What can we deduce about Deductibles?

By Clive Riddle

Mercer’s Study finds the median individual deductible jumps to $1,000

Mercer just released results from their 2008 National Survey of Employer-Sponsored Health Plans, with headlines declaring “$1,000 health plan deductible was the norm in 2008.” And this was just for traditional PPO plans, not counting consumer driven high deductible health plans. And this was the median figure, not the mean which is more susceptible to skewing upwards given the wide range of benefit design out there. And this was for individual, not family coverage.

Certainly the ongoing increase of consumer cost sharing built into plan design, and the growth in consumer driven high deductible health plans that has paved the way for the trend and acceptance in higher deductibles in traditional PPO plans as well. As Blaine Bos, of Mercer tell us, “The introduction of the HSA may have changed employers’ thinking on just how high a deductible can go without causing employees to revolt. Raising the deductible has become the fallback for employers faced with cost increases they can’t handle. It’s the easiest way to reduce cost without taking more out of every employee’s paycheck.”

But not so fast, there’s a little more to the deductible story than just $1,000 individual deductibles. Deductible amounts are quite different for small versus large employers. Mercer found the median deductible for large employers is just $300. Other surveys have borne this out as well. The Kaiser Family Foundatio/HRET Employer Health Benefits Annual Survey yielded lower deductible amounts for traditional PPOs, but with the same separation by size: a mean of $560 overall, but $917 for small employers and $413 for large employers.

It also shouldn’t be glossed over that the KFF/HRET study found the mean deductible at $560, a far cry from $1,000. Too bad KFF didn’t share what the median was, but they report the following distribution: 52% under $500; 30% $500 to $999; 13% $1,000-1,999; and 4% $2,000+.

The trend for first dollar coverage of wellness and certain value-based benefits should be noted as well. While deductibles are rising fast, more employers are adopting plans designs with first dollar coverage for specific wellness and "value based" items. This at least make a larger deductible a little more palatable, and allows plan design to influence desired objectives.

Getting to the bottom of Counter-Intuitive Data

By Clive Riddle

The KFF/HRET Annual Survey of Employer Sponsored Benefits and Smaller versus Larger Group Premium Costs

Results were recently released from The Kaiser Family Foundation and Health Research & Educational Trust  Annual Survey of Employer Sponsored Benefits. This year’s 214 page document is a must read if you want a statistical photo album, as opposed to a snapshot, of employer health benefits landscape.

While the KFF/HRET is rightfully one of the most often cited, and leading sources for employer health benefit statistics, the results occasionally contain data that seems counter-intuitive.  Digging through this year’s document, the comparison of  smaller versus larger employer group premium costs raises such a red flag.

Intuition would guide us to believe that larger employer groups would experience lower premium costs and lower premium increases. Historically, a wide number of studies from national benefit consulting firms have borne this out.

But the 2008 KFF/HRET survey tells us that premiums are now cheaper for smaller firms (3-199 workers) compared to larger firms (200+ workers), with the average monthly single premium at $382 for smaller versus $397 for larger firms (3.9% higher), and the average monthly family premium at $1,008 for smaller versus $1,081 for larger firms (7.2% higher.) The report notes that in past years, any differential was not so significant.

What gives? It of course is always tempting in such situations to dismiss the information as a result of skewed data and a faulty survey. But who are we to know that this is case? Instead, the answers may still be in front of us. The report doesn’t specifically respond with answers to this vexing question, but it does supply enough detailed data to offer some explanations, if you dig one level deeper.

And in digging, it would appear that the difference could be due to benefit packages, plan funding, and demographics.

When broken down by plan of benefits, smaller firm premiums are actually more expensive for a number of categories (Family HMO, Single PPO, Single and Family HDHP) and the differential is not as pronounced where larger firms are more expense (3.2% higher for Single HMO and 2.4% higher for Family PPO) except for POS premiums, which don’t have that significant of enrollment.

Thus part of the explanation for less expensive smaller firm premiums could simply be in the mix of benefit packages (HMO vs PPO vs HDHP etc) for smaller firms vs larger firms. On top of that, a good portion of the explanation could be in the level of cost sharing, which impacts premium costs. For example, the average Single PPO deductible for smaller firms was $917, compared to $413 for larger firms.

Another component of the explanation may be in that self-funded plan costs are running higher than fully funded plans. The report indicates that family self-funded premiums average 6.2% higher than fully funded premiums. The report also tells as that only 12% of smaller firms have some level of self-funding compared to 77% of larger firms. Furthermore, more large firms are trending towards self funding. 62% of workers with employers having 5,000+ employees self-funded in 1999, increasing to 89% in 2008, and 62% of workers with employers having 1,000 to 4,999 employees self-funded in 1999 compared to 76% in 2008.

Lastly, demographics can provide some of the explanation. Larger groups tend to have a slightly older population, and the report indicates that firms with less than 35% of workers aged 26 or under had 6.7% higher premium costs than firms with more than 35% of workers aged 56 and under. Larger groups tend to have workers with higher wage levels, and the report indicates that firms with less than 35% of workers earning $22,000 or less had 8.3% higher premium costs than firms with more than 35% of workers earning $22,000 or less. Lastly, larger firms tend to be more unionized, and the report indicates that firms with at least some union employees had 4.3% higher premiums than firms with no union employees.

The point of all this digging is to demonstrate, when considering reports as valuable of the KFF/HRET annual survey, not to just browse through the summary and walk away with a headline that smaller groups now have lower premiums than larger groups, as some news organizations have done, or to dismiss the survey as flawed, as some pundits have done. Digging through the data can yield explanations, which would seem to indicate that on an apples-to-apples basis, small groups aren’t really cheaper. Instead, small groups have higher cost sharing, a different mix of benefit plans, less self funding and demographics that make them “apples” compared to large firm “oranges”, and the apples do cost less than oranges in this case.

