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Prescription for Change: Health, Wellness, and Higher Education


Donna E. Shalala


As Secretary of Health and Human Services (HHS), I made it a point to engage cigarette smokers I encountered during my day. I would remind them how much they were jeopardizing their health.
I have continued that habit at the University of Miami (UM), buttonholing students and staff who I see smoking on campus. Over the years, a number of the smokers I spoke to have sent me notes of thanks for pushing them to finally follow through on their intentions to quit.

As our nation stands on the precipice of the new world that the Patient Protection and Affordable Care Act will usher in during the next several years, it has never been more important for higher education to engage employees and students in creating a culture that promotes health, wellness, and personal accountability. Just like every business, every college and university should have a clearly defined, long-term health-care strategy that outlines guiding principles not only for moderating costs but also for improving the health of its workforce.

Make no mistake about it: Initially, health-care reform will not significantly reduce our employer costs. Only healthier employees and students will do that. As educators, it is our obligation to build a healthier workforce and student body by focusing on prevention and creating a mindset of accountability for one’s own health.
No Panacea for Rising Costs
Though not perfect, the new law and its separate reconciliation legislation will do many good things, not the least of which is extending health-care coverage to an estimated 32 million Americans by 2014. Most of them are paycheck-to-paycheck, working-class individuals who have gone without health insurance for years and seek medical care only in our emergency rooms, and only in a crisis.
Of particular relevance to those of us with medical schools and affiliations with academic teaching hospitals, the reform act also establishes a Patient- Centered Outcomes Research Institute to support comparative effectiveness research. This nonprofit corporation will identify research priorities and fund and facilitate systematic reviews of existing and new research, including clinical trials and observational studies.
The reform act also will expand loan-forgiveness programs for nurses who agree to teach in accredited nursing schools, alleviating faculty and staff shortages that are plaguing our nursing schools and hospitals. And it will support the establishment or expansion of primary care residency programs at community-based Teaching Health Centers, bolstering the primary care workforce and reducing emergency room visits and hospitalizations.
But let me repeat: The reforms will not decrease our employer costs in the short run.
Consider the provision, which we are implementing in January, that requires health plans to allow young people to remain on a parent’s insurance policy up to their 26th birthday. As is the case at UM, many employer plans require adult children of employees to be full-time students in order to remain eligible for coverage. Usually, they also impose age caps lower than 25. But come January, children of employees can remain on a parent’s plan as long as they are under 26. It won’t matter if they are students or not. It won’t even matter if they are married and have children of their own.
So we can count on adding back to our insurance rolls an unknown number of dependents who dropped off our radars years ago. The number is unpredictable but has the potential to increase dependent coverage. How much depends on the institution.
Student health plans are compounding the uncertainty. Right now, they are in a state of limbo because it is unknown whether they will be considered employer plans or individual plans under health-care reform. Treatment as an employer plan would mean elimination of annual and lifetime maximums, along with preexisting conditions. Treatment as an individual plan would mean standards for loss ratios and required service categories and coverage.
Either way, the costs for graduate and undergraduate student health plans are likely to increase, even though fewer students will be in need of student health coverage. Many students will, of course, go on the plans of their parent’s employer; others will be able to purchase coverage on state-based exchanges or receive Medicaid as part of its expanded eligibility. Coverage for international students remains an open question, but it’s clear that the combination of higher costs and smaller numbers will require close monitoring of student health plans in the short and long terms.
An Ounce of Prevention
Developing an enduring, long-term strategy that focuses on wellness and prevention through accountability for one’s personal health is the only sure-fire way to prepare for these and other challenges, but we cannot do that in a vacuum. We must understand the population we’re trying to reach. We must develop the right incentives to motivate them to act. We cannot assume that, as educators, we know it all.

When I arrived at HHS in 1993, one of my first challenges was convincing seniors to get an annual flu shot. At the time, fewer than 10 percent bothered. Because Medicare paid for all but $10 for the shots, I assumed that reversing the trend would be a piece of cake. It wasn’t.
Even after we spent thousands of dollars for a public outreach campaign, a very small percentage of eligible seniors complied. Subsequent focus group discussions with seniors revealed the reason: The start of the federal fiscal year happened to coincide with flu season, which meant Medicare’s annual $100 deductible renewed at the same time. As a result, price-sensitive, Depression-era seniors were reluctant to start paying down their deductibles, even just $10, for something they considered nonessential. They were saving their deductibles for something they considered more important, such as a hospital stay after surgery.
So we exempted flu shots from the deductible, and guess what? A significant percentage of the targeted seniors got their flu shots, generating a considerable cost savings to Medicare. It is, after all, infinitely cheaper to prevent than treat the flu and its complications.
That lesson is worth remembering today. If we have too many co-payments and if the deductibles are too high, it will affect how and when people seek health care. Keep that in mind because, in the end, the success of health-care reform will have more to do with our understanding of how people behave than the actual details.

