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
Taking Action to Prevent the Harmful Impact of Short-Term Plans
This article explores the recently established rule on short-term limited duration plans - as proposed by HHS - which would not comply with consumer protections afforded under ACA.
The U.S. Department of Health and Human Services (HHS) has proposed a new rule, open for comment until April 23, 2018, that is dangerous to consumers and to health care marketplaces. This rule would expand the sale of “short-term limited duration plans” that do not have to comply with the consumer protections afforded under the Affordable Care Act (ACA) and often leave consumers uncovered for major medical expenses.
The short-term plan rule will harm consumers and health care markets
The proposed rule would alter the definition of short-term plans as a backdoor way of creating a new class of plans that do not have to comply with the ACA, extending the duration of short-term plans from policies that last for 3 months to policies that can last just short of one year. Under this rule, insurers may also be allowed to renew a short-term plan for an enrollee after that period is up.
Companies selling these plans can make large profits at consumers’ expense, and the plans do not have to cover pre-existing conditions, provide essential health benefits, include adequate provider networks, or comply with a host of other key protections, as we describe in Seven Reasons the Trump Administration's Short-Term Health Plans Are Harmful to Families. Moreover, if many young and healthy people are drawn into these plans, the plans will undermine the market for real coverage, driving up prices in the ACA-compliant marketplace.
Now is the time to take action to prevent short-term plans from harming consumers and insurance markets throughout the country. Here we outline how advocates, consumers, and states can take action to address this harmful rule.
Stakeholders can urge HHS to stop the spread of harmful short-term plans
It’s important that HHS hears from stakeholders all over the country about how short-term plans will leave those who enroll in them without adequate protection from the costs of care, and how those who seek to stay in the market for comprehensive coverage will experience spikes in premiums and jeopardized access to coverage if short-term plans are allowed to expand.
The short-term plan rule will also burden states and insurance companies that are interested in making comprehensive coverage affordable. Particularly if the rule allows the proliferation of short-term plans that last for up to 12 months to take effect after insurers have already planned their premium pricing for 2019, these plans will cause chaos for comprehensive insurance providers and states alike in maintaining a stable insurance market. These expanded short-term plans should not be put on the market at all, but at the very least HHS should delay implementation of the final rule to give states and insurers more time to plan for it to take effect.
Advocates, consumers, state officials, health care providers, and other stakeholders can all make a difference by commenting to HHS about these problems. Stakeholders can also make a difference by urging state policymakers and officials to comment on the rule as well. Comments should urge HHS to stop or at the very least delay implementation of the rule on short-term plans. Comments should be submitted here by 5 PM on Monday, April 23rd.
States can take direct action to protect against short-term plans
States can take direct action to protect consumers and insurance markets from the harm of short-term limited duration plans. States have broad authority to regulate short-term plans and can adopt new laws or issue new regulations or guidance that exceeds the standards in the proposed rule. Given other upcoming changes in 2019 that will also pose risks for the market, including the repeal of the individual mandate penalty, taking swift action is particularly important.
These strategies can provide protections for consumers and help limit market instability caused by the expansion of short-term plans.
States can prohibit short-term plans altogether. Massachusetts, New Jersey, and New York currently prohibit short-term plans, and California is pursuing a prohibition via SB910 (Hernandez).
States can require that short-term plans comply with all protections that health plans sold on the comprehensive individual market meet. For example, a few states prohibit short-term plans from refusing to sell to a consumer based on their health status— those plans cannot “underwrite,” or take people’s health status into consideration when people seek to buy them. States could protect consumers from the harm of short-term plans by applying the same requirements to them as apply to comprehensive insurance. These include requirements for external review, essential health benefits and state benefit mandates, network adequacy, medical loss ratios, and pre-existing condition protections, including a requirement that plans do not charge people rates based on their health status. States can also ensure companies that offer short-term plans have to pay any existing state-based assessments, such as insurer taxes. States could also consider assessing short-term plan insurers and using those funds for a reinsurance program for plans that meet ACA standards.
