How benefit advisers can hold healthcare plans accountable for their prices
Brokers and consultants already know that much of the growth in health benefit costs is not driven by insurer and TPA rate increases, but rather by the increase in the price and volume of healthcare services. While some of these costs are due to growing survivability rates for serious diseases and therapeutic improvements, much are avoidable, such as expenses associated with unnecessary care and unnecessarily expensive care. Evidence of variability of costs is found in the fact that unit cost and utilization can vary wildly from health system to health system, even within the same market.
Read more: 4 drivers of healthcare costs — and what advisers should do
Just because macro healthcare economics is the primary driver of overall health costs, doesn’t mean that health plans are powerless to control price increases. Even though health plans can and do negotiate rates directly with health systems in their networks, too often they don’t do everything they can to offer exceptional value to their customers. They don’t ask the right questions of health systems, they don’t practice thorough utilization management, and they don’t contract exclusively with providers who focus on high-value care. In other words, they don’t work hard enough to eliminate unnecessary costs or to bring prices down. Instead, they treat them as a given and pass those costs on to their customers.
Too often, benefit advisers take the whole healthcare market as a given, especially due to the popularity of broad preferred provider organization (PPO) networks, which include almost every system in an area. But the reality is that economics vary dramatically from system to system, so employee benefit advisors need to understand local economics in order to effectively evaluate network differences and find value. They can do this by:
- Heavily and skeptically questioning carriers and TPAs to understand their networks and participating providers. Examples of questions to ask include: Tell me your opinion about different health systems in your network? How much do negotiated fees vary for outpatient services, professional services, etc.? Why is a specific expensive provider part of your narrow / high-performance network?
It’s also important to ask when a contract with a specific health system is up and if it will be renegotiated soon, since a new contract could include very different rates from the current one. Note that some of the time, carriers will discuss rates as a function of Medicare, but because Medicare DRG rates can vary dramatically from hospital to hospital, an adviser needs to understand Medicare base rates.
- Analyzing claims. Every adviser has plenty of these available to them, and they should be analyzing those claims to determine which providers are lower cost and which are higher cost. In particular, it’s important to look at outpatient rates, facility rates, and professional rates, by specialty. It’s also important to compare the same diagnosis codes across providers. For example, claims could reveal that a hypothetical Dr. Jones operates on 100 patients out of 100, while a hypothetical Dr. Smith operates on only 50 patients out of 100 with the same condition. To figure out why this discrepancy exists, we would have to dig deeper since some doctors or practices may cater to only high-risk patients. Claim data can help shed light on health plan information that is not typically available to the public as health plan rates are often proprietary but appear on claims.
Taking all of these steps will help benefit advisers achieve something essential: holding health plans accountable for their prices. If a health plan doesn’t aggressively hunt for high value providers and reward them, you should ask why. And if you don’t like their answer, you probably identified a plan that isn’t a good fit for your clients because it doesn’t deliver on what matters most: quality care offered at an affordable price without compromising coverage.
SOURCE: Cohen, A. (04 November 2020) "How benefit advisers can hold healthcare plans accountable for their prices" (Web Blog Post). Retrieved from https://www.employeebenefitadviser.com/opinion/how-benefit-advisers-can-hold-healthcare-plans-accountable-for-their-prices
5 ways to prepare for open enrollment during COVID-19
As open enrollment draws near, it's time to critically prepare for it especially during the crazy time that the coronavirus pandemic has brought to many families. Read this blog post to learn more.
The COVID-19 pandemic has focused consumer attention on health care, germs and the impact a single illness can have on their lives, livelihoods and loved ones. With the fall open enrollment season just months away, you have the opportunity to think more critically about the specific plans you choose for yourself and your family, as well as any voluntary benefits that may be available to you, including childcare, elder care and critical illness. In a world where it feels like health is out of the individual’s control, we all want, at the very least, to feel control over our coverage.
As we know all too well, there’s a lot to consider when it comes to choosing and using health care benefits. The most important piece of becoming an informed health care consumer is ensuring you have access to — and understand — the benefits information you need to make smart health care choices. Here are five tips to keep in mind as you prepare for and participate in open enrollment.
1. Prepare for COVID-19 aftermath
As if dealing with the threat of the virus (or actually contracting it) wasn’t enough, consumers must consider the unexpected consequences. Quarantines, stay-at-home orders and business shutdowns have resulted in missed preventive care visits — including annual immunizations. For instance, many children will have missed their preschool vaccinations, which could result in an uptick in measles, mumps and rubella. If school is conducted virtually, the risk of catching one of these highly contagious diseases is somewhat reduced, though consumers should still proceed with caution as states reopen. In fact, with continued waves of COVID-19 expected well into the school season, you and your children may have to wait even longer to get vaccinations due to pent up demand and possible shortages.
Don’t forget that preventive care is covered by most plans at 100% in-network regardless of where that care is received. Schedule your appointments as soon as possible (and permissible in their area), and research other venues for receiving care, such as pharmacies, retail clinics and urgent care facilities. Most are equipped to provide standard vaccinations and/or routine physicals.
