The approaching ACA premium tax moratorium – take 2

In 2010, Congress scheduled the 2014 Affordable Care Act premium tax. Then in 2015 Congress introduced a one-year moratorium on the premium tax that would take place in 2017. This past January, Congress placed another moratorium for the ACA premium tax in 2019. Continue reading to learn more.


In 2010, Congress scheduled the 2014 introduction of the Affordable Care Act premium tax (aka the health insurer fee). Then, via the PACE Act of October 2015, Congress placed a one-year moratorium on this 4% or so premium tax for calendar year 2017. You might recall our ensuing discussion a couple of years ago about how employers sponsoring fully insured medical, dental and/or vision plans could leverage this 2017 moratorium to their advantage.

See also: ACA: 4 things employers should focus on this fall

Meanwhile, did you notice back in January that Congress placed another moratorium on this tax, this time for 2019? To review:

  • 2014-2016 – Tax applies
  • 2017 – Under moratorium
  • 2018 – Tax applies
  • 2019 – Under moratorium
  • 2020 – Tax scheduled to return

Fortunately, in moratorium years, fully insured medical, dental and vision premiums should be about 4% lower than they would have been otherwise, with these savings passed along proportionately by most employers to their plan participants.

Unfortunately, the budgetary challenge of this on-again-off-again Congressional approach is that when the tax returns, fully insured renewals naturally go up about 4% more than they would have otherwise. For example, an 8% premium increase becomes 12%.

See also: Proposals for Insurance Options That Don’t Comply with ACA Rules: Trade-offs In Cost and Regulation

Another complication occurs as employers annually compare the expected and maximum costs of self-funding their plans versus fully insuring the plans. Because this tax generally does not apply to self-funded plans, in “tax applies” years, any expected savings from self-funding will show about 4% higher than in moratorium years. This math especially complicates the financial comparison of level funding contracts to fully insured contracts (almost all level funding products are self-funded contracts).

With the Jan. 1 fully insured medical, dental and vision renewals beginning to cross our desks, what should employers do?

First, they should review the renewal’s rating methodology page and ensure that this tax was not included in the proposed 2019 premiums. If the rating methodology page was not provided, request it. If this request fails, ask for written confirmation that this tax is not included in your plan’s 2019 premiums.

Second, when comparing 2019 expected and maximum mature self-funded plan costs to 2019 fully insured premiums, extend the analysis to 2020 and project what will happen when this 4% fully insured tax tide returns.

See also: Pre-existing Conditions and Medical Underwriting in the Individual Insurance Market Prior to the ACA

Finally, complicating matters, several states, including Maryland, introduced new or higher state premium taxes for 2019. Ask your benefits consultant if these actions will impact your plans. For Maryland employers sponsoring fully insured plans, for example, the new additional one-year premium tax will essentially cancel out the 2019 ACA premium tax moratorium.

SOURCE: Pace, Z (27 September 2018) "The approaching ACA premium tax moratorium – take 2" (Web Blog Post). Retrieved from https://www.benefitnews.com/opinion/the-approaching-obamacare-premium-tax-moratorium?brief=00000152-14a5-d1cc-a5fa-7cff48fe0001


Medicare: Why an Advisor Makes All the Difference

Often those approaching Medicare eligibility are overwhelmed by the quantity of information available – and understandably so. As a form of insurance, Medicare is fundamentally different from other group/employer, individual, or family plans in that it is centered around the individual, yet any decisions made could potentially affect family members. In order to understand the costs, benefits, plans, and overall structure of Medicare, professional advice is strongly recommended when weighing options. That’s why, in this installation of CenterStage, Rob Glover, our Senior Solutions Advisor at Saxon, provided the following insightful information. Generally speaking, Medicare plans are explored during a significant lifestyle change. Having an insurance sales agent to facilitate retirement planning can help in adjusting Medicare options.

A Two-Way Relationship

Insurance agents are able to conform Medicare options around desired preferences and requirements. Each beneficiary is unique and therefore deserves a plan that delivers a standard of quality that is suited to varying budgets and ways of life. Agents can act as personal advisors and offer close collaboration when sifting through insurance plans. After becoming aware of defined healthcare coverage needs, Medicare advisors can narrow the search and find a solution that will safeguard both the individual and his or her family from looming financial damages.

It’s best to have a licensed agent with years of experience in Medicare. While textual knowledge is certainly important, learned wisdom is paramount in avoiding pitfalls throughout the process. Agents with real experience in the field are the best guides in navigating the processes, policies, and terminology of Medicare. Also, there are benefits in maintaining a relationship with them, since they are well-versed in the details of plans germane to the area. They are likely more familiar with supplier and provider networks and, using this knowledge, can provide guidance on which Medicare plan to choose.

The beneficiary-advisor relationship doesn’t end after the sale. In fact, they are often an advocate for many years after, offering consultations that address subsequent concerns with coverage. Medicare advisors can help review healthcare needs on a yearly basis to ensure the plan is lining up with changing criteria.

