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The Broader Picture on Getting Injured Employees Back to Work

The “good health = lower cost” equation is an oversimplification of reality and needs to be better understood if we’re to address the causes that help drive up costs for workers’comp.

Yes, people with medical problems are generally more expensive to care for than those without the conditions, but consider the studies that found that:

  • Reducing a significant risk factor did not produce lower costs or reduce absences. A successful weight-loss campaign did not produce any cost savings in the next two years, leading the authors to caution against expectations of a positive short-term return on investment.
  • The length of absence because of an injury depends largely on the doctor.  A study found that 3.8% of physicians in Louisiana accounted for 72% of all workers’ compensation costs. Patients who chose—or happened to have treatment from—“cost intensive physicians” could expect to have five times higher costs, even after adjusting for age, sex, medical condition, and other factors.
  • Individual beliefs affect the number of absences for back pain. Workers who have high levels of fear that work will lead to pain are absent more than workers with similar pain severity but low fear.
  • Health improvement alone does not improve return-to-work following extended absence. European researchers found that improved health did not guarantee return to work, especially when certain psychosocial factors—like depression and low self-efficacy— and work factors were present.
  • Companies that self-insure their workers’ compensation benefit have fewer employees who are injured. After controlling for a large variety of other factors, authors concluded that companies that directly manage their experience rating invest more effectively in prevention and reduce injury rates.

In sum: Health improvement may not save money or result in someone coming back to work if: a) they believe their work is harmful; b) they dislike or have conflict at work; or c) they choose a doctor who prefers longer, more expensive treatments.  Finally, a company’s commitment to prevention and safety today is driven in part by the financial risk it carries for injuries tomorrow.

Improving health is a worthy goal in itself, but, for a variety of reasons,cost savings will not be a certain result.

When we oversimplify the problem of health costs, we risk being disappointed when investments in health programs don’t bring the savings we expect. While there is no shortage of calls for programs that promote “health improvement,” that only gets us so far toward any goal of cost containment or absence reduction. Therefore, the right approach must reach beyond a condition-specific focus and provide personal expertise, aligned incentives, education, and support to the whole person and her or his family.

How Much Does Health Care Cost? More Than You Can – or Want – to Imagine

In my mind’s eye, I’ve started imagining U.S. health care spending as the Blob from the 1950s horror movie of the same name: the monstrous mass at the edge of town, consuming everything in its path. It’s expanding before our eyes, oozing all over the economy, threatening our future, and no one knows exactly how to stop it.

The other reason the Blob is a good analogy is that we no longer find it scary when there are many more modern, realistic threats (aliens, viruses, nuclear and chemical weapons) that worry us. The citizens in the movie weren’t frightened either, until it started eating them. So, after having a laugh and dismissing the Blob as a harmless story, imagine some ominous music in the background and a green, sticky substance oozing under your front door.

The Blob of health care spending continues to grow whether we acknowledge it or not. Despite recent news that our cost trend has slowed somewhat in recent years1 2 and hopes that reform will decrease costs (it won’t; early projections from the exchanges are 25% higher)3, health care spending remains one of the greatest threats to our national security and prosperity.

Unfortunately, there is neither political will nor industry incentive to limit the monster’s appetite. It is up to each of us to stop feeding its seemingly unlimited ability to consume budgets. First, let’s remind ourselves how big this monster has become and examine what we give up as a result.

How Big Is It?
The answer is that health care spending is now bigger than we can comprehend. Literally. The number is three trillion dollars per year4. That’s not a number most of us can grasp. One trillion equals one thousand billion. The idea that we are spending many times that number needs examples to understand.

Try this: if you spent $1 million dollars every single day, it would take you over 8,200 years to spend three trillion. Or, if you and 82 friends each spent $1M per day, it would take you collectively 100 years to spend $3 trillion.

Or try this: 3 trillion seconds won’t tick by for over 950 CENTURIES (95,000 years)!

Or: If we blink once every five seconds, it still would take 6,000 people living to 100 years of age to blink 3 trillion times.

More to the point, $3 trillion is almost $10,000 every year for every man, woman and child in the country.

Perhaps the most daunting part is that we spend that much each and every year, and the annual amount has quadrupled since 19905. Plus, health care now supplies one in nine jobs6. That means eight people do everything else, in every other job, in every other industry, for every one job in health care. The ratio is 8:1. Where will the ratio stop? 7:1? 6:1? Or will the Blob keep growing?

Compared To What?
From another perspective, let’s compare our health care spending with that of other countries. We spend 1.5 to 2 times as much of our Gross Domestic Product (GDP) (almost 18%) on health care than other industrialized nations, which average under 10%7. This means the Blob consumes one in every five dollars we spend on everything; a ratio of 4:1, four on everything else, one on health care. Other countries average 9:1. This means other nations can spend more on important investments, while we feed the monster. Even if we achieve a strong future economy, that disadvantage will be difficult to overcome.