Unfortunately, there are also the long-term implications of COVID-19 to consider. Research suggests that there are serious health impacts that emerge in survivors of COVID-19, such as the onset of diabetes and liver, heart and lung problems. And many who were able to ride out the virus at home are finding it’s taking months, not weeks, to fully recover. As a result, you should prepare for the possibility that you, or a loved one, may be ill and possibly out of work for an extended period of time. Be sure to evaluate all of the plans and programs your employer offers to ensure your family has the financial protections you need. For some, a richer health plan with a lower deductible, voluntary plans such as critical illness or hospital indemnity insurance, and buy-up life and disability insurance may be worth investigating for the first time.
2. Re-evaluate postponed elective procedures
Many employees or their family members have postponed or skipped elective procedures — either from fear of exposure to COVID-19 at hospitals and outpatient facilities, or because their hospitals and providers cancelled such procedures to conserve resources to treat COVID-19 patients. As a result, an estimated 28.4 million elective surgeries worldwide could be canceled or postponed in 2020 due to the virus.
As hospitals reopen, it may be difficult to schedule a procedure due to scheduling requirements and pent up demand. A second opinion may be in order if your condition stabilized, improved or worsened during the delay; there may be other treatment options available.
A delay in scheduling also provides an opportunity to “shop around” for a facility that will provide needed care at an appropriate price — especially if you are choosing to go out-of-network or have a plan without a network. Researching cost is the best way to find the most affordable providers and facilities with the best quality, based on your specific needs.
Many medical plans offer second opinion and transparency services, and there are independent organizations who provide “white glove,” personalized support in these areas. Read over your enrollment materials carefully, or check your plan’s summary plan description, to see what your employer offers. If nothing is available, ask your employer to look into it, and don’t hesitate to do some research on your own. Doing so can often result in substantial cost savings, without compromising on quality of care.
3. Confirm your caregivers
Because so few elective procedures were performed during the initial phases of the pandemic, many hospitals sustained huge financial losses. As a result, many small hospitals are closing, and large hospitals are using this opportunity to purchase smaller, independent medical practices that became more financially vulnerable during the pandemic. Further, many physicians have opted to retire or close their practices in light of the drastic reductions to their income during local shutdowns.
Be sure to check up on your preferred health care providers — especially those you might not see regularly — to confirm they are still in business and still in network (if applicable). If you live in a rural area, you may have to travel farther to reach in-network facilities. If you’re currently covered by an HMO or EPO, you may want to evaluate whether that option still makes sense, if your preferred in-network providers are no longer available.
4. Look at ALL the options
Voluntary coverages — such as critical illness, hospital indemnity, buy-up disability, and supplemental life insurance — may help ease your concerns about how you will protect your and your family’s finances if you become ill. Pandemic aside, these benefits can provide a substantial safety net at a relatively low cost. Investigate your employer’s offerings — many employers are offering virtual benefit fairs where vendors can provide more information about these benefits while remaining safe from large social gatherings.
When was the last time you changed your medical plan? If you’ve been keeping the same coverage for years, it might be time to look at what else is available. Your employer may have introduced new plans, or you may find that a different plan makes more sense financially based on how often you need health care. Don’t forget — the cheapest plan isn’t always the one with the lowest premiums.
5. Uncover every resource available
Besides your health coverage (medical, dental and vision), many employers offer other plans and programs to support your health. While you’re already focused on benefits, take the time to learn about what else is available to you. These offerings may range from the previously mentioned advocacy and transparency services and voluntary benefits, to personalized, one-on-one enrollment support, to telemedicine services and an Employee Assistance Program (EAP). Also, many employers made temporary or permanent plan changes to address COVID-19 regulations and concerns. Be sure to familiarize yourself with these changes — and when they might expire.
You may also want to consider setting aside funds in a health savings account or health care flexible spending account (if available). If your employer offers a wellness program, this might be an opportunity to start adopting better health habits to ensure you’re better equipped physically and mentally to deal with whatever lies ahead.
While open enrollment may seem daunting, devoting an hour or two to reviewing your plan options, the programs available to support you and your family physically, mentally and financially, and how to get the most from the coverages you do elect, can go a long way towards providing peace of mind as we face the unknowns of 2021.
SOURCE: Buckey, K. (17 August 2020) "5 ways to prepare for open enrollment during COVID-19" (Web Blog Post). Retrieved from https://www.employeebenefitadviser.com/list/5-ways-to-prepare-for-open-enrollment-during-covid-19
Rising cost of healthcare is hurting HSAs
With HSA's providing a way for users to be able to reduce out-of-pocket costs for healthcare, deductibles still continue to rise. Read this blog post to learn more about why continuously raised healthcare costs are hurting current HSA's and HSA's that could be used for retirement.
Employees are increasingly putting money aside for their HSAs, but they’re using almost the entirety of it to cover basic health needs every year instead of saving the money for future expenses, according to Lively’s 2019 HSA Spend Report.
