Welcome to The Teen Behavioral Network

teen titans
Image by istolethetv via Flickr

How strange that the young should always think the world is against them – when in fact that is the only time it is for them.  ~Mignon McLaughlin, The Neurotic’s Notebook, 1960

Tired of late night cell phone debates with your teens over dubious sleep-over locations and questionable acquaintances?  Worried what kind of den she is calling from ? Unsure whether those red eyes are really from studying or fighting forest fires?  Does your teen make OJ Simpson look truthful? Consider joining The Teen Behavioral Network (TBN)

At TBN, our mission has remained the same, helping teens avoid self sabotage.  During your child’s transformation from adolescence into adulthood, they are statistically at greater risk from a host of acute physical and mental illnesses ranging from situational retardation syndrome (SRS), serial mood swings (SMS), poor peripheral vision (PPV) and episodic events such as auto accidents, broken bones and ruptured relationships.

We want to take this opportunity to socialize you to the benefits, provisions and clinical protocols of our program.  TBN is an incentive based care coordination program underpinned by an exclusive network of friends, acquaintances and families.  Under a typical TBN program, your teen’s activities will require them to call an 800 number to obtain preauthorization for certain risk based activities. Our goal is to help direct them toward people, places and activities that are most likely to reduce their risk for catastrophic events which could sidetrack their progress in life.

Based on decades of evidence and outcomes based data, we have designed a comprehensive physical and mental health program that incorporates the following:

1)      Biometric, academic and psychometric baseline testing – At TBN, we believe you cannot improve what you cannot measure. Periodically, your teen will submit to a basic biometric testing administered by a primary care physician.  We will test key biometric markers such as fasting glucose (blood sugar), weight, blood alcohol and banned substances to baseline overall health status.  We triangulate this data with your child’s grade point average and a two-hour annual psychotherapy session to determine an overall risk score. The lower a teen’s risk score, the less likely they are to commit a monumentally stupid act which could irreversibly impact their future.  Our goal is to reward good behavior and to limit at risk activities to within our preferred partner network.

Based on each child’s risk score, we develop a customized plan to assist them in moving toward “first quartile” social stewardship and personal responsibility.  Our assessment may uncover abnormally high glucose and insulin levels from consumption of sodas, fatty foods and empty carbohydrate diets.  The absence of lactic acid in your teen’s muscles may suggest they are leading too sedentary a lifestyle. 

Our initial baseline risk assessment will graph your member teen’s risk status against local, regional and national peer risk groups to drive toward improvement.  As he/she achieves milestone events, our incentive plan rewards them with behavior points which can be converted into a range of valued rewards such cell phone minutes, PC and phone upgrades, sleep-overs at approved in-network homes and iTunes purchases. Failure to achieve agreed targeted benchmarks results in a series of compulsory physical and behavioral remediation programs offered through affiliated local law enforcement and armed services partnerships

2)      Preferred Partner Organization (PPO) – Every teen member will be provided a customized approved network designating “in-network” friends, family and institutions.  Members may participate in a range of activities in network with no out of pocket expense or preauthorization. 

TBN has gone to great lengths to develop a process for screening and stratifying in-network friends, families and institutions. We pride ourselves on the little things. Our “family” reviewers perform on site inspections and are sensitized to the most subtle signs of laissez-faire oversight such as the absence of alcohol or medicine cabinet inventory controls or content blocking on cable and computers.

While our criteria is kept extremely confidential, each network is unique based upon your teen’s risk profile and the risk factors attributable to other teen members. Certain low risk places or people such as a local church youth group, YMCA or deli are likely to be shared across multiple teen networks.  Certain “in network” friends may receive additional performance stars for characteristics such as intellect judgment, civic responsibility, home supervision and number of text messages sent in a 24 hour period. Five star friends are considered “centers of excellence” (COEs).  COEs are eligible for subsidized activities such as inclusion on family vacations, movies, deli and coffee coupons.

Given the extreme variability of teenagers, our PPO network guide is updated hourly

3)      Out-of Network PPO Access – A teen attempting to access out-of-network friends or institutions must submit an out of network request at least 24 hours prior to the planned event.  Our 24 hour authorization line is staffed with retired teachers, clergy, grandparents, animal trainers and clinical psychologists expert in dealing with pathological behavior.

 You will be provided five micro-chip GPS patches that can be surreptitiously  inserted in your teenagers phone, purse and/or high top sneakers.  The “soft perimeter” tracking device allows you to instantly access your teen’s location via any personal computer or cell phone.  

 Unauthorized Out of network PPO activity may include penalties such as chore deductibles and/or community service co-pays. Each teen must submit location information that includes a JPEG photograph transmitted via cell phone for verification. 

