Value-Based Care Marches On

healthMajor insurers are reporting that value-based care initiatives are yielding good results for payers, providers and patients. Employer groups and individuals covered under insured plans, Medicare and Medicaid, are receiving more consistent, quality care that is easier to navigate. This is music to the ears of Alex Azar, HHS secretary, who has been a strong supporter of value-based care.

While the concept of value-based care dates back to the Obama administration, Azar believes it can accomplish more. In a recent speech to the Federation of American Hospitals, he advocated for enabling consumers to gain more control over their health information, increasing transparency from providers and payers and easing government burdens in both Medicare and Medicaid.

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For 2019, Employers Adjust Health Benefits as Costs Near $15,000 per Employee

This article was published on August 13, 2018 on SHRM.org, written by Stephen Miller.

Plans are steering employees toward expanded telehealth options and high-value centers of excellence

With the cost of employer-sponsored health care benefits expected to approach $15,000 per employee next year, large U.S. employers continue to make changes, new research reveals.

Many want to hold down cost increases and are steering employees toward cost-effective service providers, such as telehealth options and high-value in-plan provider networks, according to the nonprofit National Business Group on Health (NBGH) survey 2019 Large Employers’ Health Care Strategy and Plan Design. The survey was conducted from May to June with 170 large employers as they finalized their 2019 health plan choices; more than 60 percent of respondents belong to the Fortune 500.

Cost Increases Hold Steady

Big employers project that their total cost of providing medical and pharmacy benefits will rise 5 percent for the sixth consecutive year in 2019. If they weren’t making benefit changes, their costs would rise 6 percent, the survey showed.

The total cost of health care, including premiums and out-of-pocket costs for employees and dependents, is estimated to average $14,800 per employee in 2019, up from $14,099 this year. Large employers will cover roughly 70 percent of those costs, leaving $4,400 on average for employees to pick up in premium contributions and out-of-pocket expenses.

Health benefit costs are still rising at two times the rate of wage increases and three times general inflation, “making this [cost] trend unaffordable and unsustainable over the long term,” Brian Marcotte, NBGH president and CEO, said at an Aug. 7 press conference in Washington, D.C.

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Consumer-Directed Health Plans

“The most unexpected data point in the survey this year is that employers are dialing back their move to consumer-directed health plans”―or CDHPs―especially as a full replacement for other health plan options, Marcotte said. CDHPs typically combine a high-deductible health insurance plan with a tax-advantaged account that employees can use to pay for medical expenses, most commonly a health savings account (HSA) or health reimbursement arrangement.

“We may be at a tipping point in terms of cost-sharing with employees,” Marcotte said.

In 2019, the number of employers offering CDHPs as a sole option will drop by 9 percent, from 39 percent to 30 percent, “reflecting a move by employers to add more choice back into the mix” by also offering traditional health plans such as preferred-provider organizations, he noted.

To lessen the pain of high deductibles while maintaining incentives for cost-conscious spending, large employers are contributing to their employees’ HSAs, on average, $500 for an individual and $2,000 for a family, NBGH found.

The shift to CDHPs as a sole option over the last decade was driven, in part, by the Affordable Care Act and its 40 percent “Cadillac tax” on high-value health plans, originally to take effect in 2018, Marcotte said. “A lot of companies moved to high-deductible health plans to minimize the impact of the Cadillac tax or to delay its impact, but the Cadillac tax has been kicked down the road, first  to 2020 and now to 2022,” Marcotte said. Many believe it may be further delayed or repealed altogether, “so employers are relaxing” about the need to reduce the scope of their plans. Continue reading

Helping with Prescription Adherence

doctorWhile prescribed medications are critical to the management of chronic illnesses such as diabetes, asthma or heart disease, they can only help when taken correctly and research shows that at least half are not taken as prescribed. This not only has a huge impact on the health of individuals but on health plan costs since failure to take medications as prescribed can result in costly emergency room visits and hospital readmissions.

Since failing to follow a doctor’s prescription plan will likely result in higher dollar claims for treatment, examining claims data is the first step to take in order to monitor this problem. Once the employees involved are identified, a health coach or support team can be assigned to help these individuals begin managing and taking their medications correctly. If cost is an issue, which is fairly common in the case of chronic problems, financial incentives or help with prescription copays might be wise.

