Your employees go to the dentist and to the doctor. They call nurse help lines and visit the eye doctor. They use employee assistance programs and go on disability.
But in many, if not most, cases, those individual silos of health care are not communicating with one another.
Now imagine a system in which all facets of the health care system work together to offer integrated care and lower costs, and you’ve got an integrated medical solution, says Mark Haegele, director, sales and account management, at HealthLink.
“Under a truly integrated medical solution, all of those components talk to each other,” says Haegele. “They have a continuous feedback loop, with medical talking to dental and a nurse line talking to disease management.”
Smart Business spoke with Haegele about the steps you can take today to begin integrating medical solutions and how doing so can improve the health of your employees and your company’s bottom line.
Why are integrated medical solutions important?
There are multiple components of a traditional benefit plan, including medical, dental, disability, vision, life, employee assistance programs, disease management, lifestyle management, medical management, case management, nurse lines and other things. And the industry is just beginning to recognize the importance and value of the information associated with each of the components and their implications for other components.
It is just now understanding that information obtained through an eye exam has a direct implication on the identification of heart failure, diabetes and other diseases as it relates to the medical plan. It is just starting to utilize the fact that the identification of gum disease has a direct correlation to and implication on premature birth.
How does integration work?
As an employer, you have to be aware that a vendor is not related to other vendors and ask, ‘What data elements, what information is important for other vendors to have?’ Then ask whether those different parties are conversing and whether they’re sharing information to try to create the best solution for the employer. Ninety percent of the time the answer is no, as even large carriers have silos within the organization that can preclude an integrated solution.
What are simple steps an employer can take today to get started?
Basic things include working with your pharmacy benefit manager and those running your disease management program to ensure there is compliance among employees with certain disease cases.
Work with your third-party administrator, carrier or broker to identify members who have hypertension and diabetes, based on claims experience, and provide it to the pharmacy benefit manager (PBM) to make sure that someone — whether it’s the PBM, broker or those running disease management — is reaching out to members to create awareness among those who are not in compliance with their treatment plan.
For example, those in your disease management program probably don’t know if people are taking their prescribed hypertension drug. They don’t have that information because there is no integration. But if you take that information from the PBM and make sure that gap is being bridged and that someone’s reaching out to members who have diagnoses of hypertension, but who aren’t taking medication, you’re creating awareness and integrating those components to create compliance.
Employers start asking, via their brokers or their health plan, ‘How are you helping my members stay compliant with their medication, and how are you pulling information from the health plan database to identify opportunities for health improvement within the plan?’
What other questions should employers be asking?
Ask how disease management is integrated with your claims operation. How does your case manager integrate with your disease manager? How does vision integrate with the medical plan? How does dental integrate with the vision and medical plan? How does your disease management program interface with pharmacy benefit management?
How does your health plan attempt, through integration, to ensure prescription compliance? Does your employee assistance program integrate with your pharmacy benefit management program as it relates to antidepressants? If you have a third-party administrator, what is it doing to feed information back to health coaches or to those in a disease management role?
What is your health plan doing to incentivize members to help prevent fraud and abuse? For example, some plans encourage members to closely review hospital bills for errors, and if the bill is adjusted as a result, return some of that savings to the member.
From claims data on the medical side, you can identify and assess the risk probability associated with your disability insurance, so you can oftentimes get a disability insurance quote that’s much more attractive than the norm because of information you’ve identified from the medical plan. If you integrate case management and disease management with disability, so your disability team has more information on the front end, it affords it the ability to better manage members, get them back to work more quickly and ultimately lower disability costs.
Finally, take a hard look at your vendor management and work with your broker about overall vendor integration strategy so that vendors become aligned over time.
You’re not going to go from a completely disjointed operation in your benefit plan to having something that’s integrated overnight. But if you start asking questions, you can begin to create some level of integration within your plan.
Mark Haegele is director, sales and account management, at HealthLink. Reach him at (314) 925-6310 or Mark.Haegele@healthlink.com.
The cost of health care for employers is rising at an average annual rate of 12 percent and, for many businesses, health care is the No. 2 or No. 3 budgetary issue stressing their bottom line.
