The Struggles of ADA Compliance
Twenty-five years after the passage of the American with Disabilities Act (ADA), employers still struggle with making reasonable accommodation for employees with qualified disabilities. Making accommodations for employees under the original ADA legislation was easier. The ADA Amendments Act of 2009, however, has changed the process for employers, making it more difficult and time consuming.
Many individuals who were not qualified under the original ADA are now qualified and the law currently allows employees to remain off work (indefinite leave) under some circumstances instead of returning to work, which seems counter to the intent of the law. And employers have yet to see clear guidance on this from the EEOC.
Regardless of employer struggles, the purpose of the ADA is clear. The law requires an employer to provide reasonable accommodation to an employee with a disability, unless doing so would cause significant difficulty or expense for the employer (“undue hardship”). An interactive process is mandated to determine if reasonable accommodation can be made for an employee with a qualified disability
Yet, here we are, 25 years after the passage of the ADA, and labor force participation by people with disabilities is actually lower than when this landmark law was passed.
Providing people with disabilities better access to transportation, public and private facilities and — above all — jobs, is something everyone should support. Greater job opportunities permit people to earn money to support themselves and thus diminishes their need for public assistance. Equally important, it affirms the dignity and the sense of self-worth that comes from making valued contributions to society.
Yet, here we are, 25 years after the passage of the ADA, and labor force participation by people with disabilities is actually lower than when this landmark law was passed.
Yet only a small proportion of disabled individuals are able to participate in the workforce. According to an online disability statistics data search tool maintained by Cornell University, 30 years ago 25.1 percent of people between the ages of 21 and 64 who had a work limitation were employed. In 1989, the year before the ADA passed, that proportion reached a high of 28.8 percent.
But by 2014, the percentage of people with a disability who were employed had fallen to 12.9 percent according to a Cornell study.
There are many reasons for the declining labor participation rate of the disabled. Overall labor participation has fallen, with especially large declines among older white males. But there is little doubt those with disabilities still face particular challenges in obtaining and maintaining a job.
As disability and absence management professionals, we have a special role to play in helping ensure they do. We need to do even more to educate colleagues and the larger public about disabilities, including those driven by behavioral health factors.
We need to work closer with those in other departments in our organizations to develop effective programs that not only comply with the law, but truly advance the goal of finding and keeping the best person for a particular position. And we need to make sure we’re doing all we can to keep pace with the creative and effective leave initiatives taking place in workplaces across the country.
Accommodating disabled workers is good for employees. It’s good for employers. And, most important, it’s the right thing to do. Twenty-five years after the passage of the ADA, there’s still a lot of work to do.
Brokers Expect More ACA Business
Now that the Supreme Court has cleared up a major question regarding federal subsidies permitted under the Affordable Care Act in its King vs. Burwell decision, some brokers and employee benefits consultants are expecting employers to seek more strategic advice.
“It provides absolute clarity that these are the federal rules we will be living under for the foreseeable future at least,” said Sean Waggoner, executive vice president, Alliant Insurance Services.
“We’ve gone from a [pre-ACA] environment where we brokered and placed insurance contracts,” he said. “Now, we are spending a lot more time consulting with clients on operational changes to their businesses based on this.”
Karin Landry, managing partner, Spring Consulting, said the ACA offers “an opportunity for the broker/consultant that wants to change and evolve and become an ACA expert, but it’s probably less business for those that don’t want to change and evolve.”
Some brokers, she said, are seeking to minimize their involvement with health care because of the law’s complexity. Others are selling their businesses or merging with another organization that offers the expertise.
As for employers, larger organizations have been prepared to comply with all of the law’s requirements, while some smaller and mid-size companies “have been taking more of a wait-and-see attitude. … I think most people feel like it’s here to stay and they have to deal with it and move forward and develop their strategies accordingly.”
“The mid-size employers who have not had a strong broker/consulting relationship,” she said, “will now need one for sure.”
Jim Winkler, chief innovation officer, Aon Health, said the “uncertainty as we awaited the Supreme Court ruling meant employers did not make significant changes to their plans for the last year or two. We now anticipate that we will see those types of changes.”
“The most immediate and pressing need, for many employers, is to come up with a more compelling strategy for their non-Medicare-eligible retirees.”
— Jim Winkler, chief innovation officer, Aon Health
Winkler said the “most immediate and pressing need for many employers is to come up with a more compelling strategy for their non-Medicare-eligible retirees.”
For employers that provide health care benefits to retirees under the age of 65, they must account for the future value of such benefits on their balance sheet, he said. With the High Court upholding the constitutionality of subsidies available via marketplace exchanges in the states, employers may opt to change from a defined-benefit medical plan to a defined-contribution plan.