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Getting People to Use Telemedicine

ebso-mobile24/7 physician access by phone or video has the potential to do great things for health plans and consumers. Getting a doctor’s help without waiting in a medical office is a great convenience, especially if you’re traveling or your primary care physician is unavailable. The challenge, however, is that telemedicine does not sell itself – it needs to be communicated over and over again if we want members to remember they have this great, easy-to-use benefit instead of driving to an urgent care center. Technology is great, but it won’t activate itself. People are creatures of habit and it takes a good deal of effort to change behavior. Low tech tactics like email reminders, flyers or refrigerator magnets may just be what the doctor ordered when trying to drive home the benefits of telemedicine.

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Reference Based Pricing Gaining

ebso-rpbWhile plenty of folks talk about reference based pricing as though it’s a fad that has come and gone, we’re finding more interest from employers all the time. This may be because many like to brand it as another form of disruption, but regardless of how you brand it, reference based pricing is becoming a more important part of our value proposition all the time. It’s becoming more widespread because it enables a self-funded plan to limit costs to an extent that few other measures, if any, can match. This is primarily because by negotiating in advance with hospitals to accept a schedule of fixed payments for certain healthcare services, carrier-sponsored provider networks can be bypassed.

The fact is that while reference based pricing may be considered disruptive by many hospitals, it works. It is a transparent approach that can save a lot of money for self-funded health plans and their members. And finding ways to help self-funded employer plans provide high quality, high value healthcare to their members is our most important job.

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Women More Vulnerable to Stress

woman holding headA study of nearly 700 individuals with coronary artery disease has revealed that hearts in men and women react differently to a temporary reduction in blood flow to heart muscles, a common symptom caused by stress. While some men may experience an increase in blood pressure and heart rate, making their heart work harder, about 1 in 5 women experienced constriction in their smaller blood vessels, which can cause more serious heart complications. American Heart Association representatives recommend physical exercise as a way to manage mental stress. Exercise will make blood vessels dilate, counteracting the constriction seen by some of the women who participated in the study. Regular exercise, like a daily walk or run, can go a long way in helping us cope with mental stress.

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The Changing Definition of Wellness

wellness-programAfter decades of preaching to workers about the importance of staying fit and physically healthy, the term worksite wellness is beginning to mean much more to employers and employees alike. Leading companies are expanding their workplace wellness initiatives to address mental health and financial security – key components of their employee’s overall well-being that go way beyond physical health.

The National Business Group on Health shows that a majority of employers are addressing emotional and mental health as well as financial security as part of their overall well-being strategy. Other initiatives, such as support for community involvement and social interaction, are pointing to a growing trend of focusing on the entire person and not just physical health or fitness. Research is showing that addressing physical health is only one way to improve the workplace experience and reduce employee turnover.

More Choice Means Greater Satisfaction

While traditional wellness programs have been more “one size fits all” and lacking in personal appeal, some employers are encouraging employees to do the things they like to do by giving employees a flat dollar amount to spend on a gym or pool membership, personal trainer or other self-defined activity they find rewarding. Volunteering to help with community causes or enrolling in educational classes are not out of the realm of possibilities, since these activities can do a lot to help an employee gain a healthier perspective on work and life.

When choices are made by individuals and not for them, better decisions often result. As people share their experiences with others, the impact on a company’s culture can be extremely positive. Better well-being becomes an important priority for everyone and not just those who like spending time on treadmills or yoga mats. From the employer’s perspective, objectives can expand beyond healthcare cost savings and increased productivity. As an example, offering health coaching is a great way to focus on the needs of individuals rather than the group as a whole. It can help companies address emotional and mental needs as well as physical needs.

If worksite wellness is a priority for your organization, this might be a good time to review the goals of your program and then to make sure the activities you are offering are in line with those objectives. There is a lot more to be gained from worksite wellness than lower medical claim costs and redefining wellness may be just what your organization needs.

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It’s Never Too Early for Sunscreen

sunscreenThe American Cancer Society reminds us that more skin cancers are diagnosed each year in the U.S. than all other cancers combined. Most are caused by too much exposure to ultraviolet (UV) rays, most of which come from exposure to the sun. One thing to remember is that you don’t have to be spending a day at the pool to be at serious risk. Simply staying in the shade will make a huge difference. If you do want to catch some rays, slip on a shirt, wear a hat and apply sunscreen with a SPF value of 30 or more. UV blocking sunglasses will help protect the delicate skin around your eyes and help you avoid certain eye diseases as well.