But there are steps employers can take to keep those costs in check, with annual increases of 4 percent or less, says Mark Haegele, director, sales and account management at HealthLink.
“The average annual trend in overall costs, which includes administrative fees, fixed costs, plan costs and pharmacy costs, is about 12 percent,” says Haegele. “That clearly has an impact on a business’s bottom line, as anything more than 3 percent has a detrimental impact on a company’s ability to offer products and services. But there are a number of things an employer can do to get those costs in line.”
Smart Business learned more from Haegele about how employers can control health care costs and boost their bottom line.
Why should employers be concerned about rising health care costs?
Unsustainable increases in health care costs, over time, will impede an employer’s ability to continue to offer services in its local market, having a profound impact on communities and the country as a whole.
How can employers lessen the burden of health care costs?
Typically, employers can implement several initiatives around wellness, health improvement and risk management. And there are a number of pilot programs that are trying to redefine how to finance health care on behalf of employers. You have to look at plan design, wellness strategies and a company’s financial structure in order to beat the street and do better than typical cost increases. Employers can structure programs specifically for their employees’ needs and design a plan that fits that particular group of employees better than a standard plan would and that also addresses aberrant cost increases. There are a number of flaws in the system that need to be addressed and a number of challenges. There are underutilized cost containment strategies related to health care, and if an employer is just paying for a base plan, it is not incorporating these specific strategies.
What areas offer potential cost savings for employers?
Areas such as specialty pharmacy should be addressed. This is an area where there are 650 biometric drugs in the pipeline, and specialty drugs represent 20 percent of that pipeline, and although just 2 percent of the population, represent 18 percent of the prescription drug cost. That is certainly an area that can be managed.
Cancer drugs are another category that is not traditionally aggressively managed. There are programs available that employers can use to get the lowest cost out of their providers via aggressive case management. These programs work with members to get home health treatment with cancer drugs and look at different ways to procure those drugs outside of the traditional system that is so expensive.
The typical path with injectable drugs is that a patient goes to the doctor, who sends the member to the hospital and gets that person on a program, charging up to 800 percent above Medicare costs. If, instead, the patient goes through a specialty pharmacy and uses a home health nurse to inject those drugs at home, that can cut costs by up to 70 percent.
Too many employers simply pay the premium and don’t think about these things, when doing so could have a significant impact on their business and their bottom line.
How can employers get started on cost savings?
Employers should sit down with their health care consultant to structure a plan that meets the specific needs of their members. They need to take a hard look at the demographics of their employees, what industry they are in, and the age and sex distribution of their population. They need to look at their ‘historical tracks in the snow,’ where people have sought care and the prevalence of chronic illnesses.
Employers can then decide where to place their benefit dollars. For example, an employer may want 100 percent coverage for diabetics, for test strips and other supplies, because it has a disproportionate prevalence of diabetes. But it may not need to offer as many benefits around other illnesses because the prevalence rate is very low. It can shift its plan design to accommodate its members’ needs.
How can employers encourage employees to be healthier?
At a bare minimum, they can educate employees by sending informational pieces centered around health and wellness, preventive guidelines, key risk factors for illnesses and actions associated with a healthy lifestyle.
On the extreme end, they can design their plan with incentives that encourage people to perform wellness activities to be eligible for an enhanced benefit plan. For example, if members get a biometric screening once a year, they will qualify for the gold plan. If not, they will default to the basic plan.
An employer can also require other wellness activities to qualify for the gold plan, such as cholesterol checks, health risk appraisals or membership in a gym. The message is that if employees want enhanced benefits, they have to take an active role in being healthy.
To encourage employees further, employers can offer other incentives. For example, if employers encourage health risk appraisals, 3 to 5 percent of employees will participate. But if the employer offers something as small as a $10 gift card, that rate increases to 40 percent.
To achieve optimal results and truly bend the typical cost trend, employers really need to employ a hands-on, active approach and take control over what is happening with the plan. By understanding the risk factors of its population and addressing what is happening with its employee population, the employer can have a drastic impact on its bottom line.
Mark Haegele is director, sales and account management at HealthLink. Reach him at (314) 925-6310 or Mark.Haegele@healthlink.com.
