The Great Wellness Revolt of 2011

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The scene opens with a fit, thirty-something man running down the hallway of an office building.  His white shirt is stained on right side by what appears to be orange juice. He frantically looks behind him to see if anyone is following him and knocks over a female colleague – spraying papers into the air.  He spins, tumbles, hesitates and then runs through a door marked, “ Human Resources – Compensation and Benefits”

He bursts into an inner office where a 50ish woman is on the phone – laughing.  She frowns glancing at him as he shuts the door and peers between her Levolor blinds.

Carol: (Covering the phone) What the hell are you doing, Johnson ?  Aren’t you supposed to be downstairs conducting the annual benefit enrollment meetings?

Johnson (Terrified, turning to show his stained shirt) : Are they coming?  Did you see anyone?  Those five women – you know the ones who go walking every day at lunch – one of them threw an orange at me right in the middle of my presentation.

Carol: (Swivels in her chair, turning her back on Johnson and is about to speak into the phone when she sees all her phone console lines blinking at once. Her cell phone begins to vibrate in her purse. She speaks into the phone)

Tim, let me get back to you.  Something seems to be going on here at Corporate. (she hangs up and let’s her phone start to ring. )

Cindy grab those calls will you?  (she glances at her cell and sees it is her West Coast HR representative. She holds up her hand to Johnson who is about to say something) Shhh! I have to take this cell call. (She answers the cell)

Phil, I hope this can wait.  I have a …..

( She listens intently as a barely audible voice is whispering on the other line )

Phil, I can barely hear you.  (frowning again) You’re where?  The women’s bathroom – – in a stall?  Phil, I don’t need to tell you that.  What?  Who is after you?  Well, did you call security?  What do you mean, the elevator is not working? The security guard says it’s too far to climb eight flights of stairs?

(She listens and stands up.  She looks out her front window and notices that several employees in suits are doing push ups and jumping jacks in the parking lot.  There are signs being removed from the back of a truck that read, “ Lower Your Cholesterol, Lower My Cost for Health Insurance”, “ That Donut You’re Eating Just Cost Me $50.00”, and “Cut Your Risk Factors, Not My Benefits.”

What the hell is going on?   What?  No Phil, I was not talking to you.  What happened? At your enrollment meeting? Flesh mob? Flash Mob? What did you….Vending machines?  A glasscutter?….Only the candy bars and chips? Apples?  How the hell did someone smuggle 500 apples into the office without us seeing them? Every desk? What?  ‘An apple a day, keeps your colon okay?” Who the hell wrote that?

A flustered secretary opens the door and Johnson hides under her desk with his butt sticking out of the narrow opening.  Carol looks down and barks.

Johnson, for God’s sake get out from underneath that desk.  Cindy, WHAT IS IT? “

Cindy (talking very quickly): Every HR representative is calling from the field.  Apparently, during the open enrollment session this morning, there was a coordinated protest over our raising premiums and decreasing benefits. Several people removed their business suits and were wearing workout clothes.  They started exercising and chanting inappropriate slogans about how this company does not care about employee healthcare.  Someone turned over all the vending machines in St Louis.  A group of CSRs in Dayton who conduct Zumba classes every day at noon have demanded that we do biometric testing on all the people working in the call center.  They seem to have somehow figured out that all of our big medical claims came from several people who have not seen the doctor in years.”

Carol looks out the window and sees an overweight security guard trying to take a sign away from a younger, much thinner man in a track-suit.  The young man is taunting the guard and running just ahead of him until the guard stops and places both hands on his knees and throws up.

Carol (talking to herself): This is getting out of hand. Ok, has anyone been hurt?

Johnson ( muffled, still under the desk ): I told you that this was a problem.  I told you.  Just look at Safeway.  They found that 66% of their diabetics were not compliant with their own treatment regimens. They cut premiums for people who engage. raising premiums for people who refuse to make lifestyle changes. Driving employee engagement.  Remember that note I brought you that someone had left next to all those cookies in the lunchroom? It was a warning from this, whatever they call themselves – wellness terrorist group.  It said, “If your LDL is over 130, don’t even think about it.” Remember, you thought it was some kind of a joke?  Well, what about the sticky note on Larry’s (the CFO’s) door: “Dear Larry, ever thought about the relationship between a lap band operation and operating income?”  Think about it, Ms. Whiffler. It all makes sense. This is a wellness rebellion!

Carol: (disgusted) Get a hold of yourself, Johnson.  This is not the Russian Revolution.  It’s a coup of those exercise nuts we see running and walking every day.  They are trying to get us to spend a lot of time and energy on something that can’t be proven to show an adequate return on investment.  I mean have you seen the call center staff in New Hampshire? Do you really think we are going to change these people’s lifestyles and get them to stop smoking and overeating? Have you ever seen what happens when we put any free food in that lunch room?  I mean I could put dog dirt on that table and if it said ”free”, someone would eat it.