Offering a set monetary amount to be used for health care on the exchange instead of offering an employer-based plan provides more plan choices for former employees — and possibly at a lower cost than their contribution to their current employer plan, Winkler said.
It also allows employers to cap their spending at a designated amount each year, Winkler said.
“I’ve worked on several of those projects already,” Alliant’s Waggoner agreed. “It creates pretty significant bottom line results for the client.”
He said the ACA’s prohibition on pre-existing condition exclusions and flattened rating table makes it easier for older adults to purchase health care plans, especially with the help of federal subsidies.
Doug Luick, area senior vice president, health and welfare consulting, Arthur J. Gallagher & Co., said that one utility electric cooperative recently made the decision to sunset its early retiree medical provision, which was “almost a handcuff around them,” as it resulted in high claims exposure, limited benefit plans and ever-increasing costs.
As of 2016, he said, the organization will fund health reimbursement accounts (HRAs) for retirees instead, allowing them to purchase their own health care benefits via the exchanges.
Winkler noted that with the assurance that subsidies are available, employers may begin to help part-time or seasonal employees access the public exchanges to access health benefits.
“Those employees have been living outside the insurance system,” he said.
The Tools of the Trade
Integrating medical management with pharmacy benefit management is the Holy Grail in workers’ compensation. But getting it right involves diligence, good team communication and robust controls over the costs of monitoring technology.
Risk managers in workers’ compensation can feel good about the fact that opioid use is declining slightly. But experts who gathered for a pharmacy risk management roundtable in Philadelphia in June pointed to a number of reasons why workers’ compensation professionals have more than enough work cut out for them going forward.
For one, although opioid use is declining, its abuse and overuse in legacy workers’ compensation claims is still very much a problem. An epidemic rages nationally, with prescription drug overdose deaths outpacing those from the abuse of heroin and cocaine combined.
In addition, increased use of compound medications and unregulated physician dispensing are resulting in price gouging and poor medical outcomes.
Although individual states are attempting to address the problem of physician dispensing of prescriptions in workers’ comp, there is no national prohibition against it: That despite substantial evidence that the practice can result in ruinous workers’ compensation medical bills and poor patient outcomes.
“The issue is that there isn’t enough formal evidence to indicate improved outcomes from the use of compounds or physician dispensed drugs, and there are also legitimate concerns with patient safety,” said roundtable participant Jim Andrews, executive vice president, pharmacy, for Duluth, Ga.-based pharmacy benefit manager Healthcare Solutions.
Andrews’ concerns were echoed by another roundtable participant, Dr. Jennifer Dragoun, Philadelphia-based vice president and chief medical officer with AmeriHealth Casualty.
“When we’re seeing worsening outcomes and increasing costs, that’s the worst possible combination of events,” Dr. Dragoun said.
Whereas two years ago, topical creams and other compounds with two to three medications in them were causing concern, now we’re seeing compounds with seven or more medicines in them.
How those medicines are interacting with one another, and in the case of a compound cream, how quickly they’re being absorbed by the patient, are unknowns that are creating undue health risks.
“These medicines haven’t been tested for that route of administration,” Dragoun said.
In other words, the compounds have not been reviewed or approved by the FDA.
Carol Valentic, vice president of cost containment and medical management with third-party administrator Broadspire, said her company’s approach to that issue is to send a letter to providers, through the company’s pharmacy benefit administrator, alerting them to the fact that compounds are not FDA-approved and could be dangerous.
Other roundtable participants said they employ utilization review of every prescribed compound medication. They’re finding that the inflation of the average wholesale price for prescriptions that pharmacy benefit managers are battling in the case of single medications is happening with compounds as well, to the surprise of probably no one.
“The cost of compounds is doubling every year,” Healthcare Solutions’ Andrews said.
Kim Clark, vice president of utilization management with Patriot Care Management Inc., a division of Patriot National, Inc., said Patriot has their own software, DecisionUR, and opioids as well as compound prescriptions can be directed from the PBM to Utilization Review.
In the area of new worries in workers’ compensation, and there are plenty of them, Dragoun also pointed to the introduction of extremely high cost, albeit extremely effective specialty medications, such as those being used to treat Hepatitis C. Treatments in this area can run into the hundreds of thousands of dollars.
Domestic drug manufacturers, pressed to pursue profits as their product lines mature and their margins level off, are jockeying for dominance in this area.
“This seems to be a route that a lot of drug makers are going after. Very narrow markets but with extremely high cost medications,” said Deborah Gleason, clinical resources manager, medical programs, with ESIS, the Philadelphia-based third-party administrator that is part of ACE Group.
Tools of the Trade
Given how substantially the use of prescriptions can balloon the cost of a workers’ compensation claim and undermine outcomes, a number of tools are in the market that can help risk managers rein in costs.
