Does Your Employer Want to Manage Your Chronic Care?
Some offer financial rewards if you let them be your doctor:
The Good:
Let’s say you work for Pitney Bowes. If you need regular medication as part of your condition, the company makes an exception to its normal three-tier system — 10 percent of the drug’s cost for generics, 30 percent for preferred drugs and 50 percent for nonpreferred. Those with chronic conditions would pay the lowest copay, 10 percent, even if the drug is classified as nonpreferred.
The Bad:
Along with carrots, there may be sticks. Quad/Graphics offers a zero copay on drugs for people with diabetes enrolled in its chronic care program. (Participants saved an average of $540 last year.) But employees who stop participating in the plan go back to paying regular copays…
The Ugly:
Employees must buy into the programs for them to work. Often they do not. Entrenched habits that contribute to a chronic illness — lack of exercise, poor diet, little sleep — can be hard to break. Many patients stop taking their prescriptions. “I’d say less than a third, maybe even a fifth, of the people who these programs are targeted for actually comply,” said Dr. Levine.
How about letting the employee manage his own care?
Ken, what a novel idea! I think you have to be on the outside of the health policy community in order to think of things like that.
If we’re happy to let our employer buy our care, then we should be happy for our employer to meddle in the way our care is received. I’m always amazed that compliance is such a big deal. Why is it so hard to do the right thing, especially when the consequences are so bad?
Virginia, I think “meddle” is the right word. And I am afraid there is going to be a lot more meddling in the future.
Isn’t there some kind of adage that says, he who pays the piper …. Why is that so hard for people to understand?
My health, my privacy, my decision. As Nancy Reagan once said, “Just say NO!”
There was an article a year ago in the Boston Globe about Scotts (the lawn care company) that, in 2005, began a policy of excluding new job applicants that smoked. While still on probation, one employee was caught by a urinalysis and fired. He sued and the judge sided with the employer.
I don’t like the idea of employers telling workers they cannot smoke off the job. But I also imagine Scotts got tire of paying for bad behavior. That is why we need personal & portable health coverage.
You would think that medication compliance would be an easy thing. The fact is that it’s not. All the evidence is that people aren’t very rational.
If you’ve had a stroke, daily Coumadin reduces the chance of a second one from about 24% to about 3%. You would think that a stroke patient would be very highly motivated to take their daily pill. Despite that, compliance is very low.
They did a very interesting set of behavioral economics experiments on Coumadin compliance. They tried paying you every day you took your medication, that didn’t work very well. They tried paying you in advance for several days but imposing a fine for every day you didn’t take your medication, that was more effective. The most effective way to raise compliance was with a lottery. Every day, you have a chance to win a certain amount of money. But, you don’t get the money if you didn’t take your dose that day.
@artk
I wonder if the reporting requirements related to proving the pills were taking each day wouldn’t contribute to people not taking their pills.
I can take my pill, and that is one irritation. Following whatever mechanisms are necessary to prove that I took it is another discrete action, and consequently another irritation.
It would make gathering reliable compliance statistics a nightmare.
Compliance is not always easy. For example, Coumadin has side effects. There are lots of drug interactions to worry about. People taking Coumadin have to have regular blood tests. They have to watch their intake of vitamin K and alcohol.
And how is compliance determined? Is someone going to watch every patient take every dose?
Devon,
The employee is wrong in this case if it was disclosed upfront that the employer was hiring non-smoking employees only. If the employee did not like that policy, he could find work elsewhere.
Unfortunately, the employee committed fraud by lying about his smoking habit to his employer and was fired for it.
Instead of acknowledging his personal responsibility in this matter the now ex-employee wasted the courts time. This had nothing to do with insurance portability; fraud maybe?
Linda, ThomasL: Compliance measurement was actually very simple. The used an internet enabled pill box that detected every time a pill was removed. I don’t remember who did the study, it could have been Kevin Volpp or George Loewenstein or Dan Ariely.
So, I get a lottery ticket every time someone removes a pill from a box? Sounds good.
Now, how do you determine that I’ve swallowed it or even that I was the one who removed it? Do I still get my meds if the internet is down or I’m somewhere where there isn’t any internet?
Judging from what you say they measured pills withdrawn from boxes.
Maybe I could train my dog…
Personal and portable healthcare coverage is the answer. Costs would be driven down by an informed consumer who is responsible for payment of the premiums and the payments to the medical entity. Comparison shopping would abound and the free market would reign. No one ever expects their employer to provide auto insurance and here in Texas it is the law. I am amazed that people expect their employer or their government to supply their health insurance.
Well Linda, if your somewhere where there isn’t any internet, than your evil twin posted your last response. Once you’re removed to pill from the box, it pretty damn certain you’ve taken the pill. You should do a little reading in behavioral economics, they have made some interesting finding. The did one test on placebos and electric shocks. Did you know that the more expensive the placebo, the better it acted as a painkiller. That might be the lesson of our health care system, spending more makes us believe it’s better.
Today’s postings included an article about an AIDS patient who fills his prescriptions regularly, takes his meds irregularly, and sells the excess meds on the black market. This suggests that it is by no means certain that people who have the pills take the pills.
As for the claim that more spending makes us falsely believe that health care is better or more effective when it isn’t, I suggest trying placebo birth control pills or placebo dialysis.
@Linda
You make an excellent last point. I wonder if, rather than a “mind-over-matter” kind of explanation most people offer for the placebo effect there is not another equally valid possibility — that some categories of malady are basically no big deal, ie to the extent that they exist they can be ignored if one chooses to do so.
If one can consistently point to where the placebo is wonderful at fixing X, maybe X is not so much a real-world problem.
Placebo dialysis, as you say, doesn’t get you so far.
I have a more than nagging suspicion that much of the art of medicine is prescribing real pills to cure imaginary diseases.
I have no hope that will change with central control. That is something that thrives under third-party payment.
Marlynn,
“Personal and portable healthcare coverage is the answer.”
If you mean Individual Family Plans? They already exist. You do not have to buy your employers group policy as long as you don’t have a pre-existing condition. The difference is the underwriting associated with both plans. Group Plans are guaranteed issue while Individual Plans are underwritten. Underwriting is to avoid adverse selection which means if you are sick you do not get coverage. So it is the insurance companies who are pushing people onto Group Plans. Not employees expecting coverage from their employer as IFP’s are cheaper.