- States can restrict the duration of short-term plans. For example, states can pass laws prohibiting short-term plans from lasting for longer than 3 months. This will ensure that these plans are used as they were intended- to fill short gaps in coverage- and not as a long-term solution to substitute for real coverage. Some states already limit the period for which a short-term plan can be sold to less than the nearly 12 months allowed in the proposed federal rule. For a good index of such state laws, see State Regulation of Coverage Options Outside of the Affordable Care Act: Limiting Risk to the Individual Market from the Georgetown Center on Health Insurance Reform.
- States can prohibit short-term plans from renewing consumers’ policies beyond their allowed duration: To ensure that short-term plans are not treated as a replacement for comprehensive insurance, states can prohibit plans from renewing their contract with a consumer once the duration of the short-term plan is over. For example, a state could prohibit insurers from selling a short-term policy to anyone who has enrolled in one during the last 12 months.
- States can require strong disclosure and marketing rules to ensure short-term plans are transparent about their shortfalls. States can require short-term plans to include prominent disclosures in marketing materials (including websites), application forms, and other forms to warn people about what the plans do not cover and how they may expose consumers to high out-of-pocket costs. For example, Colorado requires short-term plans to provide such a disclosure to warn people about the lack of coverage for pre-existing conditions in short-term plans. Additionally, states can require short-term plans to supply simple, clear, and comparable information about what benefits they do and do not cover, and corresponding cost-sharing requirements. Comprehensive plans must comply with requirements to produce a summary of benefits and coverage, and states could apply such requirements to short-term plans as well.
There are additional protections that states may want to consider to protect people from the harms of short-term plans. For additional discussion of how states can take action, see State Options to Protect Consumers and Stabilize the Market: Responding to President Trump’s Executive Order on Short-Term Health Plans by the Georgetown Center on Health Insurance reform.
State legislators and insurance departments can lead the efforts to enact these important protections. And, they along with any health care ombudsman programs or other organizations that assist health insurance consumers in the state may know of complaints and problems regarding short-term plans that can inform what protections the state should enact. State attorneys general, Better Business Bureaus, or other consumer protection agencies may also be aware of problems and can be helpful allies in efforts to prevent short-term plans from harming consumers and insurance markets alike.
Additionally, the National Association of Insurance Commissioners (NAIC) is currently updating its model law for states on Accident and Sickness Insurance Minimum Standards (Model #170) and its companion regulation, the Model Regulation to Implement the Accident and Sickness Insurance Minimum Standards Model Act (Model #171). NAIC consumer representatives including Families USA are advocating to make these models as robust possible in their protection of consumers and the market from the damage of short-term plans. (See the March 2018 report by the NAIC consumer representatives and former Montana regulator Christina Goe, Non-ACA-Compliant Plans and the Risk of Market Segmentation.)
This article was brought to you by Families USA by Claire McAndrew on April 2018.
Resisting Popular Healthcare Trends and Getting Creative
In this article, experts explore the idea that companies need to use the many tools at their disposal, as opposed to relying specifically on one popular trend.
A recent study found that substantial wellness incentives and high-deductible health plans are not the quick fix to improving health care costs they were originally thought to be.
Employers pinned their hopes on high-deductible health plans, but HDHPs only represent 30 percent of medical plans offered by employers, according to the “2018 Medical Trends and Observations Report” released in early March by DirectPath and research and advisory company Gartner.
“Increasingly, employers are realizing that true, long-term cost management will come from a combination of tools and that they need to enlist employees in the effort in a meaningful way,” said Kim Buckey, vice president of client services at employee engagement firm DirectPath.
Employers have explored different options starting with managed care plans and health maintenance organizations the past several decades, moving toward consumer directed health plans years later and considering wellness programs and private exchanges after that, according to Buckey. These solutions could provide short-term relief but not singlehandedly solve the problem, she said.