Let’s also compare to spending on other national interests. Public medical spending now exceeds our budget for Social Security or Defense8, despite the amazing fact that the U.S. spends more on defense than the next ten highest-spending countries combined9.

Reading, Writing Or Ritalin®?
Most disturbing, the amount our government spends on health care has increased eleven times faster than education spending over the last 50 years, and we now spend 33% more on health care than education (8.2% of GDP versus 6%)10. This hasn’t been a conscious choice to put arrhythmia ahead of arithmetic, but that’s how the Blob works … a slow advance, gobbling up resources. The trade-off may feed the hungry monster today, but at what cost to our global competitiveness in a future labor market? Remember this represents only public spending on health care, ignoring the 40% paid privately.

Entitlements and Interest Are Crowding Out Other Spending

Total Government Healthcare Spending Increases Are Staggering

Each Of Us Feeds The Health Care Blob
Neither government nor medicine will save us from the extreme financial threat of health care. We have to do it ourselves.

Of course medicine (the so-called Medical-Industrial Complex that IS the Blob) will keep telling the public that they need more and better care; another surgery, another medicine, another exam will make us feel better. And of course that message makes us feel cared for and justified in our continued over-use of over-priced services. While someone else pays, we shrug and get another test, just to be on the safe side.

But the battle against the Blob can’t be won by asking the Blob itself to go on a diet, or asking legislators who are sponsored by the Blob to limit its consumption. And, like in the movie, the public doesn’t perceive the magnitude of the threat; until it may be too late.

What will it take to tame the monster? Each of us asking questions, pushing back on the system, objecting to outrageous pricing, and taking care of ourselves. Do your part: feed the Blob a little less this month.

This article was first posted on Altarum.org.

References

1 Ryu AJ, Gibson TB, McKellar MR, Chernew ME. The slowdown in health care spending in 2009-11 reflected factors other than the weak economy and thus may persist. Health Aff (Millwood). 2013;32(5):835-40. Epub 2013/05/08.

2 Cutler DM, Sahni NR. If slow rate of health care spending growth persists, projections may be off by $770 billion. Health Aff (Millwood). 2013;32(5):841-50. Epub 2013/05/08.

3 Hancock J. Maryland Offers Glimpse At Obamacare Insurance Math. Kaiser Health News [Internet]. 2013 May 20, 2013.

4 Munro D. U.S. Healthcare hits $3 trillion. Forbes [Internet]. 2012 May 20, 2013.

5 Hartman M, Martin AB, Benson J, Catlin A. National health spending in 2011: Overall growth remains low, but some payers and services show signs of acceleration. Health Aff (Millwood). 2013;32(1):87-99. Epub 2013/01/09.

6 Altarum Institute. Health Sector Economic Indicator Briefs 2013 May 20, 2013.

7 PBS NewsHour. Health costs: How the U.S. compares with other countries. October 22, 2012.

8 Meeker M. A Basic Summary of America's Financial Statements, February 2011. May 20, 2013.

9 Cory Booker says U.S. military spending is greater than the next 10-12 countries combined. The New Jersey Star-Ledger PolitiFact [Internet]. 2013 May 21, 2013.

10 Meeker M. A Basic Summary of America's Financial Statements, February 2011. May 20, 2013.

Choice In Health Care? A Hassle Worth The Effort

It was almost a miracle, an immediate answer to my question about the cost of an ultrasound.

“$196 including the interpretation, and we price-match if you find a better price somewhere else.”

In my eight years having a health savings account (HSA), clear, immediate information about cost has been extremely rare. Most often, “How much?” provokes the dismissive evasion of “It depends” or irritation, followed by “We have no way of knowing.”

In other instances, office personnel launch into detailed explanations about how deductibles and insurance work in an effort to convince me I don't really need to know. Another tactic is to stall: “A representative can call you with an estimated price in 3-5 days, but it will only be an estimate.” Or the sad response, accompanied by a look of pity, “So you can't afford insurance?”

When I asked a surgeon about the hospital-acquired infection rates in the hospital where he performs his operations, he had the audacity to give an annoyed don't-worry-yourself-about-such-things expression and report that “In my area of the hospital,” patients don't get infections. This contradicted my knowledge that some of his own patients had, in fact, developed infections.

Asking questions about care is a hassle, an inconvenience, and sometimes a frustrating battle against a system unfamiliar with sharing information or control. By tradition, we can't get a test without a doctor's order, we can't receive our own test until the doctor gets it first, we can't know how much things cost, and we can't refill a drug for the 100th time without getting another prescription exactly the same as the first 99.

