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Want a Job? You May Have to Quit Smoking

The Orlando Sentinel
December 24, 2007

Alex Silva remembers the day well. He was a pack-a-day smoker in the fall of 2002 when his boss told him the news: One year hence, Silva and every other CFI Westgate Resort employee in Florida would be prohibited from smoking -- not just on the job or on Westgate property, but anywhere, any time.

Silva, a manager in the time-share company's marketing department, loved his job and had a family to support. He immediately started working out more and smoking less.

Shortly before the Westgate smoking ban took effect on Sept. 1, 2003, Silva smoked his last ultra light.

Quitting cigarettes "was very hard," recalled Silva, 33, who doubts he would have made the effort if he hadn't been forced into it. "It was the company's decision. I knew I had no more options, and this will be good for me."

Westgate's hard-line policy on smoking is unusual only in its reach. While the Florida Clean Indoor Act already has all but banished smoking from the immediate workplace, more and more employers are extending the ban to anywhere on their property while also aggressively promoting smoking-cessation programs.

Local examples include Florida Hospital, Orlando Regional Healthcare and Health Central, which together employ roughly 38,000 employees. They jointly announced last month they would ban smoking anywhere on their properties beginning next summer. Lockheed Martin (NYSE:LMT) , with 7,500 workers in Central Florida, imposed a campus-wide ban at its facilities at the beginning of this year.

Bans aren't the only anti-smoking weapons available to employers. With irrefutable evidence that smokers as a group have higher health costs, more employers are considering the idea of charging higher health-insurance premiums to their workers who smoke.

It's legal, and at least two large employers in Central Florida have already taken that step.

Financial-services giant JPMorgan Chase (NYSE:JPM PRH) (NYSE:JPM PRX) (NYSE:JPM PRK) (NYSE:JPM PRJ) (NYSE:JPT) (NYSE:JPM) , which has more than 1,700 employees in Central Florida, this year imposed an additional health-insurance premium on workers who smoke -- reportedly $30 a pay period.

And starting in January, Tribune Co., owner of the Orlando Sentinel, will charge employees who use tobacco products an extra $100 a month for their health insurance.

Penalizing smokers with higher insurance premiums is still viewed by most employers as too much of a morale-buster, but that's going to change, predicted Becky Cherney, who speaks for many of the region's largest employers as president of the Florida Health Care Coalition.

"Employers are saying they can no longer afford to subsidize bad behavior," Cherney said. "We've known for a long time that smoking is hazardous to health, and people are still smoking. Education hasn't worked; [smoking-]cessation programs haven't worked. You have to make the individual pay for the bad habit."

Even a leading critic of hard-line employer smoking policies accepts that logic. Smokers do have higher health-care costs, and "it's not unfair to make you pay for the extra costs you've created," said Lewis Maltby, president of the National Workrights Institute in Princeton, N.J.

'It goes on and on'

But it's still a dangerous road, Maltby said, noting that obesity is rapidly overtaking smoking as America's most costly health-care problem. "Are you going to make fat people pay more, or those of us who have dangerous hobbies like skiing or hang gliding? It goes on and on. Pretty soon, your employer knows everything about your private life in order to save on health-care costs."

Maltby's bigger concern is the total smoking ban, which he views as a fundamental civil- rights issue, since it extends beyond the workplace into an individual's home. He notes that 29 states and the District of Columbia have so-called lifestyle-rights laws that protect employees' rights to smoke when they're not at work.

But not Florida. "When I found out it was legal to discriminate against smokers [in 2002], those were my marching orders," said Westgate's chief executive, David Siegel, who gave his tobacco-using employees a year's notice before the total ban went into effect.

Siegel said he had tried everything else -- banning smoking from sales rooms, offering a host of smoking-cessation programs, lecturing just about any smoker he encountered on the wisdom of quitting. The most effective previous move, he said, was in 2000, when Westgate doubled employees' share of health-insurance premiums but gave non-smokers a 50 percent credit.

"It meant smokers would pay twice as much for their health insurance as non-smokers. Immediately, 40 people stopped smoking," he said, shaking his head at what he views as foolishness. "People stop for monetary reasons. Why isn't health enough of a reason?"

But not all of his employees stopped, even with the higher premiums. Westgate's total smoking ban, now more than 4 years old, "has been a win-win for everybody," Siegel said. Since 2003, health-insurance premiums for the company and its employees have been going up by 5 percent or less a year, far below the rate increases of most other employers, and this year premiums will rise by less than 3 percent.