The logic behind HDHPs was that if employees had skin in the game, they’d be more conscientious about looking for lower-cost options in medical care and become smarter health care consumers, Buckey said. But what this idea did not address the larger issue: employees’ lack of health literacy and little understanding of health insurance comprehension.
“Employees historically just hadn’t had the knowledge or the tools to truly become educated consumers,” she said.
The report, based on an analysis of 900 employee benefit health plans, also found that fewer companies are offering wellness incentives. Some 31 percent of employers offer them today, according to the 2018 report. This number is considerably lower than the 2017 report, which found that 58 percent of employers offered incentives, and the 2016 report, which found that 50 percent did.
“That was surprising because using incentives to drive employee behavior was a big component of most companies’ strategies across the past couple years,” said Brian Kropp, HR practice leader at Gartner. “What companies are finding in a lot of cases is that the incentives were most likely used by healthiest people whose health care costs were already quite low.”
For many companies, incentives have been cutting health care costs for employees who were already spending less rather than making prices more reasonable for people with higher expenses, he said.
This is not the ideal result since the idea behind incentives was, for example, to convince unhealthy people to get an annual physical. This would supposedly help them find health problems before they became serious and more expensive to treat.
“The idea that incentives as currently structured at most companies are becoming of less interest because they’re not as effective as we thought,” Kropp said.
The decline in incentive use may also have to do with concerns about the future legality of these plans, according to the report. A federal judge ruled in December 2017 that the EEOC’s incentive rules — which deem a wellness program voluntary if the incentive or penalty was no more than 30 percent of the cost of the health plan — will only continue until the end of 2018.
Other reports have found different data on wellness incentives. Jessica Grossmeier, vice president of research for the think tank Health Enhancement Research Organization, shared that a Mercer report in 2016 found that two-thirds of employers were using incentives to encourage employee to participate in wellness programs and that 29 percent provided incentives for achieving, maintaining or showing progress toward specific health status targets.
Whether employers will maintain their commitment to using financial wellness incentives will depend on the individual employer and what happens with the EEOC incentive rule. For the time being, employers can take the conservative approach and offer no incentives, take the middle-ground approach and offer modest incentives, or take the aggressive approach and offer up to 30 percent incentives as usual, according to law firm K&L Gates.
Privacy is another concern with wellness programs, Buckey said. Despite generous incentives, some employees may hesitate to participate in these programs because of privacy concerns. Some wellness programs provide employers with aggregate data about the current health status and health risks of their employee population. “With financial and health data breaches increasingly in the news, I think we will see a leveling off or even a lack of interest in participating in programs whether data — even in aggregate — is collected about an employee’s health,” Buckey said.
While strategies such as relying on wellness programs to lower health care costs or using HDHPs to make employees smarter health care consumers have not become the ultimate fix, there are some ways employers can get more creative with their strategy, according to Buckey. She suggested several ways for employers to take a multi-pronged approach to health care cost management.
Employers can offer transparency services, which allow employees to compare pricing for the same service near their home, when they are planning an elective high-cost service like diagnostic tests or surgeries. Employers can also provide better enrollment support in open enrollment so that employees choose the right plan and more carefully manage pharmacy costs by adding measures like mandatary generics or step therapy.
Buckey also mentioned that some of her company’s clients provide patient-advocacy services.
“[It] helps employees identify billing errors and resolve disputes with providers and insurance companies,” she said. “This frees up the employees to focus on their work, rather than financial and medical concerns.”
It’s important for companies to get creative with their health care benefits more than ever before, Kropp said. In the past, employees knew that the health insurance they received at one company was comparable to what they’d receive at many other companies. What the insurance was exactly didn’t matter because most employees felt the plans were more or less the same, he said.
Now companies are starting to realize that better health care plans are a significant differentiator for attracting talent in a competitive labor market, he added. As information for employees and candidates became more transparent and accessible, it became easier as a candidate to understand what health plan offerings looked like at other companies.
“It is a relatively new phenomenon of companies becoming much more vocal about their benefits offerings as a way to compete in a tight labor market,” Kropp said.
This article is from Workforce written by Andie Burjek on April 10, 2018.