Presenteeism Quantified

By Clive Riddle

CIGNA last week released Yankelovich survey results quantifying various aspects of "presenteeism", which they define as "the phenomenon of employees being physically present at work, but not performing their duties at full capacity due to illness and various distractions."

Jodi Prohofsky, CIGNA Health Solutions Unit SVP of Operations tells us "The survey demonstrates very clearly what every employee knows – that life impacts work and work impacts life. The challenge for employers is to find ways to reduce that impact by offering workplace programs focused on employee health and well-being, and then encourage their employees to use these programs. It’s important for employers to create a culture of wellness in the workplace so that every employee has the opportunity to achieve his or her full health and productivity.”

Here's selected results from their study:

• On average, people admitted to spending between 2 ½ and five hours per week resolving personal issues while at work, spiking during particularly stressful or eventful weeks.
• 61% of employees reported for duty while they were sick or coping with family and personal matters, with an average number of  6.9 "presenteeism" days per employee for the past six months, compared to 3.0 actual absence days per employee for the past six months.
• Employees average 2.4 hours per week dealing with personal issues in a typical week, and 4.7 hours during a stressful week
• 62% of employees admitted to being  less productive on those days they were sick or had to deal with personal issues, 
• 38% of employees reported to work sick or with a significant person issue out of a sense of duty, and 25 % reported because they needed the income. 
• 66% of employees admitted they don’t get enough sleep, and 45% said that their lack of sleep hurt their work performance. 
• Of those saying that a lack of sleep affected them at work, 50% were less productive, 43% were irritable, 42 % were unable to focus, 40% delayed projects,  28%  admitted to making errors, and 12% fell asleep on the job (multiple answers allowed.)
• Employee strategies to stay alert bode well for Starbucks. the top strategy was to drink caffeinated beverages (57%). 20% said they take a nap to stay refreshed.

The lines continue to blur between human resource issues and benefits issues, and employers, health plans, providers, and solutions companies are all building on a trend to address workplace issue like presenteeism through delivery and management of health care benefit. Expect to see health plans, wellness companies, care management companies, pharmaceutical programs, and various vendors to continue to step up involvement is this area.

The Underinsured: 45 vs. 17 million

The Underinsured: 45 vs. 17 million
In addition to the uninsured, there is a significant population of underinsured Americans that don’t have adequate coverage to come close to addressing their medical needs. These underinsureds face significant financial burdens and barriers to receiving necessary care, and are a significant problem for health care providers as well.

But a basic problem in examining this population is defining the scope. While identifying the uninsured is pretty straight-forward, "under-insured" is a relative term that can mean different things to different groups of stakeholders. How many underinsured Americans are there? That depends upon how you define underinsured.

If we use a definition advanced by Consumer Reports, the number could be 45.2 million. If we use a definition advanced by AHRQ, the number could be 17.1 million. That’s quite a spread.

Consumer Reports recently released results from a health insurance survey conducted by the Consumer Reports National Research Center in May 2007, which sampled 2,905 Americans between ages 18 and 64 and among other things tackled the issue of the underinsured.

Consumer Reports defines the underinsured as persons with health plan coverage that have two or more of the following complaints about their health plans: "It does not adequately cover costs of prescription drugs; doctor visits; medical tests; surgery or other medical procedures; catastrophic medical conditions; or the deductible is too high."

Applying this definition to their survey respondents, Consumer Reports estimates 24% of the U.S. adult population under age 65, which based on current U.S. census figures of 188.4 million adults in this age group, works out to an estimated 45.2 million people. Consumer Reports indicated the "median household income of respondents who were "underinsured" was $58,950, well above the U.S. median. Twenty-two percent live in households making more than $100,000."

According to the survey, 43% o of the underinsured reported that they postponed going to the doctor because they couldn't afford it, 28% of the underinsured put off filling prescriptions, 27% said they were still in debt to doctors and hospitals, and 3% of the underinsured said medical bills had forced them to declare bankruptcy. Consumer Reports broke out responses to the following circumstances by "Well Insured" vs. Underinsured categories:

Circumstance	Well Insured	Underinsured
Prepared to handle unexpected major medical costs in next 12 months	65%	37%
Postponed needed medical care in past 12 months due to costs	22%	56%
Dug deep into savings to pay medical bills	9%	33%
Made important job-related decisions based mainly on health-care needs	11%	21%
Health plan does not adequately cover prescription-drug costs	7%	63%
Decisions about retirement affected by medical expenses (adults 50+)	12%	34%

Of course, the Consumer Reports definition is entirely subjective. Researchers from the Agency for Healthcare Research and Quality (AHRQ) last year tackled this definition with a more objective measure, and published their findings in JAMA. The AHRQ definition of underinsured?  "insured persons with health care service burdens in excess of 10% of tax-adjusted family income." 

On this basis AHRQ found that in "2003, there were 48.8 million individuals (19.2%) living in families spending more than 10% of family income on health care, an increase of 11.7 million persons since 1996. Of these individuals, about 18.7 million (7.3%) were spending more than 20% of family income. In 2003, individuals with higher-than-average risk of incurring high total burdens included poor and low-income persons and those with nongroup coverage, aged 55 to 64 years, living in a non-metropolitan statistical area, in fair or poor health, having any type of limitation, or having a chronic medical condition. Applying our definition of underinsured to the insured population, an estimated 17.1 million persons younger than 65 years were underinsured in 2003, including 9.3 million persons with private employment-related insurance, 1.3 million persons with private nongroup policies, and 6.6 million persons with public coverage."

Thus the number of underinsured under age 65 Americans might be 45.2 million, according to the Consumer Reports definition, or  17.1 million according to AHRQ. Quite a difference in numbers.