“People are putting money in and taking money out on a very regular basis, as opposed to trying to create some sort of nest egg for down the road,” says Alex Cyriac, CEO and Co-Founder of Lively.
The San Francisco-based HSA provider says 96% of annual contributions were spent on expected expenses and routine visits as opposed to unexpected health events and retirement care. In 2019, the average HSA account holder spent their savings on doctor visits and services (50%), prescription drug costs (10%), dental care (16%), and vision and eyewear (5%).
The rising cost of healthcare is a factor in these savings trends: Americans spent $11,172 per person on healthcare in 2018, including the rising cost of health insurance, which increased 13.2%, according to National Health Expenditure Accounts. For retirees, the figures are shocking: a healthy 65-year-old couple retiring in 2019 is projected to spend $369,000 in today’s dollars on healthcare over their lifetime, according to consulting firm Milliman.
“Because people can't even afford to save, there's going to be a very low likelihood that most Americans are going to be able to afford their healthcare costs in retirement,” says Shobin Uralil, COO and Co-Founder of Lively.
HSAs were intended to be a way for consumers to save and spend for medical expenses tax-free. Additionally, its biggest benefit comes from being able to use funds saved in an HSA in retirement — when earnings are lowest and healthcare is most expensive. However, just 4% of HSA users had invested assets, according to the Employee Benefit Research Institute.
While HSAs have surged in popularity as a way for more Americans to reduce overall out-of-pocket healthcare spending, more education is required to help account holders understand the benefits of saving and investing their annual contributions for the long-term, the Lively report states.
“As deductibles continue to rise, people just don't seem to have an alternative source for being able to fund those expenses, so they are continuing to dip into their HSA.” Cyriac says. “I think this is just reflective of the broader market trend of healthcare costs continuing to rise, and more and more of those costs being disproportionately passed down to the user.”
SOURCE: Nedlund, E. (29 January 2020) "Rising cost of healthcare is hurting HSAs" (Web Blog Post). Retrieved from https://www.employeebenefitadviser.com/news/rising-cost-of-healthcare-is-hurting-hsas
Getting digital transformation in healthcare on the fast track
Outdated protocols, overextended workforces and hundreds of wasted hours in administrative tasks are just a few of the opportunities for a digital overhaul in the healthcare industry. There are tremendous opportunities for digital transformation in the healthcare industry. Read this blog post to learn more.
At first glance, the healthcare field seems to be a goldmine for digital innovation. An overextended workforce, outdated protocols, hundreds of wasted hours in administrative tasks, a patient population that is wide open to digital solutions, a multitude of inefficiencies and redundancies — the opportunities for digital overhaul in healthcare are myriad.
Yet every year the graveyard of digital health tools gets more crowded as innovators fail to overcome healthcare’s uniquely complex barriers to their adoption.
Goldmine and graveyard, the tremendous opportunities for digital transformation in healthcare and the seemingly insurmountable barriers to its adoption are two sides of a coin. They spring from the same root causes: the lack of financial incentives to implement digital solutions; the high stakes that necessitate a cautious approach; and most significantly, providers’ seeming unwillingness to abandon proven workflows or sunk costs to take a chance on a disruptive solution.
This last cause is often the greatest barrier to getting innovation through the door.
Clinicians are the primary end-users of digital health, and a clinical champion can make all the difference in whether a solution is adopted. But in the face of the physician shortage in the United States, doctors don’t have time to trade out their proven workflows to take a risk on a solution that may or may not be successful, and will almost certainly take time to learn and implement into their practice. The majority of providers are already at capacity — 80% have no time to see more patients or take on more duties. Thus what seems like an unwillingness to change is often an inability to find the time to change.
Many physicians agree that digital tools and solutions are worthwhile in theory, but with an average workload of 40-60 hours a week, they don’t have the space in their schedules to evaluate these solutions. As it is, the amount of patients that a physician sees in a day (the most rewarding part of their jobs, according to 80% of doctors) has been reduced in recent years to make time for the mountains of non-clinical paperwork and administrative duties that they are responsible for.
Because of their packed schedules, physicians often default to the status quo for sanity’s sake: 40% of physicians see up to 20 patients per day, with another 40% seeing more (anywhere from 21 to over 70); and all spend almost a quarter of their day on administrative duties like inputting data into EMRs. If physicians do have a chance to sit down with innovators, it’s in the margins of their day — instead of an exciting opportunity for change, a pitch-meeting with an innovator represents another 15 minutes they have to take from their family at the end of a long day, an extra 10 minutes of sleep lost in the morning to get into the office early, the interruption of the small respite of a lunch break.
It’s no surprise that in a 2018 survey conducted by the Physician’s Foundation, 89% of physicians polled felt that they had somewhat to very little influence on changes in healthcare — they have no time to research chances to optimize their practice, and thus essentially no voice in its improvement. Yet only a physician has the kind of intimate knowledge of his or her needs and workflow that can drive effective innovations. Perhaps digital innovations have failed to take hold because the people making decisions around tools to help doctors are not doctors.
