How Companies Can Ensure Employees Feel Supported While on Leave


By Gene Lanzoni, Marketing, Thought Leadership, Customer Insights 
The Guardian Life Insurance Company of America


 

With the expansion of the American with Disabilities Act (ADA) more than a decade ago, employers have become more aware of their responsibilities with not only how to stay compliant, but the role they play in helping employees return to work. According to the U.S. Centers for Disease Control and Prevention (CDC), lost productivity due to absenteeism in the U.S. cost employers $225.8 billion annually, or $1,685 per employee. In today’s competitive labor market, many employers are looking for ways to retain their employees and adopting leave practices that help employees return to work from an extended absence due to injury or disability is becoming a priority.

As such, employers are responding with more personalized leave management and more robust stay-at-work (SAW) accommodations. Guardian’s most recent biennial Absence Management Activity Index and Study–“The Value of Leave Management Integration,” found three in four employers with a high level of return-to-work (RTW) and SAW programs reported decreased absenteeism, compared to only 40% of companies with no formal SAW program.

Guardian’s study also reveals employers are paying greater attention to the employee experience, one that offers a more supportive environment with additional flexibility, resources, and education. Employers seeking to upgrade their absence management programs to generate positive outcomes like high employee satisfaction and retention should consider the following:

Better Return-to-Work and Stay-at-Work Accommodations 

While it’s important to communicate with employees throughout their disability leave, it’s equally important to provide them with a smooth transition back to work. Employers should establish a strong RTW program that guides employees in a way that makes them feel supported. Guardian’s study indicates 70% of employees who completed an RTW program feel their employer cares about them. Additionally, companies that have four to six RTW initiatives see a 78% reduction in lost time, compared with 48% of companies that have no RTW initiatives. 

Employers have become more aware of their responsibilities under the ADA and are identifying ways to help their employees stay at work following an absence. These activities have expanded beyond traditional vocational rehabilitation to include interactive processes, transitional work plans, and worksite modifications to accommodate employees with disabilities. Providing employees with resources like nurse case management and duration guidelines can help reduce the likelihood of a relapse. Guardian’s study found organizations with the most comprehensive RTW programs appear to achieve greater success reducing lost time and improving employee retention. 


Flexibility and Personalization Go a Long Way 

Today’s technology makes it easy to communicate and inform a company’s workforce through various channels. So, it’s not surprising our study reveals that the accessibility of information has a great influence on employees when they are on leave. Every employee has a preference of how they’d like to communicate with their employer about leave, and Guardian’s study finds the majority of employees prefer to have 24/7 access to personal and mobile communications.

Employers that leverage new technology, including automated dialers, text messaging and chats are leaders in the absence management space because they demonstrate a willingness to accommodate to an employee’s schedule and individual needs. In fact, Guardian’s study reveals 21% of Index leaders use automated dialing technology, compared with 9% that lag on program improvements. The same goes for interactive voice response systems – 16% of Index leaders leverage this technology, compared with only 7% of those that rank lower in the Index. 

At the end of the day, many employees want to work for a company they feel cares about their well-being and that will help them navigate the journey through their disability. The data collected from Guardian’s Absence Management Activity IndexSM and Study supports the notion that employers who prioritize these programs see positive results in employee satisfaction and overall retention.


Unless otherwise noted, the source of all information is from the 2019 Guardian Absence Management Activity Index℠ and Study – “The Value of Leave Management Integration.




Podcast: Living and Working With Endometriosis



Introduction

Carol Harnett [00:00:00] Hi everyone, this is Carol Harnett. I’m the president of The Council for Disability Awareness. Welcome to our show: the Financial Health and Income Network.  I am very excited to launch what we hope will be a continuing series with people who are working and living with chronic conditions, illnesses and diseases.  I am so pleased to say that our first topic will be on endometriosis.

 


You can hear the full podcast or if you’d rather read than listen, we captured the transcript from the conversation below.


 

Carol Harnett [00:00:32] I’ve worked in and around healthcare my whole life, and worked around the data in healthcare my entire career, and I have never thought about endometriosis as a separate category.  What brought it to my attention is my guest, Tawnia Jacobson. She is a nurse who has a master’s degree in Science with a concentration in Biology, and is also a Certified Nurse Anesthetist.

I often put firewalls between the different parts of my life. This is one of those times when I let the different parts of my life blend together. Tawnia is also my CycleBar instructor, and that is how I came to know her. She did something that I think has a high degree of impact for everyone around health and particularly for women with endometriosis.

During the month of March, which is an awareness month for endometriosis, she shared publicly through her Instagram account, her experience with endometriosis along with a lot of very important facts. The one that captured me the most is that 1 in 10 women in the United States have endometriosis, which is the same as the diabetes rate in the United States.

When we think about the amount of time and energy that we put around diabetes, which we should, we don’t put any time and energy around addressing endometriosis. So, Tawnia, thank you so much for being willing to join us today and talk with us and educate us on this topic.  

Tawnia Jacobson [00:02:05.40] Absolutely Carol. Thank you so much for having me.  This is an extremely important topic for everybody, but obviously near and dear to my heart with personal experience.

Carol Harnett [0:02:18.42]: For that reason, I want to turn a lot of the show over to you. I would love you to start, if you don’t mind, first with grounding people with a definition of what endometriosis is, and then your story as it relates to that.

Defining Endometriosis

Tawnia Jacobson [02:37.08]: Endometriosis, by definition, is a systemic disease that occurs when tissue that normally lines the inside of your uterus is found elsewhere in the body, mostly in the pelvis or the pelvic cavity. But it can also appear on the bladder,  the bowel, the lungs (into the diaphragm) , and even the brain, in worst-case scenarios.

It causes pain, organ dysfunction, and infertility. The cause of endometriosis is unknown, but there are many theories surrounding it.  Genetics, stem cells, blood and lymph system distribution are all possibilities. Inflammation is a key factor, and they believe that maybe some environmental toxins may be linked to it.  Again, no definitive cause, and the diagnosis unfortunately takes a very long time. As Carol mentioned, the prevalence is extremely high, it’s 1 in 10 women. So if you yourself don’t have it, absolutely somebody you know has it or may not even know that they have it, but are experiencing signs and symptoms of having endometriosis.

A Challenging Diagnosis

Tawnia Jacobson [0:04:00.16]: A lot of people ask why it takes so long to diagnose and it’s mainly because most obstetrics and gynecology doctors themselves don’t even know that much about it. The average patient will see eight to ten doctors before they receive an actual diagnosis. After years and years of pain and suffering, many patients are told that it’s “in their head”, that it’s just “IBS” — irritable bowel syndrome — because so many of us have so many bowel symptoms that go along with this.

When it’s confused to be a GI issue, you might be sent away from your GYN (gynecologist), to a gastroenterologist and go through every process and procedure known to man for that, and really that’s not the initial cause. With a lot of confusion and pain, it becomes a mental battle and game for many patients and it’s very frustrating.

I can now back up and talk about my story.

Tawnia Jacobson | Symptoms: Pain, Heavy Menstrual Bleeding, Fatigue, Migraines

Tawnia Jacobson [0:05:05.25]: I would say that this whole thing probably started for me when I started menstruating at the age of 16. With heavy, heavy bleeding, I missed many days of high school. I was fatigued. I would get headaches. My mother actually had a history of very heavy periods as well, and had a hysterectomy at the age of 30 because of heavy bleeding. She couldn’t handle it anymore. At the time, whether they knew or not that she had endometriosis has really been left to be discovered, but it doesn’t matter. They performed a hysterectomy to treat her pain and bleeding, and that’s all I know. My mom kind of just said, “Yeah, I had really bad periods, too,” and we went about business and life. When I moved to college, the pain was worse. I would be knocked out for at least a week at a time in addition to the week of premenstrual symptoms.

One Solution | Birth Control

Tawnia Jacobson [0:06.10.01]: I finally started seeing a GYN (gynecologist) early in college who suggested birth control. She diagnosed me with menstrual migraines. She thought if we could even out my hormone swings it would prevent my migraines. Then, obviously, if I wasn’t bleeding, I wouldn’t have as much pain or symptoms of cramping and bleeding.

I went on birth control early on, probably by the time I was 19, and stayed on birth control for about 7 years. I came off birth control at about 2008; (we can talk a little bit more about how birth control can suppress endometriosis symptoms later).

Without being able to remember too much, in general, I just always felt crappy around my period. I was exhausted. There were probably days — many days — when I called out of work. But the bleeding was so intense that I would have to take extra clothes with me everywhere I went because I would easily bleed through what I had on.

Again, I was just always told it was normal. Even my GYN was like, “Yeah”, some people just get this. This is normal.” She offered me narcotics to deal with the pain. I never took them as I am not the type of person who would even take Ibuprofen regularly. So I spent a lot of time in bed, a lot of time sleeping with heating pads, and just dealing with it.  This continued for years and years.

Next Step | Trying to Conceive

Tawnia Jacobson [0:07.45.76]: I think the next step in my journey came when my husband and I decided to start trying for a family. Probably around 2014, we became more active in trying. And even though I had been off of birth control since 2008, we were obviously not preventing pregnancy, but it hadn’t happened. But 2014 is when we started to try a little bit more actively.

I was feeling a lot more left lower quadrant pain, and I think once you become hyper-focused on your schedule and looking at a calendar all the time,  you start to become very in-tune with your body. I was just noticing so many things. So I sat down and talked to my GYN about it. She said, “Let’s start by getting some labs and do an ultrasound, so that we can  rule out cysts.”

At the time I didn’t have any signs or symptoms of ovarian cysts other than just pain which seemed to be focused in my left lower quadrant.  Labs came back and showed that I had a low AMH, which is an Anti-Müllerian hormone. This test is fairly new. They’ve been using it maybe 10 to 12 years. So again, six years ago or five years ago, or however long it was I got this information, my GYN  didn’t feel that comfortable with dealing with it. She said, “With this information, it means you have a low ovarian reserve, and I’m not really sure how to treat you moving forward. I need to send you to a fertility specialist.”

This was obviously devastating news, and not what you want to hear when you’re just starting your journey.  But I thought, “Great! This is a specialist, somebody who is going to listen a little bit more to my symptoms and put a little more thought into my cycle and what has been going on for years.”

A Specialist, and Diagnostic Laparoscopy

Tawnia Jacobson [0:09.36.93]: We went on that journey, and have been on that journey for the past four years. It has been equal parts devastating and frustrating, but it was during that time that we all, as a team, made the decision that I probably most likely had endometriosis. The only problem was, the only way to diagnose endometriosis is via invasive surgical procedure. You have to have a diagnostic laparoscopy in order to obtain a sample of tissue to send to pathology for diagnosis. It was years of frustration and a lot of changes to my cycles, (very short cycles). Another thing to add is that after we were told we wouldn’t conceive naturally, I did conceive naturally.  Unfortunately I sustained a miscarriage at about 10 to 11 weeks. It was at that point that my cycles seemed to be even more sporadic and painful. It was then that I finally said, “Okay, I have to do something, so let’s have surgery.”

In 2017 I had my first surgery by a fertility specialist who claimed that he could fix my endometriosis and get me pregnant. I trusted him and I went through surgery. Within three months, my symptoms were worse than they had been before. I was in a very ugly place mentally and emotionally, and I was begging for a birth control again because I said, “I can’t continue feeling like this. I’m not myself. It hurts every day.”  It went from being painful a week to two weeks out of the month to three to four weeks out of the month. There were very few good days. I was keeping a calendar. I was keeping food diaries. It was consuming my life and it was miserable. So I begged and pleaded for birth control, and he talked me out of it because he said, “You are looking to start a family” and I said, “I understand that but this isn’t working.” So instead he put me on Clomid.

I took a course of Clomid hoping to get pregnant, but instead I ended up getting a grapefruit-sized cyst.  Luckily it did not require surgical resection, but I endured many, many days of pain until it rectified itself. After that, I foolishly put myself on a course of DHEA hoping that would improve my egg supply for getting pregnant once again; not realizing that those are the worst things you can do for endometriosis.

Breakthrough

Tawnia Jacobson [0:12.20.51]: By the fall of 2017,  I was just in a really bad place.  It was not good for my relationships. It was not good for my marriage. I knew that I needed to do something. I just didn’t know what I needed to do.

As fate would have it, one of my neighbors and I were talking one day. We had just built a house in a new development and she was a new neighbor. We were talking about infertility. She mentioned that she had endometriosis as well, and she led me down the path of Nancy’s Nook, which is an endometriosis education forum on Facebook that literally changed my life.

I went on there and I read for a couple of hours every day. I learned more than I ever learned about endometriosis in my entire life in about four hours, and it changed my life. It was Nancy’s Nook who educated me, who ultimately led me to my surgeon, who performed excision surgery, which is the gold standard for treatment right now. I had surgery last March and have felt like a new person ever since then.

Carol Harnett [0:13:34.05]: Wow, as I was listening, you probably heard me gasping because it’s incredible to listen to your experience in one fell swoop. I can’t imagine what that was like to live through.

Tawnia Jacobson [0:13.49.22]: I try to keep it as condensed possible, but it was many, many years of suffering, and many years going in the wrong direction.

I mentioned keeping food diaries.  I changed my diet so many times. I had tried gluten-free and dairy-free. It was around that time that I actually got pregnant. Part of me was like “Wow, is that what it takes?” Then I eventually went vegan; I had cut out all meat. If you read a little bit more about endometriosis, you realize that they encourage an anti-inflammatory diet. A lot of that means getting rid of red meat. My husband and I tried vegan for a while, and none of this was helping any of my symptoms. It was basically just torturing me more mentally because it was all-consuming.

Finally, The Right Surgeon, The Right Procedure

Tawnia Jacobson [0:14.32.20]: I talked about meeting the surgeon who basically changed my life. It was the excision surgery that changed my life. It was the appropriate treatment. My first surgery was ablation, which means they burn the tissue.  They don’t actually get rid of it, they just burn it, and hope to prevent it from growing back. The tissue, I guess it could be described as an iceberg. The tissue that you see is visible endometriosis, but lives much deeper than that. The part of the iceberg that you don’t see below the surface is actually the problem. You burn what you see, but you leave behind what you don’t see, and it will continue to grow. Since you’re in there basically irritating it, making it more angry, the endometriosis becomes worse. That’s why when I had my first surgery, within three to four months, I was feeling worse than I did before. We made it angry. Until I went to the correct surgeon and had the proper procedure done, my symptoms weren’t going to get any better.

Since having surgery, (a four-hour procedure), I was diagnosed with moderate endometriosis.
I did not have it on my diaphragm, Thank God, but  it was covering much of my pelvic orifice. It was growing on both ovaries and wrapped around ligaments. I had right leg pain that nobody ever paid any attention to but me. I would live from day-to-day, working out regularly, and then I would have to take one to two weeks off of my workouts at a time because my right leg was bothering me so much.

When I found the surgeon who ended up helping me, he didn’t even bat an eye.  As soon as I said “right leg pain down my back,” he was like, “Oh, yeah, your ligaments are involved.” And sure enough, when he went in there, the endometriosis was wrapped around my uterosacral ligaments. He had to dig down in there and clean that all out and I haven’t had any leg pain since surgery.

Carol Harnett [0:16:34.62]: You’re generous to share this. I know that when we look at data for why people go out of work and we look at their health data (we call it disability data), but it’s not the disability people think about. When we say disability data, we are almost always talking about illness or injuries that people have that prevent them from working — usually on a temporary basis.

Ablations and hysterectomies are procedures we’re seeing both in endometriosis and in perimenopausal women who are having difficulty with heavy bleeding. It’s interesting, too, because these procedures aren’t always successful in the perimenopausal population.  I did more background reading so I could ask you intelligent questions. I read about excision surgery and was disappointed to find that there’s a limited number of surgeons in the U.S. who have the expertise to do this surgery.

Tawnia Jacobson [0:17.29.92]: About 150, I think, worldwide.

Carol Harnett [0:17:33.91]: Yes, I think there’s about 100 in the U.S. When you think about it, I assume they’re clustered in bigger geographic areas. I think about women who this might be a good solution for — at least a strategy to manage it — those who may have to travel to see somebody who’s able to do this procedure. This is concerning because that may exclude women of certain means to be able to do that.  That always concerns me.