Siegel, who says his brief flirtation with cigarettes ended in 1959, is so strongly opposed to the habit that he would like to see smoking banned completely. Short of that, he hopes his company's smoking ban -- effective in Florida and every other Westgate location where it's allowed by state law -- becomes a model for other employers.

"I'm shocked we're the only ones," he said. "Probably 90 percent of companies don't know you can do this."

One notable exception is Weyco Inc., a small Michigan health-benefits company that gained national attention when it imposed a total smoking ban on its employees in 2005.

A problem for morale?

But it's not just ignorance that keeps companies from emulating Westgate and Weyco. Employers are increasingly offering their workers smoking-cessation programs, but regulating a legal off-duty behavior is too far a stretch for most companies, said Kay Wolf, a labor-and-employment lawyer with Ford & Harrison in Orlando.

"Employers realize it's a morale problem for the 20 to 25 percent of people who smoke," she said. "Once you get past all the [positive] ways to get them to stop, employers look at [smoking bans] and say, 'We're not going there.' "

CSX Transportation, which has nearly 4,000 workers in Jacksonville and roughly 200 in Central Florida, is giving the positive approach as aggressive a push as it can.

In-house surveys show that more than a third of its employees use tobacco products and 27 percent smoke cigarettes. "The national average is 20 percent -- we're about 7 percent high," said Kenneth Glover, the company's director of health and wellness.

This year, the company moved its smoking areas further from employee walkways, but it has not considered harsher measures such as higher health-care premiums or outright bans, Glover said.

Instead, the company has been offering free health screenings to workers for the past two years and has identified thousands of smokers. Those who express an interest in quitting are given an array of options, typically starting with a visit to a doctor, and the company helps pay for smoking-cessation drugs and nicotine-replacement therapies.

"It takes the average smoker six to nine attempts to stop. We subsidize up to six quit attempts," said Glover, adding that each attempt may cost the company as much as $400.

It's a big investment, he acknowledges, "but we've looked at one cost model, and the potential saving for us is about $2.3 million a year."

Paid help isn't common

Maltby, of the National Workrights Institute, said only one of four U.S. companies pays for smoking-cessation programs. Most "won't pay for classes; they won't give employees time to go to classes; they won't even pay for the [nicotine] patch. They haven't tried the voluntary approach," he said.

And while few companies have gone the punitive route, Maltby said, "If you talk to people in the corporate health business, they'll tell you it's coming."

Dale Maloney, a Maitland health-insurance broker, thinks so. "Fifty to 70 percent of health-care costs are predicated on poor behavior," he said. "All employers are looking at what they can do to assist their employees in behavioral changes to bring down the cost of health-care."

That may mean higher health premiums for smokers, or even the Westgate model, which worked for Tania Cachia.

Cachia, 23, joined Westgate a couple of years ago, after the total ban had been imposed. She had heard about an opening in the company's marketing department that sounded right for her. Then she heard about the smoking ban.

"I quit the day before my interview," Cachia recalled. "I was nervous; I was still in withdrawal. I told the recruiter, 'I'm sorry, but I just quit smoking,' and he said, 'OK, you're hired.' "

Quitting was tough, she said, "but it really helped working in an environment where nobody smokes."

Closing the gate: Managing diabetes, a gateway illness, helps head off other chronic conditions

By Leah Carlson Shepherd 

February 1, 2008

Identifying and treating workers with diabetes can be a gateway that helps to reveal or prevent other conditions that often coexist with diabetes, such as heart disease, depression, high blood pressure, high cholesterol and obesity.

"Diabetes is such a high-impact disease, affecting 10% of the population, and costly, as well," says Dr. Philip Hagen, director of health management resources at the Mayo Clinic, a health research and treatment center.

Diabetes management also is an opportunity for employers to get the best value for health care dollars, since the treatments for diabetes (improved diet and increased exercise) also are very effective at preventing and treating those comorbid conditions. "There's a lot of synergy to be gained by focusing on exercise and nutrition," he confirms.

In fact, it's possible to cut your risk of developing diabetes in half with reasonable adjustments to diet and physical activity, he notes. "It doesn't have to be an expensive drug. It doesn't have to take an expensive program to reduce risk, especially if you have a large population," he tells EBN. "If you get people to lose five or 10 pounds and keep it off, that has pretty impressive effects on preventing diabetes. Every little bit helps."

