,450 for singles and $6,900 for families.

Read your bill

Mistakes happen. Protect yourself from overpaying by checking your bill. If you see something you don’t understand or think there’s an error, contact your provider and ask about the charge.

Combating the Effects of Employee Stress

By Norbert “Bert” Alicea, MA, CEAP, Executive Vice President of EAP+Work/Life Services, Health Advocate

Employee stress, dubbed the “nation’s fastest growing occupational disease,” has become a major problem for organizations of all sizes.

According to a survey from the American Psychological Association, nearly one third of American workers reported feeling stressed or tense on a regular basis while at work. The causes of stress are widespread and include a lack of work/life balance from juggling household and family responsibilities; everyday challenges from student debt to retirement concerns to information overload; and workplace stressors such as feeling undervalued, under-compensated and overworked.

Whatever the cause, stressed workers tend to be fatigued, prone to mistakes and injuries, and are more likely to be absent. Most significantly, they incur healthcare costs two times the average of other employees. In total, the consequences of stress-related illnesses, from depression to heart disease, costs businesses an estimated $200 to $300 billion a year in lost productivity.

However, with a proactive dual strategy of organizational change and individual stress management, businesses can take steps to promote healthier, more productive employees while reducing healthcare costs.

The True Toll of Stress

The American Institute of Stress estimates that one million employees miss work each day because of stress. But even when employees come to work, emotional distress can reduce a worker’s capacity to perform by up to 50 percent.

If the stress is not addressed, a variety of potential issues may result including absenteeism, job resignations, and an increased risk of developing chronic and costly diseases such as heart disease, diabetes, certain cancers and/or mental health problems like anxiety and depression.

Furthermore, as a means to cope with stress, many employees turn to the risky use of alcohol, prescription pain medications and other substances. Left untreated, substance abuse can cost an employer upwards of $13,000 per employee per year, according to a recent National Institutes of Health study.

How Employers Can Be Proactive

The first step is to evaluate the scope of stress in the organization by looking at absenteeism, illness and turnover rates as well as performance problems. Employee surveys, Health Risk Assessments and internal committees can pinpoint specific stressors and identify if they are company-wide or concentrated in a particular department. It’s also crucial to work directly with employees, including through exit interviews, to get their input about strategies that could help reduce stress.

While some changes to the corporate culture may need to be instituted, such as flexible work hours, workload redistribution, and better employee recognition, the following are some key ways to address and reduce employee stress:

  • Provide access to an Employee Assistance Program (EAP). EAPs, which often include in-person and/or telephonic counseling benefits, help assess and provide support for personal/emotional issues that affect performance and productivity as well as those that create stress. Issues may range from substance abuse to family problems and financial issues. EAPs that help address substance abuse issues, for example, can reduce workers’ compensation claims, employer healthcare costs, and absenteeism. These programs can also help employees with related work/life issues that may impact their stress levels, such as locating resources for eldercare support for those who may be caring for older loved ones.
  • Incorporate health advocacy into employee benefits. Offering an expert who can personally address healthcare issues, such as helping to resolve medical bills and interacting with insurance companies and providers, can help employees reduce worry and stay focused on their job.
  • Offer an accessible, well-rounded wellness program. A multichannel program that addresses the overall well-being of employees–including physical, emotional and financial health–through web-based workshops alongside traditional coaching components can help reduce stress while increasing productivity.

As an integral part of these efforts, engagement strategies can include built-in incentives to reward enrollment and sustained involvement as well as for making healthy lifestyle changes. Additionally, providing consistent employee communications can help drive them to take action.

Don’t wait to take action. Contact us.

Beyond lowering healthcare costs, a continued commitment to reducing stress and providing support to improve the well-being of all workers, no matter what they are going though, produces many benefits. Workers who are less stressed, for example, are more resilient and inclined to stay with their companies.

Learn how Health Advocate can help you create a customized, comprehensive program to promote total well-being, leading to a stronger, healthier, and more productive and satisfied workforce and reduced healthcare costs.


Next Story >> Clinical Corner: Depression in the Workplace: Reversing the Toll on Productivity, Health and the Bottom Line