(Carol suddenly remembers the king-sized Butterfinger bar she has in her desk drawer. She sighs and thinks: what I would not give to eat that baby and take a nap. The phone rings.  Cindy looks at the console.  She glances up)

Cindy: It’s Mr. Lawson on line one (the Chief Financial Officer )

Carol: Ok, nobody panic. (looks at Johnson and hisses ) and no more talk about fitness mutinies and exercise insurrections. (Picks up the phone and composes herself) Hi, Larry.  What can I do for you?  (A loud voice penetrates the entire office out of the handset) What? Oh my. Well, yes, I….No, I did not know someone left that note on your door until a few days ago.  What?  What did this one say? (she stops and tries to suppress a smile) A manatee? Oh, yes, now I remember – the large, endangered mammals in Florida?…..No, I do not think they were threatening you by choosing to compare you to an endangered species…..Absolutely, we will fire the person on sight if we can find them. Yes, yes, ok…I will circle back to you in a few hours.  We seem to have some issues with the employees around the benefit plan cuts and premium increases.  (more yelling)

Yes, I think they understand we have a new private equity owner who expects us to improve earnings. Yes, better cutting benefits and increasing contributions than reducing the workforce.  No, I don’t think they know how thankless our jobs are. (She glances at Johnson who has now emerged from under the desk. He is rolling his eyes and sticking his finger down his throat and pretending to gag. She gives him a sharp disapproving look. ) Yes, yes, right away.

Johnson: You know he could stand to lose about 50 lbs. I bet he thinks BMI is a kind of foreign car and that a Statin is a Borough of Manhattan. He’s the one who stopped us from reducing the PPO network and implementing some of those changes that would have redirected people to lower cost, higher quality hospitals – all because his doctor was not in the narrower network.

Carol looks out the window.  Over 50 people are engaged in an impromptu Zumba class.  Three overweight security guards are seated watching them in a golf cart.  One is drinking a Coke and smoking.

Carol: Well, he is the boss.

Johnson: Yes, a boss that dropped on our heads like a 300 lb wrecking ball.

Well, boss, what are you proposing we tell everybody around the country?   We have HR reps hiding in bathrooms. The “Fitness Taliban” in control of a half a dozen offices. I can count the lawsuits now from our overweight employees claiming a hostile work environment. (Imitating Keifer Sutherland’s character Jack Bauer  in “24” ) Well, Madam President, what is our next move? Your team is awaiting further instructions.

( Silence. Johnson continues) You know, if we had just dug in our trainers around biometric testing, penalties for smoking, incentives for wellness and compliance based rewards to make sure people adhere to their chronic illness medications, we could have prevented this mutiny.

Carol: (Irritated) Quit using that word.  Who the hell is going to do all this testing and keeping track? You?  Me? We just fired four HR reps. We have cut our budget and we now have the lowest ratio of HR/Benefits staff to employees in our industry.  The sad truth is, Johnson, it’s easier to pay the increased costs and then pass them on to all employees then try to get them to change.  We are in the business of selling HR and payroll administration systems, not the business of trying to get someone’s spouse from eating Oreos.

Johnson: Well, I’m telling you that our costs have increased 50% in the last three years and we have passed on 80% of those increases to our people.  Wages have increased by about 12% in that same period.  My guess is most people’s take home pay has been consumed by our new high deductible plans, increased cost sharing and new drug plan formulary.  They are pissed off.

Carol: So, what do you propose, Mr Bleeding Heart?

Johnson: Actually, my heart is in great shape. Cholesterol? 145.  Triglycerides? 110. Fasting glucose ? Less than 80. I run three days a week and I have given up dairy. Cherie (his girlfriend ) has just turned vegan.

Carol: ( Rolling her eyes) You sound like one of those P90X terrorists.

Johnson: Well, if the shoe doesn’t fit, then you can’t wear it. Look, I say, we immediately circle back to all employees and tell them that we have heard them.  We can easily launch a voluntary biometric plan for our renewal and offer to hold premiums flat for those who participate.  For those who choose to not get tested, they will pay the increased cost of coverage.

We can get our insurer to pay for the testing and use the penalties to offset the partial costs of the increase.  We then meet with Larry and Ron (the CEO) and show them a five-year pro forma of our current medical trends and the impact of us reducing medical trends by 3% each year. Those guys understand profits.  Every dollar saved times a 10X multiple is money in their pocket when we go public.

We pay over $ 15mm in claims.  The savings of a lower compounded medical trend, reduced catastrophic claims, improved productivity and morale will more than make up for the “hassle factor.” Quite frankly, those that consider healthy living an imposition are probably the same ones back at their desks today eating Krispy Kremes while the healthy employees are protesting. If we can just find people who are sick and don’t know it and stabilize those that are chronically ill by reducing financial, physical or mental barriers to care, we would be a great shape. (He smiles) No pun intended.

Think about how we nickel and dime our people on travel and other administrative costs, yet we completely ignore these rising costs because we find it easier and less “disruptive” just pass to them on to the employees.  Well, guess what?  They are telling us, enough is enough.  We have to do something different and be more responsible.  You cannot engage employees if your management is not engaged.

Carol: (looking out the window.  One of the security guards has joined the Zumba class while the other two have left the parking lot on foot leaving the golf cart behind) Okay, call all the reps and let’s have an emergency follow-up meeting this afternoon.  Dust off that proposal from the insurer and our broker and let’s put some numbers around it.

Johnson smiles approvingly and leaves her office.  She shuts the door and falls back into her chair.  A button pops off her blouse and she shakes her head, feeling sorry for herself.  She remembers the Butterfinger and opens the drawer.  She glances at it and then picks it up.  She stands and goes to the window. She tears open the wrapper.

She turns and decisively walks out to her secretary’s desk.  She drops the candy bar in the waste can.

Cindy, hold my calls. I’m going outside to do some Zumba.