Identifying prediabetics, those on the verge of developing diabetes, can go a long way toward prevention. "I see a lot of employers doing that better and better. I see a lot of employers doing a know your numbers' campaign and linking that to a health risk assessment," Hagen observes.

"Careful management of the disease is crucial to avoiding complications and onset of other health problems. Employers can encourage their health vendors to identify diabetes risks, encourage individuals to be tested, and to promote effective care management strategies. This is a business imperative," states a recent report from the National Business Coalition on Health.

"Employers increasingly recognize the impact of diabetes on the health and productivity of their workforce, and there is growing evidence that effective management of diabetes reduces complications, reduces health care costs and protects employee productivity," says Andrew Webber, president of NBCH.

Case in point

The Federal Reserve Bank of Dallas, which has 1,300 employees, has offered an onsite diabetes management program for the last four years, along with an onsite health clinic and an onsite gym. It provides an annual diabetes screening and monthly meetings with a diabetes educator from a local hospital.

It recently started offering one-on-one coaching and waiving the cost of diabetes medications and supplies for the program participants who report their biometric results. They get free glucose monitors and software for keeping track of their insulin variations. About 35 workers join the program each year.

"A number of employees got off their diabetes medications completely, as a result of their lifestyle changes," says Bob Queyrouze, compensation, benefits, health and productivity consultant for the bank. "If we can affect several lives, then we feel like we're making some progress."

It wasn't a hard decision to start the program. "Diabetes is one of the predominant risk factors in our population. It was a high-cost issue for us from a claims perspective, and it seemed to be an area that you can get your arms around. What you're trying to do is influence people's lifestyles more than anything else," Queyrouze comments.

Meanwhile, Hospira, an Illinois-based specialty pharmacy and medication delivery company, provides financial incentives through waived copays and additional education for diabetics.

The company recently participated in the Midwest Business Group on Health's diabetes self-management program, called Taking Control of Your Health. "Hospira chose to participate in [the program] to help reduce the costs and improve the health of our employees with diabetes," explains Pam Hannon, benefits director at Hospira.

"We believe we will have happier and healthier employees as well as lower long-term medical and absenteeism costs for this group. Most importantly, employee response has been overwhelmingly favorable, with more than 130 individuals enrolled in the program to date," Hannon says.

Combating a prevalent condition

More than 20.8 million people in the U.S. have diagnosed or undiagnosed diabetes, and since the 1980s, the prevalence of diabetes in the United States has more than doubled and is expected to reach 39 million by 2050, according to NBCH. More than 1.5 million new cases are diagnosed per year, and more than 9% of people aged 20 years and older are currently living with the disease.

In addition, recent research from NBCH shows:

• Almost all health plans screen diabetic members for both depression and tobacco use.

• Roughly 37% of health plans coordinate comorbid conditions with a centralized case manager, while 49% of plans coordinate behavioral health and chronic care services separately.

• More than 38% of health plans reduce copays for selected medications, tests or services for diabetic members, and 28% reduce deductibles.

• 82% of health plans offer general reminders, while 71% send specific reminders based on missed services, and 85% offer live outbound telephone management programs as standard options.

• About 77% of health plans use reminders to support prescription compliance, while 60% alert the doctor if the patient does not refill a medication, and 39% seek intervention through the pharmacist.

• 37% of health plans use the Internet for online medical consultation.

Meanwhile, 95% of employers offer a disease management program for diabetes in their health plan with the largest enrollment, according to the Kaiser Family Foundation.

Tips for employers

Hagen believes the best approach is to use a combination of onsite, telephonic, online and printed materials to educate and motivate workers.

He feels it's a mistake to rely solely on one form of communication or a one-time event that's not repeated.

"Start to think about reaching the most people in some way," he advises. "Take a multimodal approach. Know that small, sustained changes result in a big payoff."

Queyrouze recommends the onsite approach, rather than online or telephonic, because "employees create a support network, and it's a very personal message coming from the employer that We care about your health.'"

Financial incentives can be effective, too.

The free medication "definitely helps people and gets the interest up, the commitment to participate," Queyrouze admits.