Too often, patients are not properly taking medications, following up on care after release from the hospital or correctly managing chronic diseases.
Medical management can help change that, as utilization management nurses and medical case managers work with members to make sure they’re getting the most out of their health care benefits, says Dr. Bob Sorrenti, medical director at HealthLink.
“Medical management includes utilization management, in which we look at services to make sure they are medically necessary so the impact of inappropriate medical services can be eliminated,” Sorrenti says. “It also includes disease management, putting a focus on people who have high-risk conditions, such as cardiac disease or diabetes, looking at what drives the cost of care and better managing those drivers.”
Smart Business spoke with Sorrenti about how medical management can improve care and how employers can encourage employees to take advantage of available services.
What is medical management?
In a broad sense, through a variety of different types of interventions, medical management addresses the use of services and their appropriateness according to medical standards, the quality of members’ experiences as they receive health care, and ultimately, the cost of the medical care. For example, if someone were using the emergency room multiple times in inappropriate ways, a case manager might approach that person about finding a primary care physician. By doing so, the member will save money by paying a lesser co-pay and get a better level of care than that person is getting by frequent use of the ER.
Medical management strives to make sure that physicians are following accepted standards of care and doing the kinds of tests that are appropriate according to those standards. It’s not only about saving money; it also helps members avoid being exposed to unnecessary services down the line. As a result, the member has gotten more quality in the level of care, in line with what are the accepted practices in medicine.
How would a utilization manager interact with someone with a chronic condition?
That patient might be impacted in a number of ways. If you were admitted to the hospital, you or your provider would let the utilization management team know. The utilization management nurse would contact your physician and hospital to learn why you were admitted and what the plan of care was going to be.
As your stay in the hospital continued, the UM nurse would make sure you were in the right setting for your needs and that you weren’t staying in the hospital beyond the appropriate time.
As your discharge approached, the UM nurse would start thinking about what services you needed after discharge. Do you need to go to a rehabilitation facility or to a skilled nursing facility? Do you need support services at home, such as home health care? Do you understand what your benefits are for these types of care?
The UM nurse would help facilitate the arrangement of those services within your benefits, making sure you were using your network providers and thus minimizing any out-of-pocket expenses. After discharge, a case manager might become involved to look at gaps in your understanding of what you’re supposed to be doing and make sure that when you got home, you were following your doctor’s directions as to what medication you were supposed to be taking and where you were supposed to be getting your care.
How can medical management help prepare a patient for surgery?
For example, our UM nurses call members who are having elective surgery, both before they go into the hospital and after they leave. The purpose is to ask, ‘Are you clear on what’s going to happen with your surgery? Do you have your care lined up when you go home from surgery? Do you have someone to take care of you? If you have steps in your house, do you know how the surgery is going to interfere with your ability to do steps?’
After the surgery, the UM nurse would follow up and ask, ‘Are you clear on the doctor’s instructions? Have you gotten the tests that you were supposed to get? Do you have an appointment to see the doctor?’
The readmission rates have been reported to run from 7 percent to as high as 20 percent in the Medicare population. The key to reducing those rates is to make sure members are following up with their physicians after discharge. Making those phone calls is very important to support members and to make sure they are doing the right thing.
It’s not about saying no to someone and denying services; it’s about how to help members make sure they are doing the right thing.
How can employers encourage employees to take advantage of medical management?
One thing employers can do is stress to members the importance of engagement with the medical management staff. In the past, people have seen something of an adversarial relationship with medical management people and wanted to keep them at arm’s length. If employers can encourage employees to cooperate with the medical management staff that can go a long way to benefiting the member and the plan.
Employers can also stress the importance and value of members actively participating in medical case management. Medical case management often targets members with complicated and extensive care needs. As the case managers help to build the care plan, the member is essential to the success of that plan. The case manager can be of great support and assistance to the member and help them work their way through the complexities of medical care.
Dr. Bob Sorrenti is medical director at HealthLink. He can be reached at (978) 474-5108 or Bob.Sorrenti@wellpoint.com.
Many employers shy away from funding their own health insurance, fearing that doing so could lead them into bankruptcy.