For Mature Audiences Only

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1939 is considered by most film critics to be the Golden Year of Hollywood.  Classic films such as “The Wizard of Oz”, “Gone With the Wind”, “Goodbye Mister Chips”, “Ninotchka” and “Mr. Smith Goes To Washington” were across the marquees of America.  Films of the late Thirties, Forties and even early Fifties relied on character actors, great screenplays, innuendo and film noir lighting to depict suspense, eroticism or violence.  After all, the viewer’s imagination was infinitely more vivid and could conjure images more powerful than any a film censor might seek to leave on the cutting room floor.  In 1945, America came home from a world war and a generation of grey flannel suits, flooded the cinemas – – a little less innocent and a little more open to confronting the taboos of a changing society.

The films of the fifties began to chip away at social issues in movies such as “Twelve Angry Men” “The Blackboard Jungle” and “Invasion of The Body Snatchers”.  The Sixties broke open dated, conservative levees with a deluge of personal expression and social indictment.  Directors like Kubrick, Peckinpah and Losey sought to turn the violence and dystopia of modern society into an art form where one did not leave the theatre reassured but instead questioned the veneer of our own civility.  America had lost its innocence in the jungles of Laos and Cambodia and with banishment from Eden, we sought to come to grips with our traumatic coming of age by questioning everything.  Pitted against a backdrop of iconoclastic writers, directors and producers and an audience eager to witness a more graphic vision of its own imperfection, stood those who must rate films to protect us from ourselves.

The motion picture rating system that resulted in PG, R and X films established an era of rationed viewing holding just out of reach to anyone under 18, a celluloid apple from a delicious and corrupt garden.  An R or X rating instantly perfumed a film to a point that any boy under the age of 14 would risks eternal damnation for the glimpse of Julie Christie’s breast.  Most parents lied – attempting to explain to their children that if they actually saw an X rated movie that their head would explode, various body parts would fall off and the remaining bits would be used by Satan to feed his pot belly pigs.  We were not eating from this self-righteous trough of lies.

We became knights in search of the holy grail of explicit films. It was each boy’s quest to see an R or X rated film.  Perhaps your brain might melt, but like many other trappings of adulthood – you would enjoy every minute of it.  As I sat perched on a Pasadena hillside watching across a summer purple twilight, I could see a skyline to the West of colliding searchlights.  Somewhere in distant Hollywood, the premiere of an R rated film was ushering in a new aspect of popular culture.

My father worked very hard and got little relief parachuting into a hostel of four truants each evening.  He found his catharsis in violent detective and action films.  He called them “shoot-‘em-ups” – – mostly PG 13 and R rated gangster and detective movies.  The smooth handed, film noir gumshoe of the 40’s and 50’s had morphed into a hardened vigilante determined to purify society of its vermin and he loved every minute of it.  In a world where bad guys often slithered their way out accountability on a liberal legal technicality, there was nothing more reassuring than to see justice administered with a .44 magnum.

My mother experienced milder versions of crime and punishment every day raising her boys and found no escape in  films like “ Death Wish”, “The French Connection “ and “ Shaft”.  On those evenings when he could not persuade her to join him at the movies,  I would stand wistfully by the door like a dog waiting to be let out, hoping that I might serve as her surrogate at the Esquire theatre in Pasadena.  My Dad would catch my eye, and my mother would mount a weak protest.   I would soon be settling into a rich faux velvet seat supplied with popcorn and my pregnant anticipation.  It was sheer joy spending a school night watching Charles Bronson rid the world of pimps, two-bit hustlers and injustice.  With the final credits, I would slump into passenger seat exhaustion only to awaken to the sound of the rhythmic ticking of the car’s turn indicator and the reassuring sound of an engine idling in a garage.

I would dream all night of drug deals gone bad, tough gangsters and yes, female anatomy.  I would hold court the next day in school and recount every frame to a wide eyed and thoroughly jealous band of fifth graders.

Yet, as with all good things, the R rated gravy train did not last.  Our attendance of graphic films ended one fateful night when my father convinced my mother to bring the entire family to a new Western called “High Plains Drifter” with Clint Eastwood.  Our prepubescent entourage included my then, five-year old younger brother due to a shortage of baby sitters.  My parents had once again had a date night foiled as their dwindling list of care givers had cancelled at the last moment.

With four boys under age 12, we had been scandalously labeled as “incorrigible” by a past sitter and word had spread through the babysitting ranks to a point that we could only attract higher risk or higher cost sitters. The short list included unemployed hippy sons of friends and blue haired ladies who would drink my parents liquor and tip over at 8:16 while watching Lawrence Welk.

Desperate to escape the house that evening, my mother consented to attend the movie that my father described as ” a brilliant avant garde Western that got great reviews.”  As we listened through the heating duct, he went right to the hard sell her for bringing us along. “Look, it’s a 9:45pm movie.  They will all be asleep by 10pm.  They won’t make it past the credits.”

In a rare moment of weakness, my mother relented. When we pulled up to the box office, she was very unhappy to see that the film was rated “R”.  We were delighted.  I sat as far from her as I could so she could not cover my eyes during the more graphic parts of the movie.   The film opened to a dusty high desert town in some remote, god forsaken part of the American West.  Across heatwaves rising like phantom snakes off burning sand, a lone rider suddenly appears out of thin air – a demon on a mission.

I glanced over and saw that my youngest brother was still very much awake and watching as the rider, dismounted and entered the windswept ghost town. A provocatively dressed woman with a parasol appears strolling down a storefront sidewalk.  To the chagrin of several of the town’s “upright” female citizens, she is clearly attracting attention from men inside the stores, bars and barber shops. She stops as she sees the stranger dismount and walks toward him – clearly trying to get the stranger’s attention.  When the Clint aka The Man with No Name  does not acknowledge the woman, she curses him –  chastising him for not tipping his hat to a “lady”.

