As health-care benefits
become more varied and complex, employers face the challenge
of creating order out of chaos for the workers who will use them
.Gone are the days when the employer offered a single plan that
typically was a simple fee-for-service arrangement.
Today, employees are
faced with the daunting task of choosing from an assortment of
health-care options and making some sense out of their decision.
Too often, this latter challenge surfaces when the employee needs
immediate health care - when questions and concerns must be addressed.
While health maintenance
organizations (HMOs) may offer support services to plan participants,
"many don't promote these services, nor do they track their
use or results," says Paul Alvarez, national director of
business development at Golden, Colo. - based Health Decisions,
which develops and supports a range of health information, referral
and nurse-counseling services.
Recognizing the growing
complexity of health-care benefits and the proportional confusion
it has engendered within the workforce, employers are now taking
matters into their own hands through expanded education programs,
employee-friendly benefits brochures and by posting benefits
information on intranets. Some are partnering with companies
such as Health Decisions to empower workers to make the best
and most efficient use of their health benefits.
"If you step
back and look at benefit plans before - the extent of the employer's
involvement would be to issue an insurance card, and the employee
knew that if he went to the doctor, the plan would pay 80 percent.
Now it's so much more sophisticated," says Michael Millenson,
a principal with the Health Care and Group Benefits Practice
in the Chicago office of William M. Mercer Inc.
"Health plans
are very confusing - employees need help," he says.
Alvarez concurs, saying
that as a greater portion of health-care costs are borne by employees,
companies must give them effective tools to realize the greatest
return on their health-care investments.
Enhancing
Appreciation
Opportunity and obligation
are the two primary drivers behind employers' growing attention
to their health-care benefits and how they fare with employees,
says Mary Case, principal at the Kwasha Lipton Group of Coopers
& Lybrand in Fort Lee, N.J.
According to Case,
many companies see an opportunity to enhance employee appreciation
of their benefits programs by offering assistance in the areas
of choice, information and access. Others are responding because
benefits problems can threaten morale.
Case says many companies
are adopting communications strategies which present their health
benefits programs through real-life scenarios rather than through
cut-and-dry benefits descriptions.
Employees are also
receiving enrollment assistance through modeling programs, which
provide a quick review of fixed and variable costs, such as claims,
and assume certain benefit use to make projections. Modeling
programs, says Case, are particularly helpful to employees wrestling
with several plan choices.
Dave Fortosis, who
heads the health-care practice in the Chicago office of Hewitt
Associates, says a growing number of companies use managed-care
plan "report cards," which are made available to employees
at enrollment. The areas frequently evaluated are preventive
care, medical and surgical success rates, women's health access
and patient satisfaction, Fortosis says.
While the report cards
help workers gain information, Fortosis says it is the employers
that often know very little about their workers' health-care
plans, especially in instances where plans have been acquired
over time through the decisions of different HR executives.
This shortcoming has
prompted the employers to "go out of their way to measure
performance and to share this information [with employees] early
on," he says.
But companies aren't
just helping employees make informed benefits choices. They are
also adding services to respond to needs beyond enrollment, says
Monica Jerussi, also a principal at the Kwasha Lipton Group's
Fort Lee Office.
Jerussi says employers
are making a variety of reference materials that offer benefit
plan guidance available when a "life event" - such
as marriage or a birth - signals change.
Other developments
for employees include maintaining up-to-date online provider
directories; providing 24-hour nurse hot lines; folding the long
list of health-care telephone numbers into one toll-free number
for benefits information; and creating a centralized benefits
customer service function, say Jerussi and Case.
Outsourced
Help
In recent years, several
companies have emerged that offer services to midsize employers
hoping to foster employees' understanding of their health-care
benefits, experts say.
Benefits Access Inc.,
a Hartford, Conn.-based wholly owned subsidiary of CIGNA, offers
integrated benefits counseling and administration services to
CIGNA and non-CIGNA insured companies with 1,000 to 10,000 employees.
The mission of the
company is to help its clients' employees use their benefits
plans and get the most value from them, says Ricky Swaye, president.
"The choices
and complexities of today's insurance and financial options have
left many consumers, who buy employee benefits at their company,
lacking the needed information to effectively access their benefits,"
says Swaye. "Many large employers have the staff and resources
in place to help employees use their benefits. Now, midsize companies
have the opportunity to benefit from that experience."
According to Swaye,
Benefits Access provides employees and their families guidance
via specially trained Benefits Access counselors on how to best
use company benefits. They also provide assistance in resolving
claim disputes.
The service covers
all the benefits plans a company offers to its employees, says
Swaye. "[We] help them with some of the most misunderstood
benefits options, such as covered medical services, when they
most need them."
According to Swaye,
75 percent of the activity reported by Benefits Access involves
issues surrounding medical benefits. He says this enables his
company to play a critical role in helping the employee, while
also providing essential feedback to the employer.