But for some companies, this alternative method of health plan funding may not be any riskier than using a traditional fully funded plan, and it has the added benefits of potentially lowering your premiums and benefitting your company should the plan show a surplus, says Mark Haegele, director, sales and account management, at HealthLink.
“There is the misperception that alternative funding is too risky for companies with fewer than 500 employees,” says Haegele. “But if you structure the plan properly, you can minimize potential risks while seeing the benefits that come from a healthier-than-average work force.”
Smart Business spoke with Haegele about how businesses with as few as 20 employees can take advantage of alternative funding.
What kinds of companies can benefit from alternative funding?
Alternative funding is becoming popular for employers with 20 to 200 employees that believe their population is healthy and that don’t understand why they face rate increases of 15 to 20 percent or more. If an employer feels it doesn’t have control over its plan, and it actively supports the health and welfare of its employees, it is a great candidate.
Many companies keep paying the same increases each year, hoping for something different, but may instead continue to pay more with no opportunity to share in the benefits of having a healthier-than-average work force. Take ownership of the plan and evaluate the alternatives.
The dynamics are such in the marketplace, with health care reform implications and new products to protect businesses, that now is a great opportunity to take a hard look at whether alternative funding is the right choice for your company.
How does alternative funding work?
With alternative funding, employers are still buying insurance over a specific risk threshold. Some people use the term ‘self-funding,’ but that is a misnomer because you’re not taking on all the risk. It’s partially funded for most employers, generally, unless they have more than 1,000 employees.
Employers should ask their broker or consultant for a proposal for an administrative services-only health plan that has four main components: a third-party administrator, a health network, a pharmacy benefit manager and a reinsurance carrier. Assess the plan based on how much risk the employer is willing to take on and evaluate proposals from reinsurance carriers based on risk tolerance.
With an appropriate alternative funded plan, the employer may be taking on no more risk than with a fully insured health plan, and its maximum exposure may be no more than it would be if the plan were fully funded. Typically, the employer will purchase specific and aggregate reinsurance; claims up to a specific threshold on an individual person are the responsibility of the employer, and the reinsurance kicks in for anything over that amount.
Alternative funding gives employers the flexibility to design a health plan that fits their member populations. Coupled with education and access to wellness programs, alternative funding will deliver a measurable health care cost savings over an extended period of time.
What are the current benefits of choosing an alternative funded plan?
First, the employer avoids premium tax. Second, it has lower fixed costs than with a traditional plan.
Third, it has the ability to customize its plan design in accordance with specific employee needs. Under fully insured, a plan must meet state mandates such as coverage of bariatric surgery and infertility treatments. But if an employer has an employee population that is all young, single, healthy men, it doesn’t have to cover those mandates.
It has complete control over its plan and can move its dollars to better suit its employees’ needs. For example, if it has a population with a high number of diabetics, or employees with high blood pressure, and it wants to cover those conditions 100 percent, it can do so.
In addition, it has control over plan information. If the plan is fully insured, the employer generally doesn’t have access to the trends associated with its population. With alternative funding, it has total access to that information, which gives it the ability to adjust the health plan to best suit its members’ needs.
As a result, the employer can turn that data into actionable information. For example, it can identify members with chronic illnesses and enhance the benefits to ensure compliance with medication and standard treatment protocol to improve the health of its employee population. That data can also allow it to identify if employees are misusing the emergency room, driving up costs. It can then educate them about the proper use of the ER and the availability of services such as a 24-hour nurse line, clinics and urgent care centers.
An alternative funded plan also gives employers the ability to manage cash flow. With fully insured, the company pays a premium every month, and any upside goes to the insurance company; if it has low claims, it still pays the same premium. But with an alternative funded plan, the employer only has to spend the dollars for the care provided that month.
What are the future benefits?
Under health care reform, there is a defined tax for insurance companies that goes into effect in 2014. That tax bill for insurance companies is estimated at $8 billion in 2014 and as much as $12 billion by 2018, which will be passed on to employers. If an employer has an alternative funded plan, it will avoid paying toward that upcoming tax.
With changes in the market, now is the ideal time for employers to make a change and take ownership of their plan through alternative funding.
Mark Haegele is director, sales and account management, at HealthLink. Reach him at (314) 925-6310 or Mark.Haegele@healthlink.com.