Services Worth Using

Independent advisors can offer many options across a multitude of carriers. Some agents are able to compare dozens of providers by contracting many different insurance companies. This method of contracting also aids in eliminating biases during plan research and comparison. The independent advisor can assist in making an informed decision on a Medicare insurance plan that is in line with the individual needs of the beneficiary. There aren’t any fees associated with merely utilizing an advisor. To elaborate, the rates linked to insurance plans already cover advisors’ commissions and thus render the decision on whether or not to employ one free from frugal urges. Therefore, there’s no reason not to seek the advice of a discerning sales agent to make the enrollment process easier. Licensed sales agents in the Medicare field take part in numerous hours of continued education and training annually. They are knowledgeable to pertinent information that could shape the decision-making process in addition to their understanding of a client’s defined parameters. Nevertheless, beneficiaries can only change insurance once within a year and can wind up “stuck” in a chosen plan unless the said beneficiary is eligible for a Special Enrollment Period. Regardless of position in the retirement process, time becomes increasingly more important. Utilizing an informed advisor will lead to time saved on plan comparison and research as they can help pinpoint a solution that fits the circumstances rather than waste time through trial and error. Licensed advisors are able to grant a one-stop shopping experience. Through innovative technology, they can access any and all relevant information at any time. Some create webinars regarding important issues, answer frequently asked questions, and elicit 24/7 assistance. Within some websites, beneficiaries can enroll in Medicare Advantage plans, request proposals, and research and compare options.

If you would like to learn more, contact Rob Glover at 513.703.7720 or rglover@gosaxon.com.


Top 10 health conditions costing employers the most

As healthcare costs continue to rise, employers continue to look for ways to target those costs. Read this blog post to learn more.


As healthcare costs continue to rise, more employers are looking at ways to target those costs. One step they are taking is looking at what health conditions are hitting their pocketbooks the hardest.

“About half of employers use disease management programs to help manage the costs of these very expensive chronic conditions,” says Julie Stich, associate vice president of content at the International Foundation of Employee Benefits Plans. “In addition, about three in five employers use health screenings and health risk assessments to help employees identify and monitor these conditions so that they can be managed more effectively. Early identification helps the employer and the employee.”

What conditions are costly for employers to cover? In IFEPB’s Workplace Wellness Trends 2017 Survey, more than 500 employers were asked to select the top three conditions impacting plan costs. The following 10 topped the list.

10. High-risk pregnancy

Although high-risk pregnancies have seen a dip of 1% since 2015, they still bottom out the list in 2017; 5.6% of employers report these costs are a leading cost concern for health plans.

9. Smoking

Smoking has remained a consistent concern of employers over the last several years; 8.6% of employers report smoking has a significant impact on health plans.

8. High cholesterol

While high cholesterol still has a major impact on health costs — 11.6% say it’s a top cause of rising healthcare costs — that number is significantly lower from where it was in 2015 (19.3%).

7. Depression/mental illness

For 13.9% of employers, mental health has a big influence on healthcare costs. This is down from 22.8% in 2015.

ACA: 4 things employers should focus on this fall

Yes, employers still need to worry about the Affordable Care Act and its many rules and regulations. Read this blog post for more information.


During the coming months, employers may have questions about whether they still need to worry about the Affordable Care Act (ACA). The answer is yes; the ACA is alive and well, despite renewed legal challenges and the elimination of the individual mandate beginning next year.

While the Tax Cuts and Jobs Act reduced the tax penalty for individuals who don’t have health coverage to $0, effective for 2019, employers are still subject to penalties for failing to comply with certain ACA rules. For example, the IRS is currently enforcing “employer shared responsibility payments” (ESRP) penalties against large employers who fail to meet the ACA requirements to offer qualifying health coverage to their full-time employees. For this purpose, large employers are those with 50 or more full-time or full-time equivalent employees. Here are four things about the ACA that employers should focus on now to avoid significant financial liabilities.

1. The IRS is currently assessing penalties using 226-J letters

In 2017, the IRS began assessing ESRP penalties against large employers that failed to offer qualifying health coverage to at least 95 percent of their full-time employees. An ESRP penalty assessment comes in the form of a 226-J letter, which explains that the employer may be liable for the penalty, based on information obtained by the IRS from Forms 1095-C filed by the employer for that coverage year, and tax returns filed by the employer’s employees. The employer has only 30 days to respond to the 226-J letter, using IRS Form 14764, which is enclosed with the 226-J letter. The employer must complete and return IRS Form 14765 to challenge any part of the assessment.

The short timeframe for responding to a 226-J letter means that staff who are likely to be the first to receive communications from the IRS should have a plan in place to react quickly. Training for staff should include information about who to notify and what documentation to keep readily available to support an appeal. Not responding to the IRS 226-J letter will result in a final assessment of the proposed penalty. These penalties can be significant. In the worst case, an employer with inadequate health coverage could pay for the cost of the coverage, as well as penalties of $2,000/year (as indexed) for every full time employee (less 30), even those who received health coverage from the employer.

Depending on the employer’s response to the initial assessment, the IRS will then send the employer one of four types of 227 acknowledgment letters. If the employer disputes the penalty, the IRS could accept the employer’s explanation and reduce the penalty to $0 (a 227-K letter). But if the IRS rejects any part of the employer’s response, the employer will receive either a 227-L letter, with a lower penalty amount, or a 227-M letter, a notice that the amount of the initial assessment hasn’t changed. These letters will explain steps the employer has to take to continue disputing the assessment, including applicable deadlines. The next phase of the appeal might include requesting a telephone conference or meeting with an IRS supervisor, or requesting a hearing with the IRS Office of Appeals.