I actually didn’t ask you about this earlier when we started this show, or even when we’ve talked about this a little bit, but I think you referenced in one of your social media posts that there are some insurance limitations for some of the procedures. Did I remember that correctly?

Insurance Coverage and Financial Implications

Tawnia Jacobson [0:18.26.65]: Yeah, I’m going to be very careful with how I speak to this because I am not a professional in the industry. I can only speak to my personal experience, and I actually have a girlfriend who’s really going through a very frustrating situation herself with insurance regarding this.  I can say from my experience, yes, my surgeon was out of state. He was technically out-of-network, which is true for many women who are searching to find an endometriosis expert to treat them because they are very few and far between. Many of them are grouped together, like you said. We’re fortunate in New England to have in New York, Massachusetts and Maine certified surgeons who are experts in excision surgery but, unfortunately, your insurance does restrict you being able to go out of state. Lucky for me, my insurance at the time had an out-of-network option. The hospital, the lab and the anesthesia services were partly covered by my insurance. Now the surgeon himself is paid out of pocket simply because he doesn’t get reimbursed for the procedure.

This is where I’m going to be very careful with how I speak.  How I understand it is that there are basically no CPT codes for the excision surgery itself. They will lump it into the same category as ablation. My surgery was four hours long. My bowel was not involved, but many women do have bowel involvement which can sometimes involve a colorectal surgeon as well. So, if you’re in there 4 to 8 hours (sometimes 10 hours if you’re having diaphragm involvement as well) and you’re only getting reimbursed for an ablation procedure, which can be done in about an hour, you’re losing a lot of money.  That is a lot of time, energy and expense being put out there that you’re not getting reimbursed for. I believe that’s why many of these surgeons require out-of-pocket pay.

Carol Harnett [0:20:39.22]: You have to save!

Tawnia Jacobson [0:20.41.84]: Yeah exactly. My surgeon offered a payment plan. You spoke about people traveling; he gets patients from all over the world.  He had patients flying from India the week that I met him. He’s been doing this for 30 plus years so he is seeing people worldwide. It’s unfortunate because not everybody has the means to be able to do this.  When I was going through the process of finding a surgeon and scheduling surgery, I had befriended somebody through social media who lives in California. She was suffering so much and could not find a surgeon out there who was local and in-network for her insurance. She was fighting the good fight. She was appealing every time I turned around and she was just hoping and praying that she’d be able to find some loophole to be able to allow her to have excision surgery. I can proudly say today that she finally did get surgery! She had excision surgery in December, but I was at the point where I was like,  “Oh my God, I need to start saving money and fly her out here to see my surgeon,” because after I had surgery, I felt so much better. I want every person who is experiencing this pain to be able to find somebody who can help them because they deserve it.

Back to the insurance question -, my girlfriend is experiencing a very similar situation. She has had three ablation surgeries locally, at one of our local hospitals, and it’s not working for her. She needs excision and her insurance has denied her request, twice, to go see my surgeon in She’s still fighting, still trying to figure that out.

A Word About PPO Plans | More Options

Carol Harnett [0:22:19.74]: I’ll just add a quick point. I’ve been in and around insurance for the last ten plus years of my life, in addition to what I do at The Council for Disability Awareness., When you’re going through the open enrollment process, if your employer offers health insurance, (employers of a certain size are all required to offer health insurance) or have to go into the individual market yourself, it’s really important to make sure you’re in a preferred provider (PPO) plan.  At least when you go out of network, it’s pricey (you have a much more significant copay until you reach your out-of-pocket maximum), but at least it gives you options.

This advice applies not just for this situation, but for all situations, particularly if you want to go to what we would call a “center of excellence.” I would consider 100 surgeons in the country to be 100 separate centers of excellence for how to treat this condition — endometriosis — by excision.

This is not a push for you to buy more health insurance than you need.  A PPO health plan costs more money, but when you or one of your loved ones is impacted, you will be ever so thankful that you had options.

Carol Harnett [0:23:25.28]: I am looking at the clock and we have about 6 minutes and there are two questions I want to ask. You referenced a couple of times that when you were in high school you missed school and missed work.  Something that The Council for Disability Awareness focuses on is how illnesses, injuries and diseases can impact people’s ability to work.

The most recent research article I could find was published in 2017. The researchers studied the impact of endometriosis on work and life and said that on average (and the range is enormous), women lose about 5.3 hours per week to endometriosis. Whether that’s being absent or unable to do something, or not being able to do it in the way they normally could.

Can you talk a little bit more about how endometriosis impacted your ability to work for certain, but also your ability to do things in your own life?  I have met you as a very active person, so could you share with people what that is like.

Living and Working with Endometriosis

Tawnia Jacobson [0:24.51.98]: There were days missed from work, days where I had been up all night writhing in pain, or had a wicked headache and just felt terrible the next day and knew that I couldn’t function to my full capacity. That being said, fortunately for me, the worst of my symptoms developed about nine months before I had excision surgery and coincided with me  taking a new position at my job. It was a leadership role. It was administrative. I was putting so much time and energy into my new role, that it was depleting me to the point where between that and my symptoms, I couldn’t function in life outside of work.

I think the new job gave me the drive to get up every single day. Even though I was miserable mentally and physically, I had a purpose. I got up and would work four days a week, but I would then come home and be useless. I would be on the couch with a heat pack taking more ibuprofen than I had ever taken in my life.  Luckily, I had a husband who could pick up the pieces, but it wasn’t good for our relationship, and it was taking a toll on us. I just can’t help but think of women who are supporting themselves as single mothers, or women who are single and alone, and don’t have somebody to help them emotionally or physically.

I couldn’t cook, I couldn’t clean, and I didn’t do my own laundry. I was really kind of  useless outside of work. I had the ability to get there and do that, but that was kind of my purpose in life. I’ve often thought about if I hadn’t taken that new job, where would I be because I think I would have given up. I think I wouldn’t have wanted to get up anymore every single day. It’s funny how timing works out like that.  Prior to that position, I definitely missed a ton of work.

I definitely would call out. I said it used to be a week at a time,  and I would feel crummy, but then it became three weeks out of the month.  It was affecting me so much so that actually my words to my husband were: “I either have to find a surgeon who can help me or who believed my pain and my symptoms, or I have to be admitted to a mental institution, because something’s not right with me. I’m in a very dark place and I’m not myself.”  Those words really sent the message home, and he was like, “We have to do something.”

Fortunately for me, my something was Facebook and educating myself. I said it to you before and I have said it to other people, “It’s embarrassing. I’m a healthcare professional. I’ve studied science my entire life.” I didn’t know what endometriosis meant. I thought it just meant bad periods, painful bleeding, painful sex.  It was an excuse to me. Unfortunately, that’s what many people think and that’s the kind of the stigma you had mentioned. It’s a woman’s disease and women don’t normally talk about their reproductive systems. People don’t usually want to hear about women’s reproductive systems, and that’s unfortunate, because if we can tie this back to the beginning and talk about the prevalence being the same as diabetes. Diabetes isn’t always pretty either, and it affects every organ system in the body — just like endometriosis can affect almost every organ system in the body. Everyone’s symptoms might present a little bit differently, but they can involve major organ systems.

Carol Harnett [0:28:18.58]: I appreciate you sharing all that, particularly your comments about your mental health, because when I looked at this 2018 research study, they looked at lists of symptoms. The more symptoms you have, the more likely you are to be out of work for a period of time.  The number two symptom (pain being number one) was mental health, because people were feeling unaddressed and confused.

I am so grateful you’re talking about mental health because, by coincidence, we are live recording this on May 1st, which is the beginning of Mental Health Awareness Month, in addition to Disability Insurance Awareness Month, and I’ve committed to talking a lot about mental health.

We have 60 seconds left to our time together, so I’m going to ask for a 30 second headline. Looking back on what you know now, what’s the number one piece of advice you would give to people?

Tawnia’s Best Advice | Educate Yourself

Tawnia Jacobson [0:29.15.14]: Educate yourself. Don’t trust that the doctors know exactly what they’re talking about. I don’t say that negatively, because I work with physicians every single day, but they’re not all experts in what you’re experiencing. Be your own advocate; do your own research, and find the specialist in the area that you need.

For me, it was endometriosis; Nancy’s Nook saved my life. I wish I would have found that resource earlier. If people are struggling, go look at the documentary on endowhat.com. It is life-changing.  

Carol Harnett [0:29:48.41]: Thank you so much, Tawnia, for being our guest. In my opinion, this  is the best show we’ve ever done.

For everyone who has been listening, we hope this show has helped you.

I want to say thank you to all of our listeners. Have a great day, and there’ll be a transcript that accompanies this show so it is easier for  you to get all of the information that we referenced. We will make sure there’s links for all of it.

Thank you again, Tawnia.  

Tawnia Jacobson [0:30.11.97]: Thank you for having me –  such a great topic.




Trends in Disability Insurance Claims Management

Originally posted by Ian Bridgman at The Claim Lab April 30, 2019

Last month we started a series of newsletters (February) to introduce the concept of data enrichment of claims information and we discussed how this will help us to understand what’s really preventing return to work for complex claims.

Maybe for those short term disability plans of 3 to 6 months, the duration is driven by diagnosis. In the healthcare industry, recovery is measured over a 6 month period. So by its very nature a claim that has gone on longer than 6 months has complications…

We have been told for many years in the claims world that we should not over medicalize claims, yet when claim managers get stuck, they order an IME!

We know that the likelihood is that there is something else going on: work issues, poor motivation, anxiety, depression, domestic issues, medication dependence, etc. on top of the primary diagnosis.

These are the psychosocial factors, that after the first few months of a claim, should really be driving our claim management process.

An experienced claim manager could, probably after 7 mins on the phone, start to dig into some of these issues, BUT we don’t have many experienced claim managers any more, and if we do, their case loads are too high, and new claim managers are lacking the required skills.

Just imagine for a moment, that we had developed a way of understanding these psychosocial influencers without the need for an experienced claim manager!

Click here to read the full post at The Claim Lab


The Claim Lab is an organization that has been conceived to help Disability and Worker’s Compensation Insurance companies improve claims outcomes using innovative techniques.  Learn more at www.claimlab.org.




Podcast: What Every Employer Should Know About Social Security Disability Insurance



Introduction

Carol Harnett: [00:00:00] Hello, this is Carol Harnett. I’m the president of The Council for Disability Awareness. Welcome to our podcast, which is called The Financial Health and Income Network. Today we are going to talk specifically to employers about how Social Security Disability Insurance works and how it can help protect employees who can no longer work due to an illness or an injury.

What is important for employers to know in a grounding basis, around disability insurance products is that in the group insurance market, there is a product that most employers are probably familiar with called long term disability insurance. About one third of employees — according to the Bureau of Labor Statistics — in the United States have what’s called an LTD policy — a long term disability insurance policy — that’s either fully paid by the employer, or partially paid by the employer.

In addition to that, about half of Americans have some form of disability coverage, most of which makes up the difference. It is either a group policy that the employee pays all of the premium for instead of getting assistance from their employer, or they may be doing something called an individual disability insurance policy that they secure working directly with an agent or an advisor and an individual disability carrier.

Today we are going to focus on this very specific type of coverage that is provided by the federal government but has a very well-defined process, including a very well-defined approval process, application process, and review process. This is Social Security Disability Insurance.


You can hear the full podcast or if you’d rather read than listen, we captured the transcript from the conversation below.


Introducing Ted Norwood from IBI, Inc.

I’m really pleased to have a subject matter expert with us on the show today. My guest is Ted Norwood. He’s the general counsel and director of representation at Integrated Benefits, Inc. We are very pleased that IBI, which is their acronym, is a member of The Council for Disability Awareness and supports us. So we thank them for that. Welcome Ted. We’re so pleased to have you here with us today.

Ted Norwood: [00:02:21] Thanks Carol. It is a pleasure to be here. I’m really excited to let people know about how all this works because it is a frequently misunderstood system.

Carol Harnett: [00:02:36] If you don’t mind, I’m going to kick you off in the most basic of all things, which is: we assume that everybody understands what SSDI is, and with them we use the acronym all the time, and A, nobody even understands what the acronym means and B, really doesn’t understand what the coverage is. Can you go right to the basics and ground our employer listeners in that?

What is SSDI?

Ted Norwood: [00:03:08] Sure. SSDI– commonly just referred to as Social Security Disability– is a disability program through the federal government’s social security system that you pay into from your paycheck through your taxes.

It covers anyone that pays in. It doesn’t cover lots of federal employees, people that don’t pay those taxes. For instance, lots of teachers aren’t covered– they’re covered by different things. Railroad workers are covered by a separate policy, but they must pay in, and that differentiates it from the other social security disability program that people often combine with it or get confused by, which is SSI, or supplemental security income. This is a disability program for people that don’t have the work history or haven’t paid in. It’s a much smaller benefit.

SSDI is a better benefit; it’s a pretty strong benefit with an average payout of $1,600 a month. After being disabled for twenty-nine months, you become Medicare-eligible, and it will last until Social Security finds that you are no longer disabled or until you hit full retirement age. And they do reviews every two to five years of your case to see if you’re still disabled.

Although social security policy can bore some people– the big takeaway is that Social Security Disability is designed to work with long term disability to provide the best policies. A combination is the most important thing.

Carol Harnett: [00:05:08] That’s really well said and it’s a great basic summary. One thing I’d like to ask is– and I think some of our listeners are not familiar with — is I’ve often heard that you have to pay quote-unquote a certain amount of quarters into Social Security before you would become eligible for SSDI. What does that mean when people say that?

What is Elligibility for SSDI?

Ted Norwood: [00:05:35] It means you have to work a certain amount. You know, if you just go out and get a job and then claim disability right away, you haven’t really paid in enough to qualify. The rule is about 40 quarters, which is about 10 years of work. If you’re younger than that, there are formulas for adjusting that. When people are applying for Social Security disability, they usually have a significant amount of work history, and if they don’t have the work history, then they have to apply for the SSI. So most of your applicants are people that have a strong work record, but they’re not able to do the job that they’ve been doing anymore.

Carol Harnett: [00:06:32] Those are good points. When you say a strong work record, is that a nice way of saying that these are people who are older, who have worked for a period of time? If so, do you happen to know what the average age might be for a typical applicant?

Applicant Profile

Ted Norwood: [00:06:51] Uh-oh, I think I’m busted here because I don’t know what the average age of the typical applicant would be, but I would say it would skew older. Young people are covered. If you’re working at a salary job, odds are you’re probably covered if you’re going through, or if you have a steady job, or even steady seasonal work, but the average applicant is older. That’s probably mostly a factor of the wear and tear that goes on to your body after years of working. You know in your 20s and 30s you’re going to be stronger and more flexible, with better recovery and stuff, and less likely to have those over time injuries. So I would say that average applicant is probably around 50 if I had to guess.

Carol Harnett: [00:07:52] Okay, that seems fair. When I think about what I know about long term disability claims, we do know when people are younger that is often when we’ll see more accident related reasons for being out of work, while illness is usually the major reason why people are out on long term disability. Accidents will play a larger role the younger you are and then the older you are obviously illness tends to play the biggest role.

Now you just made a point that I think is really important for employers to understand, which is a big differentiator between long term disability insurance and SSDI, and that is this idea of what type of work are you disabled from? Are you disabled from your ability to do your own occupation, or your own job, or are you disabled from being able to do any kind of work? And can you shed some light for listeners on the requirements around your inability to work when you apply for SSDI?

Clarify the Inability to Work

Ted Norwood: [00:09:05] Absolutely. This is a critical difference between the private disability and this public disability. When people think that they’re disabled, and they can’t work as an engineer anymore, or they can’t work in their factory anymore, or as a teacher, they think: well, “I’m disabled.” If you have a private policy, then that’ll mean you will be disabled, probably for a couple of years at least.

