Disability, absence and the health reform era

The total cost of employee absence for many employers is high, and the correlation between employee health and disability is clear. This article reviews several challenges employers face in managing employee health and absence in a well-integrated manner. Although such an undertaking is not easy, the additional cost national health care reform may bring makes the interrelationship between employer profitability and employee absence, health and disability more crucial than ever for employers to recognize and manage.     

The Effects of Offering Health Plan Choice Within Employment-Based Purchasing Groups

Employers may offer employees a choice of health plans either to promote competition among plans or to better cater to employee preferences for different types of products. This article examines whether the relationship between the availability of choice and insurance costs and coverage are consistent with these models of employer behavior. The results indicate that employers who offer choice have lower average premiums, primarily because employees are enrolled in less generous plans, and cover a greater proportion of workers than those who do not. The results are consistent with employers offering choice to accommodate diverse worker preferences.     

Spillover effects of increased health insurance enrollment on workers’ compensation insurance

The Patient Protection and Affordable Care Act (ACA) was designed to increase the accessibility and affordability of health insurance. While the ACA did not contain direct provisions related to workers’ compensation (WC), because health‐related coverage is a significant portion of WC costs, the ACA could have unintentionally impacted the WC market. Specifically, expanded health insurance enrollment could reduce WC losses and result in higher performance among insurers participating in the WC market. Using insurer‐state level data, we consider the impact of increased health insurance enrollment on the performance of property‐casualty (PC) insurers. Utilizing multiple measures of performance, we find that the post‐ACA period is generally associated with greater profitability for PC insurers operating in the WC market, a positive unintended consequence of this federal regulation.     

Why Are Managed Care Plans Less Expensive: Risk Selection,Utilization, or Reimbursement?

This article develops a new method of decomposing the cost difference between HMO and non‐HMO plans into observed risk selection, unobserved risk selection, utilization differences, and differences in provider reimbursement rates. We implement this method using a large national sample of employer‐sponsored health insurance enrollees from the Community Tracking Study Household Survey. We find no evidence that HMO plans attract a disproportionate share of low‐risk enrollees; the US$188 difference between HMO and non‐HMO medical expenditures per enrollee can be explained by the relatively low provider reimbursement rates paid by HMO plans. This indicates there may be little need for employers to risk adjust insurance premiums or otherwise restrict employee choice of plan types.     

Limiting the ACA's Threats to Small Group Health Insurance Markets

We identify three threats to small group health insurance markets that may result from the 2014 implementation of certain provisions in the Affordable Care Act (ACA). First, small employers with predominantly low‐income employees may tend to opt out of small group markets because their employees will be better off with subsidized individual coverage. Second, small employers with employees of heterogeneous income levels will have strong incentives to offer coverage that is either “unaffordable” or fails to provide “minimum value” in order to preserve the availability of government subsidies for their low‐income employees. Finally, small employers that continue to offer group plans will face increased incentives to self‐insure those plans, further contracting small group markets and subjecting them to adverse selection. Collectively, these forces may destabilize small group markets and increase the ACA's fiscal cost. We therefore conclude by offering various reforms aimed at offsetting these risks and preserving the viability of small group markets.     

Spousal surcharge programs--an overview

Spousal surcharge programs help employers whose goal is to provide "above-average" health benefit plans by limiting the potential "financial leakage" liabilities from covering the spouses of employees who are eligible for other health care coverage. Spousal surcharge programs are just one alternative available to help employers manage the rising cost of providing health care coverage to dependents. This article explores the prevalence, plan design, financial implications, administrative and other considerations in implementing a spousal surcharge program.     

Who Gets What From Employer Pay or Play Mandates?

Critics of pay or play mandates, borrowing from the large empirical minimum wage literature, argue that they reduce employment. Borrowing from a smaller empirical minimum wage literature, we argue that they also are a blunt instrument for funding health insurance for the working poor. The vast majority of those who benefit from pay or play mandates, which require employers to either provide appropriate health insurance for their workers or pay a flat per hour tax to offset the cost of health care live in families with incomes twice the poverty line or more, and depending on how coverage is determined, the mandate will leave a significant share of the working poor ineligible for such benefits either because their hourly wage rate is too high or they work for smaller exempt firms.     