2. ACA reporting requirements and penalties still apply

Along with the ESRP penalties, the Form 1094-C and 1095-C reporting requirements still apply to large employers. The IRS uses information on Forms 1095-C in applying the ESRP rules and deciding whether to assess penalties against the reporting employer. Large employers must file Forms 1095-C every year with the IRS and send them to full-time employees in order to document compliance with the ACA requirement to offer qualified, affordable coverage to at least 95 percent of full-time employees. Technically, the forms are due to employees by January 31, and to the IRS by March 31, each year, to report compliance for the prior year. In the past, the IRS has extended the deadline for providing the forms to employees, but not the deadline for filing with the IRS. 

Penalties can apply if an employer fails to file with the IRS or provide the forms to employees, and the penalty amount can be doubled if the IRS determines that the employer intentionally disregarded the filing requirement. These penalties can apply if an employer fails to file or provide the forms at all, files and provides the forms late, or if the forms are timely filed and provided, but are incorrect or incomplete.

In some instances, the IRS has assessed ESRP penalties based on Form 1095-C reporting errors. So, in addition to the reporting-related penalties, inaccurate information on Forms 1095-C can lead to erroneous ESRP assessments that the employer will then need to refute, using the IRS forms and procedures described above.

Employers should carefully monitor their ACA filings and reports, and consider correcting prior forms if errors are discovered. Employers should also continue tracking offers of coverage made for each month of 2018, to prepare for compliance with the Form 1095-C reporting requirement early in 2019.

3. “Summary of Benefits and Coverage” disclosure forms are still required

The ACA added a new disclosure requirement for group health plans, called a “Summary of Benefits and Coverage” or “SBC,” that’s intended to help employees make an “apples to apples” comparison of different benefit plan features, such as deductibles, out-of-pocket maximums, and copayments for various benefits and services. This requirement still applies, and SBCs must be provided during open enrollment, upon an employee’s initial eligibility for coverage under the plan, and in response to a request from an employee. The template SBC form and instructions for completing it were updated for coverage periods starting after April 1, 2017. For 2018, a penalty of $1,128 per participant can apply to the failure to provide an SBC as required. 

4. The “Cadillac Tax” has not been repealed

The ACA’s so-called Cadillac tax — an annual excise tax on high-cost health coverage — was initially scheduled to take effect in 2018. The Cadillac tax has been repeatedly delayed, and the federal budget bill passed in January delayed it again through December 31, 2021. Despite the repeated delays, the Cadillac tax has not been repealed and is currently scheduled to apply to health coverage offered on or after January 1, 2022. This might be an issue to consider for employers who are negotiating collective bargaining agreements in 2018 that include terms for health benefits extending beyond 2021. 

While uncertainty continues to surround the ACA, employers should remain aware of continuing compliance requirements to avoid the potentially significant penalties that remain in effect under the ACA. 

Boyette, J; Masson, L (21 August 2018) "ACA: 4 things employers should focus on this fall" (Web Blog Post). Retrieved from https://www.benefitspro.com/2018/08/21/aca-4-things-employers-should-focus-on-this-fall/


New rule pushes for hospital price transparency

The Centers for Medicare & Medicaid Services is pushing for a new rule that will force hospitals to provide patients with a list of the cost of all their charges. Continue reading to learn more.


The Centers for Medicare & Medicaid Services announced a proposed rule aimed at providing patients with a clear price listing of the cost of their hospital charges. In an effort to fulfill the proposed rule’s objective, CMS suggested an amendment to the requirements previously established by Section 2718(e) of the Affordable Care Act.

CMS issued the final rule (CMS-1694-F), which included the suggested amendment discussed in the April 24, 2018 proposed rule. Currently, under Section 2718(e), hospitals are given the option to either (i) make public a list of the hospital’s standard charges or (ii) implement policies for allowing the public to view a list of the hospital’s standard charges in response to an individual request.

Beginning January 1, 2019, however, hospitals will be required to make available a list of their current standard charges via the Internet in a machine readable format and to update this information at least annually, or more often as appropriate.

This could be in the form of the chargemaster itself of another form of the hospital’s choice, as long as the information is in machine readable format. CMS believes that this update will further promote price transparency by improving public accessibility of hospital charge information.

In the final rule, CMS explains that it is aware of the challenges that continue to exist because the chargemaster data may not accurately reflect what any given individual is likely to pay for a particular service or visit.

Additionally, the comments received in response to the proposed rule argue that the chargemaster data would not be useful to patients because it is confusing as to the amount of the actual out-of-pocket costs imposed on a particular patient.

CMS further explains that it is currently reviewing the concerns addressed in the comments, and is considering ways to further improve the accessibility and usability of the information disclosed by the hospitals.

SOURCE: Goldman, M; Grushkin, J; Fierro, C (16 August 2018) "New rule pushes for hospital price transparency" (Web Blog Post). Retrieved by https://www.employeebenefitadviser.com/opinion/cms-rule-pushes-for-hospital-price-transparency


How employers can manage the skyrocketing cost of specialty drugs

The number of specialty drugs continues to grow. At the end of 2016, there were 700 specialty drugs in development, compared to the 10 that were in development in 1990. Continue reading to learn more.