Feedback and the desire
for improved technology to meet employees' benefits information
needs brought Bally Total Fitness to Benefits Access, says Lois
Balodis, assistant vice president of administration at its Chicago
office. The commercial operator of fitness centers, which has
320 facilities around the country, faced the challenge of ensuring
that the small but widespread groups of employees had access
to quick and reliable benefits information.
"It was virtually
impossible to have someone on site at each facility who has the
[benefits] expertise," says Balodis.
Prior to contracting
with Benefits Access, Bally Total Fitness had a benefits inquiry
voice-mail procedure, which guaranteed a response within 24 hours.
But the company soon recognized that pressing benefits questions
- those which can potentially rob someone of a night's sleep
- needed to be answered immediately.
A customer since July
1997, Bally Total Fitness now has the technological capability
of providing its employees with real-time responses, in addition
to up-to-date benefits information.
"Bally expects
this new counseling service to help streamline support service
to our widely dispersed employees by providing access to a single
800 number for all the benefits plans we offer," Balodis
says. She stresses that "communication is the key word -
employees have to understand their benefits to appreciate them,
and they have to know how to get the answers to the questions
they have."
Posture
Changes
While benefits consultants
say companies genuinely want to make their employees' lives easier
in regard to health-care issues, there is no denying that the
implications of angry, and potentially litigious, employees are
also driving their actions.
"The momentum
has been building up over the last several years," says
Vincent M. Riccardi, founder and president of American Medical
Consumers (AMC), a LaCrescenta, Calif.-based for- profit organization
that counsels consumers on provider choice and various treatment
issues.
"Every week you
see articles in the newspapers and television spots detailing
problems with health benefits and access to health care - it's
cumulative and the [negative] perception is here to stay,"
he says.
Riccardi believes
that to a certain extent, the medical community and health benefits
providers have fueled the fire by not facing problems head on.
"There is a reluctance
in medicine to see a complaint as a legitimate complaint. But
the instant a complaint is [formally] lodged, they see the potential
for litigation and all of a sudden postures change."
Similarly, Riccardi
says benefits providers tend to minimize problems - citing as
a glaring example one provider that removed the work "complaint"
from its lexicon, instead calling such occurrences "member
perception reports."
"If it's a complaint
- let's talk about it," says Riccardi. Among the services
AMC offers are consumer advocacy through coaching and tutoring;
reviews of medical records to advise on how to pursue potential
areas of dispute; and assistance in constructing and maintaining
a personal medical record.
Since becoming operational
in December 1995, AMC has logged more than 910 inquiries, of
which more than 750 involved a provider or treatment-related
problem. Riccardi, who plans to expand his services to employers,
likens his company's role to that of a personal trainer. AMC
helps the consumer build muscle through education and resources
to know and protect their rights as medical consumers,
According to Riccardi,
employers who are willing to provide such resources to their
employees - empowering them to resolve health benefits problems
before they mushroom - are likely to see positive results.
Lon Records, president
of Target Specialty Products, a wholesale distributor of specialty
agricultural chemicals in Santa Fe Springs, Calif., concurs saying
employees are looking for someone who doesn't have a vested interest
in the outcome to help them sort out health-care issues.
Records says capitation
and the attending pressures it creates are "driving a wedge"
between many key relationships within the health-care industry
- among them doctors and patients, doctors and health-care plans
and patients and hospitals.
"I was disappointed
with the health care being provided to our employees in some
instances," says Records, whose company employs more than
100 people at six branch locations.
"I didn't have
the time to put on the pressure [for improved service]. I'd been
searching for a long time to find someone to help sort these
things out - to be in the employees' corner."
That search led Records
to Care Counsel, a San Rafael, Calif.-based vendor of health-care
assistance programs. Lawrence N. Gelb, president and CEO of Care
Counsel, says the company offers telephone-based services which
provide help in health plan choice; coaching so employees take
a more assertive role in the health-care system; employee advocacy
for those needing a liaison to resolve issues with medical providers;
and access for employees to use their health-care plan's resources.
Gelb is confident
that more and more employers will embrace the advocacy concept
within the context of their health benefits plans.
"Now is the time,"
says Gelb. "There continues to be tremendous media attention
to issues related to benefits and managed care. We are seeing
a lot of service problems out there, and everybody is looking
for a single source to resolve their problems."
Rick Gulley, Care
Counsel's vice chairman who is responsible for employee benefits
at Robert F. Driver Co. Inc., a large San Diego-based insurance
brokerage firm, sees his firm as the employer's ombudsman, who
advocates for the employee.
While Gulley says
brokers and third-party payers often try to provide similar services
to health- care plan participants, most either lack the "skill
sets" to be effective or are hampered with unresolvable
conflicts of interest.
Employers, he continues,
must explore products to enable their employees to successfully
navigate their health plans.
The bottom line to
the employer, agrees Kwasha Lipton's Case, is that a health-care
benefit is only as good as the employees think it is.
"If you haven't
designed your programs so people can appreciate them, you haven't
gotten much for a very large investment," she says.
"The company
that spends millions of dollars on health-care benefits which
end up making employees unhappy has not spent its money wisely.