In a vintage burst of  erotic violence,  Clint hoists the woman over his shoulder and into a local barn where he proceeds to have his way.  At first, she resists violently but  slowly and inevitably yields.  The scene concludes with a vertical shot of Clint buttoning his trousers while the woman lays exhausted on a dirty pile of hay. You could have heard a pin drop in the theatre.  Suddenly, an innocent voice broke our cinematic silence,  “What did he do to her, Mom? “.

The entire theatre burst out in repressed laughter.  My mother, horrified by the fact that my brother was still awake and suddenly self conscious that we were the only children in this movie immediately insisted to my father that we leave.  I can still see him hanging back as we exited the movie – trying to get one last glimpse of Clint as he visited vengeance on the corrupt townspeople. It would be a six year drought before another Turpin male would get a bite from the R rated apple again.

In the 80’s and 90’s, cable television and the internet changed everything.  X became M.  M became R.  R became PG 13.  PG 13 became PG and G meant animated or Disney.  The graphic film, once condemned as a symptom of the decline of society, became a mainstream feature of popular culture.  While more liberal people viewed this evolution as a natural result of a more liberated society, others viewed it as a popular culture declaring war on us.  A new generation of adolescents no longer needed to skulk in backyard tree houses perusing someone’s discarded Playboy magazine or sneaking into “Dirty Harry”.  One merely had to now turn on cable TV at 11pm on a Friday night or Google any part of one’s anatomy to end up at a website offering graphic images.

While the years have exposed me to images considered unfit for society in the 70’s,  I am still convinced my body parts will fall off and my head will explode.  However, the collateral damage now arises out of frustration —  trying to assemble firewalls and filters to prevent my curious and resourceful kids from sneaking into these highly accessible peep shows.

I sometimes feel like a hypocrite having seen a Clockwork Orange before my 14th birthday.  However, the specialists reassure me that my upbringing was truly a result of being raised in the Jurassic period of parenting and as such, I am allowed to be as two-faced as I want to be in the name of protecting my kids from the barrage of negative images and graphic, senseless violence all just a click away.

I admit to also falling into that he’s almost a man rationale where I will allow my guys to watch some blood and guts.  However, half the time that I consent to allow them to see a questionable film, i am finding out that they have already seen it at a friend’s house.  I actually once considered letting a group of boys on a sleepover watch the Omen to retaliate for Texas Chain Saw Massacre and the Saw marathon that my son witnessed at another person’s home.

It is a battle that rages in our household every week over what movies and television shows are appropriate.  Being raised on ultra-violence, I am not the best enforcer ( that was a good movie with Clint Eastwood ).  Technology and shifting social mores have introduced many advantages but it has also allowed “popular culture” to invade our homes and seep into the porous and fragile minds of our impressionable kids.

In retrospect, a few R rated movies did not turn me into Ted Bundy or put me on the roof of a building with a high-powered rifle.  However, I remember those dreams after coming home from those movies.  It was a restless sleep where the world was either a disturbing futuristic dystopia or an urban cesspool populated by sociopaths, indifference and a single vigilante who like Christ, sacrifices himself to save an indifferent world.  While I wore these cinematic rites of passage to school like medals of honor, the experiences were also a burden to a child who could not process all that he had seen. I could not resist taking a bite from the apple and with it, came banishment from Eden – the real price of admission to an R rated film and adult knowledge.

In the Jurassic 70s, no one really realized the mild PTSD that accompanied Dirty Harry like a cheap cologne, but I now understand why my wife wants me to draw a harder line on R rated movies for the kids.

As The Outlaw Josey Wales once mused, “a man’s got to know his limitations”.

Fear and Footsie on Metro North

I don’t have a fear of dying, I just don’t want to be there when it happens.

– Woody Allen

Every time I board the Metro North, I ritualistically choose the window in the two passenger aisle.   Inevitably, a Talmadge Hill or Glenbrook commuter crosses my 38th Parallel invading my personal space. We sit, silent sardines packed in the belly of an iron beast rattling toward the city.

As I drift between my blackberry and a depressing NY Times, his leg shifts and brushes mine.  He mumbles “sorry”, not wanting me to think he did this on purpose. I retract my leg quickly as if electrocuted.  Later,  he falls asleep and his foot is touching mine.  I must shift my shoe but not so quickly that he wakes and thinks I have some sort of “problem”.  So I wait for the proper moment and then, ever-so-slightly, break contact off with his interloping foot.  My new window seat position has my back slightly turned to the aisle and my legs are now bent to the window.   By the time we arrive in Grand Central, I am hunched over like Golem protecting his “precious” ring.  Yes, it’s just another exhausting morning for this mild neurotic.

I am certain I am not alone in my garden of odd peccadilloes. In fact, it is every psychotherapist’s raison d’etri to crawl like entomologists through the jungles of our minds catching and examining the strange paramecium that wriggle in the darkness of our subconscious.  The Metro North seat mate contact thing is just one of the many odd little habits that I carry around with me like a tattered blankie. The root cause of my personal defects may never be diagnosed.  Did my mother inhale too much foot powder during her pregnancy.  Perhaps it is a more deeply metastasized problem arising out of my childhood. Perhaps it was the infamous 1971 Brussels Sprout Affair where my no-nonsense father made my brother eat dog-saliva coated sprouts after he caught Tom shoving them into the maw of our normally dependable canine disposal.  Was it having a Democrat and a Republican for parents?  Whatever the reason, each of us occasionally dredges our dark mental swamp where weird little ideas and notions swim in seclusion.