We have retained several per diem private investigators to assist the out of network approval review process.  For a few extra dollars a month you can receive full individual and family background checks and a risk dossier outlining of all public domain information of every person and institution with whom your child may be attempting to affiliate..

4)      Appeals – Teens desiring to appeal out of network denials can request a supervisory appeal from our verification team. Our appeals teams are composed of recovering alcoholics, parole officers and social workers – – all bi-lingual in text messaging and English.  We have recently contracted with Apple to introduce “ iTruth”, a polygraph based wireless application for the iPhone where teens can  attach sensor pads from their phone USB port to their temples. Through an ASP server, users can be evaluated to determine if they are telling the truth. Future programs include iBlow, a breathalyzer app and iBrain, a dopamine and serotonin measurement device.

5)      Final Appeals – Some determined teens may refuse to accept appeals as a basis for final resolution. In these cases, we have designated a “final appeals” protocol. A teen may invoke two final appeal challenges within a one year coverage period – similar to professional football’s red flag challenge.  We employ retired juvenile court judges on 24/7 retainers to arbitrate specific appeals.  Appeal overturn rates for 2010 were less than .005%.  Problematic or disrespectful members will be automatically redirected to a payphone at Bellevue Hospital for the Criminally Insane where teens can attempt to reason with equally irrational people.  These calls are recorded and forwarded to the member parent for entertainment value.

At TBN, our program is simple – – we seek to improve the health and well-being of your teen and to assist them as they navigate a period where they are physiologically and socially incapable of distinguishing risk and consequences.  Youth participants are socialized to understand that in a small town, one’s reputation is easy to lose and hard to recover.

Our motto: “Trust But Verify” reflects our mission to establish guard rails characterized by mutual respect, honesty and consequences for behavior.  We will leave no teen behind and our goal is to ensure that any misstep is minor ……………….(no pun intended).

Keeping Christmas Real

Carter family Christmas portrait, 12/25/1978
Image by The U.S. National Archives via Flickr

December seems to slip through my fingers faster than a toddler in a department store. The early days of Yule are a collision of the spiritual and temporal as I stagger toward another year’s finish line. My brakeless sleigh ride seems to pick up speed as we approach the winter solstice. While nature may be slowing into silent, denuded hibernation, our material commitments only accelerate and fray my red ribbon nerves. The tree may be trimmed, and the ornaments hung with care; Ancient garlands adorn our mantles and snake down a spiral staircase – yet, we come to realize in mid-December that we have miles to go before we can sleep. 

I occasionally catch myself slipping into adult self- pity wondering where the wonder has gone.  I may stand for a few uninterrupted moments staring at our Dickens Village trying to project myself down into the bustling mews of a Christmas Eve in Victorian London. I am suddenly on Oxford Street. I tip my top hat to a gaggle of carolers and exchange pleasantries with a street vendor who deposits steaming chestnuts into my coat pockets for two shillings.  The temperature is falling and the night is holding its breath in anticipation of a great snow that will soon blanket the charred and ancient slate gray homes, frosting the glass of local shops and businesses.  It is a wonderful working class world merrily harvesting the goodwill of another Christmas.

The skaters move in perpetual figure eights across an alabaster pond as children sled down cotton ball hillsides. The gas lanterns cast an eerie light across the stoop of Scrooge and Marley’s as a spectral figure chases after the gnarled skinflint in his night-clothes.  Perhaps if I stare at the village hard enough, I might actually disappear into history like some bizarre episode of the Twilight Zone.  My family would find the dog whimpering near the illuminated Victorian houses as they search our house in vain for their missing patriarch.  As the sobriety of my demise hits them, they cry out loud – regretting every night they took me for granted.  Suddenly, my youngest son notices a new figurine – a ruddy, middle-aged fellow with top-hat and green pea coat, arms full of Ye Olde Curiosity Shoppe gifts as he moves across a worn brick Common of snow toward an undisclosed engagement. “Dad?’ he whispers.

A voice from another room shatters my daydream. “Hon, we have alot cards and I could use some help.” It is a summons from the present.  I am lifted like Harry Potter out of Diagon Alley – landing awkwardly on a kitchen table top facing a table full of my holiday nemeses – – Christmas cards.

Somewhere in time, I soured to holiday greeting cards.  Personally, I am a huge fan of the handwritten note.  However the additional burden of writing and sending over 300 cards in a season where each day brings a new avalanche warning of mounting responsibilities, has convinced me that something must be thrown out of the Christmas aircraft or we will lose altitude and our sanity. I have become cynical to this rich century old tradition as just another form of commercial manipulation visited on me by some subliminal marketing expert in the greeting card industry.  

My spouse is filled with evergreen annoyance at my habitual refusal to help sign and send out cards.  Over the years, her retaliation has been to merely prune our list of recipients of anyone that knew me before she and I met.  I have essentially gone dark with anyone I knew between 1961 and 1986.  This leaves her a few leftover cards to send to people from her past – like a kindergarten teacher who has been dead for 15 years and whose card is faithfully returned to sender each December 28th.  

