Behind the scenes help Featured

8:00pm EDT April 25, 2009

All health plans are not alike and offer different services and benefits to consumers. But one common thread is that health care costs are continuing to increase and are expected to exceed $8,000 per person this year. You cannot control future health care costs and improve your employees’ health unless you find a carrier that will work behind the scenes to effectively manage your total medical spending and solve these problems by providing value-added services.

“Knowing more about these services can help an employer sleep better at night, knowing that they are getting great value for their health care dollar and that their employees are being cared for by a team of professionals,” says Amy O’Meara Chambers, associate vice president of market development at Priority Health.

Smart Business spoke with Chambers about behind-the-scenes work that takes place at health plans, how to take advantage of value-added services offered by health plans, questions to ask regarding your health plan, and what elements make up a good health plan.

What goes on behind the scenes with health plans that employers or consumers might not know about?

Health plans have many services in place to keep members healthy. These services help employers maintain a work force that is healthier and more productive. Employers also see their health care expenditures’ bottom line improve.

Health plans also have many health experts on staff who are tasked with bringing the best health care solutions to members. These people research, work on quality initiatives, help coordinate member care and help members manage chronic disease. Health plan experts are also conferring with community doctors, nurses and pharmacists either in committee formats or one-on-ones, discussing individual member cases to determine the best course of action.

What are some value-added services offered by health plans, and how do they work?

Examples include case and condition management, disease management, wellness programs and prevention. These services monitor and utilize data that’s received through medical claims to identify complex member cases and chronic conditions. Health plans also reach out and help members coordinate their care while experiencing intensive treatments and offer educational support to those with chronic conditions.

Other areas of value-added services are wellness programs and first-dollar preventive care. These services encourage members to take an active role in their health care and address health issues early. Members have preventive care built into their coverage and have access to programs such as community wellness classes, fitness discounts at area retailers and interactive tools on the plan’s Web site.

What questions should employers ask their health plan regarding the services in their contract?

Take advantage of your health care dollar by educating yourself on all your health plan has to offer. There could be free wellness programs just waiting to be utilized, but if you don’t ask, you may never know they’re available. Your employees will be thankful for their reduced gym memberships or free classes on something such as ‘quick and healthy meals.’ Healthy employees make for a healthy bottom line.

What kind of reporting can you expect from a health plan to help structure effective programs for employees?

Employers are able to make good decisions when they receive accurate and actionable data reporting. Financial data supplied to large groups help guide them toward the best funding option, whether it’s self-funding, shared funding or fully funding their health plan’s expenses.

Health and wellness information is presented to assist with identification of opportunities for case and disease management as well as wellness programming support. Lastly, plan design data is reported with a focus on utilization by benefit type to identify potential changes to member liability and alignment of benefits with the employer’s benefit strategy. Smaller groups that take advantage of a community or book rating do not typically have access to group specific data reporting; however, data becomes more available as groups reach or exceed 50 employees.

What sets a great health plan apart from a good health plan?

Great health plans provide excellent health care that is affordable. These plans receive high honors when compared with peers and garner respect from the employer and provider communities and the membership at large.

Great health plans offer a range of products that complement your employer benefits strategy. They offer excellent claims systems, the highest caliber customer service and excellent health management programs that show a return on investment, online tools, etc.

AMY O’Meara CHAMBERS is the associate vice president of market development at Priority Health. Reach her at (616) 464-8540 or