Response to SHP Changes

In our Oct. 8 issue, we ran an article on changes to the State Health Plan that may reduce coverage for people who smoke or have a high body mass index. Readers responded with questions and comments about the new regulations and their personal experiences with the health plan. Here’s a sample of the letters we received:

Claim Denied

Thank you for providing such a comprehensive look at the changes coming up with the State Health Plan (SHP). First of all, I want to clearly state that I support these changes, but I’d like to toss my two cents in by relating a story about my experience with the SHP’s approach to weight loss.

In the summer of 2008 I began exploring the possibility of weight loss surgery. As a morbidly obese woman who had tried every diet without success, and who was now facing several serious co-morbidities, I felt that a better tool for weight loss was warranted. I chose to pursue an adjustable gastric band (a LapBand in my case). As part of the pre-surgical process, I was required to meet with a registered dietitian to discuss pre- and post-procedure nutrition and the food-related lifestyle changes that would support a healthy and successful weight loss.

Imagine my shock when the SHP denied my claim for the cost of this appointment! Apparently, nutrition consultations are not covered, even under a doctor’s orders. I was referred by human resources and the SHP to programs such as Weight Watchers on Campus, “Eat Smart, Move More, Weigh Less,” and Wolfpack Wellness. Remember, I was seeking major surgery because none of these were effective in helping me to keep excess weight off. I wonder, will coverage be changed to support the changes in the requirements? Will we not only be required to lose weight but also have to bear the burden of the full cost of what I consider to be a vital part of an appropriate, healthcare-based approach to better health?

Lanakila Michaels Alexander
Graduate Programs, Department of Genetics

Looks Like Discrimination

This looks like discrimination. Why would smoking and weight be selected as special areas of health concern while neither drinking nor drugs is mentioned?

Brenda Flood
Forestry and Environmental Resources Academic Research

Letter to SHP

Editor’s note: The following message was sent by Ms. Oktyabrsky to the State Health Plan last week.

I have recently received a new information brochure that explains the new rules related to BMI. The plan intends to “punish”  people whose BMI isn’t reduced from 40 to 35 in the next couple of years by switching their coverage from 80/20 to 70/30. The intention certainly is quite generous because doctors consider anything above 25 to be an abnormal BMI.

On the other hand, I wonder why wouldn’t the State Health Plan encourage or reward those state employees whose BMI is already 25 or less by providing them with  90/10 insurance coverage – the option that has been completely taken away from us. Having three levels of coverage would be fair and would give a good incentive not only to those who need to self-improve from obesity stage II to stage I but also for state employees who do everything they can to stay fit and healthy. Based on my own experience I know that this requires very hard work: sticking to healthy eating habits and serious personal devotion to a daily exercise routine.

Please consider my suggestion that is supported by many of my co-workers at NCSU. Thank you.

Larisa Oktyabrsky
Office of Research & Graduate Studies

Unfair

I am not overweight and I do not smoke. However I do not think it is fair to enact recommendations which mitigate against the participation of people who are overweight and who smoke. Let’s face it, many people are fat not because they want to but because they have a problem. Some were even born that way. How can you solve their problem by adding on another problem, reducing their health benefit?

It is not fair to them, although to be honest with you, it is intended to make it better for people like me who do not smoke and who are not overweight. Still seems rather draconian!

Juliette Lee-Campbell
Office of Research Administration, College of Engineering

Outstanding

I think the changes to the plan are right on track. We are trying to teach our students to be well balanced in mind and body. Part of that is teaching them a healthy lifestyle. They see us every day on campus. If we are fat and smoking they think that is acceptable.

In addition, my family works very hard to eat well and exercise regularly, including our young children. Why should we have the burden of paying for other people’s poor habits that result in overweight children and parents with higher health costs. For too long being unhealthy has produced a negative externality that other healthy people suffer in our health expenses. Way to go, and let’s shift even more of the expense to those who make a choice to be unhealthy.