If we are going to break the barriers to digital transformation in healthcare, we need to expect physicians to think critically about how their job needs to evolve. And no one can do this without time to reflect on and evaluate the status quo. In the corporate world, executives and other employees are encouraged to do research, to take time in their schedules for professional development. Many tech giants — most famously Google, but also Facebook, Linkedin, Apple, and others — employ the 20% time model, where roughly one-fifth of an employee’s schedule is focused on personal side projects (those side projects have turned into Gmail, Google Maps, Twitter, Slack, and Groupon, to name a few). This is the model that we need to embrace in the healthcare system.
We need to look past the excuse that “doctors are traditionally conservative” and that is why innovation is dead in the water. While that narrative may have explained why cutting edge technology is not more readily adopted by physicians, there are other problems that it doesn’t account for — like why rates of compliance for new protocols and best practices are abysmally low. Those symptoms should point us to a different solution, a solution we can do something about. Not “doctors need to get with the times” but doctors need to get some time.
One solution is to advocate for a higher price per consultation that can eliminate the existential need to pack daily schedules with patient appointments. Under the current model, doctors are incentivized to take as many appointments as possible, double — even triple — booking slots to squeeze as much productivity out of current rates of reimbursement. But with increased reimbursement per consultation, physicians can more easily cover the cost of their salaries for their employers, which can then allow providers to take more time out of the clinic and in the office, thinking critically about their roles and how to improve their delivery of care.
Of course, this begs the question — who pays? The ones who stand to benefit most, of course. Giving physicians more time to develop professionally and research solutions is in the best interest of those who take on the burden of health costs, health insurance providers and the government (ie, taxpayers). Patient outcomes are almost guaranteed to improve when physicians have the time to stay up to date on best practices, and this directly reduces the burden of cost on those stakeholders.
Physician salaries represent a very small part of healthcare costs, paling in comparison to drugs and diagnostic care. If more money was paid to the physician on the front end to develop and implement more preventative solutions — by payers or government subsidies — the cost savings would increase exponentially, making an increase in physician salary an astute business move as well as one that can have a dramatic impact on patients’ lives.
SOURCE: Pablo Segura, J. (11 October 2019) "Getting digital transformation in healthcare on the fast track" (Web Blog Post). Retrieved from https://www.benefitnews.com/opinion/getting-digital-transformation-in-healthcare-on-the-fast-track
Giving onsite clinics an engagement booster shot
In efforts to reduce healthcare spend and increase the population's health, many employers are offering a variety of employee wellness services and programs. Read this blog post to learn more about increasing engagement in onsite clinics.
Employers of all sizes and industries are currently offering a variety of wellness services that include preventive, acute, primary, chronic disease and occupational healthcare programs at or near the worksite. These benefits are intended to reduce healthcare spend, increase the population’s health and productivity and positively impact recruitment and retention efforts.
In fact, according to two 2018 studies by the National Association of Worksite Health Centers, more than one-third of all employers and close to 50% of large firms are now operating worksite clinics. But just because employers offer such benefits doesn’t mean employees will take advantage of these services, even when they’re free.
But many employers are frustrated to find that 20% or less of the targeted or covered workers utilizes their programs — with millions of dollars in benefits wasted.
Failure can be caused by lack of promotion, inadequate incentives, poor communications or providers who don’t fit into the culture of the employer. However, one of the most significant problems than can undermine a benefit program, especially a worksite clinic, is when employees don’t trust that their personal health data will be confidential and fear it will be used for employment decisions.
Employers who achieve high benefit utilization build the foundation for success by informing their workforce, prior to a benefit or clinic being available and on an ongoing basis, of the many federal and state confidentiality and privacy laws that dictate who can receive personal and occupational health information and the limitations placed on employers.
Communications, posters, presentations and other marketing vehicles must assure employees that the employer will only see aggregate, not personal data from the offered benefit programs. Emphasize that the program’s or clinic’s medical providers will be the only individuals dealing with this information, and that by law they are legally and ethically obligated to keep this confidential.
Understanding the culture and labor-management dynamics of an organization are also critical to building trust. To increase use, it’s often best to market the program or facility under a new brand name, such as “The Healthy Life” or use the name of the provider who manages the program or clinic, rather than the employer’s name.
The physical design or location of a benefit program or clinic also needs to be kept in mind. Clinical or counseling activities should be separate from business offices or fitness centers where a person taking advantage of the benefit could be seen by their peers, managers and supervisors.
Achieving engagement in a health benefit program or clinic is key to its success, as well as obtaining the resources and support of senior management for its expansion and continuance. The design, marketing and location of benefit programs need to be well-planned so the workforce is confident that the confidentiality of their patient records will be maintained and not used for employment decisions.