Social Security is different. Social Security I call a “catastrophic” disability policy– that’s an unofficial term– but it only covers you if you’re disabled from any work. The language of the Act says from being able to perform jobs that exist in significant numbers. Once upon a time they liberally interpreted that and they’d cut you some slack, but over the last 15 or more years, they’ve really cracked down, and when they say significant numbers, I mean almost any job.

So, if you are, let’s say you’re 49 and and you had a really good job at a Ford plant, and you have some back problems. Maybe you had some cancer, something going on, something severe, you no longer can do that job. But if Social Security thinks that you can be a ticket taker at the movie theater on a full-time basis– which I don’t even know what movie theaters employ those people– they’re going to deny your case.  They use a lot of outdated information, which isn’t necessarily their fault, but it’s difficult and they’re very tough.

An important thing to understand is that if you’re relying on Social Security, you have to be really, really limited.  If you can’t do hard physical work, but you could do a sit-down job, there’s a really good chance you won’t get your Social Security. The terrible thing about that is that if you’re used to doing hard work, and then you want to transition to a sit-down job, it might be really hard, especially if you’re older, to transition to that. So you end up in this gap where Social Security says, “you’re not disabled, you’re capable of performing some jobs. You’re just unemployed.”  Meanwhile, unemployment says yeah, you’re unemployed; but you know, our insurance only lasts for so long, and it’s really tough for people to find the resources to be able to make those transitions and get those jobs.

Job Function Differentiation

Carol Harnett: [00:12:00] That’s a really fair point. In long term disability insurance– provided, both by an employer and bought individually by the consumer, does somebody quote-unquote meet the definition of disability? We don’t expect someone who’s done a job like a physician, for example, or a senior executive in a company, to do a job that goes outside of their knowledge, skills, and abilities. We don’t expect them to be that ticket taker at a movie theater. It’s a much closer alliance to work, that either is exactly like what they used to do, or similar to what they used to do, using transferable skills.

Sometimes, a surgeon may no longer be able to do surgery because she has a hand tremor, but she could do medical reviews for an insurance company. She could also see patients and screen them for whether they’re a candidate for surgery. That is big difference between a private disability insurance policy and a public one like SSDI, is that correct?

Accommodations for Work: Private vs. SSDI

Ted Norwood: [00:13:28] Yes, and I would add that lots of private policies that I’ve seen factor in income. For instance, you are a successful surgeon who develops a hand tremor. Although you might make several hundred thousand dollars a year, you will go to an insurance review physician position, and you are probably not going to come close to that salary.

The policies on the private side will lots of times accommodate that. They might say: “Hey, this is an offset– because you’re capable of doing this or we expect you to try to find this,” but they make up the difference. Social Security says that if you have a really solid job making $60,000 a year, but they think that you might still be able to do this job, which is minimum wage,  they expect you to go do it.

Carol Harnett: [00:14:34] Yes, I think that’s that is probably not on their radar.

Ted Norwood: [00:14:42] No. When I’ve talked to employers and when I talk to claimants and people in general, they really don’t know anything about it, I always tell them that that’s fine. Hopefully you don’t have to really ever know about the details of Social Security Disability. You find if you have to go through it, that’s really unfortunate, but once you become an employer, and you’re making decisions about whether or not to offer policies to your employees, it’s then it becomes important to understand what they’re really facing. If you think that someone will, they can just get on Social Security, you know, if they can’t work here– that’s not as easy as it may sound. Unfortunately. I wish it were.

Carol Harnett: [00:15:36] You mentioned an average benefit, but because we’re talking about the monetary side of Social Security now, can you help listeners understand the range of payments? And can you also clarify, is there a cap or a maximum that somebody might receive on Social Security Disability?

Payments

Ted Norwood: [00:16:02] Well sure. Once you go on Social Security Disability, your payment depends on your work history and your payment history. When I say your work history, that means what you’ve paid in. You don’t pay into Social Security if you make over a certain salary or income per year; you only pay up to a cap. The max benefit, what does it end up being? I think I want to say it’s about three thousand dollars, and it can go up if you have dependents because it gives you extra benefits if you have minor dependents during the same time you’re out. But you know, you can’t replace a large salary just on Social Security disability.

Carol Harnett: [00:17:00] And if there were a minimum payment?

Ted Norwood: [00:17:05] Well, the minimum payment would be about eight hundred dollars. The SSI benefit, which varies– and that’s for people that don’t have any SSDI coverage at all– usually is somewhere between five and eight hundred depending on all the factors that go into that. So SSDI is always going to be better than that.

And I say “always.” You know, whenever as a lawyer I say “always” that really just means “almost always.” Sure enough, some lawyer’s listening saying “no, that’s not true; here is the example where it’s different.” And yes, but speaking generally, for someone to take away,I would say, $800, but that’s very low.

Carol Harnett: [00:17:56] It’s not a lot of money; this is a monthly payment, just to clarify for our listeners.

Ted Norwood: [00:18:03] Yes. It’s a monthly payment.

Attorney Required

One of the things I should mention — talking about lawyers– another difference between private insurance and Social Security is you almost need to have a lawyer to get on Social Security [Disability]. If you have a terminal illness, you probably don’t, but you’re taking a risk doing it yourself. To use the Social Security’s Disability program, it’s strongly encouraged that you use an attorney– even by Social Security.

Private insurance, you don’t need an attorney to get on. Sometimes there are disputes between insurers and claimants, and you might need a specific type of attorney when that comes up. But for the most part, you don’t get an attorney to activate your private disability policy; that’s a big advantage, too.

Carol Harnett: [00:19:04] Yes. You’re leading right into the next question, which is: What is the process? How do you apply and when do you apply for Social Security disability? How does the process work and how quickly might you receive a decision?

The Application Process

Ted Norwood: [00:19:22] Social Security only covers disabilities that arise from a medically identified problem that will last for 12 months or more.

If you break both your legs, but you’re probably going to be better in six to eight months, then you won’t qualify. If there are complications with that and it ends up taking 12 months before you can go back to work, then you could qualify. However, Social Security’s going to look at that very suspiciously.

Once you are out, or once you know you’re probably going to be out for a year and facing a kind of a grim diagnosis — there’s a lot of really grim stuff we deal with in disability, obviously– then you should apply. Once you’re sure you’re not going to be able to do this for a long time, then you want to apply.

You can file online. Everyone should be online creating their My SSA Account, even if they’re not about to apply.  It’s good that Social Security’s trying to expand their online presence and getting that set up helps them out.  You can go online and apply. You can also go up to your district office; the same place where you get your Social Security card, and file an application. Social Security will take it, make sure you have coverage for SSDI. Then, they send it out to the state agency, which is a federally-funded state agency.

Evaluation

They will evaluate you. The first step takes somewhere between two and six months, and this depends on how quickly they get your doctor’s records, how backed up they are, how difficult your case is, and if they have to send you to an exam.

After the initial evaluation, there’s about a 35% chance of being awarded– which means a 65% chance of being denied. The next step is to then file a reconsideration, which is just a review by that same state agency. There are certain regions in the country currently where you don’t have to file for reconsideration, but Social Security just changed that and they’re moving to everyone going back to reconsideration.


Annual Chart for SSDI’s Overall Award/Denials at Each Level


Reconsideration

Reconsideration. It’s the exact same process again, but they have someone else at the agency look at it. Obviously since it’s the same agency, they’re not going to have the same award rate of their own denial, so it’s about a 15% chance they’ll pay that case. So an 85% chance you’re going to be denied.

Now you are 6 to 12 months into your application and you still don’t have benefits. Now you request a hearing with an administrative law judge. Your case gets back to the federal Social Security program. They’ll assign your case to a hearing office, which is different than your district office, and there’s a long wait for that. It’s somewhere between 12 and 20 months. Depending on where you are, there are a few offices that are under 12 months, and there are some offices that are getting close to 30 months of waiting time.

Building a Case

Now you wait and you build your case. Hopefully you keep going to the doctor. You don’t get any benefits, or any insurance, and you wait until you get in front of a judge. You explain your case to the judge, and you’ll give him all of you medical records that you can get a hold of, and he’ll make a decision. Hopefully you have a good attorney.

At that point you have about a 45 percent chance to be awarded. If you’re denied by an ALJ you do have an appeal within Social Security to their Appeals Council. It’s another year usually and they don’t send many cases back because they’re really trying to not add to that backlog they already have and they basically dare you to take your case to Federal Court.

Appeals in Federal Court

If you talk to your attorney and they want to take your case to Federal Court, you can do that. The courts love this because courts are ALWAYS looking to have lots of cases– that’s a lawyer joke!  Social Security floods the courts with these cases. At that point, your case is no longer actually in the agency, it’s in federal court, and you’re actually suing Social Security and saying, “hey, you guys didn’t follow your own rules, and you wrongfully denied my disability.”


Click to get average wait time for a hearing in your area.


The odss are 50/50 in the federal courts, but it’s important to remember that most attorneys will only take very strong cases to federal court. It’s a really long, difficult process and you can’t just take your chances up there. You’ve got to have a really good case now. I will say this: most attorneys only take really good cases to begin with.

One thing that’s important is there’s a myth of disability fraud, It doesn’t really exist, because you have to work so long to get coverage to even qualify. If you haven’t worked enough, your scam isn’t going to work, because you just can’t get benefits. You get awarded, only after a long, difficult process. That is, if you work long enough to qualify. You go two years without income, and then all you get is $1,800 a month, which is certainly less than you were making before. So it’s a really, really bad scam. But people continue to think there’s a lot of fraud, when most of the rot is actually on the inside.

Carol Harnett: [00:26:00] I would ask a clarifying question: you’ve mentioned having an attorney help you with your case. Is there a charge for people when they have an attorney help?

Associated Attorney Fees

Ted Norwood: [00:26:11] Social Security has really set some strict rules on on fees, and your fee always has to be approved by Social Security. You cannot charge a fee up front. All fees are– if the claimant is paying it– your fee has to be contingent, and the max you can get is 25 percent. If you use Social Security’s fee agreement, the cap is $6,000. An attorney can charge their fees and expenses to a claimant. Most do, but some don’t though, and some attorneys will ask for money up front to hold to cover expenses and stuff, but most don’t. It’s pretty much free for you to get the attorney to do their work, but they’ll only take your case if they think they can win. If they don’t think you have a case then it’s not a sound business decision for them.

Carol Harnett: [00:27:08] Great. Well, I can’t believe how fast this time is going. We have a little less than three minutes.

Ted Norwood: [00:27:14] I saw that.

Carol Harnett: [00:27:16] I had to look at my list of questions and I think the best one to choose at this point is: in your experience what final closing words of advice would you give to employers when you think about disability in general and Social Security disability insurance on top of that?

Final Word to Employers

Ted Norwood: [00:27:35] Group private disability insurance is a pretty affordable benefit, and it is a lifesaver for your employees if they go out of work. Fighting with Social Security is so hard. Everyone we represent that has LTD says, “that $10 a month was the best decision I ever made.” They get their benefits quicker. They still have to go through the Social Security process, because there’s an offset to that LTD, but they have money, they’re getting something. They’re not scrambling.

Social Security– if you have to wait for Social Security, it doesn’t just decimate your spirit and your income; it decimates your insurance coverage; your ability to pay for the doctors, who eventually stop seeing you. It ruins marriages and relationships and strains your family because people lose their houses. And it is long and difficult and tragic. It’s so affordable and such a good benefit to give to your employees. When they go out sick, or they get cancer, they wear down– and they’re better-taken care of. I believe in it,  and it was not even on my radar when I came out of law school; I hope employers at least look into it.

Carol Harnett: [00:29:08] Well said. I’ve known a gentleman by the name of Dick Mucci who currently runs the group insurance operation at Lincoln Financial. He has worked in and around individual disability and group disability, the private industry, his whole career. He has always said he couldn’t imagine why employers wouldn’t provide long-term disability coverage. It’s difficult for an employer to lay someone off after three or six months and leave them without some form of an income to help them get through long term disability.

So with that, Ted, I’m going to say, thank you so much for the information you shared. It’s been a privilege to have you on this show.

Ted Norwood: [00:29:54] Thanks for having me; I appreciate it. Good luck, everyone.

Carol Harnett: [00:29:57] Thank you, everyone. Bye-bye.


Click below for more articles from Ted Norwood about Social Security Disability Insurance.




Windfall or Investment? How to Make the Most of that Tax Refund


Are you on track to receive a tax refund? If so, it can feel like a windfall or even like winning the lottery. The natural desire to spend “found money” can easily spiral into ideas of grandeur. While jetting off on vacation, or buying that new gas grille, are worthy causes, take a pause. There are a few financial strategies you might consider first.


In response to a new NerdWallet.com survey, 54% of folks who expect to get a refund said they plan to save or invest the money….And some of them actually will!


Pay Down Credit Card Debt

If you have run up your credit cards over the year, paying off the balance should be your first step. That’s because unpaid charges come with a hefty interest rate that can mean you wind up paying even more for everything you’ve purchased. Whittling down debt should top your financial “to-do” list. Applying a tax refund can take care of a large amount of this in one fell swoop. This gives you a highly motivating head start.

Set Up An Emergency Fund

Are you one of the 60 percent of Americans who can’t cover an unexpected $1,000 expense? Building up your emergency fund can be a smart move to help you with those unexpected realities of life—from faulty car brakes to a leaky roof to a sick pet. Just remember that the money should only be used for true “emergencies” (and no, a sale at your favorite department store doesn’t count).

Time for Home Improvements

While saving for a rainy day might be fiscally responsible, it also might strike you as a little boring. Tackling important home improvements can give you the benefit of improving the value of your home—while giving you something you can enjoy today. According to Remodeling magazine’s 2019 Cost Vs. Value report, the top home improvement that brings the most value is a garage door replacement, while other top projects that will simultaneously boost your satisfaction include minor kitchen remodels and deck additions.

Another smart choice—although, admittedly, less exciting than a sparkling new kitchen—is to make energy upgrades. Believe it or not, when Remodeling Magazine used to include insulation on its list of home improvement projects, attic insulation had an astonishing 117 percent ROI. Adding insulation and other energy-efficient features may also allow you to keep more money in your wallet all year long in the form of reduced energy bills.

Share Some Goodwill – Make a Donation

Spending money on yourself is fun—but spending it on someone else can feel even better. If there’s a cause you’ve been wanting to support, allocating part of your refund to a local school or women’s shelter can put a spring in your step that no new sandals ever could.

Reward Yourself

Of course, we don’t want to be spoilsports. Sometimes getting a tax refund is a fun way to reward yourself for the hard work you’ve done all year. So by all means, earmark it for a whim. Use it for a long weekend at a nearby resort or a wardrobe refresh. Just make sure that any choices you make today won’t impact your financial future. Perhaps consider allocating the majority of the refund to one of the financial goals above. Then, use a small percentage for a planned splurge. Ensure that you identify exactly what you’re spending it for. Letting the money absorb back into your account, or spending it something forgettable won’t have the same emotional impact as putting it toward something specific and enjoyable, even if it means delaying the gratification.

Review and Adjust Your Withholding

Remember, as exciting as it is to get what feels like a windfall as a tax return, that money actually is yours. It could have been in your paycheck all year long. Having that extra bump throughout the year can allow you to keep your emergency fund strong. It also can be the difference in paying off your credit card bills in full. This offers ongoing financial rewards. You could also use it for a weekly date night or support the nearby senior center regularly.

If you’d like to revisit your withholding to potentially make changes, talk to your HR department. They can help review your current status and the paperwork required to change it. Of course, it’s always wise to talk with a tax professional if you have any questions. But letting Uncle Sam keep your money all year—interest free!—is rarely the best use for it.





An Employer’s Guide to Understanding Social Security Disability Insurance



Introduction

Carol Harnett: [00:00:00] Hello, this is Carol Harnett. I’m the president of The Council for Disability Awareness. Welcome to our podcast, which is called The Financial Health and Income Network. Today we are going to talk specifically to employers about how Social Security Disability Insurance works and how it can help protect employees who can no longer work due to an illness or an injury.

What is important for employers to know in a grounding basis, around disability insurance products is that in the group insurance market, there is a product that most employers are probably familiar with called long term disability insurance. About one third of employees — according to the Bureau of Labor Statistics — in the United States have what’s called an LTD policy — a long term disability insurance policy — that’s either fully paid by the employer, or partially paid by the employer.