Christmas cards have been responsible for more holiday tension in my house than the VISA bill. We take Christmas cards very seriously. Each one is faithfully completed with a personal message.  To my more considerate spouse, cards are a critical accoutrement to the season – – a mistletoe effort to stay close to family and friends. She will pen notes until her hands cramp into frozen talons. There is a hard and fast protocol in our home that no Christmas card goes out without a handwritten message. A personal note lends sincerity to your wishes for a “wonderful holiday season”.  There is an extreme bias that a card arriving with nothing written is the equivalent of driving by someone’s house and honking the horn

The entire process is time-consuming and exhausting and distracts her from what should be her highest priority – me. Over the years, I have unsuccessfully lobbied to “take a year off” from the highly manual and debilitating process of signing and sending cards. As I watch her write, label and lick our annual missives, I can understand how postal workers might completely snap from the sheer repetition of processing the tidal wave of season greetings.

With the advent of Shutterfly, the tension of our annual card production has been mitigated. One can now upload digital photos into a range of configurations, push a button and receive, two days later, 300 picture perfect greeting cards at your door courtesy of UPS.  Technology has further simplified the process of adding and deleting acquaintances, friends and business associates. However, the process of sending, messaging and receiving cards leaves me feeling like the Grinch. My kids, on the other hand, could care less about sending cards and in this age of castrated text messages and electronic cards, they view our annual postal blitz as a form of self-mutilation.  They do, however, take a keen interest in which photographs we use for the family picture.  

As the troops gathered around the Mac to manufacture this year’s collage of family photos, I was working and did not want to be disturbed.  I did not want to voluntarily leap into the mosh pit of in-fighting over which photos would be selected.  A voice moaned, “I look horrible in that one.”  “Oh my god, my nose looks like I got stung by a yellow jacket, forget that one. “ Another voice pleads, “No, wait a minute. I like that one. You don’t look so ugly.  Well, actually you do…” I could hear scuffling and finally détente as my wife yelled for me to come to the next room and “choose a photo of myself.”

I moaned. I prefer cards that just show photos of the kids.  I am happy to step out of the frame and deny someone I grew up with the satisfaction of knowing that they are aging better than I am. For some reason, no matter what camera I use, it keeps producing images of a lumpy, salt and pepper middle-aged changeling.  I just cannot understand it. I have come to dread the holiday picture as I refuse to go gently into that aging good night.  Yet, on a rare occasion, the light hits me just right and my shirt is not bunching around my midsection.  I might approve this photo only to be told that I am being selfish because no one else in my one picture looks “good”. “Dad, no way.  I look bizarre.” 

Normally vanity kicks in and I join the fracas trying to find some low light, airbrushed Blanche Dubois photo that can be manipulated to appear that I am not everyone’s father – including my spouse. This year, I did not have the energy to search months of photographs and instead sanctioned them to “just pick something.” I could hear them confer in the low, dulcet tones like a tribal council.  “Ok,” someone yelled. “I think we have it.”

The cards arrived the next day from Shutterfly.  The cover image was a gorgeous winter photo taken of our home during a December storm.  The image was tastefully stenciled with one word: “Joy”.  So far, so good. I opened the card to find a series of handsome photographs of each family member accompanied by a shrunken family photo taken at the Grand Canyon last April.  There was just one problem – there was no picture of me.  I was a mere shadowy figure in our family shot but otherwise, I was missing in action.  “We couldn’t find one that we thought you would like. So we did not include one.”

I was suddenly concerned that everyone who receives our card would read too much into my missing photo.  .Friends relying on our annual card as a touchstone for measuring our life’s progress might wonder if I had been mangled in an industrial accident and now must be relegated to the shadows for my own self defense.  “Ouch!  Looks like Mike must have really let himself go.  He didn’t make the cut for the card.”

 I suddenly felt like the Elephant Man.  “I am not an animal! There must be a few good pictures of me – somewhere!” I was met with blank stares and perplexed looks. So this is what it had come to.  I was now officially “the man who lives under the stairs.” 

The cards are now coursing through the clotted veins of the US Postal Service – across thousands of miles of farmland, ocean and urban landscape to settle into the mailboxes of friends and family.  Our mug shots will adorn refrigerators, creative strands of garland and bowed stacks that rest on the tops of coffee tables.  We will add some spice and cinnamon goodwill to hundreds of home.  Yep, ol’ Boo Radley and his posse.

Next year, I pick the photos.  They will be paparazzi shots of surly teens, morning grumps and pale, mid-winter, Vitamin D starved zombies.  I’m going to fit right in and have the theme for our holiday greeting: “Keeping Christmas Real.”