Two opportunities created by association health plans
The new regulations around association health plans (AHPs) — which loosen restrictions for small businesses, franchises and associations — create two distinct opportunities in the benefits industry.
The first is for brokers, who will be crucial advisors to employers eligible for the new coverage options now available.
The second opportunity is for benefits and HR tech vendors, who will be instrumental in managing the transactional and administrative challenges that would otherwise hinder AHP success.
What challenges do association health plans represent? Let’s consider an example — the Nashville Hot Chicken restaurant franchise.
Let’s say Nashville Hot Chicken has 1,000 franchisees, each with five full-time employees. Before AHP options became available to this organization, these five-employee groups would either have had to pursue small group coverage, or employees would have had to find individual plans.
Both options likely would have been prohibitively expensive for the organization or the employees. With the new AHP regulations, however, these 1,000 franchisees may be able to pull all 5,000 workers together and create a large group benefits plan.
In doing so, they would reap the advantages of collective purchasing, just like large groups do. However, this AHP would not work like a regular group plan.
If a regular group has 5,000 employees, they would all be part of a centrally-operated payroll system and the insurance companies would receive just one check for all of the employees enrolled at the group. But under an AHP of franchisees, all the payroll systems would operate independently, and there is no clear, centralized entity to pay carriers.
This creates a massive administrative headache for Nashville Hot Chicken corporate, as well as all the individual franchise owners. In other words, who is going to manage the AHP?
Here’s where the brokers come in. Employers need brokers to walk them through all the complexities of AHPs, including sourcing carriers, third-party vendors, and compliance needs.
It would also be incredibly impractical to manage 5,000 employees through 1,000 separate businesses without a benefits and HR platform.
But brokers can provide a solution to this challenge by adopting a platform. With a benefits and HR system, the various administrative differences from franchisee to franchisee can be accounted for, while still allowing the 5,000-life group to enroll in the group offering.
By removing the administrative headache, benefits tech makes AHPs a real option for Nashville Hot Chicken. But it also gives the tech-savvy broker a clear leg up on the competition. A broker without a tech solution will be at a severe disadvantage for Nashville Hot Chicken’s business compared to a broker who has a platform.
So as small employers, franchisees and industry associations band together for group coverage, benefits tech can give brokers a competitive differentiator for this new business segment.
Read the article.
Source:
Tolbert A. (1 March 2018). "Two opportunities created by association health plans" [Web Blog Post]. Retrieved from address https://www.benefitspro.com/2018/03/01/two-opportunities-created-by-association-health-pl/
DOL cracks down on efforts to find missing retirement plan participants
In this article from Benefits Pro, the DOL auditors are taking action on missing participants in retirement plans.
The Department of Labor’s auditors are pushing harder on plan sponsors to make better efforts to find missing terminated vested participants in retirement plans. In return, there’s a call for more guidance on just how far sponsors have to go to do so.
According to a report in Pensions & Investments, the matter has become more urgent in the wake of MetLife’s experience. After the company had “lost track” of some 13,500 participants, the DOL entered the picture. The company’s earlier efforts to find those lost participants were deemed unacceptable, and then state and federal inquiries began.
But DOL auditors, according to a letter from the American Benefits Council to Deputy Assistant Secretary of Labor Timothy Hauser last fall requesting formal rulemaking on comprehensive guidance for plan fiduciaries, have been “inconsistent and alarming” in routine examinations.
The report says, “Some auditors said that failure to find a missing participant was a breach of fiduciary duty, or forfeiting funds back into a plan until participants are found is a prohibited transaction, and plan sponsors could be penalized. Auditors also have insisted that sponsors try different search methods every year or reach out to friends and former colleagues of the missing participant or through social media. Some plan sponsors have been told they must do ‘whatever it takes’ to find participants who are missing or not responding to communications.”