Things get interesting when peccadilloes morph into phobias. It is also the DNA of human comedy.  Some irrational fears that I have encountered among friends and relatives include: an anxiety over hot liquids, distress about drains, dread of dark windows, concern over clowns (it is real and called coulrophobia), or just a freaking strange obsession when someone with socks touches your feet when you are also wearing socks. There are others I can personally relate to:  a fear of the basement, fear of elevators, aversions to taking one’s pulse or even so much as having a vein under surveillance.

My father has lived for years with Bolshephobia ( fear of Bolsheviks ).  The aversion resulted in an intense dislike of Democrats, or anyone who ever uses the terms ” redistribution”, “fair” or “equal”. He is terrified of politicians from Northern California.  Growing up, we oftened accused my mother of having intensely irrational fears.  She had a visceral aversion to sleep overs at friend’s homes when only a teenaged sibling was babysitting.  She had hives over our attending rock concerts, riding motorcycles, hitchhiking or coming home with a girl with body tats and an ex-boyfriend who had the mailing address – Prisoner No. 95435, San Quentin, CA. How paranoid can a parent be ?

Phobias often plague the rich and famous.  Most are familiar with the chronically misophobic billionaire Howard Hughes who spent the last several years of his life locked naked in a Las Vegas penthouse apartment that was sanitized hourly and meticulously monitored. Less known, is the famous hexakosioihexekontahexaphobic – artist Marc Chagall who feared goats until, on the advice of his therapist, he confronted his demons by painting his horned tormentors floating harmlessly while being subdued by cherubs.

Yes, many suffer from a strange brew of irrational fears:  Soceraphobia : the fear of parent in laws.  The fear of Germans?Teutophobia.  Tuetophobes tend to also fear personal trainers and engineers.  Pogonophobes have a great fear of people with beards.  Bearded ladies are often used to treat this condition as this mental double negative can snap someone out of their anxieties or in a few rare cases, make them jump out of a third story window.   Lachanophobics are normally under the age of 12 and fear vegetables.  Selenophobics possess a deep fear of the moon.  I do recall a selenophobic event after a college frat party where I was absolutely certain the moon was following me.  No matter which way I turned, it was after me.

I have actually invented a few clinical terms for my own private peeves: kareokaphobia – the fear of singing in public.  Teshaphobia – fear of John Tesh music and purgaphobia – the fear of shopping with one’s spouse.  Many men suffer from Stamaphobia  – the fear of being asked to carpool to a birthday party in Stamford.

Angst, paranoia, needling fear — are all merely symptoms of being human.  Psychotherapists and psychologists have financed many a ski trip to San Moritz mining the diamonds of anxiety that are littered across the acres of our subconscious minds. In the end, Woody Allen, Monk, Jack Nicholson and a more open society have made it ok to be a tad neurotic.  Everyone sees the world through their own unique looking glass.  My kaleidoscope sees beautiful colors, odd shapes and the occasional shadow created by fractured perspective.

The aperture of the guy now seated next to me on the Metro North? I am not sure what he sees.  I only wish his foot would stop touching mine.

Is Your Lack of “MQ” Costing You Money ?

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As health reform continues to play out across state legislatures and within Washington, employers continue to wrestle with rising costs and the corrosive effects of skyrocketing medical trends. It’s clear that there is enormous variability among employers in their confidence and abilities to identify, mitigate and manage the complexities of the employer sponsored healthcare delivery system.

Many industry pricing and billing practices are opaque. Employers are not always getting good advice and often have to entrust the management and control of employee benefit plans to generalists who do not have the time, resources or ability to engage in managing a corporate expense that has eclipsed a composite average of $11,000 per covered employee.

If employer sponsored healthcare is going to survive to drive market based changes that cut fraud, waste and insist on personal health improvement, corporate decision makers must improve their Medical Quotient (MQ). While larger employers such as Safeway have begun to reap the dividends of lower costs by driving employee health improvement and employee engagement through prevention and chronic illness management, small and mid-sized businesses are increasingly getting failing scores for understanding and managing their own cost drivers.

Success in managing medical costs begins with understanding one’s own MQ and committing to improve it against a rapidly changing market that is exceeding the rate of change of many HR and financial professionals. Jack Welch once commented, “When the rate of change outside an organization exceeds the rate of change within, the end is near.” While ignorance can be bliss, it is an expensive consequence in employer sponsored healthcare. Can HR generalists and less engaged CFOs and CEOs finally grab the horns of their own population health costs and drive toward a healthier tomorrow?