The Employer's Role in Reforming the U.S. Health Care System

In 2005 large U.S. employers spent an average of almost $7,400 per head on health care benefits, a 73% increase in the last five years. If the current trend continues, American companies may find it difficult to compete in a global marketplace where international competitors provide labor with heath care at a fraction of U.S. costs. This article argues that effective reform of the U.S. health care system will require major efforts from all major “stakeholders,” starting with the federal government and state and local governments and including insurance companies and the “consumers” of health care services. By far the important role, however, is reserved for private‐sector employers, which have been the incubator for recent innovations in American health care and are in the best position to coordinate and drive health care reform. But incremental steps in cost‐sharing, small‐scale pilot projects of consumer‐based designs, and employee awareness campaigns will not be enough. Employers need to take radical steps to break through the inertia that has built up among all stakeholders over the past 50 years. Chief among the author's proposals for employers are the following:

• ? In choosing a health care plan for employees, use value‐based purchasing criteria that consider more than just the price and access to services.
• ? Help consumers by demanding information from providers and insurers about the cost and efficacy of health care services, and of alternative treatments, before the choices are made.
• ? Encourage “consumerism” by setting up benefit plans that have a Health Reimbursement Arrangement (HRA) or a Health Savings Account (HSA) component.

As the author states in closing, “Let these reforms begin with employers as the organizing force to drive needed change across the system. That may very well be the only way to save our employment‐based model.”     

Employer strategies to combat health care plan fraud

Each year health care fraud drains millions of dollars from employer-sponsored health plans. Historically, employers have taken a rather tolerant view of fraud. As the pressure to manage health plan costs increases, however, many employers are beginning to see the detection and prosecution of fraud as an appropriate part of a cost management program. Fraud in medical insurance covers a wide range of activities in terms of cost and sophistication--from misrepresenting information on a claim, to billing for services never rendered, to falsifying the existence of an entire medical organization. To complicate matters, fraudulent activities can emanate from many, many sources. Perpetrators can include employees, dependents or associates of employees, providers and employees of providers--virtually anyone able to make a claim against a plan. This article addresses actions that employers can take to reduce losses from fraud. The first section suggests policy statements and administrative procedures and guidelines that can be used to discourage employee fraud. Section two addresses the most prevalent form of fraud--provider fraud. To combat provider fraud, employers should set corporate guidelines and should enlist the assistance of employees in identifying fraudulent provider activities. Section three suggests ways to improve fraud detection through the claims payment system--often the first line of defense against fraud. Finally, section four discusses the possibility of civil and criminal remedies and reviews the legal theories under which an increasing number of fraud cases have been prosecuted.     

The mental health paradox

The authors review the evidence that mental health coverage pays for itself by reducing overall health care costs, satisfies and helps patients who receive it, reduces employee absenteeism and improves employee functioning. They then explain the factors contributing to the decline in mental health services valuations and what employers can do to minimize them.     

U.S. tax policy and health insurance demand: Can a regressive policy improve welfare?

The U.S. tax policy on health insurance is regressive because it subsidizes only those offered group insurance through their employers, who also tend to have a relatively high income. Moreover, the subsidy takes the form of deductions from the progressive income tax system giving high income earners a larger subsidy. To understand the effect of the policy, we construct a dynamic general equilibrium model with heterogenous agents and an endogenous demand for health insurance. A complete removal of the subsidy may lead to a partial collapse of the group insurance market, reduce the insurance coverage and deteriorate welfare. There is, however, room for improving the coverage and welfare by extending a refundable credit to the individual insurance market.     

Medicaid coverage expansions and liability insurance

Do changes in the population covered by health insurance affect liability insurers, who compensate billions of dollars in medical claims each year? We examine this question by exploiting the selective rollout across states of Medicaid expansions under the Affordable Care Act. Using data on insurer losses across a range of insurance lines, and employing a triple‐difference research design that contrasts states, years, and lines of insurance, we demonstrate that coverage expansions reduce auto liability and workers’ compensation outlays by 6–11 percent, but do not measurably impact other lines of insurance. Our analysis provides some of the first evidence regarding the use of the tort system particularized to the low‐income population and is the first to consider the impacts of health insurance on medical professional liability and commercial auto insurance claims.     