High Stakes Health Reform – Employers: In or Out?

poker

It’s high noon for private healthcare. Over the last decade, large, medium and small employers that procure and manage over $1T of private healthcare spend for an estimated 180M Americans have been engaged in an expensive game of Texas Hold ‘Em – – wagering with and against a continuum of stakeholders that all seem to possess more powerful hands. As providers consolidate, insurers retrench and the government wrestles with obligations of an uncontrolled fee for service Medicare, the costs of staying at the final table are taking its toll.

To many veteran observers, it appears that employers may be on the brink of folding their cards. As finance and HR professionals consider the table stakes and costs to remain in the game, the Affordable Care Act (ACA) has suddenly provided a potential golden opportunity to step away from a fifty year obligation without incurring onerous near term financial consequences.

As individuals and small business have continued to lapse into the ranks of the uninsured, those small and mid-sized businesses choosing to continue to offer health insurance are coming to the realization that the Affordable Care Act will not result in the moderating of double digit medical trends. In the near term, some contend costs will continue to rise by much as 25-40% before the launch of 2014’s guarantee issue health exchanges.

Larger employers are already cynical to whether reform will actually work for them or against them. Bigger firms and collectively bargained plans are beginning to understand that if small and mid-sized employers drop out of offering private healthcare, the decline of employer plans will leave them as the sole remaining source for private insurance cost shifting. As the cards are turned, the outcomes are far from certain – – and as we have come to discover, business hates uncertainty.

A skilled poker player can recognize the ”tells” of players attempting to buy time or bluff in hopes of seeing another turn of the ACA river card. One can almost hear the private sector thinking: “Do I drop my insurance and pay a penalty that is considerably less than my current financial obligations to provide care?” “Do I keep providing coverage and hope that public policy changes drive improved quality and price controls that will get my costs under control?” “What if the GOP wins in 2012?” “What if Obama gets reelected?” Do I really think the $ 2000 penalty for failure to cover my employees will stay at $2,000 if costs skyrocket?” ”Do I wait and see what others at the table do not wanting to be the first to fold?” “How in the hell did I get into this game in the first place?”

It’s even odds at best when predicting how employers are likely to respond to ACA. What was once considered unthinkable – severing the social contract of providing healthcare to one’s employees – is now not only under serious consideration, but is enabled by a series of intended and unintended consequences resulting from the passage of health reform. Consider some of the emerging fact patterns:

 1) The Social Contract of Healthcare Has Changed under ACA– The Affordable Care Act has mandated that insurance offered through exchanges is “guarantee issue” – eliminating the potential for anyone with a pre-existing condition to be denied coverage or be “rated up” for health status. Historically, employers have worked hard to honor the implied social contract that employer sponsored benefits forged with their employees – – a contract that ensured that an individual would be offered guarantee issue coverage as part of a group purchasing arrangement.

The value of guarantee issue employee coverage coupled with the favorable tax treatment of sponsored benefits has maintained a private sector incentive to use healthcare as a tool to attract and retain employees. Employers are stepping back from this assumption as they consider costs, possible changes in tax treatment and the safety net of exchanges. Some may no longer feel the intrinsic value of offering coverage is worth the potential risk of continuing to provide it – particularly if escalating premiums and public to private cost shifting threaten to further erode earnings.

2) The Culture of American Business Has Changed – It seems less and less relevant whether a business is public or private. The nature of the US workforce and the firms that employ them have changed since the grey flannel days of the career employee. Public firms live quarter to quarter and an increasing number of private firms are either owned or operated by those seeking greater returns on private equity. Businesses are struggling to balance a desire to create long-term value and the very real pressures of an uncertain domestic and global economy.

The notion of investing in employee health improvement plans that may not fully yield returns for two to three years is an unattractive proposition for financial professionals dealing with the need for more immediate financial synergies. The burden of healthcare is weighing on employers and they are doing the math. If penalties for dropping coverage create an opportunity to arbitrage the cost of healthcare, firms could see a net windfall of as much $ 2,000 – $5,000 per employee. This savings expressed as additional earnings per share or as a multiple of earnings is too attractive to not consider as employers push for cost savings and higher EBITDA. As the average American now works for eight different employers over the course of one’s professional life, traditional incentives to create longer term employment such as defined benefit pension, plans, retiree medical and rich employee benefit plans are disappearing – – unless explicitly negotiated as part of a collective bargaining agreement. Employers are asking the difficult question– “would employees rather have a job or healthcare?”

3) Small and Mid-Sized Employers Don’t Manage Healthcare As A Business Risk – Employers have spent too much time looking at healthcare as an expense and not as a business risk. Any effective risk management process first focuses on identifying all the factors driving losses. As data reveals unique risk patterns, the risk manager seeks ways to eliminate or mitigate risk, models scenarios for retaining risk and assesses the most cost-effective way to finance their risk. Ultimately, risk transfer in the form of insurance is the last step an employer employs. The more risk an employer retains, the more they seem to understand the correlation between loss control and loss ratios.