In the past two decades, the number of specialty medications — which treat rare and complex diseases such as multiple sclerosis, pulmonary arterial hypertension, hepatitis C, HIV, cystic fibrosis, some types of cancer and hemophilia — has grown exponentially. In 1990, there were only 10 specialty drugs on the market. By 2015, that number had increased to 300 medications, and by the end of 2016 there were approximately 700 more specialty drugs in development.

These medications are usually very high cost, with some new biologic medications costing more than $750,000 a year. Why are the costs so high? There are a number of factors, including the facts that distribution networks are limited, these medications are complicated to develop and distribute, and there are few, if any, generic alternatives for these drugs.

See also: 6 ways to mitigate specialty drug costs

The Pew Charitable Trusts found that although only 1% to 2% of Americans use specialty medications, they account for approximately 38% of total drug spending in the U.S.

So, how can employers better gain control over the cost of specialty medications? Because there are hundreds of specialty medications, there’s no single strategy for cost management that can be applied universally. To build an effective cost management strategy, employers need to first analyze employee use of specialty medications. The best strategy will approach specialty medication management by disease class and drug by drug.

However, there are key building blocks of a strategy that will both manage costs and ensure that employees have access to the medications they need. Here are six things employers can do.

Assess benefit plan design structure. Employers should consider how they are incenting employees to spend their benefit dollars appropriately and wisely. A multi-tiered medication formulary where employees pay less out of pocket for generic drugs and lower cost medications and more for costly medications is one approach that’s proven effective. To help employees afford these higher out-of-pocket costs, employers can promote manufacturer copay savings programs, which many drug makers offer.

Think about utilization management. This can include requiring prior authorization for high-cost specialty medications and step therapies (employees must start with lower cost therapies and can move up to more costly ones if those are not effective).

Consider a custom pharmacy network design. By narrowing the network of pharmacies that fill specialty medication prescriptions, employers can negotiate a better unit price. A freestanding specialty pharmacy or a pharmacy benefits manager can provide savings by optimizing discounts for both employers and employees.

Offer second opinion and other support services for rare and complex diseases. A newly diagnosed rare or complex disease patient will see, on average, seven different specialists over the course of eight years before getting a true diagnosis and appropriate treatment path. These programs aim to reduce that burden and ensure success with that treatment once it’s identified. A second opinion from a top specialist in the field provides an expert assessment of the diagnosis and recommendations on the most effective treatment protocol. This not only helps manage costs, it lowers the risk of misdiagnosis and inappropriate treatment. Additional case management services can include one-to-one counseling and, when the drug regimen requires, in-home nursing services to help patients better manage their disease and improve outcomes.

See also: How employers can increase employee use of second opinions

Offer site of care choices. Where specialty drugs are administered can have a significant impact on what they cost. Medications administered in an outpatient clinic at a hospital can cost five times as much as those that are injected or infused in a physician’s office or at the patient’s home. Offering services such as home infusion or injection delivered by nurses or incenting patients with lower copays when they receive their medications at their physician’s office can lower overall specialty drug costs.

Educate employees. When an employee or covered family member is diagnosed with a rare or complex condition that will require a higher level of care and the use of specialty medications, employers can connect employees with case managers or similar services that provide education about the condition and the medication, such as how to manage side effects or what alternative medications are available, which can increase employee adherence with the medication regimen.

SOURCE: Varn, M (8 August 2018) "How employers can manage the skyrocketing cost of specialty drugs" (Web Blog Post). Retrieved from https://www.benefitnews.com/opinion/specialty-pharmaceuticals-and-how-employers-can-manage-cost


Quality trumps convenience among employees

Convenience, or quality? Take a look into why researchers are saying quality of a doctors visit outshines convenience when scheduling the next appointment.


Faced with the choice between going to a conveniently located doctor’s office or a more qualified physician, group health plan members are four times more likely to embrace the better-perceived medical professional.

“Traditional metrics like patient ratings, prescribing rates and volume of patients seen were not nearly as compelling to respondents as more qualitative, contextualized statements about a doctor’s clinical expertise,” according to Nate Freese, senior director of data strategy at Grand Rounds, a healthcare service provider for employees in need of local and remote specialty care.

The data is based on a study of 1,100 members covered by Grand Rounds, which is headquartered in San Francisco.

While surprising, Freese says that result depends on the information and messaging that’s provided to employees. Just 14% of respondents based their choice on clinical expertise if they saw traditional physician profiles, whereas it was 69% if they saw contextualized profiles. Contextualized profiles offered more information in complete sentences compared to traditional profiles. These profiles also compared data against other doctors and specialists, such as appointment wait times, expertise and patient satisfaction.

Freese is encouraged by these findings, which were recently presented at the National Healthcare Ratings Summit. “Don’t sell employees short in terms of their ability to appreciate quality and willingness to sacrifice convenience,” he says.

Offering more subjective interpretation of hard quality metrics would be helpful, Freese explains, as long as employers and their advisers are careful not to “overstep what can be reasonably inferred based on available data.”

Another caveat to consider is that finding high quality providers may not be inherently more difficult in narrow networks. Rather, he says, the issue is when health plan members “lack the ability to identify them. And so, it’s more about presenting information in the right way.”

