Is there a better model out there for better health outcomes that uses the health care system less? Yes there is!
How do you take Marmot’s information about how social status affects our health and use it to make a positive difference in the workplace? This is how you can.
When I left CIBC, one of Canada’s largest banks, 17 years ago the most prescribed drug in the plan was Prozac – an anti depressant. The bulk of the staff were women in clerical roles – at the bottom of the hierarchy with the least amount of control. Why were they so depressed and what did this mean? Our healthcare costs were exploding. The plan cost $200 million then and our projections showed that it would cost $500 million in ten years. Why was this? After all working at the bank did not expose workers to a risky or dangerous workplace.
What Dr David Brown and our team discovered was that everything that Dr Marmot had predicted The bank’s highly bureaucratic culture – very top down and controlling towards those at the bottom such as the fron line female staff – was creating waves of debilitating disability. You see this in any organization where the work is tightly controlled - why teachers are now so stressed. The social stress in the workplace was driving the incidence of disability. (BTW do you see the link back to the family too? – lack of “Voice” and too much control set up social stress and so too much cortisol)
Until then, we, at CIBC, like everyone else had treated this resulting illness by using the medical system. We had intervened to great the symptoms of the illness and disability. We found the key stressor that drive the cortisol and then the breakdown in health and the incidence of disability.
For David Brown’s historic achievement was to look upstream from the disability itself and look at the social and cultural drivers that caused it. In short, it was stress – social stress caused by the overall culture and made worse by some managers in particular – that set the staff up to become ill. David’s great work was to find ways of identifying the hotspots early and intervening socially to mediate the cultural tension. The results have been amazing.
My sense is that this model can be replicated in any health system. Here below the fold is what we did.
Load can be reduced by non medical interventions at much lower costs and with much better results.
In 1993, CIBC was reviewing its own health costs. CIBC has close to 40,000 employees whose families are included in the plan. Our projections looking forward showed that our gross current costs for health benefits and disability were then $200 million a year and it looked as if it would reach $500 million in 10 years. This was an unacceptable cost for the Chairman and we were instructed to bring both the rate of increase down and also the end number.
To do this, we had to reduce the load – the rate and incidence of disability – that demanded heavy treatment and absence from work. Reducing the load in a way that is politically acceptable became our project objective. Until then we had, like most health systems, looked only at the delivery and only looked for “efficiencies” in that. We had not looked at who was ill and why and if this illness could be prevented. We had been over focused on the medical model.
Using this lens, we learned that we could avoid most of the medical use. That we could both prevent illness and make people well when they were ill with minimal medical intervention.
We discovered the cultural/social aspects of illness and how they affected everything.
- Finding the Drivers of Load - By mapping the outcomes and so the route to the risks, CIBC was able to determine that some of the top drivers of health (or ill health) were not the traditional “usual suspects”. It was disability that had the most and worst costs. This was an area that we could get to the root of. We knew how to prevent this, we knew how to reduce the risks and we knew how to get people back to work well. This, the greatest driver of risk, illness and medical treatment had its causes and cures in the social realm and NOT in medicine. So this, the largest component of the risks and costs, could be modified though policy development as opposed to program development. Program changes did follow to align with the policy principles but the big returns were in policy. This is the opposite of what we used to do.
- Choice and Market Segment - We recognized that, just as we could not serve the public with a one size banking offering, it was not smart either to offer a one size benefits offering. We saw the value of segmenting our employees into a Lifecycle. Young singles, young married with young kids etc all the way up to late middle age. Prior to that we only saw the health problem. We had forgotten to see people as people and to see the people before we saw the illness
- Culture – We acknowledged that so long as CIBC assumed that disability was only a medical issue, we were never going to be able to reduce the load. So we deliberately aimed to change the culture for health at CIBC. We had a top down paternalistic approach. This meant that the employee’s health was our concern. So they could and did game the system and always be unhappy. Everything was seen in the medical lens. We could never do enough. So our primary design intent was to shift the culture from a paternalistic to child to an adult to adult relationship – where the employee took charge of their health and where CIBC looked at what truly caused disability.
Here are the lessons that we learned at CIBC that can apply to the work ahead for any large population. It could work for a Province, for Medicare or for your organization.
- Culture. We learned that culture was the most important guiding factor. We saw the evidence that the more control and social value people have the better their health.
- To Get ahead of your problems – You need a Map - We could not anything of value without knowing what was going on. We knew that we had to have a “map” and instruments to enable us to set a course. To get this map and these tools, we used business market research principles. We looked at outcomes, at segments and at issues just as we would do if we were looking at a new business venture. This gave us the kind of information that enabled us to take action. It showed us who was getting ill , where they were and why. It showed us where we could find the best return. It gave us advance warning of trends.
- Bring the people into the work – We learned that if you work on health, people get very nervous. So we took for us a new approach. We shared the problem AND the direction of the way out. We talked to people all the way through the process especially when we did not know the answers. In a real dialogue like this we learned 3 vital things. We learned that, if our staff had a chance, they would take charge of their health. All were worried about a catastrophic illness – we had caps on all our programs. All wanted more choice. We used this feedback in our design
- Don’t design until you have a framework – We learned it was best to wait to act until we had a a high level framework that we could test. The most important parts of the framework were these:
- We knew where the bulk of the risk/problem lay. We were surprised to discover that acute Illness and casual illness were not what drove the most costs. We learned that most of the load came from disability.: when staff had chronic health breakdown. This could be back pain, pain, or any of the regular chronic diseases. Our research showed that this was often set off by stress at the work place. We isolated the issue. Conflict with the manager or other employees. We learned about the who and the where and the why. We could then build a system to enable us to intervene all along the lifecycle. We also learned to our surprise that most of the work that would have to be done here was not medical but involved spotting problems early and using social interventions. We designed a system to deal with all of this.
- Take the greatest fear off the table and so buy acceptance for other things – Fear could have made any change impossible. When we learned that our main cost drivers were the kind of chronic disease that had social origins and social remediations, we could also put acute illness in a new context. We could arrive at a formula that would assure everyone that if they did endure such a catastrophe, they would be covered. This was a huge breakthrough for all concerned.
- With fear off the table we could negotiate - With catastrophe covered we had room to take some big costs off the table. For instance, Birth Control Pills. All thought that this was a good deal.
- We learned that Segmentation, Incentives and Pricing go a long way to change behaviour - As much as anything, we wanted to engage the staff in their own health. We wanted them to have choice and control in as many areas as possible. Segmentation as a concept gave us this result. With this segmentation that came from our early analysis, we had lots of room to play with pricing and incentives in our program design. We biased much of what we offered with prevention.
- We learned how to give staff information about how they could take better charge of their health by using smart surveys. 14,000 staff annually take a survey that not only feeds back key data to the centre but allows each person to see how they are doing in terms of the population. The questions are designed to shape behaviour and the social and tracking element to reinforce personal change.
- Communicate Communicate Communicate - Politics are just as real in a bank as in a province. CIB, used to do policy work in secret and then have problems in rolling out. We learned not to do that. We also learned that it was not enough to be open. We learned to trial new things deliberately. For new programs we would build in public and trial in the bank with employees in full public. We always were clear that this was a trial. Again, this was shift in culture. The executive would develop the principles, the experts a design and then the tool or program would be constructed and tested in the line by the line.
In later posts I will tell you about how this was done in detail.