In addition to that, about half of Americans have some form of disability coverage, most of which makes up the difference. It is either a group policy that the employee pays all of the premium for instead of getting assistance from their employer, or they may be doing something called an individual disability insurance policy that they secure working directly with an agent or an advisor and an individual disability carrier.

Today we are going to focus on this very specific type of coverage that is provided by the federal government but has a very well-defined process, including a very well-defined approval process, application process, and review process. This is Social Security Disability Insurance.


You can hear the full podcast or if you’d rather read than listen, we captured the transcript from the conversation below.


Introducing Ted Norwood from IBI, Inc.

I’m really pleased to have a subject matter expert with us on the show today. My guest is Ted Norwood. He’s the general counsel and director of representation at Integrated Benefits, Inc. We are very pleased that IBI, which is their acronym, is a member of The Council for Disability Awareness and supports us. So we thank them for that. Welcome Ted. We’re so pleased to have you here with us today.

Ted Norwood: [00:02:21] Thanks Carol. It is a pleasure to be here. I’m really excited to let people know about how all this works because it is a frequently misunderstood system.

Carol Harnett: [00:02:36] If you don’t mind, I’m going to kick you off in the most basic of all things, which is: we assume that everybody understands what SSDI is, and with them we use the acronym all the time, and A, nobody even understands what the acronym means and B, really doesn’t understand what the coverage is. Can you go right to the basics and ground our employer listeners in that?

What is SSDI?

Ted Norwood: [00:03:08] Sure. SSDI– commonly just referred to as Social Security Disability– is a disability program through the federal government’s social security system that you pay into from your paycheck through your taxes.

It covers anyone that pays in. It doesn’t cover lots of federal employees, people that don’t pay those taxes. For instance, lots of teachers aren’t covered– they’re covered by different things. Railroad workers are covered by a separate policy, but they must pay in, and that differentiates it from the other social security disability program that people often combine with it or get confused by, which is SSI, or supplemental security income. This is a disability program for people that don’t have the work history or haven’t paid in. It’s a much smaller benefit.

SSDI is a better benefit; it’s a pretty strong benefit with an average payout of $1,600 a month. After being disabled for twenty-nine months, you become Medicare-eligible, and it will last until Social Security finds that you are no longer disabled or until you hit full retirement age. And they do reviews every two to five years of your case to see if you’re still disabled.

Although social security policy can bore some people– the big takeaway is that Social Security Disability is designed to work with long term disability to provide the best policies. A combination is the most important thing.

Carol Harnett: [00:05:08] That’s really well said and it’s a great basic summary. One thing I’d like to ask is– and I think some of our listeners are not familiar with — is I’ve often heard that you have to pay quote-unquote a certain amount of quarters into Social Security before you would become eligible for SSDI. What does that mean when people say that?

What is Elligibility for SSDI?

Ted Norwood: [00:05:35] It means you have to work a certain amount. You know, if you just go out and get a job and then claim disability right away, you haven’t really paid in enough to qualify. The rule is about 40 quarters, which is about 10 years of work. If you’re younger than that, there are formulas for adjusting that. When people are applying for Social Security disability, they usually have a significant amount of work history, and if they don’t have the work history, then they have to apply for the SSI. So most of your applicants are people that have a strong work record, but they’re not able to do the job that they’ve been doing anymore.

Carol Harnett: [00:06:32] Those are good points. When you say a strong work record, is that a nice way of saying that these are people who are older, who have worked for a period of time? If so, do you happen to know what the average age might be for a typical applicant?

Applicant Profile

Ted Norwood: [00:06:51] Uh-oh, I think I’m busted here because I don’t know what the average age of the typical applicant would be, but I would say it would skew older. Young people are covered. If you’re working at a salary job, odds are you’re probably covered if you’re going through, or if you have a steady job, or even steady seasonal work, but the average applicant is older. That’s probably mostly a factor of the wear and tear that goes on to your body after years of working. You know in your 20s and 30s you’re going to be stronger and more flexible, with better recovery and stuff, and less likely to have those over time injuries. So I would say that average applicant is probably around 50 if I had to guess.

Carol Harnett: [00:07:52] Okay, that seems fair. When I think about what I know about long term disability claims, we do know when people are younger that is often when we’ll see more accident related reasons for being out of work, while illness is usually the major reason why people are out on long term disability. Accidents will play a larger role the younger you are and then the older you are obviously illness tends to play the biggest role.

Now you just made a point that I think is really important for employers to understand, which is a big differentiator between long term disability insurance and SSDI, and that is this idea of what type of work are you disabled from? Are you disabled from your ability to do your own occupation, or your own job, or are you disabled from being able to do any kind of work? And can you shed some light for listeners on the requirements around your inability to work when you apply for SSDI?

Clarify the Inability to Work

Ted Norwood: [00:09:05] Absolutely. This is a critical difference between the private disability and this public disability. When people think that they’re disabled, and they can’t work as an engineer anymore, or they can’t work in their factory anymore, or as a teacher, they think: well, “I’m disabled.” If you have a private policy, then that’ll mean you will be disabled, probably for a couple of years at least.

Social Security is different. Social Security I call a “catastrophic” disability policy– that’s an unofficial term– but it only covers you if you’re disabled from any work. The language of the Act says from being able to perform jobs that exist in significant numbers. Once upon a time they liberally interpreted that and they’d cut you some slack, but over the last 15 or more years, they’ve really cracked down, and when they say significant numbers, I mean almost any job.

So, if you are, let’s say you’re 49 and and you had a really good job at a Ford plant, and you have some back problems. Maybe you had some cancer, something going on, something severe, you no longer can do that job. But if Social Security thinks that you can be a ticket taker at the movie theater on a full-time basis– which I don’t even know what movie theaters employ those people– they’re going to deny your case.  They use a lot of outdated information, which isn’t necessarily their fault, but it’s difficult and they’re very tough.

An important thing to understand is that if you’re relying on Social Security, you have to be really, really limited.  If you can’t do hard physical work, but you could do a sit-down job, there’s a really good chance you won’t get your Social Security. The terrible thing about that is that if you’re used to doing hard work, and then you want to transition to a sit-down job, it might be really hard, especially if you’re older, to transition to that. So you end up in this gap where Social Security says, “you’re not disabled, you’re capable of performing some jobs. You’re just unemployed.”  Meanwhile, unemployment says yeah, you’re unemployed; but you know, our insurance only lasts for so long, and it’s really tough for people to find the resources to be able to make those transitions and get those jobs.

Job Function Differentiation

Carol Harnett: [00:12:00] That’s a really fair point. In long term disability insurance– provided, both by an employer and bought individually by the consumer, does somebody quote-unquote meet the definition of disability? We don’t expect someone who’s done a job like a physician, for example, or a senior executive in a company, to do a job that goes outside of their knowledge, skills, and abilities. We don’t expect them to be that ticket taker at a movie theater. It’s a much closer alliance to work, that either is exactly like what they used to do, or similar to what they used to do, using transferable skills.

Sometimes, a surgeon may no longer be able to do surgery because she has a hand tremor, but she could do medical reviews for an insurance company. She could also see patients and screen them for whether they’re a candidate for surgery. That is big difference between a private disability insurance policy and a public one like SSDI, is that correct?

Accommodations for Work: Private vs. SSDI

Ted Norwood: [00:13:28] Yes, and I would add that lots of private policies that I’ve seen factor in income. For instance, you are a successful surgeon who develops a hand tremor. Although you might make several hundred thousand dollars a year, you will go to an insurance review physician position, and you are probably not going to come close to that salary.

The policies on the private side will lots of times accommodate that. They might say: “Hey, this is an offset– because you’re capable of doing this or we expect you to try to find this,” but they make up the difference. Social Security says that if you have a really solid job making $60,000 a year, but they think that you might still be able to do this job, which is minimum wage,  they expect you to go do it.

Carol Harnett: [00:14:34] Yes, I think that’s that is probably not on their radar.

Ted Norwood: [00:14:42] No. When I’ve talked to employers and when I talk to claimants and people in general, they really don’t know anything about it, I always tell them that that’s fine. Hopefully you don’t have to really ever know about the details of Social Security Disability. You find if you have to go through it, that’s really unfortunate, but once you become an employer, and you’re making decisions about whether or not to offer policies to your employees, it’s then it becomes important to understand what they’re really facing. If you think that someone will, they can just get on Social Security, you know, if they can’t work here– that’s not as easy as it may sound. Unfortunately. I wish it were.

Carol Harnett: [00:15:36] You mentioned an average benefit, but because we’re talking about the monetary side of Social Security now, can you help listeners understand the range of payments? And can you also clarify, is there a cap or a maximum that somebody might receive on Social Security Disability?

Payments

Ted Norwood: [00:16:02] Well sure. Once you go on Social Security Disability, your payment depends on your work history and your payment history. When I say your work history, that means what you’ve paid in. You don’t pay into Social Security if you make over a certain salary or income per year; you only pay up to a cap. The max benefit, what does it end up being? I think I want to say it’s about three thousand dollars, and it can go up if you have dependents because it gives you extra benefits if you have minor dependents during the same time you’re out. But you know, you can’t replace a large salary just on Social Security disability.

Carol Harnett: [00:17:00] And if there were a minimum payment?

Ted Norwood: [00:17:05] Well, the minimum payment would be about eight hundred dollars. The SSI benefit, which varies– and that’s for people that don’t have any SSDI coverage at all– usually is somewhere between five and eight hundred depending on all the factors that go into that. So SSDI is always going to be better than that.

And I say “always.” You know, whenever as a lawyer I say “always” that really just means “almost always.” Sure enough, some lawyer’s listening saying “no, that’s not true; here is the example where it’s different.” And yes, but speaking generally, for someone to take away,I would say, $800, but that’s very low.

Carol Harnett: [00:17:56] It’s not a lot of money; this is a monthly payment, just to clarify for our listeners.

Ted Norwood: [00:18:03] Yes. It’s a monthly payment.

Attorney Required

One of the things I should mention — talking about lawyers– another difference between private insurance and Social Security is you almost need to have a lawyer to get on Social Security [Disability]. If you have a terminal illness, you probably don’t, but you’re taking a risk doing it yourself. To use the Social Security’s Disability program, it’s strongly encouraged that you use an attorney– even by Social Security.

Private insurance, you don’t need an attorney to get on. Sometimes there are disputes between insurers and claimants, and you might need a specific type of attorney when that comes up. But for the most part, you don’t get an attorney to activate your private disability policy; that’s a big advantage, too.

Carol Harnett: [00:19:04] Yes. You’re leading right into the next question, which is: What is the process? How do you apply and when do you apply for Social Security disability? How does the process work and how quickly might you receive a decision?

The Application Process

Ted Norwood: [00:19:22] Social Security only covers disabilities that arise from a medically identified problem that will last for 12 months or more.

If you break both your legs, but you’re probably going to be better in six to eight months, then you won’t qualify. If there are complications with that and it ends up taking 12 months before you can go back to work, then you could qualify. However, Social Security’s going to look at that very suspiciously.

Once you are out, or once you know you’re probably going to be out for a year and facing a kind of a grim diagnosis — there’s a lot of really grim stuff we deal with in disability, obviously– then you should apply. Once you’re sure you’re not going to be able to do this for a long time, then you want to apply.

You can file online. Everyone should be online creating their My SSA Account, even if they’re not about to apply.  It’s good that Social Security’s trying to expand their online presence and getting that set up helps them out.  You can go online and apply. You can also go up to your district office; the same place where you get your Social Security card, and file an application. Social Security will take it, make sure you have coverage for SSDI. Then, they send it out to the state agency, which is a federally-funded state agency.

Evaluation

They will evaluate you. The first step takes somewhere between two and six months, and this depends on how quickly they get your doctor’s records, how backed up they are, how difficult your case is, and if they have to send you to an exam.

After the initial evaluation, there’s about a 35% chance of being awarded– which means a 65% chance of being denied. The next step is to then file a reconsideration, which is just a review by that same state agency. There are certain regions in the country currently where you don’t have to file for reconsideration, but Social Security just changed that and they’re moving to everyone going back to reconsideration.


Annual Chart for SSDI’s Overall Award/Denials at Each Level


Reconsideration

Reconsideration. It’s the exact same process again, but they have someone else at the agency look at it. Obviously since it’s the same agency, they’re not going to have the same award rate of their own denial, so it’s about a 15% chance they’ll pay that case. So an 85% chance you’re going to be denied.

Now you are 6 to 12 months into your application and you still don’t have benefits. Now you request a hearing with an administrative law judge. Your case gets back to the federal Social Security program. They’ll assign your case to a hearing office, which is different than your district office, and there’s a long wait for that. It’s somewhere between 12 and 20 months. Depending on where you are, there are a few offices that are under 12 months, and there are some offices that are getting close to 30 months of waiting time.

Building a Case

Now you wait and you build your case. Hopefully you keep going to the doctor. You don’t get any benefits, or any insurance, and you wait until you get in front of a judge. You explain your case to the judge, and you’ll give him all of you medical records that you can get a hold of, and he’ll make a decision. Hopefully you have a good attorney.

At that point you have about a 45 percent chance to be awarded. If you’re denied by an ALJ you do have an appeal within Social Security to their Appeals Council. It’s another year usually and they don’t send many cases back because they’re really trying to not add to that backlog they already have and they basically dare you to take your case to Federal Court.

Appeals in Federal Court

If you talk to your attorney and they want to take your case to Federal Court, you can do that. The courts love this because courts are ALWAYS looking to have lots of cases– that’s a lawyer joke!  Social Security floods the courts with these cases. At that point, your case is no longer actually in the agency, it’s in federal court, and you’re actually suing Social Security and saying, “hey, you guys didn’t follow your own rules, and you wrongfully denied my disability.”


Click to get average wait time for a hearing in your area.


The odss are 50/50 in the federal courts, but it’s important to remember that most attorneys will only take very strong cases to federal court. It’s a really long, difficult process and you can’t just take your chances up there. You’ve got to have a really good case now. I will say this: most attorneys only take really good cases to begin with.

One thing that’s important is there’s a myth of disability fraud, It doesn’t really exist, because you have to work so long to get coverage to even qualify. If you haven’t worked enough, your scam isn’t going to work, because you just can’t get benefits. You get awarded, only after a long, difficult process. That is, if you work long enough to qualify. You go two years without income, and then all you get is $1,800 a month, which is certainly less than you were making before. So it’s a really, really bad scam. But people continue to think there’s a lot of fraud, when most of the rot is actually on the inside.

Carol Harnett: [00:26:00] I would ask a clarifying question: you’ve mentioned having an attorney help you with your case. Is there a charge for people when they have an attorney help?

Associated Attorney Fees

Ted Norwood: [00:26:11] Social Security has really set some strict rules on on fees, and your fee always has to be approved by Social Security. You cannot charge a fee up front. All fees are– if the claimant is paying it– your fee has to be contingent, and the max you can get is 25 percent. If you use Social Security’s fee agreement, the cap is $6,000. An attorney can charge their fees and expenses to a claimant. Most do, but some don’t though, and some attorneys will ask for money up front to hold to cover expenses and stuff, but most don’t. It’s pretty much free for you to get the attorney to do their work, but they’ll only take your case if they think they can win. If they don’t think you have a case then it’s not a sound business decision for them.

Carol Harnett: [00:27:08] Great. Well, I can’t believe how fast this time is going. We have a little less than three minutes.

Ted Norwood: [00:27:14] I saw that.

Carol Harnett: [00:27:16] I had to look at my list of questions and I think the best one to choose at this point is: in your experience what final closing words of advice would you give to employers when you think about disability in general and Social Security disability insurance on top of that?

Final Word to Employers

Ted Norwood: [00:27:35] Group private disability insurance is a pretty affordable benefit, and it is a lifesaver for your employees if they go out of work. Fighting with Social Security is so hard. Everyone we represent that has LTD says, “that $10 a month was the best decision I ever made.” They get their benefits quicker. They still have to go through the Social Security process, because there’s an offset to that LTD, but they have money, they’re getting something. They’re not scrambling.

