As costs rise, employers seek more active role in health care system

Aetna is in the health insurance business, but as an employer, it’s not immune to the rising costs of health care.

So the company uses wellness programs to encourage its workers to improve their health and health plans designed to make them more aware of the costs. Employees pay less for medications to treat chronic diseases than they would for other drugs. Nonsmokers get a discount on their health insurance premiums, and smokers who quit get the lower rate as soon as they do. In the cafeteria, the healthy foods are cheaper than the burgers and fries.

With health care costs increasing at an unsustainable rate, programs to keep workers healthy represent critical investments that require the commitment of top executives, Aetna Chairman Ronald A. Williams told business leaders in New Haven.

“Health and wellness have to become, ultimately, the business of the business itself,” Williams said in a speech titled “The Business Imperative for Wellness.”

Williams spoke at a meeting of the Connecticut Business Group on Health, a 10-month-old organization created to give employers a larger voice on health care issues, including delivery system changes and other ways to improve the quality and cost of care.

While the federal government has been using Medicare payment rates to push changes in how health care is delivered, employers remain the major source of health care coverage in the United States. “We ought to have a voice,” said Lori Pasqualini, president of the business group and chief financial and administrative officer at Ability Beyond Disability.

Large companies that pay their own medical claims can influence health care usage and costs through the design of their health plans–charging workers less for medications that will prevent more costly problems, for example, or paying health care providers to counsel parents about nutrition to prevent childhood obesity.

But smaller employers also can influence the health of their workers through wellness programs, officials from Northeast Utilities, Sacred Heart University, American Institute for Foreign Study and other employers said.

Proponents of the programs say offering workers incentives to take health risk assessments, quit smoking, exercise and get appropriate screenings and preventive care can cut both direct health care costs and indirect costs that stem from absenteeism and turnover.

Still, implementing them can be a challenge, particularly for smaller companies and those whose leaders don’t want to incur potential start-up costs. Introducing health programs can be particularly complex in industries like manufacturing, where time away from the job means time away from production. Wellness programs must comply with federal nondiscrimination requirements, and legal interpretations of what is permissible are still evolving. And even programs that are working might struggle to get participation from workers who most need to improve their health and from employees’ families.

Williams spoke of the importance of setting the right tone with the program. “The notion is be supportive, don’t be punitive,” he said.

Ultimately, he said, wellness must be part of a company’s culture. At Aetna, employees aren’t expected to run marathons. “But the minute we made it socially permissible on your break simply to get up and walk around the building, people started doing it.”

One Company’s Experience

The “culture of health” is a key concept at Stamford-based Pitney Bowes, one of the companies best known for its health care efforts. The company’s health insurance plans are designed to encourage people to take care of themselves. On-site medical clinics focus on preventing disease and healthy food is prominently displayed in the cafeteria at the company headquarters.

And leaders say it pays off. The company says its per-employee health care costs are between 15 percent and 20 percent below what similar companies spend.

In 1990, the company created a system to collect data from its health plans, pharmaceutical benefits and workers compensation. That allowed officials to identify needs and build programs to address them.

One problem it identified was the prevalence of chronic health conditions–about half the company’s population had at least one. That might sound bad, Dr. Brent Pawlecki, the company’s medical director, said.

“But it wasn’t having the chronic condition which was the problem,” he said. “It was having the chronic health condition and not being on proper therapy or being on proper therapy [and] not being compliant with that therapy.”

So the company began a campaign to encourage people to manage their conditions. One outgrowth was a change in the drug benefits plan aimed at removing barriers to taking medications. Employees at high risk for cardiovascular conditions get statins and ACE inhibitors for free, and all employees pay 10 percent coinsurance for medications that treat conditions including asthma, diabetes, hypertension and osteoporosis–less than they would pay for other drugs.

From 2001, when the drug plan changed, to 2008, the rate of people taking the medications as prescribed for five years rose by 5 percent for hypertension, 7 percent for diabetes, and 42 percent for asthma.

The on-site medical clinics are similarly focused on preventing long-term problems. Employees might visit for a flu shot or a strep test, but the medical staff uses the time as chance to address other potential problems too. If a worker smokes, a nurse practitioner will offer counseling, support services, medication or other programs to help the person quit. During the visit, an employee might reveal she is caring for an ill relative and end up with a referral to an elder care support group the employee assistance program runs.

“It gives you an opportunity to open the door, find out what’s going on with them,” said Patricia Sweet, who manages the company’s Connecticut medical clinics.

Building the healthier culture also required addressing things that undermine health, Pawlecki said, like the “delectable desserts” section in the cafeteria, which used to be located by the check-out counter. Now the sweets are in a less prominent spot and the impulse-buy section is filled with fruit.

The printers, once located by each employee’s desk, are now farther away. Getting the printed documents becomes a built-in stretch break.

There’s even a staircase in the building’s atrium that wasn’t part of the architectural plan. It was added to make skipping the elevator more appealing.

The company estimates that two-thirds of its health care savings come from disease management programs, wellness programs, on-site clinics and enrollees’ health care choices. The rest is the result of value-based purchasing and the benefits plan design.

Pawlecki said he knew the emphasis on health had infiltrated the culture when he overheard a conversation in the cafeteria.

“One person was giving the other a hard time about ordering the cheeseburger and fries and said ‘Hey, you should be over at the salad bar instead,’” he said. “These are the kinds of things that start to get built in and the support network that starts to be built up.”

As a large company, Pitney Bowes has advantages smaller companies do not. But Pawlecki said much of what the wellness programs emphasize can be applied to other employers, like the goals: Zero tobacco use, flossing once a day, eating five fruits and vegetables a day, having a body-mass index of 25 or less, 30 minutes of activity a day, and 100 percent use of seat belts and helmets.

“Those are health behaviors that cost absolutely nothing to do,” he said. “But if people are participating in these types of programs or these kinds of health behaviors, they’re going to prevent many, many health conditions from going on down the road.”