Too often, health insurance is managed as an annual marketing (risk transfer) exercise with little time dedicated to the initial steps designed to diagnose and reduce underlying cost drivers. Since 80% of all group healthcare expenses arise from medical claims and at least 60% of these claims are related to modifiable health risks, one would think employers would see the value in employing more resources to impact and understand these major costs. It seems many firms lack the will, resources or energy to intervene in employee and dependent health and lifestyle. The consequences of this failure to intervene are self-evident in the escalating rates of obesity, lack of compliance with basic preventive health programs and a rising rate of chronic illness among the working employed.

4) Human Resource Generalists Often Lack The Resources and C Suite Support To Tackle Tough Change – HR is being asked to more than ever – with fewer resources. Ratios of HR professionals to staff have steadily declined in the last decade while the costs of managing human capital have soared. The historical inclusion of employee benefits and healthcare as part of their universe of HR responsibilities reveals the best and worst in firms. For many public and private employers, healthcare and employee benefits are secondary skill sets to HR generalists who are focused on a range of business and human capital issues.

In these difficult economic times, HR is often focused on limiting disruption to employees – – ensuring broad open access networks, limited medical management oversight and minimal hassle. The system that has resulted is one whose incentives are perversely built around treating chronic illness and not preventing it. HR teams are understaffed and often unable to build the infrastructure required to assess, mitigate and manage employee population health risks. The added burden of regulations such as HIPAA and ADA have spooked employers from wanting to be too prescriptive with employees over lifestyles and chronic conditions that may be borne out of a personal failure to manage health. The C Suite has expressed anger at increases but has generally been unengaged – electing to intervene in the eleventh hour of renewals instead of actively managing and supporting the internal efforts required to rein in their second largest cost beyond payroll. Firms that have shown HR and the C Suite engagement are posting as much as 10% lower annual medical trends according to a recent National Business Group on Health survey.

5) The GOP has not offered a coherent alternative to ACA where employer sponsored benefits would serve as a linchpin to market reforms – It seems clear to most industry insiders that if ACA is left to its current design – replete with its incentives to drop coverage, increase essential benefits, and avoid focus on personal health improvement – it will begin to unravel employer based healthcare. Providers have long since contended that private healthcare has subsidized public care as government cost shifts in an effort to reduce its growing burdens of Medicaid and Medicare.

Without private insurance as a counter balance and reimbursement incubator for more aggressive market based solutions, the current trajectory seems to be pointing us towards a single payer system. As larger numbers of consumers are pushed to purchase through exchanges dominated by a limited number of private commercial insurers, escalating costs and lack of choice may cause consumers to call for a more affordable “public” option beyond private insurance. Some feel the architects of ACA specifically designed the legislation to set these wheels in motion. The GOP has not seemingly connected the dots to articulate to the American people why the private sector should serve as the catalyst for market reforms. Many feel a single payer system within the US is necessary and inevitable given our infinite demands and finite resources. Others argue, the private sector has never really legislatively enabled to fulfill its role as a market force.

A political opportunity exists for an employer advocate to emerge in Washington – offering a blueprint that anchors employer sponsored plans, unleashes true market forces capable of forcing rationalization of oversupply, reducing variability in outcomes, restoring the role of the primary care provider, improving quality and enabling universal transparency.

6) ACA May Incent Employers to Dump Coverage – ACA offers employers a lower healthcare exit cost by pegging incentives to drop coverage well below the true actuarial cost of healthcare. A large percentage of industries will have workers eligible for generous federal subsidies (400% of the FPL). Many will quickly see the logic of dumping coverage and in doing so, immediate improve struggling margins.

Other employers will be hesitant to play first mover but will gratefully follow a competitor who may choose to dump coverage. CBO estimates for coverage dumping are extremely low in the first years of exchanges. The cost estimates of ACA also fail to identify the rising costs of federal subsidies if more workers buy through exchanges. The only real impediment to dumping healthcare is business’ distrust that the current penalty for dropping coverage will remain at $ 2,000. Many believe that future CBO estimates and GAO studies will reveal the need to adjust employer penalties to track with rising medical inflation. Today’s $ 2,000 penalty could morph into tomorrow’s $6,000 cost per exchange covered insured. Burdened by this knowledge, employers are justifiably cynical toward a government that remains $ 38T underfunded in its existing Medicare obligations.

7) Few Employers Seem Willing To Play The Role of Market Force – ACA passed with significantly less resistance from business than the united private sector front thrown against Hillary Care in 1994. In the 16 years since Clinton health reform was defeated, retiree and existing employee medical obligations have swelled along with the average costs of collectively bargained public plans. There is an increasingly emotionless calculus being discussed in private and public board rooms of America.