Providing compelling quality information can achieve the same results of a narrow network, he notes. But he hastens to add that even narrow networks must be sufficiently broad enough for members to have a reasonable amount of choice. Geography also plays a role. “You could be in the broadest network, but by virtue of where you live, have reduced choice,” he says.

Michael Hough, executive vice president and U.S. founder of Advance Medical, believes the quality metrics that are currently available are insufficient for several reasons. “We’re looking at things like frequency and whether the outcomes are horrible,” he says. “But just because the outcomes weren’t horrible doesn’t mean they were good, either.” Desired outcomes depend on what’s going on with patients and whether their objectives are being achieved.

The context of care is “extremely important,” Hough explains, noting the importance of relationships between the patient and a trained physician based on human interaction, as well as the delivery of services. Also, while he believes the rise of telemedicine and self-service “is good for many parts of our lives,” Hough cautions that it’s not necessarily true for healthcare because meaningful relationships trump convenience.

SOURCE:
Shutan, B (22 June 2018) "Quality trumps convenience among employees" [Web Blog Post]. Retrieved from https://www.employeebenefitadviser.com/news/quality-trumps-convenience-among-employees?tag=00000151-16d0-def7-a1db-97f0240f0000


Top 10 health conditions costing employers the most

Conditions that impact plan costs can be problematic. Here is a look into the top 10 health conditions hitting the hardest on employers wallets.


As healthcare costs continue to rise, more employers are looking at ways to target those costs. One step they are taking is looking at what health conditions are hitting their pocketbooks the hardest.

“About half of employers use disease management programs to help manage the costs of these very expensive chronic conditions,” says Julie Stich, associate vice president of content at the International Foundation of Employee Benefits Plans. “In addition, about three in five employers use health screenings and health risk assessments to help employees identify and monitor these conditions so that they can be managed more effectively. Early identification helps the employer and the employee.”

What conditions are costly for employers to cover? In IFEPB’s Workplace Wellness Trends 2017 Survey, more than 500 employers were asked to select the top three conditions impacting plan costs. The following 10 topped the list.

10. High-risk pregnancy

Although high-risk pregnancies have seen a dip of 1% since 2015, they still bottom out the list in 2017; 5.6% of employers report these costs are a leading cost concern for health plans.

9. Smoking

Smoking has remained a consistent concern of employers over the last several years; 8.6% of employers report smoking has significant impact on health plans.

8. High cholesterol

While high cholesterol still has a major impact on health costs- 11.6% say it's a top cause of raising healthcare costs- that number is significantly lower from where it was in 2015 (19.3%).

7. Depression/ mental illness

For 13.9% of employers, mental health has a big influence on healthcare costs. This is down from 22.8% in 2015.

6. Hypertension/ high blood pressure

This is the first condition in IFEBP's report to have dropped a ranking in the last two years. In 2015, hypertension/ high blood pressure ranked 5th with 28.9% of employers reporting it is a high cost condition. In 2017, the condition dropped to 6th with 27.6% of employers noting high costs associated with the disease.

5. Heart disease

This year's study found that 28.4% of employers reported high costs associated with heart disease. In 2015, heart disease was the second highest cost driver with 37.1% of employers citing high costs from the disease.

4. Arthritis/back/musculoskeletal

Nearly three in 10 employers (28.9%) say these conditions are drivers of their health plan costs, compared to 34.5% in 2015.

3. Obesity

Obesity is still a top concern for employers, but slightly less so than it was two years ago. In 2017, 29% of employers found obesity to be a burden on health plans. In 2015, 32.45 cited obesity as a major cost driver.

2. Cancer (all kinds)

Cancer has become more expensive for employers. Now, 35.4% of employers report cancer increasing the costs of health plans, compared to 32% in 2015.

1. Diabetes

The king of raising health costs, diabetes has topped the list both in 2015 and 2017. In the most recent report, 44.3% of employers say diabetes is among the conditions impacting plan costs.

SOURCE:
Otto. N (18 June 2018) "Top 10 health conditions costing employers the most" [Web Blog Post]. Retrieved from https://www.employeebenefitadviser.com/slideshow/top-10-health-conditions-costing-employers-the-most


Are You And Your Primary Care Doc Ready To Talk About Your DNA?

Knowing your genes could save your life, especially if a genetic mutation is hereditary. See why incorporating DNA testing is a crucial part of your primary care.


If you have a genetic mutation that increases your risk for a treatable medical condition, would you want to know? For many people the answer is yes. But such information is not commonly part of routine primary care.

For patients at Geisinger Health System, that could soon change. Starting in the next month or so, the Pennsylvania-based system will offer DNA sequencing to 1,000 patients, with the goal to eventually extend the offer to all 3 million Geisinger patients.

The test will look for mutations in at least 77 genes that are associated with dozens of medical conditions ranging from heart disease to cancer, as well as variability in how people respond to pharmaceuticals based on heredity.

“We’re giving more precision to the very important decisions that people need to make,” said Dr. David Feinberg, Geisinger’s president and CEO. In the same way that primary care providers currently suggest checking someone’s cholesterol, “we would have that discussion with patients,” he said. “‘It looks like we haven’t done your genome. Why don’t we do that?’”

Some physicians and health policy analysts question whether such genetic information is necessary to provide good primary care — or feasible for many primary care physicians.