One is urine drug monitoring, which can catch cases of drug diversion, or instances where an injured worker is ingesting unprescribed substances. But the use of that test can create its own problems, namely overutilization.
Gleason, with ESIS, Inc., and others use urine drug monitoring. But when the test is overused, say by being conducted every month instead of quarterly as is recommended, the members of the Philadelphia roundtable said its costs can outrun its usefulness.
Test results are frequently inconsistent, signaling that the injured workers aren’t taking the prescribed medication or are taking something they shouldn’t be. Drug testing shouldn’t be used in isolation but rather as a component of integrated medical management.
“What’s emerging today, and in some companies more prevalently, is the integration of managed care with pharmacy benefit management,” roundtable participant Valentic said.
“When we’re seeing worsening outcomes and increasing costs, that’s the worst possible combination of events.”
— Dr. Jennifer Dragoun, Vice President and Chief Medical Officer, AmeriHealth Casualty
In other words, it’s not enough to flag a script or pick up a urine drug monitoring test result. There needs to be a plan or a system in place that says what action should be taken with the patient once that information has been received.
Identifying a potential problem early and taking action on it is key, said ESIS’ Gleason. She added that the patient’s psychological state, including how they react to and perceive pain, is something that more risk practitioners should consider.
Obstacles to assessing someone’s psychological or psychosocial state, according to roundtable members, include a lack of awareness or acceptance of its possible advantages on the part of patients and physicians. After all, we’re talking about an assessment, a list of questions, that should take no more than 15 minutes to carry out.
If a treating physician or case manager doesn‘t conduct a psychological test but is still concerned about the potential for pain medication abuse, there is one key question they can ask an injured worker, according to AmeriHealth Casualty’s Dragoun.
“There is one question that predicts far more than any other attribute of a patient whether they are likely to abuse narcotics, and that is if they have a personal or family history of substance abuse,” Dragoun said.
“You know they may ask that about the patient, but I don’t know how many ask it about the family,” Patriot Care Management’s Kim Clark said.
Pharmacogenetic testing, that is testing an individual for how they might react to certain drugs or combinations of drugs, and not — let’s be clear about this — whether they are predisposed to addiction, is also entering the market.
But as is the case with urine drug monitoring, the use of pharmacogenetic testing is no cure-all and the cost of it needs to be carefully managed.
Some vendors are pitching that it be applied to every case in a payer’s portfolio. The roundtable participants in Philadelphia agreed that it should be used with far more discretion than that.
Regulating the Regulators
It’s a given in the insurance business and in workers’ compensation that regulators in all 50 states call the shots. There are few national laws that regulate the hazards faced by workers’ compensation risk managers and injured workers.
Having said that, is it really such a pipe dream to think that the federal government could step in and provide leadership in an area that is so prone to confusion, risk and self-serving behavior on the part of some vendors and medical practitioners?
If the Philadelphia roundtable as a group could point to one place where federal regulators could do some good it would be in the area of physician dispensing. Many states have enacted legislation to curb the practice, as there is no data to prove better outcomes, and regulation by the federal government would be of benefit, the Philadelphia roundtable concluded.
Another area would be to require FDA oversight for compounds.
“The minute you need to have FDA approval of a compound, that’s going to stop it,” Broadspire’s Valentic said.
It’s a notion worth considering. After all, lives are at stake here.
Given the lack of oversight from the federal government, the roundtable participants pointed to measures in a number of states that are worth emulating. The Texas closed formulary, which limits the range of medications that can be prescribed, is one example.
The requirement in the State of New York that a prescribing physician check a state registry — what’s known as a prescription drug monitoring program — to check whether a patient is already taking or has a prescription for a controlled substance, is another good example of a state government stepping in to ensure the safety of its residents.
“The minute you need to have FDA approval of a compound, that’s going to stop it.”
— Carol Valentic, Vice President of Cost Containment, Medical Management, Broadspire
Pennsylvania also earned praise from the roundtable for recently passing a measure limiting the amount of medication that a physician can dispense to an initial supply.
With different regulations in every state and with the average wholesale cost of prescriptions constantly on the rise, pharmacy benefit management is an art requiring constant vigilance.
“It’s not an original thought, but if you stop and think about all the things that are happening in society with the addictions and the costs, the cost of doing nothing is greater than the cost of doing something.
I think that’s why everybody is doing something,” Healthcare Solutions’ Andrews said.
For more information about Healthcare Solutions, please visit www.healthcaresolutions.com.
Opinions of the roundtable participants are the opinions of each individual contributor and are not necessarily reflective of their respective companies.
This article was produced by the R&I Brand Studio, a unit of the advertising department of Risk & Insurance, in collaboration with Healthcare Solutions. The editorial staff of Risk & Insurance had no role in its preparation.