Social Security– if you have to wait for Social Security, it doesn’t just decimate your spirit and your income; it decimates your insurance coverage; your ability to pay for the doctors, who eventually stop seeing you. It ruins marriages and relationships and strains your family because people lose their houses. And it is long and difficult and tragic. It’s so affordable and such a good benefit to give to your employees. When they go out sick, or they get cancer, they wear down– and they’re better-taken care of. I believe in it,  and it was not even on my radar when I came out of law school; I hope employers at least look into it.

Carol Harnett: [00:29:08] Well said. I’ve known a gentleman by the name of Dick Mucci who currently runs the group insurance operation at Lincoln Financial. He has worked in and around individual disability and group disability, the private industry, his whole career. He has always said he couldn’t imagine why employers wouldn’t provide long-term disability coverage. It’s difficult for an employer to lay someone off after three or six months and leave them without some form of an income to help them get through long term disability.

So with that, Ted, I’m going to say, thank you so much for the information you shared. It’s been a privilege to have you on this show.

Ted Norwood: [00:29:54] Thanks for having me; I appreciate it. Good luck, everyone.

Carol Harnett: [00:29:57] Thank you, everyone. Bye-bye.


Click below for more articles from Ted Norwood about Social Security Disability Insurance.




How Employer-Provided Disability Insurance Can Help When SSDI Falls Short

Important details about employer paid insurance to help fill the gap when social security income is delayed or falls short

Half of American workers have some sort of disability coverage: either employer-paid long term disability insurance, one they pay for through an agent, and/ or one funded by the federal government called Social Security Disability Insurance (or SSDI). Below are facts regarding SSDI and LTD. It is important for employers to know that SSDI is designed to work with long term disability to provide the best policies for employees.

The following content has been provided to the CDA by Ted Norwood, the General Counsel and Director of Representation, at Integrated Benefits, Inc.

The Relationship Between SSDI and Private Group Insurance


  • According to the Council for Disability Awareness, half of those who don’t work for the government have some form of employer-paid disability insurance. This could be short-term disability only, long-term disability only, or both STD and LTD. These benefits are important because 25 percent of today’s 20-year-olds will at some point miss a year or more of work due to medical problems.
  • As companies become leaner, employees become even more vital to the organization’s success and more difficult and expensive to replace. In the long term, losing employees is difficult. Certainly, an increasing number of employers recognize the value of employee well-being. In fact, many companies now recognize the value of caring for employees as people, not just assets.  Therefore, private disability insurance benefits in the workplace is an important way for employers to care for employee financial health.
  • About half of workers in the private sector do not have income-replacement benefits. If they’re unable to work for an extended period of time, they must rely on the Social Security Administration’s Disability Income (SSDI) program – if they qualify – to partially replace their salaries.


Facts About SSDI


  • You must have worked to qualify and made Social Security contributions. (Teachers often do not make Social Security contributions.)
  • You must qualify medically and vocationally.
  • SSA does not consider income in its evaluation of disability.
  • The SSA only evaluates whether an individual could perform the function of a job that exists.
  • SSDI Application Process – The wait is long (15 months or more). It can be challenging to get approved, and it lacks good recovery resources.


Group Long Term Disability Policies Protect Employees from the Disadvantages of SSDI


  • These LTD policies usually start with an own-occupation period of two years. As a result, the employee receive benefits immediately on completion of the elimination period (3 or 6 months).
  • Group LTD policies usually pay higher benefits than SSDI does. They typically treat SSDI benefits as an “offset” which means the additional coverage is available at an affordable price.
  • Group insurers typically require claimants to apply for SSDI benefits, but most of them will also provide a lawyer to assist with the applications.
  • Group LTD policies have better opportunities to provide vocational rehabilitation and return to work services.


For more from Ted Norwood on SSDI check out the following articles:





How Supplemental Benefits Complement an Employer’s Benefits Package


How Supplemental Benefits Work and How Employers Can Maximize Them


Carol Harnett [00:04.40]: Hi everyone, this is Carol Harnett. I am the president for the Council for Disability Awareness. The name of our show is the Financial Health and Income Network.

The Council for Disability Awareness is doing a campaign to help employers plan for annual enrollment for employees in 2019. The purpose is to give them material to consider, and help direct, motivate and shape their planning this year. Today’s topic is one that’s become particularly important over the last decade or more. The topic is something that’s called supplemental benefits.


Listen to the full podcast here, or if you’d rather read than listen, we captured the transcript from the conversation below.


I’m really pleased today to introduce our guest, Phil Bruen. He is the vice president for group life and disability products at MetLife. MetLife is a founding sponsor of the Council for Disability Awareness. We are so pleased and thankful for their support and particularly pleased to have Phil here today. Welcome Phil.

Phil Bruen [01:05.36]:  Hello Carol. Hello everyone. I’m glad to be here.

Carol Harnett [01:09.85]: Great! Well, without wasting any time, let’s get into this topic of supplemental benefits. Let’s just start with something really basic for people who might not be clear.  What are supplemental benefits?

Phil Bruen [01:25]: Thanks, Carol. Actually, as I think about it, we do hear the term supplemental benefits everywhere. I’d like to introduce the concept of thinking of these as complementary benefits to a core benefit program. When we think about supplemental, it’s something on top of, or an additive to supplement the benefits an individual has. A better way to think about it instead is that they’re highly complementary to a core benefit plan.

We also think about these in three categories which could include core benefits. One would be those benefits that help individuals in a broad sense around health. The second would be those benefits that help an individual with life that could be life insurance. Health protection, life protection and financial protection.

Within those categories, there are different types of benefits that can be offered.  

When you think about financial protection and a voluntary benefit that’s very popular would be legal services. That could help individuals with estate planning and wills, or something like a speeding ticket.  It’s as simple as that. Accesss to a high-quality network of attorneys, nationally certified. It’s become a very popular benefit. Worksite property and casualty is another one that you could consider as financial protection.

Certainly, a healthcare plan is foundational. I’d suggest that disability is another foundational benefit because it protects an individual’s income. It is an employer-paid benefit and dental usually falls in that core benefit category. But it can be offered on a voluntary basis.

The way I think about it, first as a suite of benefits to offer an employer to help meet their needs that are complementary to an employer-paid program or a benefit plan. That’s how I would suggest we think about supplemental benefits in general.

Carol Harnett [03:56.88]: I like that Phil.. You’re the first time I’ve heard that called it complementary. It doesn’t mean others haven’t it’s just the first time I’ve heard it.  If I’m connecting this correctly, supplemental benefits are interchanged with voluntary benefits, and I like this idea of a suite of benefits that complement the core. I think that’s really important. Since you’ve sort of foreshadowed this idea of core benefits and complementary benefits, why should an employer consider adding them to their employee benefits package?

Phil Bruen [04:39.89]: Great question. I think the first and foremost reason is really what’s happening with an employer’s health care plan.

If I think of that category of health protection. The health care plan is foundational, but with rise of employer-offered medical with high deductible, employees or dependents, could be left with significant out-of-pocket costs they simply can’t afford. As an example, in last year’s MetLife Employee Benefit Trend Study, more than half of U.S. workers live paycheck-to-paycheck. The Federal Reserve reported that 40% of Americans could not afford an unexpected $400 cost. If we have a medical episode, and that bill is likely more than $400, having a benefit like critical illness, accident or hospital indemnity, can help fill those gaps in for those unexpected moments that tie really to health and health protection.

Carol Harnett [05:52.94]: Thank you. I think that’s a great example. If you don’t mind, I’ll ask you to continue on that. This is some of the more popular complementary benefits that I’ve heard spoken of, particularly leading with the critical illness benefit. Can you help people understand what those products are actually designed to do and what they cover.?

Phil Bruen [06:20.98]: Absolutely. What’s great about these benefits is that they tend to fit four different employee populations. If you think of someone who has a lot of children, or are in a younger population, versus someone who might be a little bit more mature in the organization, they may have different needs. They also may have different budgets related to the health care plan and what might be unexpected. We found that accident, critical illness and hospital indemnity have some of the lowest understanding scores. In our Employee Benefit Trend Study, just a little over a third of employees said they understood how accident insurance works. Only over a quarter,  29%, said they understood how critical illness insurance works. For hospital indemnity only 26% understand how hospital indemnity insurance program works. It’s not just offering the benefits, but educating employees on where these might work, how they might fit, and how they complement their health care plan. This is compared to dental where two thirds of employees say they understand how their dental insurance works, and vision where 62% say they understand how it works. It is understandable.

I’ll spend a little bit of time to describe some of these. Critical illness – the benefit is fairly descriptive. That’s a benefit that would be paid in a lump sum.  Depending if the employee covers both themselves or their spouse, a benefit would be paid in a lump sum for serious, or full benefit, like cancer.

There are different definitions of cancer as that’s a fairly common condition. Partial benefits for cancer would be a partial payment, not a full payment, for more limited cancer condition, coronary bypass graft, or major organ failure. These are examples of the categories that would be payable in a lump sum.  It is intended for something that is very severe. Eighty-seven perecent of claim activity are in those listed conditions that I just outlined. The average benefit payment is $15,000.

What would be more of a severe condition? An individual with cancer, or someone with a major artery condition, like an organ failure, is going to have a lot of costs that aren’t covered under the plan. They may also have transportation costs, and other related costs. That is what that benefit is really structured and designed to do – help individuals in terms of a complementary protection.

Carol Harnett [09:24.23]:  I sometimes speculate that part of the reason why employees get confused about critical illness, because I agree with you, I believe it’s an appropriately named benefit particularly the way you’ve just described it. I recall that when Walgreens went to a high-deductible health plan for benefit-eligible employees, they went to a five thousand dollar deductible. They phrased this to mitigate the five thousand dollar deductible, so they paid for a five thousand dollar critical illness benefit.  As a result, it appeared that their employees thought that benefit was meant to offset the deductible. What you’re saying is that’s only true if it meets one of these critical situations.

Phil Bruen [10:15.28]: That’s correct. Another way I think about this too is we have these conversations you can even tie it to disability. If you think about a disability benefit certainly that’s a baseline level of protection or a layer of protection. You can see it as something that might complement a disability policy because if anyone is impacted by these conditions as I’ve described, there’s over 30 conditions that are covered. I just highlighted the top conditions.

It essentially is intended to cover those severe conditions where the individual would have additional expenses associated with those conditions, where their disability protection isn’t enough. It’s probably a consolation, or a combination of both additional costs related to that condition. There is impact where individuals would have higher deductibles and co-pays and maximum out-of-pocket benefits where these conditions will likely trigger that maximum. That’s a way to think about that and a common way to position it is with this concept of short-term disability. Then it’s an additional benefit in those situations where a short-term disability event is more severe.

Carol Harnett [11:42.88]: Thank you. I think that’s really helpful. And I interrupted you I know you were going to I think about accident next.

Phil Bruen [11:50.72]: Accident has a very different premium structure. It’s usually more affordable, but it does help fill the gap for those unexpected events that might happen. I can give you some examples of this in terms of where this comes up. It’s would apply to emergency room visits or medical testing, and follow-up for physician, for certain fractures, medical appliances, therapy services outpatient surgery, lacerations, ambulance, and some other critical urgent care events. About 57% of the accident claims are covered with that list of examples with average benefit payout of 1,700. That’s an example where it can help fill the gap. It’s an affordable level of coverage typically how it’s outlined. It’s a scheduled payment that can address part of a copay or an out-of-pocket deductible, to help supplement that in these circumstances.

As you can imagine folks who have children, or who have kids playing in sports, where they may have torn cartilage, laceration or eye injury or something of that nature. They can see and understand where this might be the kind of protection that could help them. That’s the accident benefit.

Again, in the same way, you get a sense of hospital indemnity. It pays a benefit, usually around hospitalization, both for sickness, for admission or confinement, or accident confinement or an ICU confinement benefit. It’s a bit more of a severe condition typically, so it’s a broad coverage.

The condition is really around hospital confinement of some form. That’s a situation where deductibles are going to be higher in terms of the actual co-pays and out-of-pocket expense. It’s a way to help cover some of that cost. Eighty percent of the benefits are usually paid for those three confinement scenarios, and the average benefit payment is $1,500. The price point there would be a little bit different, not quite as much as critical Illness.  It’s a good example where individuals look at their own personal circumstances. They look at their budget for their own family situation, and find one of these that may work better for them than another.

I have just a little bit on dental. I highlight this because sometimes dental is more often a core benefit. Dental is quite often fairly heavily employee-paid, either by the share of premium that the employee pays, or the co-pays. We are seeing some movement towards a greater increase in the offering of a voluntary dental plan.

The reality is that dental plan designs have remained unchanged for a long time. They can be outdated. I think it’s helpful to lift the hood to make sure the plan design elements meet employee needs. We would offer a plan design review to make sure that these benefits as they’re described provide the most value and are modernized to meet current oral health care needs. When there’s a voluntary plan, it’s helpful in offering a dental plan to offer two options. One is a richer plan, and one that may be a lower price point for individuals who have less oral health care needs and may want a less costly plan that they can afford.

It’s going to be fairly logical and important that it’s communicated along with the enrollment strategies. This is to help employees understand the value of a dental plan. Receiving regular dental care is important not only to oral health, but its impact on overall health and well-being.

Carol Harnett [16:37.18]: Well said, and I’m glad to hear that you will review plan design with employers when they’re looking at dental, because I have seen in another part of my life where I write about employee benefits that some employers still have a plan design that reflects the origin of dental insurance, which is the 1960s and have caps of a thousand dollars, which certainly didn’t don’t scale as well to 2019. So I think that’s really important.  

Phil Bruen [17:12.89]: With dental, It’s really all all about those details. There’s no question.

Carol Harnett [17:15.93]: Absolutely. It’s funny Walgreens has been very public in some ways about their utilization. They found with dental, and I’m curious about whether you see this, that while it’s a very popular benefit, in a two-year period, 70% of their employees never used the dental benefit. Are you seeing similar trends or do you see higher utilization than that?

Phil Bruen [17:44.59]: Actually we do see higher utilization.  The more individuals use their dental plan, the more it helps demonstrate the value of the benefit itself, from an employer perspective. It’s an area we look closely at. When we plan into the future we help support the regular habit of going to the dentist – preventive care. Most plans pay all, or virtually all, the costs for preventive dental treatment. Doing that can avoid other costs over time, that not only impacts oral health, but overall physical health and well-being.

Carol Harnett [18:41.23]: I remember the early research that came out with the connection between heart disease and dental disease. I think that’s something people often miss. I’m looking at the clock and we have just a little more than 11 minutes left. Is there another benefit you’d like to highlight for us, or would you like to move on to discussing another element?

Phil Bruen [19:06.77]: I think that was good to just get a sense of those coverages. Feel free to fire away if you would.

Carol Harnett [19:17.65]: This has been great. I am sure for employers who are listening, it both can be overwhelming, but also confirming the way you are explaining it. It helps people start to figure out how do you lay out lack a blueprint for what you might want to do with benefits. Since supplemental benefits, or complementary benefits, are often employee-paid fully, and sometimes partially, how can an employer help their employees, their staff, learn more about these complementary and supplemental benefits and consider enrolling in them?

Phil Bruen [19:58.83]: There’s quite a bit. I think that’s a great question.The first aspect of that is it’s never too soon to start planning for the enrollment season – the annual open enrollment season. Thinking about what an employer wants to accomplish in that annual enrollment season, and thinking about that on a multi-year strategy, as something over time. What are the goals to accomplish?

I think that’s where it all starts. We learned this from the employee benefit trend study – employees are confused and they are stressed by the enrollment process. Only half are confident that they made the right decisions. Nearly half are stressed with the process, and over a third say they’re confused. To the degree that an employer can work with their broker partners, and others, to help map out a comprehensive enrollment and communication strategy, I think that’s where it starts. It potentially starts with an assessment or a survey. That is a good place to start. Determine gaps, in terms of understanding benefits that are available, and build a communication strategy that’s multi-pronged with multiple touch points. Employee demographics, their desires, dreams, and location can come into play.

