Prevailing Winds Lessons from Viagra

Workforce talked with Lynn Franzoi, senior vice president for benefits at Fox Inc., an experienced benefits negotiator based in Beverly Hills, California, about the climate for the debate about what health care should cover. Fox Inc. was a 1997 Workforce Optimas winner because of Franzoi’s creativity in benefits management. She made these points about lessons from the Viagra story:

What’s your greatest challenge in providing health insurance coverage to Fox employees?
Employees often expect that everything they medically want or need will be covered. A pregnant employee whose physician prescribed vitamins not covered on the Fox plan declared that for its refusal to pay the $10 per month, Fox could cause her child to have birth defects. I asked her, ‘For $10 a month, you would take that risk for your child?’

Recent research suggests that many people have no idea what their employer-sponsored health care costs. Is that your experience?
Employees often understand the total cost of their health care coverage for the first time only when they leave the company and receive their COBRA paperwork. Most often, they believe that their payroll deduction, deductible and co-payments represent the total cost of the plan.

What expectations of health care coverage have you seen that you consider out of bounds?
Employees often expect the employer to cover the costs of personal decisions. Employees who travel internationally for personal reasons to countries that require vaccinations against such diseases as yellow fever may expect their employers to cover these costs. Fox offers a medical evacuation policy for $18 a day for 10 days; employees expect the employer to pay for this, as well, despite the choice to travel and the minimal cost of the insurance compared with thousands for medical evacuation.

What other trends have you been seeing?
Employees will request highly advertised treatments. Employees at Fox did ask for coverage for Viagra. Fox’s decision on Viagra, birth control and infertility treatments is that they’re not medical necessities, so they’re not covered.

What about cosmetic surgery?
Not covered, unless it’s to correct a disfiguring injury that occurred while the person was covered under the plan. We do pay for breast implant after mastectomy, or surgery to correct a birth defect that impairs a bodily function.

What about treatment for obesity?
It’s not covered. That’s a pretty standard decision in health plans. It goes to the question of where you draw the line. We can’t mandate behavior change.

What’s the principle at work in these decisions? What could make you change your mind about one of them?
If we had a lot of requests for a particular treatment, we would seek expert medical review of the pros and cons. Cost and efficacy are the major factors. For example, often we will decide to pay for an uncovered treatment if it is cost-neutral, but the potential results are greater than the standard treatment.

In the mid-1990s, we covered drug implants for CMV (cytomegalovirus, a condition often associated with AIDS that can lead to blindness). The alternative was infusion, which often led to kidney failure and the need for dialysis treatment. It was an outpatient visit, the drug was free because it was experimental, and we faced only the cost of the anesthesiologist and the facility. The outcome was much better for the patient, so we covered it. That’s how we decide.

Franzoi constantly looks for ways to remind employees that an employer can’t possibly pay for every perceived health need, that they must absorb some of their health care costs-especially when those costs reflect personal decisions-and that, like financial well-being in retirement, wellness during working years is a personal responsibility. But the winds seem to be against her.