A heart attack and a couple of diagnoses of cancer prompted Ellis County to do something aggressive about its employees' health.
The rash of medical catastrophes in the early 1990s not only drove the county's insurance cost through the roof; it also got the county to urge employees to think differently about looking after their own well-being.
When the county signed up with the Texas Association of Counties' CountyChoice program in 1996, Ellis County was just starting to provide a 511-page medical self-care guide to every employee. New staff are provided the book also, as well as a talk with Deputy Treasurer Cheryl Chambers about how to most effectively take advantage of the county's health coverage.
In addition to the payroll, tax, nepotism and retirement forms, Chambers gives each new hire a short spiel about their medical coverage.
"I go through the medical provider book and how to find specialists first, but then I go through the self-care guide with them and talk about alternatives to seeing the doctor every time a problem occurs," she said. "Employees should understand that going to the emergency room or seeing the doctor for the smaller complaints ends up costing the county and the employees themselves with higher insurance payments."
The book is organized by symptom. "Once you find the symptom you're having, the guide provides the range of possibilities and suggests what appropriate actions should be taken," she said. "Instead of assuming you have bronchitis, you look up 'cough' and see if there are other possibilities you need to be aware of."
Many employees, especially parents of smaller children, have reported the self-care guide to be a good place to get answers that ease the mind.
She also changed the behavior of her own husband, an avid hunter who has a tendency to rub up against poison ivy.
"After the first couple of times, I realized that I could just call the doctor's office to get a prescription phoned into the pharmacy," she said. "That saves us the $15 co-pay and the insurance company another billing for a doctors' visit."
Chambers also talks to new staffers about the advantage of asking doctors to prescribe generic drugs and how preventive exams for breast or prostate cancer can preclude a ton of pain, heartbreak and, well, expense.
"A lot of it is information people have heard about but no one's ever told them one-to-one about it," she said. "They seem to appreciate" the information.
Chambers circulates bulletin board fliers and payroll stuffers on health information in her role of working on the county's benefits, along with Treasurer Mark Price, Auditor Yvonne Odom and Judge Al Cornelius.
Odom, who serves on the TAC Insurance Trust Fund Board, said Ellis County employees are also urged to take advantage of Informed Choice, a nurse hotline provided by Blue Cross and Blue Shield of Texas, Inc. exclusively for its members.
"You get a registered nurse on the line who visits with you about what the symptoms might indicate and what a typical treatment might be," she said. "And they don't hesitate to tell you to see a doctor if the circumstances suggest it."
And, a couple days later, the nurse calls back to see if everything worked out, she said. "It's really nice to know that someone will follow up."
Treasurer Price told a story about his young daughter who had an unusual cough one night. He and his wife got on the phone with an Informed Choice nurse, who walked then through a series a questions and suggested some hot vapor treatment as an alternative to a drive across the county to an emergency clinic.
"As a first-time parent, it was very reassuring to have a professional voice on the line," he said. "Had we not called, we definitely were going to the doctor."
The Ellis County effort is the beginning of an effort that TAC Employee Benefits representatives call "demand-side management" of health care costs.
"Managed care does a real good job of managing the supply side of costs, by limiting the amounts that medical providers can charge," explained Sarah Davis, who recently obtained a degree in Health and Wellness Promotion. "But with a low co-pay, we often see inappropriate use of medical care, especially when people run to the doctor for every ache and scrape and bruise."
Controlling the demand means educating people about their own health and the health care system, and encouraging employees to know when to interact with the system, Davis said.
A major aspect is education about prevention. Depending on the job site, that could take the form of "brown-bag" lunches, where nutrition or exercise opportunities can be presented and discussed.
"But those kinds of sessions shouldn't turn into preaching times," Davis said. "I'm not concerned with whether you have 32-inch waist so much as whether you can climb three flights of stairs without being out of breath or whether you have the flexibility to bend over to pick something up without grunting and moaning."
On the other hand, she said, over-exercise should be avoided also. "There are people out there who run 50 miles a week but who have no social life," she said. "That's not wellness; that's a nut."
Similarly, stress management was among the sessions Davis taught during a summer wellness pilot program conducted by CountyChoice in several South Texas counties.
"Ninety-five percent of physician visits can be directly related to stress, in one way or another," she said.
She explained that figure in the context of the human evolutionary "fight-or-flee" response developed during the time of the cave people.
"If a sabre-tooth tiger came along, the options were to fight or flee, but inside the body, hormones were being released that put the muscles at a heightened state of readiness," she said. "That hormonal reaction still occurs today, when people are stressed."
If no method of reducing stress is found, the body's immune system is worn down.
"If your body stays in a constant state of alert, it can be manifested in headaches or gastrointestinal problems or an upper respiratory infection," she said. "Basically, your body gets run-down and when a virus or bacteria comes along, you're more susceptible to it."
She said several major corporations have incorporated stress management as a key element in their wellness efforts. In the last few years, corporations that made major investments in the demand-side management concept include General Motors, Bell South, Coca Cola, AT&T and Motorola, among others.
Davis said the corporate interest is bottom-line: smarter employees who know how to take care of themselves see the doctor less often (lowering premiums), take less time off (reducing absenteeism) and are happier people are more likely to stay in the same job (increasing productivity).
But she emphasized that wellness promotion in a county should be a long-term strategy, with the understanding that insurance costs can be driven up by unexpected catastrophic illnesses.
Ellis County Auditor Odom agreed. "We had a premature baby born this year, so we know our insurance premium is not going down just because we're doing this," she said. "But really we're doing this for our employees, so that they'll be healthier and happier people."