Consider the following as you gauge your own MQ:

1. A Value based plan design:

a) indexes an employee’s maximum out-of-pocket to their gross earnings

b) limits co-pays and out-of-pocket costs for drugs and specific treatment therapies to facilitate chronic condition compliance

c) offers multiple plan design options based on an employee’s gross earnings

d) waives all cost sharing for all benefits to remove barriers to care

e) establishes a fixed fee amount that an employee must pay for every service rendered under a health plan to promote consumerism

2. The American’s With Disabilities Act (ADA) and the Health Insurance Portability and Accountability Act (HIPAA) preclude an employer from:

a) collecting and evaluating (through Human Resources) claims data on each employee and then setting contribution penalties based on chronic conditions

b) collecting and evaluating (through a Third Party) claims data on each employee and then setting contribution incentives based on prevalence of risk factors and compliance with wellness program engagement

c) relegating smokers to a less comprehensive plan design if they refuse to engage in smoking cessation

d) charging up to 30% contribution differentials to those employees or spouse who do not participate in a health risk assessment, biometric testing or general wellness program

3. Match the following percentage of modifiable risks per 100 workers in an employer population:

a) Obese/Overweight                               1. 21%

b) Smoking                                                  2. 66%

c) Sedentary Lifestyle/No Exercise       3. 29%

d) Stress/Anxiety/Mental Health         4. 39%

e) High Blood Pressure                            5. 33%

4. What did a recent National Business Group on Health survey calculate as the additional percentage of cost increases that unengaged employers are likely to pay for healthcare versus employers who have committed to managing population risk and employee engagement:

a) 2%

b) 5%

c) 10%

d) 20%

e) No difference

5. Match the average percentage of retail charges for medical care that is generally charged by physicians and reimbursed based on the plan payer:

a) Medicare                                  1. 126%

b) Commercial Insurance        2. 250%

c) Uninsured Consumer           3. 67%

d) Medicaid                                  4. 84%

6. Match the percentage of your claims dollar attributable to its corresponding category of costs:

a) Facilities – Inpatient & Outpatient                            1. 50%

b) Physicians (Primary Care)                                          2. 12%

c) Prescription Drug                                                           3. 23%

d) Physician (Specialists)                                                 4. 15%

7. According to Compass Consumer Solutions, contracted rates for services can vary by as much as what % within the same approved PPO network?

a) 15%

b) 300%

c) 75%

d) 1000%

e) No variation – all contracted rates are consistent between providers

8. In 2014, health insurance exchanges will offer the following:

a) community rated plans that allow for preferred pricing if employers achieve health improvement and lower utilization

b) federal subsidies for all employees who choose to purchase through the exchange

c) access to the Federal Employee Benefit Plan to take advantage of government employee purchasing economics

d) bronze, silver and gold coverage options for consumers and employers under 50 employees seeking to purchase pooled, insured coverage

e) tax credits for employers who choose to drop coverage and subsidize coverage for all employees purchasing through the exchange

9. Under new health reform legislation, an insured employer of 50 or more employees’ individual loss ratio ( claims as a percentage of total premium ) cannot be less than:

a) 80%

b) 85%

c) 75%

d) 90%

e) Loss ratio rules do not apply to each employer, only across insurer books of business by license and by state

(See Answer Key for scores)

A higher MQ means a lower cost – As you tally your scores and ponder the range of questions and answers, understand that a lower MQ is costing you money. If you are relying on a broker or advisor who does not help you understand the increasing complexities of insurer underwriting, network economics and provider contracting, you are not getting full benefit for your advisory spend. It’s not enough to delegate the role of managing plans to a third-party.  A high will, but low skill brokerage relationship may have you permanently stuck in remedial Health 101 with no hope of graduating to lower costs.

Employers need to understand an increasingly complex landscape and be capable of deconstructing their healthcare spend.  Ignorance literally is costing you money. A higher MQ requires knowledge of: every insurer’s product plan design options, population health management programs, utilization data analytics options, predictive modeling tools that can forecast future utilization trends, options to identify high risk and at risk insureds through biometric testing, clinical outreach programs intended to stimulate engagement, state and federal legislative trends and more cost effective risk financing options such as self insurance. If you have a low MQ, the odds are you are probably paying too much for your risk transfer (insurance) and not enough time on understanding your claims.

The good news is that a low MQ is treatable and that sophisticated solutions are no longer the exclusive domain of the larger employer. In an industry crowded with advisors, there are no bad students, only bad teachers. A good teacher pushes their student out of their comfort zone.  In healthcare, a strong advisor forces an employer to understand the difference between change and disruption. For most mid-sized employers, the MQ resources required to properly understand and manage costs do not have to exist within your own organization. They can reside with other knowledge workers – your insurer, your broker/consultant, and third-party vendors who specialize in managing health risk. However, each year, your own understanding of your costs and the industry should be improving. In the end, the investment you make to understand your own corporate health will be paid back through the significant dividends of lower average medical costs and a greater sense of control in a turbulent market.

Answer key and explanation:

1. b Value based designs are intended to improve compliance for at risk and chronically ill employees to ensure stability in those populations and prevent higher rates of catastrophic illness arising out of unstable conditions. A Safeway study revealed a staggering 55% of diagnosed diabetic employees not complying with recommended courses of treatment. Value based designs eliminate financial barriers to care for specific conditions and help remove excuses for chronically ill to remain compliant.

2. a Contrary to those who might use ADA and HIPAA as a reason to not engage in wellness, the legislation affords employers more than enough latitude to gather biometric data through a third party ( you cannot do it yourself ),  warehouse aggregated population data through a third-party vendor and evaluate health risk profiles and trends to better understand how to impact your population’s health. You can target smoking cessation, obesity, and a range of lifestyle based behaviors that can give rise to catastrophic or acute episodic claims. This data coupled with additional information gathered through claims reviews and health risk assessments can aid any employer in better structuring incentives for employees to improve health status.