A good place to start is the term, a “heat map,” or mapping a way to look at where those gaps would be, and then building a plan to close those gaps. From there, step back. Then go back to that broader comprehensive benefit strategy, key messages that are the objective to convey there. Because those messages can be very complementary to these complementary benefits.

If the employer is changing their health care plan, they can complement that with some additional communication about the availability of critical illness, accident, hospital indemnity. It’s a very natural communication at that point in time. Put in the context of what else is happening, there are communication firms that are very skilled at helping tie those programs together. It may be that they’re also introducing a wellness program, very closely associated with some of these complementary benefits.

We’re hearing a lot about financial wellness, and financial wellness plans. Depending on how the employer is approaching that, we hear about student loan debt, and other needs that employees have, very specific to employers. If there are solutions that can help address some of that, they can also be a complementary product or benefit message tied to something like legal solutions, financial wellness solutions, as well as, auto and home purchase at the worksite.

Thinking about financial wellness in that context can help as well. I think about the planning process and reflecting the fact that employees aren’t that confident. Anything the employer can do to help give them greater confidence through effective multipoint communication strategies is going to help employees see the value in their overall benefit package as they approach annual enrollment season. Right now is actually a good time to start.

Carol Harnett [24:06.26]: Yes, absolutely. That’s a great summary because I know some people are for, and some people are against, selling products like home and auto in the workplace. If you think about it, as human beings, we think about our life as a whole. We don’t think about benefits necessarily that we get at work, and benefits that we get at home. If we can tie it all together, it can ease somebody when they’re making an overall strategy for how to protect their lives and insure their lives.  

I like how you explained that, and I have a question. I know some employers who will pay part of the premium for complimentary benefit. Is that common or is it more common for the employee to pay all of the premium?

Phil Bruen [25:502.38]: I’d say for most of these benefits it’s more common that the employee would pay for most of that benefit, but there can be times, your Walgreens example is one, it’s usually tied to some change in the healthcare plan, or some change of that nature. Although there may have been some employers with the recent tax cut who had considered enhancing their benefit package in some fashion, it’s you that’s probably more of the exception. It’s usually tied to some other action that the employer is taking where this can help reinforce the message that employers always want to offer a competitive benefit package.

It’s a tight labor market, right. A valued benefit package, comprehensive in nature, is an important consideration for employees, both staying at an employer and and also joining an employer. That may be part of it too. It could be tied to an employer within very tight labor market. They may consider enhancing their benefits to pay for a portion of the cost for some of these benefits as well.


Learn more about what are the most important benefits an employer can offer both current and prospective employees. See our blog with important facts about supplemental insurance benefits.


Carol Harnett [26:25.63]: Thank you. That’s great insight. So I’m going to give you the final word. We have about three minutes left. Are there any parting tips for employers that they should consider when adding supplemental or complementary benefits to their overall benefits package?

Phil Bruen [26:48.30]: Well, I think I covered quite a few of them already. It is helpful to think about it over a multi-year period, and not to approach or emphasize every benefit every year. It is helpful to focus on a theme for a particular year, or a campaign theme to highlight aspects of their benefits. I like the categories health protection, life protection, and then overall financial wellness or financial protection. There may be different themes in a particular year, and they can think about it over a multi-year benefit,  It creates a better approach, strategically, around a benefit strategy – as opposed to just tactically coming at it each year in terms of what they want to do. It may be helpful to step back a little bit about what to emphasize. Use a heat map, and look at what the biggest gaps are, and what an employer wants to accomplish in that particular year.

Carol Harnett [28:05.59]: I love that. What a great way to summarize. I am looking at my own notes and I had highlighted the multi-year strategy. For all the years that I’ve talked with employers about their plans, very often it’s a singular strategy every year. The idea of creating this heat map, which is another great phrase, and deciding what you’re going to focus on each year, is not only helpful to you as an employer and developing an overall compensation benefit strategy, but I think more helpful for your employees.

Phil Bruen [28:44.65]: Don’t get me wrong, I’m not talking about 10 years. I’m suggesting you have a three-year strategy.

Carol Harnett [28:55.24]: In my head, I thought three. I think three years is a great period of time particularly the way you laid it out. I like the theme of health protection, a theme of life protection, and a final theme on financial protection.

I’m going to going to close and thank you so much Phil. It’s been great to have you on the show again. You’ve become such a great resource, for not only the Council for Disability Awareness, but also for our listening audience. So thank you so much for your time and your knowledge and your expertise. I want to say thank you as well to our listeners.

Phil Bruen [29:46.82]: Thanks Carol. Bye.

Carol Harnett [29:46.24]: We wish you the best for the rest of the day and the week, and thanks to everyone else. Good-bye.




Employee Benefits 101 for Freelancers and Entrepreneurs


Carol Harnett: Hello and welcome to the Financial Health and Income Network radio program. My name is Carol Harnett, and I am the president of the Council for Disability Awareness, a non-profit organization dedicated to helping working Americans understand their employee benefits and insurance options, as well as ways to make certain they still have an income stream if they’re temporarily out of work due to an injury or illness.

Today on our podcast, I’m pleased to be joined by Jennifer Fitzgerald and Mary Beth Storjohann. Jennifer is the CEO and co-founder of Policygenius, which is a company with a simple mission: to get people the insurance coverage they need and make them feel good about it, which I just love.

And [our other guest,] Mary Beth Storjohann, is the founder of Workable Wealth, which is a business specializing in financial planning for Gen Y or the Millennials, depending on what you like to call them.

She works as a writer, speaker, and a financial coach with individuals and couples in their 20s and 30s across the country to help them make educated decisions with their money. Mary Beth is also a paid spokesperson for the Council for Disability Awareness. We’re really pleased to be working with her and particularly in helping us reach out to the Gen Y generation.

So all of our companies really are based on the concept of providing unbiased advice to consumers about how to navigate the insurance and the benefits process. All three of us interestingly enough– because our topic today is specifically on freelancers and entrepreneurs and how they might want to start thinking about their benefits– fall into one or both of those categories, so we’ll be able to provide some personal perspective.

You can hear the full podcast or if you’d rather read than listen, we captured the transcript from the conversation below.


Welcome to the show Jennifer and Mary Beth.

Jennifer Fitzgerald: [00:02:23] Thanks so much for having us.

Mary Beth Storjohann: [00:02:25] Thank you Carol.

Carol Harnett: [00:02:27] You’re very welcome. Let’s get started as I have a question that’s for both of you, but I’m going to put it to Mary Beth first. When you think about– particularly as being somebody who’s in this space, Mary Beth, how should entrepreneurs and freelancers think about protecting their health, their income, and their savings?

Mary Beth Storjohann: [00:02:51] I think the first thing as a freelancer/ entrepreneur, you have to understand that there is no big brother and no employer looking out for you; you alone are responsible for taking care of and educating yourself in those areas in terms of risk protection – that’s one of the biggest things I see.

It’s actually really an overlooked topic. People think, “oh, no.” When I mention it to a lot of my clients, it’s like a deer in headlights, “I hadn’t thought about that.” So I think the biggest thing is recognizing that you are responsible for taking action in these areas.

And then from there you really need to step back and take a look at your lifestyle and your family. What would happen to your family’s lifestyle, to your income, in the case of a sickness or death or injury? Consider what your current goals are for yourself or your current situation and for the future.

What if something happened to you? Where would those goals end up? If you want to send your kid to college, would you still be able to do that? If you wanted to buy that new home? Those are all things to think about when it comes to protecting your health and income and savings. It is basically just figuring out if it is worth the risk of not having the protection or is this something that you should take action to buy some products that are out there to protect yourself.

Carol Harnett: [00:04:02] Great. Now, Jennifer, I’m going to follow-up the same question to you. You’re in a unique space in that you actually have employees, and we’ve never talked about this, but are you the type of employer who provides your employees with benefits or do you encourage them to go out on their own to do this?

Jennifer Fitzgerald: [00:04:26] It’s a great question, Carol. Given the mission of our company, we believe in providing benefits to our employees, but that might not be the case for other entrepreneurs, particularly small business owners when you have a smaller workforce. My advice to other small business owners and entrepreneurs is to consider a couple of things:

  • One is your budget and what you can sustainably afford. The last thing you want to do is offer, or entice employees with the rich benefit offering that you have to pull back later. It’s better to start modestly and then build up over time as your budget can afford it.

  • The second thing is consider the needs of your employees. If you have younger, single, healthy employees, their needs are going to be different than employees who have families, mortgages, things like that.

So, consider your employee mix, and consider your budget. Consider that employees do look to their employer to provide these types of benefits, and manage those expectations accordingly.

Carol Harnett: [00:05:25] Thank you. You know I am going to actually go off the cuff for a minute because you both inspired me a little bit.

Now, all three of us have made decisions to be in our own businesses. And I know for myself– and I think part of it is frankly my background; although originally a physiologist, I have worked in and around insurance and consulting for a good number of years– so when I went into my own business, I actually was really conscious about making sure that I had some particular types of coverage. I absolutely wanted to have health insurance. Obviously, I worked in healthcare so I know that’s important, and obviously,s now it’s the law because I started five years ago.

But then I did– in my case, frankly – I spent a lot of time in the disability insurance industry–  I wanted to make sure I continued to protect my income. As you both went out on your own, are there some conscious decisions you made to make sure that you had some really basic benefits that were important to you?

Why don’t we have Mary Beth start because Jennifer just spoke?

Mary Beth Storjohann: [00:06:30] As an entrepreneur and a financial planner, I think I’m the most risk averse person. So I always err on the side of conservatism, and therefore I was very conservative myself. When I made the transition from employee to founding Workable Wealth, I had already thought out some private forms of disability insurance and some life insurance for myself as well.

When I made that transition, what I thought about was my husband and what my income will look like going forward, and then again ensure that we are protected in all of those areas in terms of healthcare disability and life insurance because we’re a unique situation. We don’t have kids yet. But those are things that might be on the horizon. So making sure that we’re planning for today and also for the future because that’s kind of what you do. I work with Gen Y Millennials and in this age group you have to kind of balance. So those were definitely boxes I checked off.

Carol Harnett: [00:07:21] Interesting. How about you, Jennifer?

Jennifer Fitzgerald: [00:07:23] Like Mary Beth, I was also conscious of that when I was starting out as an entrepreneur particularly because I was leaving a corporate job at an employer that provided a very generous benefits package; great health insurance, disability, and life insurance.

I wanted to make sure I could afford to be on my own and what the options were to continue those benefits. It so happens that it was easy to convert disability and life insurance to an individual policy that I could afford for myself. The health insurance, comparing what I would be paying with COBRA versus getting my own plan on the marketplace, I decided to get my own plan because that was a more cost-effective option for me, but it’s definitely something that I considered.

And it’s advice for several other friends. The startup scene is hot. A lot of people want to be entrepreneurs and start their own company. The biggest piece of advice I give them is, make sure that, if there are any benefits that you have at work and that you want, to continue to do that because it can be difficult to get disability insurance in particular if you’re a brand new entrepreneur or a freelancer. The options are more limited, so consider those carefully before you leave a job where you have benefits coverage.

Carol Harnett: [00:08:41] Yeah, that’s actually a really good point. I already had two disability policies in addition to the one. I also was in a very rich corporate benefits package before I left and struck out on my own. But I had two policies: an individual policy that was an association policy, it’s a group technically, and then I also had a voluntary policy. And to your point when you want to supplement that with an individual policy, you have to show proof of income for a period of time so it can become difficult to do that. It’s very important to think through that.

Mary Beth Storjohann: [00:09:20] I was just going to say the same thing. My policy’s actually an association policy as well, so it is a group policy. I was able to get that through one of the organizations I participate in as an independent financial planner.

For freelancers and entrepreneurs out there, I would encourage you to look at that route too. If an individual policy is not an option, look to the group policies for any organizations you’re a part of  because that can be a more affordable option.

Carol Harnett: [00:09:44] That’s a great point. And I will want to get back to you at some point Mary Beth because I remember when I went out on my own, I was maxing out my 401k. And that is the one thing I will admit I did let go. I knew I was doing better when I got back on track with the future, but I wasn’t thinking about retirement at the time I was starting a business.

So I’m going to ask Jennifer a question specific to the most important employee benefit — whether we’re working for  somebody or working for ourselves– I think we’d all agree is health insurance. In some ways we can also argue it it does protect your income because we do know the connection with medical bankruptcy.

What option should entrepreneurs and freelancers consider, Jennifer, starting with health insurance, but then looking at the broader pieces around benefits?

Jennifer Fitzgerald: [00:10:36] Sure, for health insurance, there are a few options now, thankfully more than there were a few years ago.

The first is if you’re leaving a job with coverage, you know COBRA’s there, so talk to your HR person about what it would cost to extend your health insurance coverage with your group on COBRA. That’s particularly important if you have a doctor that accepts your current plan that you’d like to keep seeing.

The second place to go are the Affordable Care Act exchanges or your state health insurance marketplace. Loss of a job or or leaving your job is an event that allows you to enroll in health insurance outside of open enrollment. And particularly for freelancers or entrepreneurs starting out, your income most likely is going to decline from your full-time job, meaning you might be eligible for a subsidy to help you pay for the monthly premium. And if that’s the case definitely go to the state marketplace, which is where you have to shop to get that subsidy.

A separate option for entrepreneurs is the all-in-one options services that provide HR, payroll, benefits. They often will have access to to health insurance plans that aren’t available on the exchange to small businesses. Definitely worth a look there, too, if you have employees that you’re needing to cover.

Carol Harnett: [00:11:55] You know, that’s a really good point, and it’s one I often forget to tell people, that there are those services out there and they seem to be picking up steam given the number of small businesses that are being started. So a lot of us would argue it’s important at some point to have some HR assistance and I think that’s good for people to consider.

Another question for both of you, but we’ll start with Mary Beth this time: how should people think about protecting their income through insurance?

One of the places we default is disability insurance. But when we think about it, particularly when you’re new in your own business, it can become an expensive insurance sometimes, particularly on the individual side, depending on your age and the provisions that you want.

So we’re trying to expand some of the conversations to things like critical illness and accident insurance as a cheaper alternative to disability insurance and as a way to maybe make up the deductible for a high deductible health plan.

So how should people think about protecting their income Mary Beth?  

Mary Beth Storjohann: [00:12:56] First, I think they actually have to start thinking about it. A lot of the clients I work with in terms of education perspective think “it won’t happen to me,” but in reality it could and it might. According to the Social Security Administration– this is a stat that I quote to a lot of my clients– is that 1 in 4 of today’s 20 year olds will end up disabled before retirement age, experiencing some sort of a disability.

The average disability actually lasts up to like almost three years, and that’s definitely long enough to do some serious damage to your finances and also long enough to fully wipe out your emergency fund because in my personal finance realm we recommend typically a 3 to 6 month cushion for your lifestyle expenses in your emergency funds. If you’re disabled for three years and have no income that’s going to definitely do some damage.

I bring it back there right away to kind of make that relationship stickier and then the thing you have to think about is first, what will happen if you’re out of work for an extended period of time, where will your income come from? You know, what if you can’t go to work and how will you pay your bills? Do you have credit cards and student loans and mortgages that still need to be paid.

You have to really step back and a lot of people just don’t even consider those questions. They think they have the emergency fund in place, and they don’t consider the longevity of what a disability will look like.

And then, understanding, what disability insurance does. So it’s when it will kick in, how much of your income will it replace, and then obviously, I think, disability insurance will cover up to 66 and 2/3 [percent] of your income, so understanding that’s definitely a better replacement ratio than zero.

And so the thing you have to consider is for example, their short-term versus long-term disability and there’s elimination periods there, so when it comes to cost effectiveness, as I mentioned before, are there any trade association policies that you can take a part in. Is it perhaps the way that you can self-insure against the short-term disability, you know for that maybe 90 day period and then purchase a long-term disability policy and save yourself some money there.

So I think there’s ways to get creative with it, but it’s understanding, It’s really going back to understanding your personal financial situation and what it what it looks like now, what it could look like if you didn’t have your income any longer, and being able to fill in those gaps.  