For employers, having a return-on-investment estimate would be useful. However, Queyrouze points out, "It costs more to collect the data and crunch the metrics than it does to do the program."

Hagen asserts: "The ROI for preventive measures is at least 2:1 and probably closer to 3:1. It's time for us to stop wringing our hands about the ROI for preventive services. Our real goal should be to keep people out of the hospital."

Patients Embrace Records System

- Washington Times, Gregory Lopes
November 30, 2007

A majority of Americans responding to a new poll say they think electronic medical records can help the U.S. health care system.

A major stumbling block to widespread use of electronic health records in doctors' offices and hospitals is privacy. However, the poll released this week by the Wall Street Journal and Harris Interactive, shows that U.S. consumers think the benefits of electronic health records outweigh the privacy risks.

The poll showed three quarters of the 2,153 American adults surveyed think the medical care patients receive would be better if physicians were able to share health information through electronic devices.

Despite a growing public awareness on the upside to sharing medical information, health care professionals have yet to fully endorse the change from pens to keyboards.

"Health care is one big area of our economy, and it is slow and resistant to modernization," says David Hsu, a management professor at the Wharton School at the University of Pennsylvania.

But recent initiatives in the private sector indicate more people and doctors could go high tech with their health care soon.

On Oct. 4, Microsoft launched HealthVault, a free Web-based service that allows users to store their medical records online and eventually share them with doctors and health care professionals.

On Oct. 17, an executive at Google noted that the search giant was also interested in the area of health information services. These developments -- and dozens of similar initiatives could push the online sharing of personal health information into the mainstream.

Today, there are two forms of electronic medical records. The relatively new Web-based personal health records are designed to be individually controlled and potentially portable.

Electronic medical records are used by industrial strength information systems that are being adopted by health care institutions and hospitals to share lab tests, X-rays, MRIs, medication history and other items internally.

The Wall Street Journal poll found that only 2 percent of the respondents currently use a personal health record, maintained on their own, but 91 percent say they should have access to their medical records kept by their doctors.

States Boost Scrutiny of Drugstore Clinics

- Wall Street Journal, Print Edition
August 09, 2007

Getting a strep-throat diagnosis in the same place you purchase greeting cards and shampoo is undeniably convenient. But is it safe?

That question is gaining urgency as the number of health clinics in retail stores multiplies. At more than 730 retail clinics nationwide, nurse practitioners now treat patients with common ailments such as rashes, red eye and allergies. CVS Caremark Corp.'s MinuteClinic is the industry leader, with 230 facilities in 20 states. Those numbers are expected to rise dramatically, even by the end of the year, with large efforts planned by CVS, Wal-Mart Stores Inc., Walgreen Co., and Target Corp.

Physician groups, including the American Medical Association, contend that the in-store clinics increase the risks of infection for both patients and shoppers. They also question the quality of their care, noting that most are staffed by nurse practitioners instead of doctors.

Retail clinics argue that the safety concerns raised by groups like the AMA are overblown and motivated by financial concerns. After all, they point out, primary-care physicians stand to lose business if patients with minor ailments head to CVS instead of their regular doctors.

Now state health regulators, who have typically granted the clinics extensive waivers from hygiene and safety restrictions, are taking a closer look at the business. Rhode Island has balked at allowing retail clinics despite repeated efforts by MinuteClinic. California passed a law this year that retail clinics must be owned by physicians. Florida now requires health clinics to post a sign indicating whether a physician is present, and medical personnel must disclose their credentials to patients. Texas and Wyoming have gone the other way, loosening some restrictions on medical treatment by nurse practitioners.

Yesterday, Massachusetts proposed new rules governing retail clinics, including a limit on how often a patient could go to one. Reviewing CVS's plan to open the first retail clinic in the state, state regulators expressed skepticism that high standards of care could be maintained in retail settings more accustomed to vitamins than vaccinations.

"This is a whole new ballgame," said Philip C. Nasca, a member of the state Public Health Council and associate dean for research at the University of Massachusetts, Amherst's School of Public Health. He and others argued that "this kind of commercialized setting" might not result in optimal patient care.

Drugstore chains like CVS are eager to establish retail clinics because patients are likely to fill their prescriptions at pharmacies already on site. The clinics typically offer basic medical care with no appointments and prices far lower than most primary-care doctors. At a CheckUps clinic in the back of some Wal-Mart stores, patients can get treatment for a urinary-tract infection for $65 or an insurance co-pay.

