Employers Versus Insurance Companies

Sue Bergeson Health Guide
  • I've had three really interesting experiences lately that have got me thinking more deeply about employers and their role in determining our health care coverage. We all know that "employers want to reduce health care costs." But I saw that in action three different times in less than two weeks.


    I was talking to two different local health care collaboratives about what they're doing to promote quality. What's a health collaborative, you ask? Well, it depends. In one situation, it was basically a small insurance company—kind of like a collective of employers who banded together to form a larger (and hopefully cheaper) insurance pool. Besides decreasing costs by creating incentives for doctors and systems that meet quality markers in treating major chronic illnesses like diabetes, they also create performance metrics that show each provider and system where they stand in terms of cost effectiveness. 

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    This is a precursor to creating tiered reimbursement systems, similar to something I talked about in one of my earlier blogs. While a tiered system is supposed to reward the doctors who are high quality and low cost, what we consumers fear is that it will do something else entirely. A tiered system might result in doctors and hospitals "cherry picking" only the least complicated and easiest patient populations ... leaving those of us who are sicker to higher-cost, lower-quality doctors. 


    Who's demanding this tiered system? The employers, of course. There seems to be a ridiculous assumption among employer groups that all illnesses are equal and everyone with a mental illness will respond in exactly the same way to treatment. Under that assumption, "quality providers" would be those who saw more patients and spent less money doing so, as well as those who followed specific "treatment guidelines" versus those who didn't.


    Mental illnesses are complicated. For example, 60% of us live as consumers with a substance use disorder, 41% of us smoke and a high percentage of us have other co-occurring illnesses like diabetes, heart disease and the like. It seems very clear that a tiered system won't work well for those of us with complicated illnesses, illnesses that don't respond to treatment right away or those complicated by other co-occurring illnesses. 


    Adding to that, nobody responds to any single medication or treatment plan in the same way. This means that the quality guidelines for, say, depression are very odd. Why is seeing a depressed patient three times in 12 weeks after the first diagnosis a quality measure?  Just seeing the patient says nothing about whether quality treatment is occurring. It's a process, not an outcome. Indeed, DBSA's surveys show that most of us define quality in ways that are completely different than these so-called "quality" indicators.


    This was hammered home to me when I participated in a very small, high-level group trying to select quality and efficiency measures within a large insurance company. There were maybe 14 of us at the table, and only three of us were from outside the company. I was the only consumer/consumer voice at the table. I was listening as this company struggled to find some realistic way to measure quality effectiveness, and it became clear they were doing this because the people who buy their insurance (employers) were demanding it. The insurance company executives knew they didn't have the data needed to show true quality and efficiency in ways that would put the consumer first. But they were being pushed to do it anyway. I was very, very impressed with the executives at this meeting, because they simply would not cave in to the demands of these people, the primary purchasers of their products. Instead, they went through the process of creating a system that actually could measure quality and efficiency based on outcomes (not processes) and consumer experience.


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    I will have had my third experience with employers well before this blog gets posted. I've been asked once again to present, to a very large group of employers, information about what employers can do about depression in the workplace. The last time I met with them, the only questions I got were ones that had to do with how they could provide programs that didn't cost anything, that didn't last long and that didn't make the company look like a bunch of depressed employees. Sigh.


    So, the next time you're cursing out your insurance company, give a thought to the plain reality that it's your employer who designed your health care plan. It's your employer who made the decisions about whether mental health is covered, what your co-pays are and how many times you have to fail first on medication you already know won't work before your doctor can prescribe (and you'll be covered for) the medication you know will work. 


    For many of us, the problem is employers, not insurance companies. And it's a problem that doesn't look like it will be solved any time soon.


    Have you checked out DBSA's info on mental health parity? What are your thoughts about advocating for more/better mental health coverage in insurance plans?

Published On: April 28, 2008