Carol Harnett: [00:15:09] Great, and I’m sure Jennifer you have some places to fill in the gaps because for people who haven’t had a chance to look at policies {audio garbled}. I think your algorithms are really interesting. So I’ll let you explain them, but, you know, how does somebody who’s trying to sort through this idea of protecting their income, how do they start to make some choices? Is there an income threshold they should be thinking about, and what are their alternatives if they don’t have a lot of excess cash?

Jennifer Fitzgerald: [00:15:37] Sure, that’s it’s a great question and one that we see a lot, particularly for people who are self-employed. I completely agree with Mary Beth’s analysis in terms of you know, trying to self-insure for the short-term and looking at the cost-effective options for long term disability insurance beyond that. Association policies are a great place to start.

I’d add on two other pieces of advice. One is if you don’t belong to an association and you can get long term disability insurance, work with a broker who can help you tweak and design a policy that’ll get it, will likely get it down to a monthly cost that you can afford, particularly if you’re younger, you can typically get a policy that you can’t afford it might require some belt-tightening in some other instances, but I think all of us would agree that it’s really really important in terms of protecting yourself, not just your income but your savings, your assets, and what you put away from retirement.

If you live in a state where these policies are available, critical illness insurance and accident Insurance can be cost-effective alternatives if you can’t find disability insurance. And what those policies do is they pay a  cash benefit if you suffer an accidental injury, or if you get diagnosed with a critical illness. That cash you can use either to meet a deductible on your health plan or to cover living expenses because if you get diagnosed with cancer or you suffer a heart attack, odds are you’re going to be out of work for some time.

So those policies can help cover the “beyond the health” cost of those conditions. So if you live in a state where those policies are available, we  highly recommend them as a short-term and often cost effective alternative to disability insurance if you can’t get it.

Carol Harnett: [00:17:29] Yeah, I don’t….  I had the great privilege of meeting. Dr. Marius Barnard who is Christiaan Barnard’s brother. And he, the two of them, were actually involved in the surgery that did the first human heart transplant in South Africa many years ago.

And most people don’t know that Dr. Marius Barnard actually created the concept of critical illness insurance. Because he used to have patients that always died. And once they developed heart transplants, he had patients who survived but were wiped out financially and so that was his reason for creating critical Illness, but I think it’s interesting at the end of his own life– and he passed away last week– he developed a very unique cancer. And he used– he had critical illness insurance– he used the lump sum payment to pay for the experimental treatment that his carrier wouldn’t. So it was an interesting application of critical illness insurance. So sometimes we don’t always realize there’s a way you can unanticipatedly benefit from having that kind of insurance.

So Jennifer I’m going to actually take a question back to you again and say are there are other products beyond health insurance and. disability insurance and even the cheaper alternatives of critical illness and accident when available. Are there other products that entrepreneurs and freelancers should consider, could consider perhaps maybe as their income flow gets a little bit better?

Jennifer Fitzgerald: [00:18:59] Definitely. So, you know the first thing that we look at beyond those needs that you mentioned is do you have a need for life insurance. And not everybody does, but if you have a dependent spouse or children or even if you have a business partner that you are part of so a lot of a lot of entrepreneurs would get life and disability insurance not only to protect themselves, but to protect the business and their business partner is going concerns.

And beyond that, you know, it’s often overlooked, but protecting yourself against business risks. So, your laptop that you use as a freelancer, you know, sometimes there’s liability that you could be on the hook for, as an entrepreneur, as a freelancer, but we always advise folks don’t overlook the business risks involved in your day-to-day as an entrepreneur or a freelancer. So, you know, there are some very affordable policies out there for property protection, liability protection, and to definitely not forget about that as as part of your overall risk management tool box.

Carol Harnett: [00:20:00] You know, I think you bring up an interesting point. My sister is also an entrepreneur and she didn’t go the VC route, but she did have private individual investors and their requirement was for her to have key man insurance, which she was able to address via a disability policy that protected the company.

So I think sometimes entrepreneurs don’t forget, you know, they don’t, they just are looking at their immediate situation and sometimes they aren’t looking at growth and what you might need to attract additional money or in cash sometimes when you want to advance the business. So that’s a really good point.

Mary Beth, is there other things that that you find either for yourself or people you counsel who are freelancer entrepreneurs that they should consider?

Mary Beth Storjohann: [00:20:44] You know, I think Jennifer checked all the boxes there. Errors and Omissions insurance, liability insurance and life insurance if you need  it.

I think for me – working with a lot of entrepreneurs and freelancers, life insurance is a big one. I work with a lot of younger couples and people who are starting their own businesses. And so it’s more than just telling them hey, you need to get life insurance, and understanding the questions to ask themselves around that. It’s important to understand what the values and goals are for your family.

One of the big things people will get is a couple hundred thousand dollar policy and they think they’re good to go. Ultimately, what it comes down to is whether your family is fully dependent on your income or another person’s income. Having that conversation and if you have small children at home, what happens if something happens to one of the spouses and you pass away and there’s one of you left? Would your significant other want to go back to work full time, or is there going to be a reduction in income there as well? It goes back to if you have a mortgage and if you want that debt wiped out so there’s no stress and you know your partner has the home fully paid off and can stay there without concern.

There’s a lot of questions you have to ask in terms of understanding how much coverage you actually need. That’s the one I really focus on with clients is disability and life insurance. There’s a lot of questions there because if something did happen, it will obviously come to a lot of changes in your life, and understanding what you would want to happen if unfortunately something did happen to you.

Carol Harnett: [00:22:15] Thank you. You both inspired a thought I actually didn’t consider asking you until now, which is that a lot of us, when we think about entrepreneurs and freelancing, we think about people early in their careers or maybe people who’ve worked for, you know, about 10 years or so and we’re seeing them make a break.

But in 2008, we saw a different trend with entrepreneurs, and that was — in some industries, massive– layoffs that we saw people in their late forties, fifties, and even early sixties becoming entrepreneurs and freelancers. Would you give different advice to someone who– let’s pick an age– let’s say is 52 years old? Would you give them different advice that you would give to somebody who’s earlier in their career? Let’s say late twenties or early thirties.

And it can be either one of you by the way.

Mary Beth Storjohann: [00:23:10] I’ll go first on that one. I know for me my financial planner answer is: It really depends on their situation. So if they’re in their fifties and they’re still going to be working for the next twenty years because they’re playing catch-up with retirement, that’s a different look than if they’re in their fifties and they have a short timeframe and they have the retirement cushion and their self insured by then.

As you get older it definitely gets into more of a detailed specific answer. You know, a twenty- and thirty-year-old, you can typically throw  out a general number that can give a bigger protection for the long term, but as you get older, I think we need more details, more specifics.

So I was going to give you the generic “it depends,” but I truly believe it. You know, I think as you get older too and your net worth grows, you get more into the types of policies that might make more sense in terms of, life insurance, term versus whole life. It really depends on your net worth and where you’re at in terms of retirement.

Carol Harnett: [00:24:05] Great.

Jennifer Fitzgerald: [00:24:06] I would agree with Mary Beth that it does get more complicated if you were in your fifties and you’re either working to catch up with retirement assets or you’re stringing together some freelance or part-time jobs because of a layoff. The complexity is that insurance is definitely more expensive whether it’s health insurance or disability insurance– and you might have other needs such as long-term care start to surface.

So it’s definitely a more complicated situation and the advice is going to be different. In some cases, disability insurance might not be available if there’s been some adverse health conditions in which case self-insurance is going to be possibly your only option. The landscape definitely changes and it’s one of the reasons why for young people in their twenties and thirties, that we we encourage them to get the policies that you need early, lock them in with a non-cancelable policy if you can, because you never know, what’s going to happen twenty or thirty years down the road.

Mary Beth Storjohann: [00:25:07] Exactly. That’s exactly what I tell my clients.

Carol Harnett: [00:25:10] You know and it makes me want to close with a question, that I tipped my hand at earlier in the show, and that is when I was going in my own business, I had Mac. I was one of those people when I first entered my career my Dad’s and Mom’s counsel to me was, “You know, we don’t care, how much money you’re making, we don’t need to know, but even if you’re not making a lot at least put something in savings for retirement – even though you’re 24 years old, 25 years old.” Often when people start their own businesses, retirement isn’t something people think about. I knew I was finally doing better in my business when I was confident to start developing vehicles to enhance my retirement future.

What is your advice as an entrepreneur for when you should start paying attention to it particularly if you start when you’re younger – because actually, it can be smaller amounts of money and a little bit easier.

Mary Beth Storjohann: [00:26:13] The earlier you start the better, and that’s always my aim with clients, starting small and putting something away. I work with twenty and thirty year-olds, you know, different, varying incomes, but most of the time especially with the variable income, I think it’s really hard.

That’s the biggest thing for an entrepreneur, the biggest thing to tackle, especially when you’re starting off, is the huge swings that you’re experiencing and actually trying to manage those. There’s lot of cash flow work that comes into helping my clients understand how to actually set up a budget and not minding setting up the emergency fund. First we need to set up your lifestyle cushion fund to pull from in those lean months, so you’re not constantly playing catch-up and feeling like you’re on that hamster wheel.

One of the first things is understanding how to manage your cash flow. Once you have that under control, you should be able to get yourself on some sort of ongoing budget, where you’re treating your retirement savings like you’re treating it as a bill. It’s something that you have to pay each month. Basically you’re making it manageable. The earlier you start the better, I always say whether it’s $25 or it’s $100 my goal is at least to be putting $100 away into an account and taking advantage of those things. Obviously, if you have a kind of debt, you want to tackle those things first. You want to make sure you’re building up the cushion, emergency cushion, and tackling the debt. And then retirement comes after those things, which is really hard as an entrepreneur.

That’s one of the big things too, I will say, is a lot of entrepreneurs who are starting their own businesses take on a ton of debt. And it’s kind of like that. There’s some sort of mindset that’s out there right now with personal development. You’re throwing money at the business; it’s okay because you might fail, but eventually it’ll catch back up and you’ll be rich or whatever that is. Breaking that debt mindset is also a big thing.

From there take advantage of the retirement plans that are out there for you. For solo entrepreneurs, there’s a solo 401K, there’s a SEP IRA, and there’s a solo IRA. Those are the ones that are going to allow you to shelter some of your income and basically save on taxes.

For younger clients who are in their twenties and thirties, one of the best things to do is still take advantage of that Roth IRA if you can. Once you get your income above above that, then you want to take advantage of the SEP IRA or solo 401K. But I say doing Roth IRA when you’re young, and again, just starting with those automatic contributions and treating it like it’s part of your bill payment, is going to be a huge thing to do.

Carol Harnett: [00:28:34] That’s great advice. Do you have anything to add to that, Jennifer?

Jennifer Fitzgerald: [00:28:38] No. Mary Beth is the expert here and she’s absolutely right that as an entrepreneur who is struggling with a variable income and doesn’t know what six months will look like, let alone what retirement thirty, forty years, down the road looks like, it’s definitely something that’s easy to put off. The way that I found that I can do it is also just treating it like a bill and then it’s something that you don’t touch or or think about.

Carol Harnett: [00:29:05] Exactly, and that’s exactly how I wound up handling it, but to both of your points, I didn’t start thinking about it until there was less variability in my income flow and kind of more money saved away.

The one thing that all of us have talked about is– but it’s because the nature of the variability of the business– that sometimes we take too much on at points because we’re afraid for the periods when we’re going to be lower than we were hoping we would be in. And that’s sometimes both the thrill and the challenge of being an entrepreneur and a freelancer.

I want to say thank you to both of you. We did this exactly in the time frame we planned. In 30 minutes, for our audience, for people who either are entrepreneurs or freelancers or considering becoming one, this is terrific advice, from people who are experts in the area and are also entrepreneurs and freelancers, to take in mind as you move forward.

Obviously health insurance is a requirement for most of us by law right now, so you want to make sure you do that. But you also do want to take a look at some other things, particularly protecting your income flow, because we are all sensitive to what a small change in your health can do to your income flow. We want people to consider that and cost compare life insurance, and as you’re doing better, to start thinking about putting away at least some money toward retirement and taking advantage of some of the vehicles that are out there.

Thank you everyone. Thank you Jennifer and Mary Beth for your participation. Please check out their companies. They’re wonderful companies, Policygenius and Workable Wealth, and until next time we’ll talk about finance and health.

Thank you everybody.  

Mary Beth Storjohann: [00:31:03] Thanks.

Jennifer Fitzgerald: [00:31:04] Thank you




How Employers Can Influence the Move to Value-Based Healthcare



Introduction

Steven Schutzer, M.D., president of the Connecticut Joint Replacement Institute, and Carol Harnett, president of The Council for Disability Awareness, share a discussion on this CDA podcast about value-based healthcare — a healthcare delivery model in which providers, including hospitals and physicians, are paid based on patient health outcomes. Under value-based care agreements, providers are rewarded for helping patients improve their health, reduce the effects and incidence of chronic disease, and live healthier lives in an evidence-based way.

The discussion covers a wide variety of topics with a focus on helping employers understand the positive impact VBHC can have on employee health and productivity and health plan performance.

Topics discussed include centers of excellence, why this movement is important and relevant to the entire population, challenges and obstacles in using a VBHC approach and how to overcome them, and how employers can measure results. 


You can hear the full podcast or if you’d rather read than listen, we captured the transcript from the conversation below.


Carol Harnett: Hello everyone. This is Carol Harnett. I’m the president of The Council for Disability Awareness, a non-profit whose role it is to educate employers, employees, and financial advisors and consultants about employee benefits in general and specifically about disability and income protection whenever we can.

Our show is called the Financial Health and Income Network, and today I am pleased to host a very special guest Dr. Steve Schutzer. Dr. Schutzer is the president of the Connecticut Joint Replacement Surgeons, the physician executive for the orthopedic service line at Saint Francis Hospital and Medical Center in Hartford, Connecticut, which is where I’m located as well. He’s also the physician director of the Connecticut Joint Replacement Institute at Saint Francis Hospital and Medical Center. I have had the pleasure of knowing Dr. Schutzer for about a year, although I knew of him for many years because he is listed in Connecticut magazine as one of the best physicians in the state, particularly for joint replacement.

Thank you for joining us, Steve. We’re so glad to have you here with us today.

Steve Schutzer, MD: Thank you so much, Carol, for having me. It’s a pleasure to spend the time with you.

CH: Anyone listening to this show can benefit from our conversation, but our targeted audience today is employers. The goal we have for the show is to help employers understand a concept that’s been around for a little while called value-based healthcare.

What is Value Based Healthcare?

Some employers may have heard this phrase within the context of something called “value-based insurance design.” Today we wanted to walk you through some of the basics of what value-based healthcare is, ground you in it, and give you enough information that you can talk about this concept with your employee benefits broker or consultant, or with an insurance carrier.

Steve, the place I want to start is with the basics of value-based healthcare, and why you choose to get involved in this initiative?

SS: So let me start with the second part of that question, Carol. As you mentioned, I’m an orthopedic surgeon with a special interest in arthroplasty — total hip and total knee replacement. And I became dissatisfied, disgruntled and even say, embarrassed at the state of our healthcare system about 12 or 15 years ago and I felt that there was a moral imperative to try to improve it. I read some books about value-based healthcare written by Professor Michael Porter on redefining healthcare and was smitten and overcome with a passion for trying to move our system to value.

Now, what is value-based healthcare? Fundamentally it is very simple. It’s a delivery model in which we as providers to hospitals and physicians are paid based on our outcomes. I mean, it’s not unlike any other sector of our economy. We are rewarded for outcomes. And this would replace the decades-old entrenched system known as fee-for-service, where providers are paid for their volume irrespective of the outcome.

Put another way, Carol, if you have a bad outcome and you got to repeat it. Well, guess what? You get paid again. And this just incentivizes more and more care delivery without any respect in terms of the outcomes that are anticipated.