Do we want to be burdened with trying to save private healthcare? Who should fix it – employers or taxpayers? The omission of business leadership actively arguing in defense of its role to assume the role of market force for change suggests that employers are quietly preparing to get out from underneath their obligations if an opportunity presents itself.

8) Employers Don’t Believe Government Can Fix Fee For Service Medicare – Employers understand healthcare is a zero sum game. As government rations reimbursement to doctors – underpaying for services in Medicare and Medicaid, the private sector is overcharged to compensate for the payment inequities. Most employers are skeptical of the government’s ability to reign in fee for service Medicare obligations leaving one logical path – – Medicare hospital and provider fee cuts getting shifted to the private sector. This only escalates the rising healthcare cost burden – forcing employers to artificially shoulder CMS’s inability to medically manage fee for service Medicare utilization.

Most economists agree that unless we fix a fee for service Medicare, the current entitlements will sink our economy. Employers do not sense that government has the will nor the acumen to tackle their own third rail of entitlements and in doing so, many employers prefer tax payers shoulder the burden of the fix, not shareholders.

9) Smaller and Mid-Sized Employers Are Trapped in One-Size-Fits-All Pools – Individuals and small business have been the initial focus of reform. Historically, most individual and small insurance programs have been fully insured and pooled with groups of a similar size to create an adequate spread of risk to actuarially predict future costs and to minimize premium volatility due to catastrophic losses.

Most small employers have been stuck in a cycle of double-digit increases as costs of care rise and insurers aggressively manage loss ratios across their entire insured pools to protect profits. A small employer often has no access to their own claims information and as such, sees little value in adopting more disruptive plan designs that might improve their own workforce health status. In the final analysis, an engaged smaller employer ends up being blended with less engaged employers and has little ability to impact their own premium increases. As a result, small employers have become conditioned as commodity buyers of insurance and regard efforts to control losses through workforce engagement as a waste of time. Over the last ten years, insurers have benefited by laws that have precluded smaller employers aggregating purchasing power outside of these carrier pools.

Regulations that restrict the formation of multiple employer welfare associations (MEWAs) have limited smaller employers’ ability to establish “ safety groups” of like-minded employers willing to engage in more aggressive designs focused on reducing trend. The myth that self insurance is inappropriate for smaller employers and the nature of commercial insurance –which often steers employers back to insured arrangements, gives small employers few options. The passage of ACA will create similar insured pools in exchanges essentially replicating existing carrier pooling methodologies that have proven ineffective in controlling medical inflation. With the introduction of minimum loss ratio requirements and tighter community rated pricing, profits will be smaller but costs will continue to rise.

10) Unions Plans Have Not Shown A Willingness to Entertain Designs That Could Protect Their Own Long Term Financial Viability – Collectively bargained plans are some of the richest benefit designs in the US. Unfortunately, the most well insured people are often our most over treated, not our healthiest. One might even argue that the absence of incentives to become better consumers conspires to keep collectively bargained plans the most expensive and inflationary programs in the market.

Couple this with a captive, aging workforce that is descending into chronic illness and one can see how employers and local governments could be very tempted to shift this population risk to a public option pool where risks can be more adequately spread across other employers and/or taxpayers. Many municipal and collectively bargained plans are likely to exceed the federal maximum allowable cost thresholds triggering a “Cadillac” tax in 2018 – incurring an excise tax of 40% for plan costs that exceed $10,200 per individual and $ 22,500 per family. The current trajectory of most bargained plans has them eclipsing these exorbitant tax triggers well before 2018. Unions have historically been reticent to adopt more innovative designs that spur their members to change the way they access the healthcare system. These solutions include participating in premium networks that reimburse medical providers based on value – – directing at risk and chronically ill patients to proven centers of excellence, reestablishing primary care gate keepers and creating incentives for employee health engagement that shifts costs to those who are not compliant with choose health compliance guidelines.

In the next two years, the stakes will only climb in the cat and mouse game of healthcare. Those who advocate private sector market reforms are hoping the symptoms of rising employer resignation are temporary and motivated by a changing political and economic climate. Most believe business can play a vital role in reshaping healthcare delivery by demanding transparency, outcomes based reimbursement, personal responsibility, employee engagement and public policy changes that force market reform and better competition.

Changes should include – – all payer legislation to increase the field of competing payers, disclosure laws like Texas HB 2015 which requires insurers to release claims data for employers as small as 100 lives. Without data, smaller private sector employers are unable to focus on their true underlying cost drivers – the state of employee/dependent health and the incentives that do not exist to promote effective prevention.