SOURCE: Boress, L. (9 July 2019) "Giving onsite clinics an engagement booster shot" (Web Blog Post). Retrieved from https://www.benefitnews.com/opinion/how-to-increase-employee-engagement-in-healthcare-benefits
Federal Appeals Court Takes Up Case That Could Upend U.S. Health System
A federal appeals court in New Orleans has taken up a case against the Affordable Care Act. If the lower court's ruling in the case, Texas v. United States, is upheld, it has the potential to shake the nation's health care system. Read this article to learn more about this case.
The fate of the Affordable Care Act is again on the line Tuesday, as a federal appeals court in New Orleans takes up a case in which a lower court judge has already ruled the massive health law unconstitutional.
If the lower court ruling is ultimately upheld, the case, Texas v. United States, has the potential to shake the nation’s entire health care system to its core. Not only would such a decision immediately affect the estimated 20 million people who get their health coverage through programs created under the law, ending the ACA would also create chaos in other parts of the health care system that were directly or indirectly changed under the law’s multitude of provisions, such as calorie counts on menus, a pathway for approval of generic copies of expensive biologic drugs and, perhaps most important politically, protections for people with preexisting conditions.
“Billions of dollars of private and public investment — impacting every corner of the American health system — have been made based on the existence of the ACA,” said a friend-of-the-court brief filed by a bipartisan group of economists and other health policy experts to the 5th Circuit Court of Appeals. Upholding the lower court’s ruling, the scholars added, “would upend all of those settled expectations and throw healthcare markets, and 1/5 of the economy, into chaos.”
Here are five important things to know about the case:
It was prompted by the tax bill Republicans passed in 2017.
The big tax cut bill passed by the GOP Congress in December 2017 eliminated the penalty included in the ACA for failure to maintain health insurance coverage. The lawsuit was filed in February 2018 by a group of Republican attorneys general and two governors. They argued that since the Supreme Court had upheld the ACA in 2012 specifically because it was a valid exercise of Congress’ taxing power, taking the tax away makes the entire rest of the law unconstitutional.
Last December, Judge Reed C. O’Connor agreed with the Republicans. “In some ways the question before the court involves the intent of both the 2010 and 2017 Congresses,” O’Connor wrote in his decision. “The former enacted the ACA. The latter sawed off the last leg it stood on.”
State and federal Democrats are defending the law.
Arguing that the rest of the law remains valid is a group of Democratic attorneys general, led by California’s Xavier Becerra.
“Our argument is simple,” said Becerra in a statement last Friday. “The health and wellbeing of nearly every American is at risk. Healthcare can mean the difference between life and death, financial stability and bankruptcy. Our families’ wellbeing should not be treated as a political football.”
The Democratic-led House of Representatives has also been granted “intervenor” status in the case.
The Trump administration has taken several positions on the lawsuit.
The defendant in the case is technically the Trump administration. Traditionally, an administration, even one that did not work to pass the law in question, defends existing law in court.
Not this time. And it is still unclear exactly what the administration’s position is on the lawsuit. “They have changed their position several times,” Sen. Chris Murphy (D-Conn.) told reporters on a conference call Monday.
When the administration first weighed in on the case, in June 2018, it said it believed that without the tax penalty only the provisions most closely connected to that penalty — including requiring insurers to sell policies to people with preexisting conditions — should be struck down. The rest of the law should stay, the Justice Department argued.
After O’Connor’s ruling, however, the administration changed its mind. In March, a spokeswoman for the Justice Department said it had “determined that the district court’s comprehensive opinion came to the correct conclusion and will support it on appeal.”
Now it appears the administration is shifting its opinion again. In a filing with the court late last week, Justice Department attorneys argued that perhaps the health law should be invalidated only in the GOP states that are suing, rather than all states. It is unclear how that would work.
Legal scholars — including those who oppose the ACA — consider the case dubious.
In a brief filed with the appeals court, legal scholars from both sides of the fight over the ACA agreed that the lawsuit’s underlying claim makes no sense.
In passing the tax bill that eliminated the ACA’s tax penalty but nothing else, Congress “made the judgment that it wanted the insurance reforms and the rest of the ACA to remain even in the absence of an enforceable insurance mandate,” wrote law professors Jonathan Adler, Nicholas Bagley, Abbe Gluck and Ilya Somin. Bagley and Gluck are supporters of the ACA; Adler and Somin have argued against it in earlier suits. “Congress itself — not a court — eliminated enforcement of the provision in question and left the rest of the statute standing. So congressional intent is clear.”
It could end up in front of the Supreme Court right in the middle of the 2020 election.
Depending on what happens at the appeals court level, the health law could be back in front of the Supreme Court — which has upheld the health law on other grounds in 2012 and 2015 — and land there in the middle of next year’s presidential campaign.
Democrats are already sharpening their rhetoric for that possibility.
“President Trump and Republicans are playing a very dangerous game with people’s lives,” Senate Minority Leader Chuck Schumer told reporters on a conference call Monday.
Murphy said he is most concerned that if the lower court ruling is upheld and the health law struck down, Republicans “won’t be able to come up with a plan” to put the health care system back together.