We have to coax people into the health-care system at the front end so they can avail themselves of the kind of preventive care that could eliminate 80 percent of all disease. The fact is, we have plenty of money for health care in this country if only we didn’t smoke, we exercised, and we ate right.
Taking Responsibility
At UM, our health-care strategy is designed to promote prevention and wellness through accountability on three fronts: employee accountability, employer accountability and, as operator of the University of Miami Health System (UHealth), provider accountability.

We encourage our employees to seek health and wellness education and demonstrate active participation in and responsibility for their own health and well-being. We want them to choose our UHealth system for their health care, but we want them to be wise health-care consumers, too, by asking the right questions and making informed health-care choices.
They, and we, need to understand that more care is not better care. Consider the recent studies published in the Archives of Internal Medicine that plainly showed some of the risks and consequences of unnecessary treatment. Researchers concluded that approximately 15,000 people will die from cancers caused by large doses of radiation from the estimated 72 million CT scans performed in the United States in 2007 alone.
It is not only the job of the doctor to consider safer, more cost-effective alternatives, but it also is the patient’s job. When one of our doctors recommended an MRI for my problem ankle, I stunned him by asking whether an X-ray would do. It did and was, of course, much cheaper and more readily available. This saved me time and the university’s insurer money.
As such, we offer high-quality and competitive insurance plans that encourage our employees to be more conscientious about the health care they’re getting and how they’re getting it, and more self-conscious about taking care of themselves. We give them incentives and opportunities to avail themselves of our resources. In fact, in 2005, we adopted many of the guidelines of the U.S. Preventive Services Task Force and eliminated co-payments for annual physicals, mammograms, colonoscopies, prostate cancer screenings, and other cost-effective preventive care.
This year, we also instituted a rewards program for employees who took proactive steps to better health. Those who completed an online health assessment and answered the call to “Know Your Numbers”—their cholesterol, glucose, blood pressure, and waist circumference measurements—earned a $150 credit on their insurance premiums. Nearly 3,700 employees participated.
We also offer an array of wellness and prevention programs, including Weight Watchers and smoking cessation classes, as well as membership discounts to employees who join and regularly exercise at either of our two world-class Wellness Centers.
This past March, our Miller School of Medicine and our public teaching hospital, Jackson Memorial, took the bold step of banning smoking everywhere on their joint campus near downtown Miami. Our Coral Gables campus already bans smoking in all campus buildings. We also have made a conscious effort to allow our students to choose healthier living. Next to the chips, candy bars, and sodas in our campus vending machines, you can find juice and healthy snacks, such as pineapples, carrots, and celery. Every week, one campus restaurant offers a tasty “Well ’Canes” meal, including a bottle of water and an apple, for under $5.
As operators of the UHealth system and staff for our community’s safety-net hospital, our long-term health-care strategy also places accountability on our providers to provide access to quality health care. That doesn’t only mean offering the kind of cutting-edge medicine available at academic medical centers like ours. It means having top-notch customer service with easy-to-make appointments, welcoming staff, and an inviting atmosphere, all of which will soon pose considerable challenges for universities with medical schools, especially those affiliated with public-safety net hospitals.

After all, when millions of Americans tuck their first health insurance cards in their wallets in 2014, they will suddenly have something else they’ve never had before: choice. Patients who once had no other place to go but the public hospital suddenly will be attractive to other hospitals and clinics. If we want to compete, we will have to sell—and deliver—quality and excellence as never before. Customer service, the facility’s appeal, efficiencies, and the way we’re organized are going to be far more important than ever. So it’s not only employee/patient behavior that has to change, but also our public sector hospitals and the universities that are affiliated with them. We have three years to get ready but no time to waste.
By now, every institution of higher learning should have a long-term health-care strategy for building a healthier workforce and for creating a powerful culture of wellness, prevention, and accountability for one’s own health so that one day, lighting up a cigarette on campus will be unthinkable.
Donna E. Shalala is president of the University of Miami. In 1993, President Clinton appointed her U.S. Secretary of Health and Human Services, a position she held for eight years.