Michael Zapata III
Entrepreneurship Program

Punishment Is Sad

I have been a faculty member at NCSU for 31 years. I have been covered by the State Health Plan and paid tens of thousands of dollars to cover my family. I have never received a cent of benefits. Thankfully I haven’t needed them and my family has been healthy. Now that I am getting “old” I am being told that if I’m a few pounds overweight or if I enjoy a cigar at a weekend wedding I am liable to be “caught” for my iniquity and punished by the state. How very sad. This certainly is an added PERK in trying to recruit the best and brightest faculty members to our university. The State of N.C. has the habit of taking two steps forward and three steps back every now and then. Certainly makes me questions several of my career choices!?

Robert I. Bruck, Ph.D.
Department of Plant Pathology

What’s Available for Extension Employees?

You mentioned in your article that employees can take advantage of programs and services on campus, like Weight Watchers at Work and fitness programs offered by Campus Recreation.

Can you please list what type of programs are available off campus, specifically for cooperative extension employees?

Regina Gardner
North Carolina Cooperative Extension

Doesn’t Seem Equitable

I wonder about the fairness of the new regulations for the health plan. For example, I understand that  smokers as a group have higher health care expenses and I’m sure that can be proven statistically. I can certainly understand charging them more for conditions directly related to their risky behavior but is it also appropriate to charge them more for conditions that have nothing whatsoever to do with smoking? Why should a smoker have to pay more than a nonsmoker for a yearly checkup, kidney infection or broken arm (assuming that they did not trip on their pack of cigarettes)? It doesn’t seem equitable to me that some individuals will be charged more for issues that are unrelated to their risk group.

Martin Dulberg
Distance Education & Learning Technology Applications

Will Refuse Random Test

I think the penalty, rather than reward, system is going to cause a lot of resentment  with employees. Those few states that have implemented plans such as this have no hard evidence that it has reduced costs. I’ve never smoked a day in my life, and I exercise and eat a healthy diet. But, according to my BMI, I’m overweight. BMI is a poor standard to judge by and I refuse to have anyone prodding at me like I’m cattle. If the SHP will accept information from my doctor, fine, but I’ll be refusing to participate in any random tests. If that means I’m forced to pay higher health care costs, so be it.

Alex Dalton
Chemistry Business Office

BMI Reduction Is Drastic

Thank you for the article in the Bulletin. I read with surprise that the allowable maximum BMI will go from 40 to 35 (in 2012). Why such a drastic drop? What was the thinking? That if they took it down gradually perhaps folks would not take it seriously?

That would be a good follow up article.

Debbie Cox
Family & Consumer Sciences

Waiving of HIPAA Protections a Concern

I think it is great that there are all kinds of initiatives at the state and at NC State to support wellness. I struggle with obesity and have been actively working with a doctor to lose weight so I can remain healthy.

Contrary to what the plan states, there are no programs to pay for weight loss. There are initiatives that employees pay for. I tried to get medication to assist with the weight loss, but MEDCO denied the pharmacy claim. I pay $150 a month to see a doctor four to five times for weigh-in, shots, blood work, etc. It is not covered by health insurance. It is not even covered by NC FLEX because they do not recognize obesity as a health condition. Yet North Carolina’s governor does! In order for me to get reimbursed I must have a condition like high blood pressure or diabetes. But according to the governor, obesity leads to these other conditions. Her motto is correct, treat it at the root cause.

I do have another resort, which is to go through bariatric surgery, since it is covered by health insurance. Yet it costs way more in the short and long term, not to mention permanent complications that may arise as a result of the surgery.

On the other hand, smokers are offered programs for cessation and can get prescribed patches to stop smoking. There is a disparity here!

One thing that no one is paying attention to is the fact that effective July 1, 2010, all state employees will not be protected by HIPAA laws. The reason is that the state is self funded and federal laws have a loophole that allow them to opt out. All of this is under the guise of the wellness initiative.

What this boils down to is that the state or the insurance company can discriminate against a participant because they have medical/mental conditions, excessive claims, disability, etc., etc., etc. Furthermore, it is possible (although for now may not be probable) that employees’ health record could be available for public review.  See http://www.hhs.gov/ocr/privacy/hipaa/faq/permitted/require/506.html

I am by no means a lawyer but I do have the foresight that someone, someday may decide that they want to look at chancellor’s or a dean’s, or the governor’s, or another state employee’s medical records. They may even take it to the point of a lawsuit to get the records. If that were to happen someone in state government might realize their mistake and change the law. But why was this slipped into the bill in the first place?

