UpDate - Vol. 13, No. 35, Page 8
June 23, 1994
Survey measures employers' attitude on health
Delaware area employers agree that significant change is needed
in the current health care funding system and nearly half favor
President Bill Clinton's health plan, despite widespread misgivings
that it will result in higher taxes. This is according to a University
of Delaware survey that measures the opinions of small, medium and
large employers throughout the First State and adjoining areas in
Maryland, New Jersey and Pennsylvania.
One of the first comprehensive studies anywhere of employer
attitudes toward health care reform, the project was conducted by Eric
D. Jacobson and Jeffrey A. Raffel of the University's College of Urban
Affairs and Public Policy and funded by the Medical Center of
Delaware.
The mail survey, conducted in early 1994, drew 300 responses, or
28 percent of the 1,069 employers contacted. Respondents included 67
large employers of 250 or more employees, 114 medium employers (with
25-249 employees) and 119 small employers (with 24 or fewer
employees). Those polled included not only businesses, but also such
non-business employers as governments, non-profit agencies and
educational institutions.
According to the survey, employers' top concern (86 percent) in
changing the health care system is slowing the increase in costs.
Respondents were quite positive about the quality of care offered
by the current system, with only 34 percent calling for increased
quality as part of any reform. Employers also were not as concerned
about insuring the uninsured-a frequently cited goal among the general
public-with only 40 percent listing it as a key goal.
Jacobson and Raffel found that the guiding principles Delaware
area employers would use to shape a health care reform plan would
include a focus on cost savings, maintaining a choice of providers,
maintenance of today's health care quality, basing reforms on a market-
based approach and a reduction in administrative waste and
inefficiency.
In the survey, employers rejected alternatives that would limit
employee choice of doctors or hospitals and were wary of government
regulation. The employers supported market-driven reforms in which
private health plans compete for the enrollment of individuals.
A majority opposed price controls and government-specified
spending caps, but almost all supported managed competition. They
viewed waste and inefficiency as a major contributor to health care
cost inflation.
According to the survey, Delaware area employers are willing to
turn to more cost-effective medical providers as a major component of
health care reform. They were supportive of a number of alternatives
that are likely to reduce health care expenditures, such as managed
care, receiving primary care from well-trained nurses, increased
waiting periods for elective procedures and specialized medical
services being located only in regional centers.
"But these employers-and the general public-may not recognize an
inherent dilemma in their desire to save money through managed care,
while also strongly supporting the value of freedom-of-choice of
medical providers," Jacobson and Raffel said. "One way to address this
dilemma is through point-of-service plans, which have a foundation of
managed care while covering care outside of provider networks at a
reduced coverage level. Few employers, however, have adopted such
plans."
Employers responding to the survey did not recognize the
important role played by individuals and personal responsibility in
controlling health care costs. While focusing on greed, waste,
inefficiency, malpractice suits and cost-shifting in the health care
system, they underemphasized such factors as the aging of the
population, increased use of medical technology, the lack of a healthy
lifestyle and the potential for financial incentives to encourage
people to look for lower-cost service.
"A search for 'villains' may take energy away from a search for
systematic and systemic reforms needed to deal with health care
inflation and increased personal responsibility," the researchers
said. "Simply put, there is great need for community education and
increased awareness about the role that individuals play in escalating
health care costs."
Delaware area employers seem largely unaware of existing
opportunities to decrease their health care costs, Jacobson and Raffel
said. While recent research has indicated that wellness programs
generate savings generally three or more times greater than the
program costs, only one-quarter of those responding to the survey
reported adopting such programs in the last three years, and fewer
than half of the respondents offered health maintenance organization
(HMO), preferred provider or point-of-service plans.
Major changes in health care will bring with it greater
evaluation of the quality of health care received, but according to
the survey, such measurements are limited today. Half of the employers
surveyed reported that they used individual employee feedback to
assess the quality of health care received, while more formal
quantitative methods, such as customer satisfaction surveys, were used
by fewer than 20 percent of the employers. Only 7 percent reported
using sophisticated outcome measures.
By comparing the findings of the employer survey with a late 1992
Delaware public opinion survey that Raffel conducted and a 1993
national survey conducted by the Harvard School of Public Health, the
researchers were able to compare how the attitudes of Delaware area
employers differ from other Delawareans and from the American public.
They found three significant differences:
* First, on the major goals of health care, employers are focused
on cost to the exclusion of other goals, while the public is
equally concerned about moving to universal coverage. "Health
reform plans which attempt to control costs without increasing
access will have limited popularity among the public," Jacobson
and Raffel said, "but plans which offer universal coverage
without controlling employers' costs will be opposed by most
employers. This presents decision makers with a dilemma, since
increasing coverage generally means higher costs."
* Second, the public was less supportive than employers of a
number of health care service provision alternatives suggested
to increase cost-effectiveness. For example, the public was far
less in favor of increasing waiting times for elective
procedures, specialized services in regional centers and
covering certain expensive medical treatments by supplemental
insurance.
* Third, the public supports universal coverage by requiring
employers to "pay-or-play" (where employers either offer basic
health insurance or else pay into a government-sponsored
insurance fund), but half of the employers- including many of
those with health care plans for their employees-were not
receptive to this requirement. While virtually all employers
agreed that employers should make a substantial contribution to
employee basic health care plans, half preferred to avoid
governmental mandates.
"Health care reformers face dilemmas about employer and public
differences over goals, service provision and plans. But despite these
dilemmas, there is widespread agreement that the current health care
system needs to be changed," Jacobson and Raffel conclude. "It will
take creative leadership to forge a consensus that transcends these
dilemmas to build a consensus in Delaware, as well as across the
nation, which meets the hopes and expectations of both employers and
the public."
-John Brennan