You know, I love that explanation because at its core it makes so much sense. I started my career on the healthcare side focused in sports medicine and then in the larger circle of rehabilitative medicine and industrial medicine. And I think what always took me back when I talked with people from the general population, or even relatives, was they would say: Well, I saw an orthopedist for my knee pain and he or she said there’s really nothing I have to worry about. And I said: Ok, can you tell me more about that? And you’d hear some pretty significant symptoms. And you’d ask if they’d ever had physical therapy and sometimes they had and sometimes they hadn’t. I even find in the general population in these conversations a lack of knowledge that there can be a difference in quality, that there can be a different outcome. That they paint all orthopedic surgeons with a similar brush; all physical therapists with a similar brush.

CH: How would you tell an employer who is also a person first, who doesn’t have a background in medicine, why value and outcomes are important even though that seems like such a basic question?

The Importance of Value-Based Outcomes

SS: You actually have articulated the question and the answer. It is extremely important and there is great variation. The problem is, Carol, that I can go on Consumer Reports and learn more about a toaster oven than I can about my surgeon who’s about to take my hip or knee. And that’s just unconscionable and unacceptable.

I’m a simple-minded guy from the Bronx as you know, and there’s something called the health care value equation, and it’s  very simple. The numerator are the outcomes that matter to a given patient for their particular problem. If it’s prostate cancer and maybe impotence or bladder control, that’s what the patient really cares about over the true cost — not the charge — but the true cost of delivering that care, and that becomes a mathematical equation upon which providers can be rated and judged.

The problem is finding information about real outcomes, even if you were a very sophisticated healthcare shopper. Even YOU would have trouble. Correct, Carol?

CH: That’s absolutely correct. I have spent a lot of my career in healthcare and then insurance and then to consulting, and I’ve had the good fortune of getting to know people like you and others. Frankly, if I ever had a non-orthopedic problem, I’d probably call you and say:  Okay, this is the problem I have. Out of all the physicians you know, who is it that you would go to if you had this situation. But most people don’t have access to that kind of a network. And it’s really, really frustrating. I think most people, including our employer listeners, don’t think about it until they’re in a situation that’s a little more challenging or a little scary, and they start to realize that, perhaps, staying even in their local community may not be the best decision for them, and that’s the first time you ever think about it.

I knew you from the original rankings at Connecticut Magazine listed once a year on the best physicians. Originally the list was created by surveying other physicians and asking them the physicians they considered to be the best in their respective specialties. I spent my time in healthcare in the greater New York and New Jersey area, so I didn’t know anybody here when I moved into the area.  So, Connecticut Magazine became my way of looking and finding even a good primary care physician. So, that’s one of the challenges. You can imagine employers who are listening thinking: Okay, so I want to get my employees value; I want to get them good care, good outcomes. What do I do?

Ways Employers Can Deliver Good Care to Employees

I will tell those employers — because I spent a lot of time in the health and productivity space — you want your employees to go to a good physician because you almost always see your employees come back to work sooner, be more productive when they return, and if they haven’t left the workplace, which is the ideal situation, they also tend to be more productive while they’re being treated. They tend to be at work more often.

What we’re both sort of foreshadowing is something that can go beyond physicians, and that is if you do need a procedure.  You would either have to go to a hospital or an outpatient surgery center or something along those lines, so there is a concept of value called a center of excellence.

Can you help audiences understand what that is about?  What is a center of excellence?

The Center of Excellence

SS: Yes, and I think that is again is a great question. Unfortunately, Carol, that term — “center of excellence” — has been bastardized to some extent because anybody can claim they are a center of excellence. But with time and over time various organizations are accrediting entities as being a true center of excellence. And each has their own proprietary criteria looking at whatever metrics they can access. Unfortunately, most of this data as you know comes from CMS administrative claims databases, which are based on coding and you know there are all sorts of potential vagaries and inconsistencies and flaws. But, be that as it may, centers of excellence do make a difference.

And you know in our Forum coming up on December 6th and 7th, we’re going to be highlighting two types of centers of excellence: one being virtual with a very fascinating company called AiR Healthcare from Minneapolis — the Wainwright company — and the other one being a physical center of excellence here: the Connecticut Joint Replacement Institute.

And here’s some very simple data for the employers who are listening. This is data from another source, but it’s factual. It was from a very large employer in the United States where they referred all of their patients who were in the queue for spine operation to a spine center of excellence and 50% of them, Carol, never had a spine operation.

Now, forget the millions of dollars of savings. Just think of the human misery of those fifty percent of patients that would have had surgery that they never needed. Now that’s for spine. Spine is difficult because there is a lot of gray area, but joints to me are kind of cut and dry.

This is the way I think. If somebody has end-stage arthritis of the hip and severe pain and can’t walk, they need a joint replacement. The same source of information from a very large employer showed that 20% of the patients scheduled for joint replacement were pulled out of the surgery queue and sent to a center of excellence, and never needed a joint replacement. And that’s just striking information.

CH: I will concur with the information you’re sharing. When I worked in sports medicine and physical rehabilitation, we had a lot of people with spine complaints, including elite and Olympic athletes. And some of them — even the athletes — would often want a quick fix.

We did research at the center I was at — and I worked at a couple of world-class rehabilitation institutes, including the Kessler Institute for Rehab in New Jersey — and we’ve done research on the topic, which we’ve seen replicated in other places and that’s when people go through back surgery, in five years, they have the same outcomes as people who went through physical therapy and returned to full activity.

And I obviously know on a patient level and a one-on-one level how important that is to share this information. But since so many people receive their health care through employers, I’m really happy we are about talking about this topic.

I will add a little bit of information to the data you shared. A person who’s become a friend of mine is Tom Emerick, who was the global leader of benefits for Walmart. He’s a very dear friend. I used to consult for Walmart when Tom was the leader there. Tom really was one of the first employers who brought in a centers of excellence model. He always tells the story about contracting with Mayo and contracting with Cleveland Clinic. The first thing they offered to any covered associate in the Walmart system that who needed an organ transplant was to go to one of these two centers of excellence. Their family member could come with them. All expenses were paid; all co-pays, all the deductibles were waived. Fifty percent of the transplant patients were turned back because they didn’t need the transplant. And that to me was one of the most shocking things I ever heard. How is that even possible?

Walmart became a real leader in this field as did many others who quickly followed suit. So, I can’t emphasize enough to employers how when we think about centers of excellence, we think about big things like that, right? We think about organ transplants.

But I will tell you from having worked in the disability insurance side of the business for a while that that’s really a small percentage of what’s happening. Big dollar ticket items from a medical perspective, but a small number of people from a population perspective. That’s why things you’re talking about such arthroplasty and spine surgery and even more common become more important to find these value centers — these centers of excellence. Places where you know your employees and their family members — if you cover their family members — are going to not only get great results, they’re going to get long-lasting great results: meaning we don’t have to do things called revisions and go back in and do surgery or have complications because they’ve been in a much better place.

SS: That’s right. We’ve just covered very briefly three different procedures: organ transplant, total joints and spine. And we’re talking about 20% to 50% of unnecessary major operations. When I drill down in that data, I was really interested that this large employer on par with Walmart had saved twenty million dollars in that year. That’s a lot of money.

What I really liked about that experience was that two-thirds was saved on the quality side and only one-third was cutting a discount. In fact, for the employer — because many of these patients are travel patients — they netted out zero because they got a deal from the provider for this new volume of patients but it cost them to transport the patient and family. So that netted out zero, but the real value was going to a center of excellence and deciding: You know what? This patient doesn’t need surgery, or having surgery and reducing those risks of complications and re-admissions.

CH: Absolutely, very well said. And I do want to remind our listeners at this point about something we talked about a little bit before getting on the air, which is that not only is this movement important — and we are certainly directing our comments right now to just the employee population and their family members if they are covered. But this is relevant to the whole population. And I would imagine you see a mix of both people who are still working and people who are retired in the work that you do. And just for a brief comment because some payers by the way as you provide retiree medical care: How does this apply to the entire population?  

An Opportunity for Better Outcomes for ALL Populations

SS: I don’t really discriminate in terms of whether they’re employees or not employees, or their age bracket. Half of my practice is Medicare and actually half of my practice are commercially insured. So, the average age for a total hip replacement in my practice is about 58. There are not necessarily older. That’s the average, which means I’ve got some in their 40s and some in their 80s and some even in the 90s. So, I don’t really discriminate between what demographic they come from.

SS: Patients are a little more demanding today. They want to get back on their feet quicker. And, again, when you have an entity that’s focused as we are like a laser beam on arthroplasty, you just keep getting better and better: refining your outcomes, refining your processes, to drive better value for the patient.

CH: Wonderful. So well said. Now, we’re talking about all the positives that are involved in value-based healthcare and we certainly know that there can be some obstacles and there can be some challenges. Can you talk a little bit about that and what employers can do to help overcome those problems?

Employers Can Provide Solutions for Obstacles to Care

SS: Carol, that’s something that we’ve been thinking about here for very long time. We’ve heard interesting comments from the payer community that the providers are “tone deaf.”

And here we’re thinking as providers: Where are the employers? We’ve got an incredible product — many other people do as well — and it’s just not gaining traction. So, we’re wondering where they are. They’re wondering where we are. So, something tells me something is in the middle and not making this happen. As you learn about the complexity of the healthcare ecosystem, it becomes clear that there are many intermediaries, some of whom are not completely aligned with value. There’s nothing specifically in it for them and overcoming that takes time.

Listen. It’s a 3.2. trillion dollar a year industry of which one-third easily is waste. But that’s one trillion dollars that you’re talking about taking from somebody’s pocket and they don’t like that. And there’s all sorts of push back and political things and lobbying that that impede this movement to value.

As you know last year, we had our first annual Moving to Value forum at the Del Mar hotel in West Hartford, CT. This year, we’re having our second forum at the Marriott in Hartford. But last year we focused on obstacles: obstacles to moving to value. And we looked at it from the perspective of the provider, the payer and the employer. And each of these stakeholders have challenges.

I would say from my perspective the biggest challenge I see gets down to benefit design. If patients are not incentivized to move to centers of excellence to change their behavior, it’s just not going to occur. If it occurs it’s going so slowly that it’s not measurable. So if I want to implore employers, I would ask them to get involved at the benefit level and really start to look at this: Does this benefit design really move patients to higher value, or is it more entrenchment in old models and old designs?

You know, again, there are obstacles all along the ecosystem. For us it’s data, its position alignment. We’ve been able to make some great changes so our positions, Carol, all abide by protocols.

We have 18 clinical protocols, which we abide by so we can measure it and look how we’re doing. That’s a big challenge to get orthopedic surgeons to agree to anything, but we’ve been able to overcome that. From the employer perspective, I can tell you that if we don’t start shifting market and rewarding the providers that are spending time and resources — a lot of money — then I’m afraid it’s just going to move slowly.

There was a great piece the other day from Michael Thompson in which 60% of employers are not capitalizing on their opportunities to address the health care waste despite the fact that they all recognize there is substantial waste and inefficiency.

CH: Much like you I grew up in the New York City area except I’m a Staten Island girl. And the story you’re telling, I’ve tried to tell employers, in particular because that’s where I’ve spent the majority of the latter half of my career in working with and educating and doing design work.

I grew up on what’s called the South Shore, which means if you live on that shore, you go down to the end of the island and you can see New York City across New York City Harbor. And I can’t tell you how many people I grew up with — and when I was young, it would be more of their grandparents and sometimes their parents — who would have cardiac issues or cancer or some major health condition. And instead of driving across the Verrazano Bridge through Brooklyn to Manhattan, or taking the ferry and going into one of the world class centers of medical excellence, they would have their surgery at St. Vincent’s or Staten Island Hospital, which I’m sure are fine for average things. But you don’t give up going to world-class cardiac center when you’ve got a pretty complicated cardiac condition when you can see the place where you can get the best care. But that happens all the time.

People go to places they’re familiar with and so you have to incentivize them. I’m so glad you brought that up. Employees have to be incentivized to do it, but the employers are also going to want to incentivize physicians and reward physicians who are giving great care and producing great outcomes.

Of course my prejudice extends all the way to people when they’re out of work. So even if I were to evaluate the services that your practice does I would be like not only do you get great medical outcomes, but your patients are back to work sooner and they’re not going back into the OR because some mistake has been made or they don’t have sepsis or they have a hospital-acquired infection. Those all become important things because it gets them back to work, feeling good, and going back to their lives. And that’s really important.

There are two things I want us to talk a little bit about before we run out of time. You want to talk about the upcoming Forum because I will tell people, again, I knew Dr. Schutzer on paper.  And then I got to meet him about a year ago when I was invited to go to your first forum and was astonished.

And please don’t take that the wrong way. I was astonished by the quality of the conference and the types of people who were there. So, I want to talk a little bit about that. And I would like you to close out our talk on value-based healthcare by explaining how an employer can measure — beyond what we already discussed — that it is working for them.

How to Evaluate Success

SS: So, first of all, the Forum is December 6th and December 7th. We are having a Thursday evening venue at the Marriott and that’s going to focus on pharmaceutical costs: “Stop Overpaying for Pharmacy” is the title. We’ve got two fabulous speakers, and then the next day on Friday we’re going to focus on primary care modernization. and centers of excellence.

As far as measurement, I always say this: orthopedic surgeons are not historically known to be a group that’s really very concerned about spend. We use expensive trinkets. Our tools are expensive; our widgets are expensive; and we’ve never really paid attention to that because, guess what? We don’t pay for them. Someone else does.

So, how have we been able to take these 10 formerly competing orthopedic surgeons with completely different motives, bring them together 11 years ago, align their interests without any economic incentive, and pull off what we’ve done here. And it comes down to data.

We’ve got a very rich database of 30,000 patients. The data is clean, credible and actionable, and it helps change behavior. So, I would ask employers when their reviewing their contracts and when they’re in discussions with provider groups to ask to see their data. I wouldn’t even sit down with a provider without that data being available.

So they shouldn’t ask to see it. They should really demand it. Then the question is: Is the data clean? And that gets very difficult because you can manipulate data anyway you want.

A very quick case in point. I’ll point myself out, Carol. A few years ago, ProPublica came out with rankings of physicians, and I looked at myself as a hip surgeon / knee surgeon. I thought it was decent.

Well, I got I got listed as a high-risk provider for hip arthroplasty. I was upset by that and I did a little digging. It turned out that I was taking patients back to the operating room because of bleeding in a day when we were using Heparin as an anticoagulant. I was taught by my mentor to not to put a bandaid on it. Take them back and wash out that bleeding. So, I thought I was doing what I thought was best for the patient, perhaps saving infections. That very next day another ranking agency came out and gave me the only five-star hip replacement surgery in the state of Connecticut. So, am I a hero, or am I a zero? So confusing to me. You have the same data.

So it is not easy. You have to dig deep. You have to look into the information. Perhaps recruit some other folks like Jeff Hogan and Paul Grady who really understand this ecosystem to provide some insight into that.

CH: You’re so generous to share a personal story like that because I can’t imagine what your face looked like when you saw yourself being lowly-rated when that is not generally how you are known in the Greater Hartford area or the Connecticut community.

I have a friend who is a specialty reconstruction surgeon. Not only does he only do breast reconstruction for women who’ve had mastectomies, but he does only what’s called the DIEP procedure, which is where a woman, as you know, donates some of her own body tissue to form the breast mound.

What I’ve learned from him is there are only 12 centers around the country that do this. It’s considered the state-of-the-art procedure. But the normal flap failure rate, which is really what these breast mounds are called is 30 percent. In his practice and in his hospital it’s only one percent. But the only reason why I know that information is because I know him. And that’s the challenge that we still have. How do we get that information shared in context?

Well, this time has just flown, and I know that we’re counting down the last minute. So, I want to first of all say thank you so much for making the time to do this. I know how incredibly busy you are in all the work you do in your own professional practice, the work you do with Moving to Value, and the upcoming Moving to Value forum.

Resources: Moving to Value

I will highly encourage people to attend this forum because I’ve attended myself before and will be attending again. This is well worth your time and effort, particularly if you’re an employer in the greater New York and New England area. Consider coming to the Moving to Value forum, which people can find out more information about at movingtovalue.com. It is being held in downtown Hartford, and we hope to see you there. Thank you so much, Steve.

SS: I really appreciate your time, Carol. I can’t thank you enough for this opportunity. Have a great weekend.

CH: You, too, and thank you to everyone who’s listened.