The new clinical program builds on a research biobank and genome-sequencing initiative called MyCode that Geisinger started in 2007 to collect and analyze its patients’ DNA. That effort has enrolled more than 200,000 people.

Like MyCode, the new clinical program is based on whole “exome” sequencing, analyzing the roughly 1 percent of the genome that provides instructions for making proteins, where most known disease-causing mutations occur.

Using this analysis, clinicians might be able to tell Geisinger patients that they have a genetic variant associated with Lynch syndrome, for example, which leads to increased risk of colon and other cancers, or familial hypercholesterolemia, which can result in high cholesterol levels and heart disease at a young age. Some people might learn they have increased susceptibility to  malignant hyperthermia, a hereditary mutation that can be fatal since it causes a severe reaction to certain medications used during anesthesia.

Samples of a patient’s blood or spit are used to provide a DNA sample. After analysis, the results are sent to the patient’s primary care doctor.

Before speaking with the patient, the doctor takes a 30-minute online continuing education tutorial to review details about genetic testing and the disorder. Then the patient is informed and invited to meet with the primary care provider, along with a genetic counselor if desired. At that point, doctor and patient can discuss treatment and prevention options, including lifestyle changes like diet and exercise that can reduce the risk of disease.

About 3.5 percent of the people who’ve been tested through Geisinger’s research program had a genetic variant that could result in a medical problem for which clinicians can recommend steps to influence their health, Feinberg said. Only actionable mutations are communicated to patients. Geisinger won’t inform them if they have a variant of the APOE gene that increases their risk for Alzheimer’s disease, for example, because there’s no clinical treatment. (Geisinger is working toward developing a policy for how to handle these results if patients ask for them.)

Wendy Wilson, a Geisinger spokeswoman, said that what they’re doing is very different from direct-to-consumer services like 23andMe, which tests customers’ saliva to determine their genetic risk for several diseases and traits and makes the results available in an online report.

“Geisinger is prescribing DNA sequencing to patients and putting DNA results in electronic health records and actually creating an action plan to prevent that predisposition from occurring. We are preventing disease from happening,” she said.

Geisinger will absorb the estimated $300 to $500 cost of the sequencing test. Insurance companies typically don’t cover DNA sequencing and limit coverage for adult genetic tests for specific mutations, such as those related to the breast cancer susceptibility genes BRCA1 or BRCA2, unless the patient has a family history of the condition or other indications they’re at high risk.

“Most of the medical spending in America is done after people have gotten sick,” said Feinberg. “We think this will decrease spending on a lot of care.”

Some clinicians aren’t so sure. Dr. H. Gilbert Welch is a professor at the Dartmouth Institute for Health Policy and Clinical Practice who has authored books about overdiagnosis and overscreening, including “Less Medicine, More Health.”

He credited Geisinger with carefully targeting the genes in which it looks for actionable mutations instead of taking an all-encompassing approach. He acknowledged that for some conditions, like Lynch syndrome, people with genetic mutations would benefit from being followed closely. But he questioned the value of DNA sequencing to identify other conditions, such as some related to heart disease.

“What are we really going to do differently for those patients?” he asked. “We should all be concerned about heart disease. We should all exercise, we should eat real food.”

Welch said he was also concerned about the cascading effect of expensive and potentially harmful medical treatment when a genetic risk is identified.

“Doctors will feel the pressure to do something: start a medication, order a test, make a referral. You have to be careful. Bad things happen,” he said.

Other clinicians question primary care physicians’ comfort with and time for incorporating DNA sequencing into their practices.

A survey of nearly 500 primary care providers in the New York City area published in Health Affairs this month found that only a third of them had ordered a genetic test, given patients a genetic test result or referred one for genetic counseling in the past year.

Only a quarter of survey respondents said they felt prepared to work with patients who had genetic testing for common diseases or were at high risk for genetic conditions. Just 14 percent reported they were confident they could interpret genetic test results.

“Even though they had training, they felt unprepared to incorporate genomics into their practice,” said Dr. Carol Horowitz, a professor at the Icahn School of Medicine at Mount Sinai in New York, who co-authored the study.

Speaking as a busy primary care practitioner, she questioned the feasibility of adding genomic medicine to regular visits.

“Geisinger is a very well-resourced health system and they’ve made a decision to incorporate that into their practices,” she said. In Harlem, where Horowitz works as an internist, it could be a daunting challenge. “Our plates are already overflowing, and now you’re going to dump a lot more on our plate.”

SOURCE:
Andrews, M (12 June 2018). "Are You And Your Primary Care Doc Ready To Talk About Your DNA?" [Web Blog Post]. Retrieved from https://khn.org/news/are-you-and-your-primary-care-doc-ready-to-talk-about-your-dna/


A look at how the opioid crisis has affected people with employer coverage

The opioid crisis is affecting more and more people each day. Discover how the opioid crisis affects you with this study on employer coverage.


With deaths from opioid overdose rising steeply in recent years, and a large segment of the population reporting knowing someone who has been addicted to prescription painkillers, the breadth of the opioid crisis should come as no surprise, affecting people across all incomes, ages, and regions. About four in ten people addicted to opioids are covered by private health insurance and Medicaid covers a similarly large share.