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Jury deems Centura Health $230K surgical bill ‘unreasonable,’ awards $766

This article was published on June 21, 2018 on BenefitsPro, written by Greg Land. Photo Source: BenefitsPro.

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A Colorado jury declared a hospital’s billing unreasonable, turning aside its lawsuit demanding almost $230,000 from a patient whose insurer already covered the cost of her surgery.

The patient had already paid her deductible and her insurer had paid the hospital about $75,000, which an audit deemed the “reasonable value of the goods and services” she had been provided, her lawyer said.

Lead attorney Ted Lavender of FisherBroyles’ Atlanta branch, who represented the former patient with office partner Kris Alderman and Denver partner Frank Porada, said testimony in the case revealed just how murky hospital billing can be and how some patients are targeted for whopping bills to make up for those who pay substantially less for the same services.

“The hospital experts explained how the rates get set, and it ultimately devolved into this idea that paying patients have to pay more to make up for nonpaying patients, the uninsured, those on Medicare and Medicaid, who don’t pay full price,” Lavender said.

In his client’s case, records showed that surgical spinal implants cost the hospital about $31,000.

“They turned around and charged $197,640 for those items on the hospital bill,” said Lavender. “That is a 624 percent markup.”

The hospital is represented by Traci Van Pelt, Michael McConnell and David Belsheim of Denver’s McConnell Fleischner Houghtaling.

Van Pelt said they will file posttrial motions and appeal the verdict.

The case involved back surgery performed on Lisa French in 2014 at St. Anthony North Health Campus, north of Denver. Hospital filings said French’s surgery was to relieve back pain and was “considered elective.”

French’s employer had a self-funded ERISA insurance plan, and she was told prior to surgery that she would owe $1,336, of which she immediately paid $1,000.

French’s contract included phrasing that she “understand[s] that I am financially responsible to to the hospital or my physicians for charges not covered or paid pursuant to this authorization.”

St. Anthony’s billed her insurance plan $303,888 after the surgery and for two presurgical consultations based on its “chargemaster” billing schedule, an industrywide practice whereby providers list all the prices they charge.

As Lavender explained, French’s employer’s insurance plan contracts with a health care consulting firm, ELAP Services, which audits claim costs and negotiates with providers for self-funded insurers. On its website, ELAP says it “assists in plan design and jointly establishes limits for payment of medical claims that correlate to the providers’ actual cost of services.”

ELAP audited the fees St. Anthony’s charged French and determined that her actual charges came out to about $70,000, Lavender said. Between her co-pays and the insurance plan, St. Anthony’s was paid $74,597.

St. Anthony’s parent company, Centura Health Corp., sued French in state District Court in Adams County, Colorado, seeking an additional $229,112 in 2017.

ELAP provides legal representation to clients facing suit pursuant to its services, and Lavender, Alderman and FisherBroyles Denver partner Frank Porada were assigned French’s defense.

According to defense filings, Fishers contract with St. Anthony’s contained no stated price and was thus ambiguous.

The hospital was already paid the reasonable value for the services, according to a defense account. The chargemaster rates are “grossly excessive and defendant had no choice but to sign the Hospital Service Agreement, making them unconscionable” and thus unenforceable, the defense said.

During a six-day trial in Brighton, Colorado, before Judge Jaclyn Brown of Colorado’s 17th Judicial District, Lavender said the entire dispute was over the prices and methodologies medical providers use.

“We had one expert, and they had three,” said Lavender. “They spent $100,000 on experts.”

“The reality is that there’s nobody to say how much they’re charging is reasonable,” Lavender said.

The jury made that determination for French on June 11, answering “no” when asked whether her bills were reasonable. The panel agreed she had a contract with St. Anthony’s to pay “all charges of the hospital,” but that those charges were “the reasonable value of the goods and services provided,” not those set by the hospital’s chargemaster.

The jury awarded the hospital $766.74.

The hospital’s attorneys did a good job explaining how hospitals have to shoulder the burden for underpayments and nonpayment by other patients, Lavender said.

“They know they’re not going to collect from everybody,” he added. “But in the end, it just reveals how antiquated and nontransparent the system is, because nobody understands the bill.”

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