“Republicans tried to come up with a replacement plan for 10 years, and they couldn’t do it,” he said.
SOURCE: Rovner, J. (9 July 2019) "Federal Appeals Court Takes Up Case That Could Upend U.S. Health System" (Web Blog Post). Retrieved from https://khn.org/news/federal-appeals-court-takes-up-case-that-could-upend-u-s-health-system/
Creating an ‘urgent care first’ mindset for employee benefits
With urgent cares continuing to pop up everywhere, it’s important to guide your employees in adopting an "urgent care first" mentality. Continue reading this blog post to learn more.
Urgent care centers are popping up everywhere, which means getting quick healthcare is easier and more convenient for patients. But these centers could also help employers minimize expensive emergency room claims. That’s why it’s important to guide employees to adopt an “urgent care first” mentality.
The concept of urgent care has been around since the 1970s, but rising healthcare costs, especially for ER care, have spurred an increase in centers across the U.S. over the last decade. In fact, from 2014 through June 2017, the number of urgent care centers rose by nearly 20%.
Urgent care centers provide care for health problems that aren’t life-threatening, but can’t wait for an appointment with a primary care provider. No one wants to suffer with a sore throat all weekend. Many urgent care centers are staffed with doctors and nurses, and provide more advanced capabilities than what’s typically available at a primary care doctor’s office. For example, some urgent care centers give stitches, provide X-rays and even MRIs.
Patients can also get treatment at urgent care for conditions they’d typically see a primary care doctor for, such as the flu or a fever, mild to moderate asthma, skin rashes, sprains and strains, and a severe sore throat or cough — illnesses that produce unnecessary high claims if treated in an ER.
Still, when a severe sore throat and high fever strike on a weekend and the doctor’s office is closed, employees may gravitate to the ER because they’re sick and need help right now. That’s where the urgent care first mindset becomes good medicine. It typically costs the employer (and often the employee) far less if that sore throat is treated in an urgent care facility.
The high cost of ER care is enough to make anyone run a high temp. From 2009 to 2016 (the most recent data available), the average amount that hospitals billed insurance carriers for an emergency room visit more than doubled, from $600 to $1,322. By contrast, urgent care typically costs about $150 per visit. Members often pay a lower copay for urgent care visits, too.
The urgent care first mindset is starting to take hold. New data analysis from Aetna shows that as urgent care centers began to proliferate, ER visits for minor health issues dropped 36%, while the use of urgent care and other non-emergency health settings increased 140%.
However, the same study shows that plans only saw a decrease in ER visits if there were several urgent care centers in the geographic region where their employees lived. Awareness is key.
Fostering an urgent care first mentality
Employers can’t just include urgent care in a benefits plan and expect employees to use it. They need to design the plan to encourage use and follow up with plenty of education.
Education about the benefits of primary care versus urgent care versus the ER should take place during open enrollment and throughout the plan year so members understand the medical necessity and financial implications of each option. Including the closest urgent care centers to employees, as well as a list of services they provide, can help encourage them to adopt an urgent care first mentality.
A word of caution: not every nearby urgent care center is actually in-network. It literally pays for employees to keep a list of nearby in-network centers handy when that inevitable weekend sore throat strikes.
Reminders about urgent care before spring allergies, summer vacations, fall school physicals and flu season can also help encourage their use.
The too-low ER copay
Plan design is another important piece of the puzzle to help steer employees to the right level of care for their needs. It’s not that unusual to see a $100 copay for an emergency department visit. While no one wants to discourage ER visits for true emergencies, it makes sense to adjust the plan design to encourage primary and urgent care visits instead. That may mean a $20 copay for primary care, a $40 copay for urgent care and a $200 to $250 copay for ER visits — which is waived if the plan participant is admitted to the hospital.
For high-deductible health plans paired with a health savings account, the savings can be even more drastic; patients may pay $200 for an urgent care visit versus $1,200 for an ER visit.
The combination of education and plan design can help curb unnecessary ER visits, which could help employers control healthcare increases from plan year to plan year. For health issues that crop up during off hours, the urgent care first mindset is good for both employers and employees, who will ultimately save time and money.
SOURCE: O'Conner, P. (5 July 2019) "Creating an ‘urgent care first’ mindset for employee benefits" (Web Blog Post). Retrieved from https://www.benefitnews.com/opinion/creating-an-urgent-care-first-mindset-for-employees
Digital health revolution: What we’ve learned so far
Digital health devices provide personalized feedback to users, helping improve their health. Continue reading this blog post to learn more about the evolving digital health revolution.
The promise of the digital health revolution is tantalizing: a multitude of connected devices providing personalized feedback to help people improve their health. Yet, some recent studies have called into question the effectiveness of these resources.
While still evolving, many compelling use-cases are starting to emerge for digital health, including a set of best practices that can help guide the maturation of this emerging field. In the near future, many people may gain access to individual health records, a modern medical record that curates information from multiple sources, including electronic health records, pharmacies and medical claims, to help support physicians in care delivery through data sharing and evidence-based guidelines.