3. a2, b1, c4, d5, e3 Most employers have no line of sight on the risks that exist within their specific population. Many of these risks arise out of modifiable behaviors. An alarming number of catastrophic claimants had not filed a claim in the preceding 24 months prior leading up to their event suggesting that they were not under a physician’s care, not compliant with basic preventive services and/or asymptomatically ill but had not seen a physician in the prior 24 months. An alarming 40% of men over 40 years of age have not seen a primary care provider in the last 24 months.

4. c In 2010, medical trend increases for engaged employers tracked a full 10% less than those of their less committed peers. To put this in perspective, calculate your total medical spend in 2010 for claims and administrative expenses. Now reduce that by 10%. Is this 10% dollar savings worth it to you to begin the process of improving your MQ?

5. a4, b1, c2, d3 As government begins to cut back reimbursements for Medicare and Medicaid, cost shifting to the uninsured and commercial insurance will accelerate. Once the uninsured are covered under PPACA in 2014, employers over 50 lives will be vulnerable to cost shifting and will need to understand the implications of this commercial pricing shift to avoid subsidizing the major shifts in healthcare reimbursement

6. a1, b2, c4, d3 Employers need to understand where services are being delivered to employees. A simple access shift such as reducing emergency room visits, expanding the use of primary care providers, using soft steerage techniques to guide employees to lower cost, equal quality outpatient care centers can save as much as 15% of one’s medical spend. This savings could be equivalent to the entire administrative spend an employer may make in a year! Loss control and financial management begin with understanding where care is most cost effectively delivered and creating incentives to access the system through these points of entry.

7. b Most employers do not realize the difference in pricing for the same procedures within their own preferred provider network. There is a significant cost an employer bears by insisting on the broadest networks and open access PPOs. Insurer negotiated fee for service discounts do not eliminate the significant variability in charges from one hospital or provider to another. Employers must possess better consumer engagement tools and create financial incentives for people to choose higher quality, lower cost providers or you will end up paying dearly for the cost of your ignorance.

8. d Sadly, health insurance exchanges will not offer significant flexibility or reduced premiums to employers over 50 employees in 2014. In many states, exchanges will not even be available until 2017 for larger employers. The exchanges will be required to engage tight community rating rules limiting the benefits an engaged employer might receive over a less healthy employer. Additionally, a surge in previously uninsured participants covered under expanded Medicaid coverage could lead to a less than desirable risk pool as chronically ill individuals, now covered under Medicaid, seek care through emergency rooms – unable to find providers willing to accept Medicaid.

Regulators will work to control proposed insurer increases with price controls on renewals but these will only serve as stop-gap measures. Employers with over 50 covered insureds need to understand reform was designed to expand coverage for the uninsured and to facilitate aggregated purchasing for individuals and small employers. As insurers lose the ability to make higher margins on smaller business, costs will move to insured employers over 50 lives who will continue to procure healthcare outside exchanges.

9. e Minimum Loss Ratios will be calculated by each insurer – by license and by line of business in each state. Employers may still experience low loss ratios but be underwritten in such a manner that they may receive higher rate increases. Pooled insurance will continue to cost shift from bad risks to good risks. This will drive smaller employers to begin to consider self funding risks to avoid state mandates, premium taxes, insured pooled underwriting cost shifting and limited line of sight on one’s own claims experience.

17-20 points – Valedictorian – You understand the issues. You should be achieving low, single digit trends

14-17 points – Honors – You know what you don’t know. Now do something about it

10-14 points – Passing – You still have a lot to learn. Ask for help.

< 10 Points – Remedial  – You may need to repeat another year of high increases

The Goblins Will Get You If You Don’t Watch Out

Image by lanier67 via Flickr

Little Orphan Annie’s come to my house to stay. To wash the cups and saucers up and brush the crumbs away.To shoo the chickens from the porch and dust the hearth and sweep, and make the fire and bake the bread to earn her board and keep. While all us other children, when the supper things is done,we sit around the kitchen fire and has the mostest fun, a listening to the witch tales that Annie tells about and the goblins will get ya if ya don’t watch out!

When the night is dark and scary and the moon is full, and creatures are a flying and the wind goes Whoooooooooo, you better mind your parents and your teachers fond and dear, and cherish them that loves ya, and dry the orphans tearsand help the poor and needy ones that cluster all about, or the goblins will get ya if ya don’t watch out!!!

– James Whitcomb Riley, 1875

Summer is just around the corner – it is a time of endless oceans of daylight falling into purple  shrouded twilights  filled with tales of the unexpected.  It was on these warm summer nights, that my brothers and I would camp in backyard “tents” of blankets anchored by ropes and lawn furniture.  We would lay motionless – adolescent grunions on the edge of a shoreline of weak light that ebbed from the windows of our back porch – telling ghost stories.

I loathed and loved my older brother’s perpetually embellished tale of the young couple stranded in their car, while their radio warned of a psychotic killer with a hook for a hand who had managed to escape from a local insane asylum.  It appears that in the 1960’s security was extremely lax at hospitals for the criminally insane.  As well, it seemed that every town had an asylum – along with supermarket, laundry mat and diner.  And what about the hospital’s choice of prosthetics? Could you at least replace a psychopath’s razor sharp hook with a rubber thumb or feather duster?  Not! Alas, the macabre tale  always concluded in some shockingly improbable ironic twist and was punctuated with the shrieking of a girl who turned one last time to catch the sight of her disemboweled boyfriend.