Overcoming Barriers to Life Insurance Coverage: A Behavioral Approach

While life insurance purchase decisions have long been studied, we still do not know how people decide if they need insurance or how much they need. Using in‐depth interviews, we peer into the black box of employee decision making to learn what people know about this employee benefit, and how they decide if it is of value for them. We find that individuals understand the need for life insurance, but find many behavioral economic barriers to getting adequate coverage, including mental accounting, money illusion, and a strong role of defaults. We then conduct an online experiment of the hypothetical employee‐benefit purchase scenario, and find a few, simple interventions could help individuals better decide their life insurance needs.     

The employer's case for health management

Employers' past solutions to rising health benefit costs--adopting managed care strategies, cost shifting to employees and reducing benefits-are no longer effectively controlling costs and are depressing the value of health benefits for employee recruitment and retention. An alternative strategy is to implement health management approaches that improve the health status of employees. These programs reduce medical costs and have a documented positive impact on workers' compensation, disability costs, absenteeism and productivity. Further, this approach is complementary to health care consumerism as a strategy for health improvement and benefit cost reduction and results in improved employee health, outlook and satisfaction.     

A review of ethical considerations in benefits planning

The rising cost of employee benefits and ongoing pressure to improve existing benefits is forcing employers to make difficult decisions. Most employers are truly concerned about the welfare of their employees and attempt to make these decisions in an ethical manner. This article offers practical advice on maintaining an ethical perspective, which the authors contend is necessary to maintain when facing these challenging responsibilities. The article identifies the various stakeholders as well as the necessary steps to consider when attempting to make an ethically sound decision involving employee benefits.     

Controlling human capital costs in the new millennium

Low productivity and high turnover can be more costly to employers than insurance premiums and medical claims. This article discusses the need for coordinated management of all behavioral health benefits. It provides two case studies that illustrate how such coordination can avert possible long-term costs and loss of a valued employee.     

Health care consumerism: engaging the real buyers--employees

Many employers have begun moving toward health care consumerism strategies designed to encourage employees to take more responsibility for their health care and the cost of that care. Recent surveys suggest ways employers can ensure their consumerism strategies succeed in engaging employees and, ultimately, encourage employees to change their behavior. This article describes what those surveys reveal about employer and employee perspectives on consumerism and suggests steps employers can take to align their interests with those of their employees in order to manage the demand for and use of health care.     

Health Insurance Choice with Flexible Spending Accounts

I model the interaction of flexible spending accounts (FSAs) and conventional insurance. I show that FSA participation reduces the desired level of insurance coverage. I also show that FSA participation can reduce the total tax cost of health insurance premium and FSA contribution exclusions.     

“Understanding Relationships Using Copulas,” by Edward Frees and Emiliano Valdez,January 1998

Presenteeism occurs when employees are present at the workplace but cannot perform at their best because of ill-health or other reasons, while absenteeism occurs when employees are absent from the workplace. Although absenteeism is important, researchers now say presenteeism can be more costly to businesses and may be responsible for as much as three times the health-related lost productivity as compared to absenteeism and may cost the U.S. economy as much as $150 billion per year. Given the cost of absenteeism and presenteeism, one of the objectives of this article is to provide actuaries with the techniques and insights needed to design disability insurance policies that take into account the dynamics of absenteeism and presenteeism. To this end we develop a simple multistate sickness-disability model of the evolution of an employee’s health over time. We assume employees receive sick pay, the size of which depends on their health state, and there is a government-sponsored unemployment insurance program. In our model it is possible for employees in good health to avoid work by staying home, which is called shirking. To reduce shirking, the employer decides to check the health status of a certain percentage of employees who “call in sick.” Given the sick-pay structure, the probability of a health check, and the existence of unemployment insurance, employees develop rational strategies about whether to engage in shirking, absenteeism, or presenteeism. These strategies are captured in a set of Volterra integral equations. We use these Volterra integral equations to show how the employer can design a disability insurance plan that can incentivise employees to eliminate shirking and to act in a manner that will maximize the employer’s expected profits.     

The consumer-driven approach: defining and measuring success

Employers' reluctance to implement consumer-driven health plans (CDHPs) is at least in part due to their not understanding how to define and measure the success of CDHPs. To assist employers, the authors define potential points of success for CDHPs in the areas of consumer engagement, consumer financial considerations and employee health and productivity. They then offer ways of measuring success in those areas, as well as in the area of employer cost control. By taking a carefully considered approach to the decision of whether to offer a CDHP, employers can grasp potential opportunities to control health care costs.