As these advances become a reality, here are several digital health strategies employers, employees and healthcare innovators should consider.
Micro-behavior change.
Part of the power of digital health is the ability to provide people with actionable information about their health status and behavior patterns. As part of that, some of the most successful digital health programs are demonstrating an ability to encourage daily “micro-behavior change” that, over time, may contribute to improved health outcomes and lower costs. For instance, wearable device walking programs can remind people to move consistently throughout the day, while offering objective metrics showcasing actual activity patterns and, ideally, reinforcing positive habits to support sustained change. Technology that encourages seemingly small healthy habits — each day — can eventually translate to meaningful improvements.
Clinical interventions.
Big data is a buzz word often associated with digital health, but the use of analytics and technology is only meaningful as part of a holistic approach to care. Through programs that incorporate clinical intervention and support by care providers, the true value of digital health can be unlocked to help make meaningful differences in people’s well-being. For instance, new programs are featuring connected asthma inhalers that use wirelessly enabled sensors to track adherence rates, including frequency and dosage, and relay that information to healthcare professionals. Armed with this tangible data, care providers can counsel patients more effectively on following recommended treatments. Rather than simply giving consumers the latest technologies and sending them along, these innovations can be most effective when integrated with a holistic care plan.
Real-time information.
One key advantage of digital resources, such as apps or websites, is the ability to provide real-time information, both to consumers and healthcare professionals. This can help improve how physicians treat people, enabling for more customized recommendations based on personal health histories and a patient’s specific health plan. For instance, new apps are enabling physicians to know which medications are covered by a person’s health plan and recommend lower-cost alternatives (if available) before the patient actually leaves the office. The ability to access real-time information — and act on it — can be crucial in the effort to use technology to empower healthcare providers and patients.
Financial incentives.
Nearly everyone wants to be healthy, but sometimes people need a nudge to take that first step toward wellness. To help drive that engagement, the use of financial incentives is becoming more widespread by employers and health plans, with targeted and structured rewards proving most effective. From using mobile apps and comparison shopping for healthcare services to encouraging expectant women to use a website to follow recommended prenatal and post-partum appointments, financial incentives can range from nominal amounts (such as gift cards) to hundreds of dollars per year. Coupling digital health resources with financial rewards can be an important step in getting — and keeping — people engaged.
The digital health market will continue to grow, with some studies estimating that the industry will exceed $379 billion by 2024. To make the most of these resources, healthcare innovators will be well served to take note of these initial concepts.
SOURCE: Madsen, R. (14 March 2019) "Digital health revolution: What we’ve learned so far" (Web Blog Post). Retrieved from https://www.benefitnews.com/opinion/digital-health-revolution-what-weve-learned-so-far?brief=00000152-14a5-d1cc-a5fa-7cff48fe0001
What HR pros should know about clinical guidelines
Sets of science-based recommendations, also known as clinical guidelines, are designed to optimize patient care in areas such as screening and testing, diagnosis and treatment. Read this blog post for what HR professionals should know about these guidelines.
Your employees and their family members frequently face tough questions about their healthcare: How do I know when it’s time to get a mammogram? When does my child need a vision screening? Should I get a thyroid screening? If I have high blood pressure or diabetes, what is the best treatment for me?
For the providers who care for them, the key question is: How do we implement appropriate, science-backed treatments for our patients, testing where needed, but avoiding potentially harmful or unnecessary (and expensive) care? The answer is to seek guidance from and use clinical guidelines —along with existing clinical skills — wisely.
Clinical guidelines are sets of science-based recommendations, designed to optimize care for patients in areas such as screening and testing, diagnosis and treatment. They are developed after a critical review by experts of current scientific data and additional evidence to help inform clinical decisions across a spectrum of specialties.
Based upon this process, guidelines are then released by a number of sources and collaborations, including academic and non-profit healthcare entities, government organizations and medical specialty organizations.
From preventive care to treatment protocols for chronic conditions, guidelines provide a framework healthcare providers use with patients to help guide care. However, it’s important to note that clinical guidelines are not rigid substitutes for professional judgment, and not all patient care can be encompassed within guidelines.
The impact on healthcare and benefits
Clinical guidelines are used in myriad ways across the healthcare spectrum, and providers are not the only ones who utilize them. Insurers also may use guidelines to develop coverage policies for specific procedures, services and treatment, which can affect the care your covered population receives.
To illustrate a key example of an intended impact of guidelines on health plan coverage, consider those issued by the U.S. Preventive Services Task Force, whose A and B level recommendations comprise the preventive services now covered at no cost under the mandate of the Affordable Care Act.
As another example, the National Committee for Quality Assurance, which accredits health plans and improves the quality of care through its evidence-based measures, uses the American Heart Association guidelines when creating its quality rules for treating high cholesterol with statin drugs.
Other examples exist among commercial coverage policies. For example, some cancer drug reimbursement policies use components from nationally recognized guidelines for cancer care.
