‘Consumer guide’ role can help employees

The move toward integrated benefits opens an important new role for those wellness professionals who are willing and able to pursue it, says Chuck Reynolds, practice area leader for the Benfield Group, a St. Louis-based health promotion consulting firm.

"We have fielded three separate requests recently related to the integration of all benefit constituencies around the idea of employee health improvement," he notes. "With that as a background, it begins to point to a new role for the wellness professional."

And that new role, he adds, could not have come at a better time. "In the old days, people would come to the wellness professionals with questions about health and fitness, but I’ve got news for them; they’re not smarter than what’s available on the Internet. What wellness professionals need to be is the resource within the organization that helps to assemble the various sources of information and benefits that make the most sense for the company and employee. If I have open enrollment and four different plans from which to choose, maybe my role as a wellness professional is to inform the employer of the real wellness benefits of each plan. In other words, you serve as a kind of consumer guide. Ask each plan to provide a description of their benefits, and then grade them."

In the area of workers’ compensation, he says, the wellness professional could work with the insurers proactively to lessen the chance of injury. "They could also serve as an advisor on all the products of people who knock on the door selling wellness benefits," he says.

Reynolds recognizes such a role is not for everyone. "It’s a totally different role, and a lot of health promotion professionals may not be comfortable with it because it’s not very ‘touchy-feely,’" he concedes. "But the opportunity is there because we see these questions starting to come up."

Know your dollars and cents

Even though employers may be more willing to invest in wellness programs, they still want to look at the numbers before making a final decision. The more you know about the potential returns of your program, the better your chances of success will be, says Ron Burt, manager of business health services, Providence Health System-Everett (WA).

"You certainly need to be able to show and justify the cost-benefit you are offering to the employer; how it will either help the organization through cost savings or cost avoidance," Burt says. "The other thing, in terms of strategy, is to take a look at cost vs. benefits in terms of the literature — and there’s more and more out there. So, you look at what it would cost to put the program together and project the cost savings associated with that investment."

The next step, says Burt, is to look at the company’s overall budget for benefits. "Then, look at the cost of health promotion and at the percentage cost of that program to the overall budget of benefits," he suggests. "Let’s say your benefits budget is $10 million and your health promotion budget will be $200,000 to $300,000. The impact in lowered health costs could be two- or three-fold that amount, so the real cost of wellness is a very small percentage of what the total benefits costs would be." (For a case study of a company that has implemented this sort of perspective, see story, p. 102.)

Burt recommends that you help your employer learn to look at controlling health care costs from a different perspective. "Too often, employers get employees to bear a bigger percentage of the costs, rather than trying to correct the problem," he notes. "Get them to look at the overall budget and the trend line — what can we do to change this trend, rather than to see it escalated — rather than seeing employees or the boss pay more, so more and more of the company’s revenues go to benefits? I have heard that almost 50% of the gross revenues generated by organizations in America go back into benefits — that’s huge."

It’s important, says Burt, to educate key decision-makers about the impact of wellness on the bottom line — and the implications of not having a wellness program. "The program has to have teeth and reach a large segment of the population, or you won’t have the documentation you need to show savings," he explains. "I’d go to the human resources department, the benefits department, and say, ‘I want to help make this organization more financially viable.’"

Then, he says, the wellness professional and benefits or HR professionals can work together to develop a comprehensive strategy to help address the issue of rising health-related costs. "This way, you have a partnership, rather than an adversarial relationship," he explains.

"Some of them might balk at the additional expense of wellness, but you’ve got to show them how it will save money," he says. "Besides, you can always respond to their questions with a question of your own: ‘If we don’t do this, what are we going to do?’"

Avoid the ‘dark side’ of managed care

Wellness professionals can also play a consumer advocate role by helping employees exercise their rights to appeal rejections of medical coverage by health plans. Although this also is beyond the traditional wellness role, it can offer a much-needed service to employees.

As each open enrollment season comes around, more and more employees are signing up with (MCOs) managed care organizations. But there’s a dark side to managed care, warns Kenneth R. Pelletier, PhD, clinical associate professor of medicine at Stanford University School of Medicine’s Center for Research and Disease Prevention in Palo Alto, CA. However, he adds, benefit managers who are able to recognize and overcome this dark side can help their employees get the most out of their health plan.

"That dark side appears when managed care is inappropriately structured to prevent people from accessing services; what the plan is saying to the company and its employees is that it is more cost-effect for us to deny payment of your claim than it is to process it," Pelletier notes.

But there is a way benefit managers can empower employees to get what they deserve, says Pelletier. "If an employee submits a claim and is denied, tell them to put in writing that they want to know — in writing — why the claim was denied, and that they want the plan to provide them with a copy of the section of the policy on which the denial was based," he suggests. "Then, have the employee copy the benefits department, so they can keep track of the complaint. Third, copy the Department of Corporations in your state because MCOs are now required to address complaints and to monitor their response."

Even if an employee gets a partial payment, but he thinks it is too little, he should go through the same procedure, says Pelletier. "You’re paying for the benefit; if you don’t think you’re getting what you’re paying for, let them know. There is a tremendous amount of consumer power that’s going unused."