In an environment built on layers of permission — have the pharmacist call the doctor who can call the insurance company — do-it-yourself requests aren't welcomed. Some providers seem genuinely insulted by requests for information. “How could you question my ________ (fill in the blank with abilities, record, skill, safety, intentions)?”

Choices in health care can be overwhelming. Which treatment? Which doctor? Which hospital? How much should I spend? What metric should I trust? In some ways it was easier when we had strict gatekeepers and coverage that paid for everything. Relying on mother-may-I rules assigns responsibility for everything to someone else, including the bill.

So why make the effort?

First, because 25-30% of the care we receive is unnecessary or could be handled with a less-invasive alternative. When employees of GE are told they need a heart procedure, transplant or back surgery, they have the option of an all-expenses paid trip with a family member to the Cleveland Clinic for a second opinion. In about one-quarter of the cases referred so far, the experts at Cleveland Clinic have determined the procedure isn't their best choice of care1. No matter how nice or qualified one doctor may be, he or she has a specific preference for how to treat a problem. That preference may not be the best option for every patient. Ask for a second opinion, you might get a very different answer.

Second, where we get care can drastically change the outcome. Check on sites like Leapfrog.org, healthgrades.com, or consumer reports and you will find huge differences between hospitals in the likelihood of being harmed by errors in care. As many as forty-thousand patients per day experience an error, such as infections, wrong medications, or falls, many of them life-threatening. At an estimated 180,000 fatal events per year, medical errors are the third-leading cause of death, behind heart disease and cancer2.

What we know is that almost half of all medical errors are preventable through low-cost efforts and policies. Yet, fewer than one-in-five hospitals implements the safety procedures known to work. This is one area where the worst offenders resist transparency, and hope you don't ask. Plus, it seems doctors themselves recommend a hospital based on familiarity, not outcomes3.

The differences are meaningful: go to a top-ranked hospital and you reduce your risk of a mistake by almost half4. If it is not an emergency, do your homework and choose wisely.

Lastly, there are two reasons to be concerned about the cost of care. One is a societal concern: at over 18% of GDP5, health care costs threaten to cripple our economy. Insurers do not choose their networks based on price or quality of care. So, it will be up to payers and consumers to put constraints on spending growth.

If you aren't motivated by the national economy, the second reason is our personal budget. With ever-increasing deductibles, it matters to our own pocketbooks to push back on providers whose prices far exceed others of similar quality. As more and more of us ask about cost and choose based on the best value, more providers will respond.

Perhaps slowly, things are changing.

More of us are inserting ourselves: If I have to pay for this, and it is happening to my body, I should know what it costs and what the results will be. We see self-serve examples like AnyBloodtestNow.com offering blood tests at a known price without having to see the doctor first6. Here's a good idea: bring the cholesterol results to your check-up so you can talk about them without scheduling another follow-up visit.

Also, some facilities, such as the $196-priced group mentioned at the beginning of this blog, are responding to increased price sensitivity by offering an upfront, guaranteed price. At least it eliminates one of the many unknowns we face during a medical episode. As a comparison, another preeminent facility took five days to answer my cost question for a simple ultrasound. The price? $625 for the test, and another $650 for the mandatory visit with one of their doctors. “But,” they said, “we can't be held to this price, it is only an estimate.” As you might guess, I chose the former.

It's not easy getting involved in these choices. I totally empathize and understand those who give up and simply go with the easiest option. My compliments to fellow health care explorers trying to navigate a seemingly endless list of decisions. I admire those who stick with it. It can make a difference.

This article was first posted on Altarum.org.

1 Lynch WD. Personal Communication. 2012.

2 Levine B. The Hospital Harm Factor. Patient Safety, Natural Health Blog [Internet]. 2011; 2012. Available from: http://www.jonbarron.org/article/hospital-harm-factor.

3 Morsi E, Lindenauer PK, Rothberg MB. Primary care physicians' use of publicly reported quality data in hospital referral decisions. Journal of hospital medicine : an official publication of the Society of Hospital Medicine. 2012;7(5):370-5. Epub 29 FEB 2012.

4 HealthGrades. Patient Safety Excellence Award™ 2011 [cited 2012 October 31]; Available from: http://www.healthgrades.com/ratings-and-awards/2011-patient-safety-excellence-award-announcement.

5 Martin AB, Lassman D, Washington B, Catlin A. Growth in US health spending remained slow in 2010; health share of gross domestic product was unchanged from 2009. Health Aff (Millwood). 2012;31(1):208-19. Epub 2012/01/11.

6Any Lab Test Now! 2012 [cited 2012 October 31]; Available from: http://www.anylabtestnow.com.