Most business leaders seem to favor the notion of smaller government, reduced public spending, effective regulation and market based reform. Healthcare is emotionally charged. It impacts every voter and as such, politicians shy away from the difficult decisions around changing behavior. The real question for the private sector is whether it is willing to step up and assume its role as a catalyst for change or whether we have passed a critical tipping point as a society where our near term profit focus and increasing agnosticism to how we achieve those profits sets in motion an irreversible change that dismantles the last predominantly private system left in the industrialized world.

By playing the right cards, employers may still be able to preserve the best parts of private healthcare and begin to lead a process reelection hungry politicians do not have the will to take on. In winning this poker game of private healthcare, business can redirect government to follow its lead and focus on fixing fee for service Medicare and Medicaid.

America needs its businesses to remain in the healthcare game. The question remains unanswered whether employers will rise to the call – – or fold their hand.

Michael Turpin is Executive Vice President and National Practice Leader of Healthcare and Employee Benefits for USI Insurance Services. USI provides a range of business and risk brokerage, consulting and administration services to mid-sized and emerging growth companies across the US. USI is privately held and is a portflio company of Goldman Sachs Capital Partners.  Turpin can be reached at Michael.Turpin@usi.biz

Her Magnificent Obsession

Gaps and holes in American football. (See Amer...
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We were sharing a cab to Chicago’s O’Hare airport when my colleague disclosed her painful secret – she had joined a Fantasy Football League (FFL) and she was out of control. As a steady handed, pragmatic attorney, I had not pegged her as someone prone to bi-polar swings of allegiance and bizarre social networking normally encountered in advanced fantasy competitors. Yet, she was rapidly exhibiting classic FFL  symptoms as she lamented her inability to watch football as a “normal person”.  We were having a rare FFL 12 Step moment.

I shivered recalling my own Southern California winter Sundays when the beach beckoned or friends called for tennis. I let the phone ring – – glued like a trailer park crack addict hopped up on statistics, lurking in my darkness at noon. Fantasy Football was no longer about winning a paltry $500 purse for possessing the season’s best record; it was about claiming the intellectual high ground and lording it over my closest friends and colleagues. It was about life – dealing with competition, unfair advantages, inside information and a universe dominated by the talented, overpaid and narcissistic superstars– sort of like investment banking. And as often the way of finance, results often defy the most meticulous preparations.

My colleague confided how Fantasy mayhem had taken hold of her life. “I am a mess. I read five papers and watch ESPN until all hours of the morning. I purchased the NFL network on cable.” She was shaking like a Hunt’s Point heroin addict. Everyone is affected – my family and all the in-laws. We all have teams. I have become an obnoxious trash talker. I actually sent a text swearing at my mother the other day when her defense returned an interception for a pick six. I used to be a Seahawks fan. Now I could care less if Seattle wins – especially since they traded my one player, Deion Branch, to the Patriots. If the ‘Hawks are playing the Bears, I want Matt Forte, the Bears running back, to score a TD. I read injury reports more than I do legal briefs. “

As I listened to her share, I felt that familiar nicotine craving for Fantasy Football as if I had just completed my last line up. In a sick twist, I chose to enable her addiction by sharing some recent private insights I had gleaned while in Foxboro. “So does anyone have Hernandez, the Pats’ rookie receiver?” I asked. She made a face. “Hernandez?” “Oh yeah,” I smiled slyly. “He’s 6’2”, fast and the youngest player in the NFL. I recently got the chance to hear a chalk talk at Gillette Stadium. Pats QB coach Bill O’Brien shared that the rookie end would be figuring much more prominently in their offense.”

A scheming shadow fell across her face. “I don’t think anyone has him.” She checked her IPhone and swooned deviously, “Ooooh, no one has taken him yet. “ She moved her thumbs – swiping sideways and punching the virtual keyboard. In a matter of seconds she looked up with a satisfied smile as if she had just completed an inside trade. “Done! That’s going to really piss off my brother in law. We play this week.”

As a recovering FFL addict, I had travelled this lonesome, dispirited road.  She was suffering from the magnificent obsession – – a midnight owl trapped in a parliament that feeds on statistics.  These lost souls comb over Sporting News, ESPN, and a range of other social media trying to string together a psycho-physical profile of every player.  In their alienated delusion, everyone around them seems parochial in their understanding of football.  At my own low point, my wife entered my den to see a confused collage of newspapers plastered all over the walls like John Nash, the schizophrenic  in “A Beautiful Mind.”

At the waning days of my disease, I had isolated myself from old FFL friends- – choosing instead to join obscure computer commissioned leagues pitting me against anonymous Mensa data jocks that probably worked nights in the bowels of Cal Tech or a Tampa Bay Best Buy fulfillment center. It was a dark time where I combed the gridiron for the slightest insight that might mean an advantage. I was a beady eyed Vegas bookie leering out from underneath my rock.