Because science is rapidly changing, guidelines are often updated, leading insurers to revisit their policies to decide if they will change how services and medications are covered for their members. Providers and health systems may modify processes of patient care in response to major changes in guidelines and/or resultant changes in payer reimbursement.
Not all guidelines are updated on a set schedule, making it even more important for providers and organizations that rely on guidelines to stay on top of changing information, as it can have a direct impact on how they work. Attending conferences, visiting the recently established ECRI Guidelines Trust, and regularly reviewing relevant professional association websites and journals can help ensure needed guidelines are current. Lack of current information can affect care decisions and potential outcomes for patients. Those who have access to the most up-to-date, evidence-based information are able to work together to make well-informed healthcare decisions.
Why it matters for employers
As employers or benefits consultants, it’s critical to ensure that your health plan, advocacy or decision support providers, and other partners that depend on this information to guide their practices and decisions understand and follow current, relevant guidelines.
Further, by combining information from relevant guidelines and data from biometric screenings, health risk assessments, claims and other sources, it’s possible for clinical advocacy and other decision support providers to identify employees with gaps in care and generate targeted communications (through a member website and/or mobile app) to help them take action to improve their health.
Clinical guidelines are science distilled into practical recommendations meant to be applied to most patients for quality healthcare. By maintaining current, relevant guidelines, organizations and providers who work with your covered population can ensure that all parties have the key information they need to make the best decisions for their health.
SOURCE: Sivalingam, J. (18 March 2019) "What HR pros should know about clinical guidelines" (Web Blog Post). Retrieved from https://www.benefitnews.com/opinion/what-hr-managers-should-know-about-clinical-guidelines?feed=00000152-a2fb-d118-ab57-b3ff6e310000
To check or not to check: Managing blood sugar in diabetic employees
There's been a growing prevalence of Type 2 diabetes in the U.S. over the last 20 years. This chronic condition significantly impacts employees, their family members and even employers clinically and financially. Read this blog post to learn more.
Over the last 20 years, there’s been a growing prevalence in the U.S. of Type 2 diabetes, a chronic condition that significantly impacts employers, their employees and family members clinically, financially and through quality of life. With that comes an increase in the use of insulin for people with Type 2 diabetes to better control blood sugar to reduce long-term complications, which includes eye, kidney and cardiac disease, as well as neuropathic complications.
Most of these patients manage their condition with oral medicines versus insulin, and it’s estimated that 75% of patients with Type 2 diabetes regularly test their blood sugar, even though doing so may not be needed. Blood sugar testing is an important tool in managing diabetes as it can help a patient be more aware of their disease and potentially control it better. But it also can be painful, inconvenient and costly.
Blood sugar testing can be an important tool in managing diabetes, and there are two types of tests. The first is a test conducted at home by the patient that shows the blood sugar at a specific point in time. The second type is called HA1c (a measure of long-term blood sugar control) that shows the average blood sugar over the last two to three months. The value of at-home testing is now thought to be questionable.
In 2012, the Patient-Centered Outcomes Research Institute began a study to evaluate the value of daily blood sugar testing for people with Type 2 diabetes not taking insulin. The endpoint for the study was whether there was a difference in HA1c levels for those who did daily testing and those that did not. The conclusion of the study found that there were no significant differences between those two populations.
In response to these findings, the institute developed an initiative called Rethink the Strip that involves stakeholders including primary care practices, healthcare providers, patients, health plans, coalitions and employers. Given the cost for test strips and monitors for patients with Type 2 diabetes who test their blood sugar daily, it’s important to adopt an evidence-based patient-centered approach around the need for and frequency of self-monitoring of blood glucose.
As employees and employers cope with the costs associated with blood sugar testing, there are several strategies that should be considered to better manage this issue. They include:
1. Support shared decision-making. Like all interventions within healthcare, it’s important to weigh both the benefits and the risks of daily blood sugar testing in a thoughtful manner between the patient and their provider.
2. Managed benefit design. Employers should pay for daily blood sugar test strips in cases where it brings value (e.g., Type 1 and Type 2 patients who are taking insulin as well as patients that are either newly diagnosed or are going through a transition period, for example, post hospitalization or beginning a new medication regimen).
3. Involve vendors. To ensure alignment in all messaging to plan members, ask health systems and/or health plans and third-party vendors to align their communication, measurement and provider feedback strategies on when it’s appropriate for daily blood sugar testing.
These strategies can help employees with diabetes understand how their daily activities (nutrition, exercise and stress) and medications impact their condition. This benefits the employee in reaching treatment goals and feeling their best, while also helping employers and employees reduce the need for unnecessary and costly test strips.
SOURCE: Berger, J. (14 March 2019) "To check or not to check: Managing blood sugar in diabetic employees" (Web Blog Post). Retrieved from https://www.employeebenefitadviser.com/opinion/managing-blood-sugar-in-diabetic-employees?brief=00000152-146e-d1cc-a5fa-7cff8fee0000