Instead of a waiting room, MinuteClinics provide chairs for customers outside the exam rooms. They also don't have their own bathrooms, so patients who need to provide urine samples must use the regular CVS bathroom. Older MinuteClinics didn't include a hand-washing station for nurse practitioners -- they used a hand sanitizer instead -- but sinks were added at the behest of regulators. "Patients have never had a problem with the design of our clinics," says Michael C. Howe, founder and chief executive of MinuteClinic.

Another issue is space. The current regulations in Massachusetts require that rooms where patients are treated include at least 80 square feet of floor space and an exam table. MinuteClinics have no exam table -- patients are treated in chairs -- and at most 54 square feet of floor space. In documents submitted to state health regulators, MinuteClinic argued that the space is sufficient for its "limited scope of services." Regulations proposed yesterday by the state, and being considered by the Public Health Council, would allow the clinics to operate with as little as 50 square feet of floor space, no waiting room and no separate bathroom.

"You're crowding people who may be sick, not to mention potentially exposing someone who's just trying to buy Doritos," says Bruce Auerbach, president-elect of the Massachusetts Medical Society and chief of emergency medicine at Sturdy Memorial Hospital in Attleboro, Mass.

Dr. Auerbach has raised a litany of other concerns about patient safety. He contends that nurse practitioners, while capable of providing the care that retail clinics offer, need supervision from on-site physicians who might catch early signs of a more serious disease.

"Every patient who presents with a sore throat does not have Streptococcus pharyngitis," also known as strep throat, Dr. Auerbach testified before state officials last month. "Every patient presenting with red eye does not have simple conjunctivitis."

MinuteClinic provided an abstract for a study, slated to be published this year in the American Journal of Medical Quality, that found it was giving appropriate care for sore throats, the most common malady among the clinic's customers. Of 57,311 patients who arrived at a MinuteClinic with a sore throat, 99.15% were given the proper treatment, the study found.

Patients, though, are more apt to use a retail clinic for the convenience rather than the care. A survey this year by Forrester Research Inc. found that retail-clinic users were very satisfied, but just 7% thought the care was better than a typical trip to the doctor's office.

CDHP users don't lack preventive care

Patients with consumer-driven health plans seek out evidence-based care and preventive care at rates equal to or higher than those in traditional health plans, according to a new study from UnitedHealth Group, a provider of CDHPs. The company compared its 2004 and 2005 patient information with national benchmark data on 10 million members in traditional health plans.

CDHP users were 16% more likely to have a cervical cancer screening, 16% more likely to receive a prostate screening and 10% more likely to get a cholesterol screening, compared to the benchmark population. In addition, CDHP users with coronary artery disease were 22% more likely to have lipid tests and equally likely to see a doctor, compared to those in traditional plans. Those in CDHPs and traditional plans shared similar rates of receiving colonoscopies and mammograms.

Critics of CDHPs say they may encourage people to skip needed care to save money, but United says these results show that’s not the case.

“Individuals [with CDHPs] are continuing to receive important health services and are not compromising the quality of their care,” says Dr. Miles Snowden, a senior vice president at UnitedHealth. “We are beginning to develop a much more compelling and fact-based view of how consumer-focused strategies are working to support both health care affordability and quality.”

Experts help small firms with health plans

This is a perfect time for small businesses that don’t offer health insurance to evaluate the feasibility of doing so, according to Vince Ashton, executive director of HealthPass, a New York-based group focusing on small employers and health insurance.

Small business owners should hire a good broker who can aid them in navigating the maze of health insurance options, networks, rules and guidelines, Ashton recommends. Equally important, he adds, owners need to talk to a friend in human resources or another small employer for advice on choosing a quality plan.

Moreover, small firms must set employee expectations in terms of coverage and look for flexible plans that offer a little “extra,” so that employees can get the most out of their health care, Ashton says.

Meanwhile, the National Association of Insurance Commissioners (NAIC) offers an online education site for small businesses that focuses on insurance options and business risks. “Many small businesses … are exposed to serious risks that could be mitigated by a better understanding of insurance options,” says Catherine Weatherford, NAIC executive vice president.      

Only 47% of small companies provide health insurance. Of those, 24% have changed their fee structure, deductibles or other components to offset the rising cost of premiums during the past year, NAIC notes.