For most recreational FFL users, a fantasy team can be exciting and fun.  Your goal is simple – select a team of individual players and then spend every waking moment attempting to throttle your opponents by outscoring them. While you must select a team defense which can deduct points from your score, fantasy football is about offensive performance – passes caught, TDs scored, and field goals successfully made. The key to fantasy management is a constant stream of real time information and perpetual engagement – which sometimes means that you forget anniversaries, neglect to pick up a child from a playdate or go to bed.

The Fantasy season is often determined by your pre-season “draft”.  Prior to your FFL season, teams gather in late August to draft their squads in a debauched and highly anticipated event not unlike the famous two week Teton gatherings of Mountain Men in the early 1900s. The draft is a time for bravado, verbal abuse and larceny. Teams with names like Madden’s Maulers and Jones Beach Bullies arrive with stacks of excel spreadsheets and perhaps even medical records. With the advent of the internet, FFL has gotten completely out of control.  Trouble starts when one begins to overanalyze the firehose of public data.  An overzealous owner may choose to follow tweets from Chad Ochocinco’s cousin “3Paks”  in hopes of divining some nugget of insight into the highly talented but mercurial receiver’s frame of mind. The fact that he cannot even understand a single 3Paks 12 character tweet is yet another blind alley on a perilous journey of frustration.

FFL data jockeys are generally the same individuals who show up with excel spreadsheets the size of War & Peace for your local fourth grade youth baseball draft. These men and women mean business and often combine to create formidable and amusing opponents. There is a personality pattern with most teams – each their own odd couple of dedicated, anal retentive statistics freaks and lazy, ne’er do well armchair quarterbacks who make rash decisions based on the most recent conversation they had about Colt McCoy with a Somali cab driver in Cleveland.

FFL skill is based on predicting how individual players are positioned to perform in any given week. A strong QB playing a team with a brilliant defensive secondary may not get the start one week in favor of a less statistically impressive “back-up” QB who is facing a team that is ranked 26th in pass defense. It is all about match-ups, health status, game conditions, and the critical wild card events that conspire to make sports and betting so unpredictable.

FFL also creates bizarre and contradictory matchups that permanently corrupt your ability to watch football as a normal fan. Perhaps you are a Giants fan and select Eli Manning as your team QB. Your receivers might by Boldin for Baltimore and the previously loathed Desean Jackson of the Eagles. You hate the Eagles (or used to) but you now like it when Jackson scores. This week’s game, your opponent is starting Brandon Jacobs, also of the Giants, at running back. A normal fan watches the entire game rooting for Eli and Brandon and cheers when the Giants score. Not you! In your twisted FFL mania, Eli might pass 85 yards to Manningham, who runs the ball to the 2 yard line. You are happy Eli completed the pass but you are angry because now you know there is a strong chance Eli will hand the ball to Brandon Jacobs who will score a TD. To your chagrin, Jacobs plows the ball across the goal line and voila, your opponent has just scored on you. Your iPhone immediately glows with a taunting text message from your opponent and you curse out loud at the television. Your wife looks at you in amazement. “I thought you liked the Giants?” You try to explain the dysfunctional world in which you are now marooned but it is too complicated. “Oh, forget it…” you sigh in disgust.

Throughout the season, teams trade players, pick up undrafted players and dump underperformers – always looking to exploit inside information and embarrass one’s opponent. Given that only one team can possess New England’s  QB Tom Brady, Raider RB Darren McFadden, Charger TE Antonio Gates or Bear kicker Robbie Gould, much of one’s success is determined in how one picks lesser known players. You must do your research or risk being mocked.  It is not uncommon for at least one neophyte FFL owner to come unprepared to a pre-season draft and select a seemingly great player that has gone undrafted through the first round. The rookie owner can’t believe their luck. These idiots he is competing with will never beat him if they are missing such obvious talents. After declaring his game changing pick of ProBowl Jones, he is stunned to learn that ProBowl is making license plates in Joliette for attempting to sell a rocket launcher to an undercover FBI agent. He may be picking up trash around Soldier Field but he won’t be playing on it. No mercy.

The season carries right up to the playoffs when a winning team is declared. After that season’s king or queen of football trivia have been crowned, a disturbing mid-winter doldrums sets in. Due to low winter light and the lack of a continuing weekly enterprise, the FFL owner’s brain becomes starved of the dopamine and serotonin that was being manufactured in such large quantities during the regular season.  January is indeed a dark post partum period where some fantasy leagues may develop sick, twisted transitional versions of competition turning to less conventional sports like golf, basketball and hockey.  The fact is you can set up a fantasy league on just about anything – – celebrities, world leaders and sixth grade math classes.  If you have access to information, there is a league waiting to be spawned.

Some FFL purists might argue that the notion of a Fantasy League for Reality Stars crosses some important line. But hey, it may kill some time while you are waiting ProBowl Jones to get out on parole.