Private insurance covers nearly 4 in 10 non-elderly adults with opioid addiction

In this analysis and a corresponding chart collection, we use claims data from large employers to examine how the opioid crisis has affected people with large employer coverage, including employees and their dependents. The analysis is based on a sample of health benefit claims from the Truven MarketScan Commercial Claims and Encounters Database, which we used to calculate the amounts paid by insurance and out-of-pocket on prescription drugs from 2004 to 2016. We use a sample of between 1.2 and 19.8 million enrollees per year to analyze the change from 2004 to 2016 in opioid-related spending and utilization.

We find that opioid prescription use and spending among people with large employer coverage increased for several years before reaching a peak in 2009. Since then, use of and spending on prescription opioids in this population has tapered off and is at even lower levels than it had been more than a decade ago. The drop-off in opioid prescribing frequency since 2009 is seen across people with diagnoses in all major disease categories, including cancer, but the drop-off is pronounced among people with complications from pregnancy or birth, musculoskeletal conditions, and injuries.

Meanwhile, though, the cost of treating opioid addiction and overdose – stemming from both prescription and illicit drug use – among people with large employer coverage has increased sharply, rising to $2.6 billion in 2016 from $0.3 billion 12 years earlier, a more than nine-fold increase.

Trends in prescription opioid use & spending among people with large employer coverage

Opioid prescription use among people with large employer coverage is highest for older enrollees: 22% of people age 55-64 had at least one opioid prescription in 2016, compared to 12% of young adults and 4% of children. Women with large employer coverage are somewhat more likely to take an opioid prescription than men (15% compared to 12%). Opioid prescription use among people with large employer coverage is also higher in the South (16%) than in the West (12%) or Northeast (11%).

Among people with large employer coverage, older enrollees are more likely to have an opioid prescription

Among people with large employer coverage, the frequency of opioid prescribing increased from 2004 (when 15.7% of enrollees had an opioid prescription) to 2009 (when 17.3% did). After reaching a peak in 2009, the rate of opioid prescribing began to fall. By 2014, the share of people with large employer coverage who received an opioid prescription (15.0%) was lower than it had been a decade earlier, and by 2016, the share was even lower, at 13.6% (a 21% decline since 2009).

The share of people with large employer coverage taking opioid prescriptions is at its lowest levels in over a decade

Among people with large employer coverage, this pattern (of increasing opioid prescription use through the late 2000s, followed by a drop-off through 2016) is similar across most major disease categories. Some of the steepest declines in opioid prescription use since 2009 were among people with complications from pregnancy or childbirth, musculoskeletal conditions, and injuries. The share of people experiencing complications from pregnancy or childbirth who received an opioid prescription peaked in 2007, when 35% received an opioid prescription, but this share dropped to 26% in 2016. Similarly, in 2007, 37% of people with large employer coverage who had a musculoskeletal condition received an opioid prescription, but the share dropped to 30% by 2016. The same decline can be seen among people with large employer coverage who experienced injuries and poisonings (37% in 2009, down to 30% in 2016).

Opioid use declined across disease categories, particularly pregnancy, musculoskeletal diseases, and injuries

We also see a sharp decline in the use of opioid prescriptions among people with cancer diagnoses, particularly in the most recent couple of years. In 2016, 26% of people with large employer coverage who had a cancer diagnosis received at least one opioid prescription, down from 32% in 2007. Despite declines in opioid prescribing for musculoskeletal conditions, people with large employer coverage who have musculoskeletal diagnoses still receive opioid medications more frequently (30%) than those with cancer diagnoses (26%).Overall in 2016, among those receiving an opioid prescription, a slightly larger share received only a single prescription in that year (61%) than did in 2006, a decade earlier (58%). The average number of prescriptions each person received also rose from 2004 until 2010 and then fell again, but this measure is imperfect because it does not adjust for the length of the supply or the strength of the drug received.

In total, large employer plans and their enrollees spent $1.4 billion in 2016 on opioid prescription painkillers, down 27% from peak spending of $1.9 billion in 2009. In 2016, $263 million, or 19% of total opioid prescription drug spending was paid out-of-pocket by enrollees.

Spending on opioid prescriptions peaked in 2009

Opioid prescriptions have represented a small share of total health spending by large employer plans and enrollees.

Treatment for Opioid Addiction & Overdose among People with Large Employer Coverage

In 2016, people with large employer coverage received $2.6 billion in services for treatment of opioid addiction and overdose, up from $0.3 billion in 2004. Of the $2.6 billion spent on treatment for opioid addiction and overdose in 2016 for people with large employer coverage, $1.3 billion was for outpatient treatment, $911 million was for inpatient care, and $435 million was for prescription drugs. In 2016, $2.3 billion in addiction and overdose services was covered by insurance and $335 million was paid out-of-pocket by patients. (This total only includes only payments for services covered at least in part by insurance, not services that are paid fully out-of-pocket and not billed to insurance, so it is likely an undercount of opioid addiction and overdose treatment expenses by this population.)

The cost of treating opioid addiction and overdose has risen even as opioid prescription use has fallen

Spending on treatment for opioid addiction and overdose represents a small but growing share of overall health spending by people with large employer coverage. In 2016, treatment for opioid addiction and overdose represented about 1% of total inpatient spending by people with large employer coverage and about 0.5% of total outpatient spending. In 2004, treatment for opioid addiction and overdose represented about 0.3% of total inpatient spending and less than 0.1% of total outpatient spending. On average, inpatient and outpatient treatment for opioid addiction and overdose added about $26 per person to the annual cost of health benefits coverage for large employers in 2016, up from about $3 in 2004.