My all-time favorite was a highly politically incorrect story aptly named, “Clubfoot Tom “. Tom was a downed WWII German pilot who had become horribly disfigured when his plane crashed while on a secret bombing run over Los Angeles ( yes, Los Angeles.  My brother failed history ).  He was 6′ 8″ tall with burns over 99% of his body.  After pulling himself from the flaming wreck, Tom lived off small animals and eventually children who would stray too far from their campgrounds.  Tom’s victims would first detect a sort of dragging noise ( footstep – dragging sound.  Footstep – drag ) in the near darkness.  Perhaps one might even hear a deep feral grunt just moments before a massive scarred monster struck with surprising quickness out of the corner of your eye.

Years later I would question several elements of the timeless Aryan cannibal. Just how does a 6’8″ man qualify as a Stuka pilot? What were the Germans bombing in Los Angeles? How come the police never caught the creature – a 6’8″ mass of scar tissue and fingernails is hard to miss. My brother would shake his head and smile sardonically.  He would have made a great politician.  He had a frustratingly impossible to verify answer for everything.  “You’re such an idiot.  The Germans were creating the master race.  Their engineers could make everything. They measured the cockpit of the wreckage and determined the man who occupied it must be at LEAST 6′ 8″.  The Germans were bombing Disneyland as the US was secretly building nuclear bombs underneath the amusement park ( Disney did not open until 1960 ).  As to your most preposterous question, they still have not caught Bigfoot and he probably has an entire family in the forest.” He would stare at me with derision.

One fact was irrefutable  Clubfoot Tom was a cannibal and German and everyone brought up on WWII movies knew Germans ate babies and committed acts of atrocity for sport. Each summer, there were endless permutations of Tom’s havoc, horror and misery.  However,  each curious case would always conclude in the same manner, “…and the last they saw Tom was somewhere right-around- HERE!” This would always be followed by excruciating silence and an almost inaudibly whispered question from the most frightened among us, “is-that-story-true? “  My brother would nod slowly, sadistically turning off his flashlight leaving us only with the seeds of the supernatural and our pregnant imaginations.

The night became eight hours of endless terror.  A squirrel became a sociopathic clown intent on killing 8 year old boys. A cat jumping into the adjacent ivy was the advance guard of a legion of shapeless pitch black goblins. On these evenings, I made it a habit to never drink water ‘lest biology force me to sprint past Club Foot Tom who was most likely lurking in the hydrangeas.  Dawn was a governor’s death row reprieve.  With the sun, an unknown neuorchemical was released in our brains melting the midnight phantoms into morning dew. The next camp out, we would beg for another story.

Years later, I would pay forward my brother’s gifts to my campers as a counselor at YMCA camp in Mammoth Lakes, California. Ok, so there were a few complaints  from parents whose kids came home wanting to sleep with them until they were 18 years old. And yes, to this day, I am still getting in trouble with my wife and other parents when this latest generation of fear junkies beg me for a scary story.  I am certain a psychologist would have a Freudian field day with my adolescent phantasms, but come on, we live in a region rich in legends of spooks, goblins, witches, ghostly apparitions and haunted woods.  A kid growing up in New England needs a regular meal of Washington Irving and Salem Witch Trials spiced with tales of an insane local “Leatherman” ( those hides were not made from deer ) and haunted Indian spirits like the Wendigo an evil spirit the native Americans believed was created whenever a human being resorted to cannibalism.

There are many who have consciously avoided horror movies their entire lives. There are those pacifists who feels Bambi was given too liberal a rating, ( the forest fire scene was terrifying ) and regularly convey deep disapproval of scary stories in a manner that only those who are married and live in the state of disapproval can understand.  (By the way, the state of disapproval is the 51st state in the US.  It has no area code or zip code but it is the largest contiguous land mass in the continental US.  All husbands pass through this place while some have taken up permanent residence.)  It is here that we tell stories to children that scare them into Sunday and where we get chastised for our prehistoric preoccupation with disappearances, murders and grisly discoveries – – all wrapped in a blood stained thick brown wrapper.

Scary stories served useful purposes since the dawn of time.  Most phantasms were invented by authority figures wanting to keep their children from doing something  dangerous.   In England, the green decomposing water faerie, Peg Prowler swam the edges of rivers and lakes, looking to snatch the ankle of a reckless child standing too close to the water’s edge.  Redcaps, who dipped their caps in human blood were found near dark forests, abandoned huts and caves.  The native Americans had good and evil spirits competing for the hearts and minds of children nestled shoulder to shoulder in long houses and lodges.  The greatest story tellers focused less on mayhem and more on metaphor to surgically embed a social guardrail into the brains of their wide-eyed audience.  Perhaps some of us enjoy seeing them squirm a little too much. However, the ghost story is an important stimulant to a child’s imagination.  It helps us to keep our strange mythology alive and to counteract a modern day adolescent digital mind stunted by graphic gratification, electronic realism and politically correct resolution that ensures nothing remains unexplained.

Lets face it.  The real world is scary enough. Clubfoot Tom has become the monster of public debt and the specter of hyperinflation.  The insane asylum escapee is now an ideological terrorist or a faceless pandemic.  I want to hide under my bed just thinking about all these crazy, non negotiable threats that loom out there beyond my control. Personally, I prefer the old stories where there was a sort of implied social contract with the cosmos.  If you followed the rules and you did what you were told, you just might make it out alive.   Don’t talk back to your elders, do your chores and go to church.  Kids who kept their wits about them always seemed to find a way through the scary places.

And remember –  bad things can happen to people and the goblins will get you if you don’t watch out.