Large defined benefit plans are creating the loudest outcry, according to members reaching out to the ERISA Industry Committee in Washington on the issue. “It’s frustrating for them because there is just a lack of guidance on what activities they have to engage in, and how long they have to be engaged in it,” Will Hansen, senior vice president of retirement and compensation policy, is quoted saying in the report.
DOL officials are aware of the lack of guidance. A DOL spokesman says in the report that “the agency places a priority on consistent actions across our compliance assistance and enforcement activities, and will continue to work with plans and plan sponsors to connect retirees and beneficiaries with their pensions.”
Still, given the agency’s focus on employers’ responsibilities, experts say that employers should try to get ahead of the issue, guidance or not. The report cites David Rogers, partner at Winston & Strawn LLP in Washington, saying, “Given the potential penalties involved and the need for a coordinated response, it is a good practice to have a missing participants policy and designated persons within the organization who make regular efforts to keep participant information current.”
In addition, it quotes Norma Sharara, a principal with Mercer’s Washington resource group, saying, “The rational plan sponsor would be well advised to up their game. At least revisit the issue so when someone comes knocking your door, you are prepared. All along you need to be in constant contact with anybody you are holding money for. Somebody has to be responsible and the Labor Department is placing the burden on the shoulders of the employer.”
On March 1, Senators. Elizabeth Warren, D-MA, and Steve Daines, R-MT, reintroduced the Retirement Savings Lost and Found Act, bipartisan legislation that would create a national online lost-and-found for retirement accounts. The bill is supposed to make it easier for participants to find accounts, as well as for employers to connect with former employees. Employers could also invest abandoned accounts in target-date funds more easily, the report said.
Read the article.
Source:
Satter M. (5 March 2018). "DOL cracks down on efforts to find missing retirement plan participants" [Web Blog Post]. Retrieved from address https://www.benefitspro.com/2018/03/05/dol-cracks-down-on-efforts-to-find-missing-retirem/
Trump urges legal action against opioid manufacturers
Where does Trump stand on the Opioid Crisis? Find out in this article from Benefits Pro.
President Trump says he wants his administration to take legal action against opioid manufacturers.
“Hopefully we can do some litigation against the opioid companies,” Trump said at an event organized at the White House on the opioid epidemic.
Earlier in the week, Attorney General Jeff Sessions announced that the Justice Department would be filing a statement of interest in support of a lawsuit launched by more than 400 local governments around the country against pharmaceutical manufacturers. The suit accuses drug-makers of using deceptive advertising to sell powerful, addictive pain medication and for covering up the dangers associated with their use.
It’s not clear whether Trump’s remarks were a reference to the action Sessions has already taken or whether the president is envisioning additional legal action, since he said during the event that he would ask the attorney general to sue.
Trump also promised during his presidential campaign to take on pharmaceutical companies over rising drug prices, accusing them of “getting away with murder.” Since his election, however, he has done very little to translate those tough words into policy. A meeting between Trump and pharmaceutical companies early in his administration was described in positive terms by both sides.
The president also has suggested stiffer sentences for drug dealers, even reflecting positively on countries that execute them.
“Some countries have a very, very tough penalty – the ultimate penalty,” he said. “And, by the way, they have much less of a drug problem than we do.”
In recent years, public opinion on criminal justice in general and the drug war specifically has shifted in favor of an approach that favors treatment over incarceration. Reducing the prison population has been a goal that has increasingly earned bipartisan support, both at the federal level and in state legislatures around the country. However, Trump and Sessions have both stuck to the “tough-on-crime” mantra that dominated in the 1990’s.
The administration has signaled that it will not support legislation to reduce mandatory minimum sentences for drug offenses. And although the Justice Department has not yet gone after marijuana distributors in states that have legalized the drug, such as Colorado and California, Sessions has rescinded an Obama-era policy that stated that the DOJ would take a hands off approach to pot in those states.
Read the article.
Source:
Craver J. (2 March 2018). "Trump urges legal action against opioid manufacturers" [Web Blog Post]. Retrieved from address https://www.benefitspro.com/2018/03/02/trump-urges-legal-action-against-opioid-manufactur/