I am very upset with the changes to the program. The most upsetting to me is the changes to HIPAA for state employees. Many of my colleagues (faculty and staff) are also upset by this. Some have been outspoken while others are afraid to speak up because of the unknown potential repercussions.

Patricia A. Fields
Educational Leadership & Policy Studies

Editor’s Note: In order to implement the wellness initiatives, the state of North Carolina has elected to exempt the State Health Plan from the federal HIPAA rules that protect employees, retirees and their dependants from discrimination based on health status related factors, including health status, medical condition (physical and mental illnesses), claims experience, receipt of health care, insurability, and disability.

Incompetent Administration

I do not agree with the changes in the State Health Plan for a number of reasons. I understand that it is in serious financial condition and changes have to occur, but obviously those who were running the show were grossly incompetent. As a result, those who depend on the plan are being penalized for the poor administration of others. I would be very interested to know the salaries of those who have been running the system and making decisions compared to the average salary of the people who will be most impacted by these new policies. To drive my point home, I want to refer to a quote in your article by the state auditor:

“The State Health Plan has agreed to a contract that requires the plan to reimburse BCBSNC [Blue Cross Blue Shield of North Carolina] its costs, but does not allow the plan to verify those costs or even know what they are. Therefore, BCBSNC could charge the plan for expenses and overhead that plan management might not agree were true costs of the plan.”

Please tell me what responsible business manager, CEO or competent individual would sign a contract where someone could charge costs to you and you could not verify those costs? As the head of a household, I would not sign such an agreement. In addition, they guaranteed BCBSNC a certain “profit”! BCBSNC is a nonprofit that has tried to become a for-profit for years, and in the meantime just uses its “profits” to give executives outrageous trips, gifts, etc. Those stories have been in the newspapers for years, so why would any State Health Plan executive decide BCBSNC was altrustic enough to not overcharge them on expenses?

So here we are, a ridiculous contract has been signed, and we are locked in until 2013,we cannot decrease the outrageous administrative fees. The plan is broke, so the members have to suffer. And to make themselves feel better, plan administrators are now offering “wellness” programs to help the members become healthier and meet the new guidelines. As though going through a pattered lecture/reading program can really help someone addicted to tobacco. According to a study by the University of Minnesota, and many other places, tobacco is as addictive as heroin (as a mood and behavior altering agent).

Nicotine is:

• 1,000 times more potent than alcohol
• 10-100 times more potent than barbiturates
• 5-10 times more potent than cocaine or morphine

A one to two pack-per-day smoker takes 200-400 hits daily for years. This constant intake of a fast-acting drug (which affects mood, concentration and performance) eventually produces dependence. Pressures to relapse are both behaviorally and pharmacologically triggered. Quitting involves a significantly serious psychological loss.

So I seriously doubt the NC HealthSmart Worksite Wellness Toolkit, including a resource book called, “Quit Now,”  is up to helping someone addicted to such a powerful substance. Neither will the economics. These initiatives by the State Health Plan are just smoke screens, to attempt to wrap this up in a drive to make workers healthier. Their initiatives are worthless to most who suffer from obesity or substance abuse and unfortunately the health plan people know it but are practicing CYA. Both obesity and substance abuse are problems with high recurrence rates and are difficult to combat.

Finally, instead of a reward system, where those who fit the “healthy lifestyle” program get to obtain the 90/10 plan, which was deleted, the whole system is a penalty where the unhealthy are relegated to the lowest plan, 70/30. The standard 80/20 plan is now the best one can do.

And to “keep us honest” we will be monitored in our workplace. Keep us honest? What about the health plan executives who have sold us down the river, what check system is in place to keep them honest? No, now the masses will arbitrarily be tested to see if they have eaten too many cupcakes, or smoked a cigar. Tested arbitrarily in the workplace, singled out and tested. Sounds like Big Brother is here and ready to oversee our lives. But who is overseeing the system, to penalize those who got us here, to evaluate and provide the best possible alternatives, and ensure we never get in this kind of mess again? Gross incompetence is not an excuse.

Lora L. Moyle
Environmental Health & Safety Center