The bulk of the total $2.6 billion in spending for treatment of opioid addiction and overdose among people with large employer coverage was treatment for young adults, totaling $1.6 billion in 2016, even though young adults are prescribed opioids less often than older adults. Males also used more treatment than women ($1.6 billion vs $1.0 billion).

Spending on opioid addiction and overdose treatment is mostly concentrated among younger people

The bulk of spending by people with large employer coverage on inpatient and outpatient treatment for opioid addiction and overdose was for employees’ children (53%) or spouses (18%), while just under a third (29%) was for employees themselves.

Among people with large employer coverage who had outpatient spending on treatment for opioid addiction and overdose, their average outpatient expenses totaled $4,695 (of which $670 was paid out-of-pocket) in 2016. Among those with inpatient spending on treatment for opioid misuse, their average inpatient expenses totaled $16,104 (with $1,628 paid out-of-pocket) in 2016. On average, inpatient expenses have risen sharply, up from $5,809 in 2004.

In 2016, 342 people per 100,000 large group enrollees received treatment for opioid overdose or addiction, including 67 people per 100,000 who received treatment in an inpatient setting.

Discussion

Among people with large employer coverage, utilization of opioid prescription painkillers has declined somewhat in recent years. Use of and spending on prescription opioids by this group peaked in 2009 and has since dropped to the lowest levels in over a decade. Across most major disease categories, we see a similar pattern of the frequency of opioid prescription use rising until the late 2000s and then declining through 2016.

Despite declining rates of opioid prescribing to those with employer coverage, spending on treatment for opioid addiction and overdose has increased rapidly, potentially tied to growing illicit use and increased awareness of opioid addiction. Opioid addiction and overdose treatment – the bulk of which is for dependents of employees – represents a small but growing share of overall employer health spending.

Methods

We analyzed a sample of claims obtained from the Truven Health Analytics MarketScan Commercial Claims and Encounters Database (Marketscan).  The database has claims provided by large employers (those with more than 1,000 employees); this analysis does not include opioid prescription or addiction treatment for other populations (such as the uninsured or those on Medicaid or Medicare).  We used a subset of claims from the years 2004 through 2016.  In 2016, there were claims for almost 20 million people representing about 23% of the 85 million people in the large group market.  Weights were applied to match counts in the Current Population Survey for large group enrollees by sex, age, state and whether the enrollee was a policy holder or dependent.  People 65 and over were excluded.

Over 14,000 national drug codes (NDC) were defined as opiates.  In general, we defined “prescription opioids” as those with a primary purpose of treating pain. Only prescriptions classified under the controlled substance act are included. We excluded from this category Methadone, Suboxone (Buprenorphine with Naloxone), and other drugs commonly used to treat addiction.  We also excluded medications not commonly prescribed (such as Pentazocine).  Each opiate script was counted as a single prescription regardless of the quantity or strength of that prescription.  The Marketscan database only includes retail prescriptions administered in an outpatient setting.  Disease categories are defined by AHRQ’s chronic condition indicators, and based on the diagnosis an enrollee receives.

In our analysis of opioid addiction and overdose treatment, we include medications used to treat overdose (e.g. Naloxone) and drugs used to treat addiction (e.g. Methadone and Suboxone). We also include inpatient and outpatient medical services to treat opioid addiction or overdose, identified by ICD-9 and ICD-10 diagnosis codes. Midway through 2015, Marketscan claims transitioned from ICD-9 to ICD-10.  While both systems classify diagnoses, there is no precise crosswalk between the two.  In consultation with a clinician, we selected both ICD-9 and ICD-10 codes which are overwhelmingly used for opioid addiction or signify misuse.  A list of these ICD codes is available upon request.  Because of the change in coding systems, it is not possible to tracks trends between 2014 and 2016.  Diagnoses related to heroin abuse were included as opiate abuse.

Because there is no precise way to identify costs associated with opioid addiction and overdose treatment, some of our rules for inclusion lead to an underestimate, while others lead to an overestimate. In general, we elected a conservative approach. For example, in some cases, opioid abuse diagnoses may be classified under a broader drug abuse diagnosis and therefore are not captured.  Additionally, we do not include the costs associated with diagnoses that commonly arise from opioid abuse, such as respiratory distress or endocarditis, unless an opioid abuse diagnosis was also present.  However, if a claim included an opioid abuse diagnosis along with other diagnoses, we included spending for all procedures during that day, even if some of those interventions were to treat concurrent medical conditions unrelated or indirectly related to opioid abuse.  If an enrollee paid fully out-of-pocket and did not use their insurance coverage, this spending is also not included.  Overall, we think these assumptions lead to an underestimate of the costs associated with opioid addiction and overdose treatment for the large employer coverage population.

SOURCE:
Cox C (24 May 2018). "A look at how the opioid crisis has affected people with employer coverage" Web Blog Post]. Retrieved from address https://www.healthsystemtracker.org/brief/a-look-at-how-the-opioid-crisis-has-affected-people-with-employer-coverage/#item-start