Ask an independent TPA what sets their business apart and you’ll likely hear something about customer service and a promise to always put their client’s health plan and its members first. Seldom have these qualities been more meaningful than during the uncertainty of the past few months.
Fortunately, self-funding provides the flexibility employers have needed throughout this crisis. By collaborating with broker partners and other colleagues, TPAs have worked to make plan design changes that lower costs while exploring ways to keep coverage in force for as many employees as possible. Unfortunately, most have been involved in the difficult decisions employers have had to make in order to sustain quarantines, stay-at-home orders and extended closures. Their team members have worked tirelessly to help members access non-emergency medical care while avoiding the risks related to the coronavirus.
In addition to addressing health benefit concerns, TPAs have demonstrated great empathy in encounters with employers, members and providers. While the majority of self-funded health plans offer a telehealth benefit, some groups have been slow to engage with this service. With many organizations working remotely during the pandemic, however, the number of virtual visits has increased significantly.
TPAs have helped many patients avoid visits to the ER by directing them to alternative care settings. Some in need of treatment for chronic illnesses have been directed to high-quality, lower-cost providers rather than traditional facilities and, in some cases, treatment has been administered in the home. Searching for solutions takes a tremendous amount of time and coordination but being an advocate for members is nothing new for TPAs.
Health benefits are complicated for everyone. In times of disruption, plan sponsors and members need every possible tool at their disposal. Self-funding offers manyvaluable tools. When backed by expert administration and open communication, these tools can help health plans build trust and take great care of employees.
Uninsured people needing medical treatment for the coronavirus will be able to get that treatment without concerns about out-of-pocket costs or unexpected charges. Thanks to the federal stimulus package passed by Congress in early April, hospitals and healthcare providers that treat these folks will be paid for unreimbursed care at current Medicare rates.
While the law does not require that health insurance carriers and employer-sponsored health plans waive cost-sharing charges such as deductibles and coinsurance for coronavirus patients requiring medical treatment, many groups are pushing for this relief. In response, some large insurance carriers and health plans have said they would waive out-of-pocket costs for in-network COVID-treatment through the end of May. Pressure for this relief is expected to mount as shutdowns of non-essential businesses continue and more and more workers are laid off or furloughed.
Relief for HDHPs and HSAs
In another emergency ruling, the IRS said that HSA users with high deductible health plan coverage can use their coverage to pay for testing for SARS-CoV-2, the virus that causes COVID-19 pneumonia, without having to be concerned about satisfying the minimum deductible requirements common to HSA coverage. The same flexibility will now also apply to HSA account holders who need to use their coverage to pay for treatment of COVID-19 pneumonia. The IRS has cautioned that this guidance only applies to the COVID-19 emergency and does not void the other requirements governing High Deductible Health Plans and Health Savings Accounts. Since regulations and requirements regarding benefits for COVID-19 continue to evolve rapidly, plan members are advised to consult their health plan before seeking testing or treatment.
A recent survey by a data analytics firm found that benefits objectives often vary based on company size. Results showed that while smaller companies were focused on increasing employee productivity, mid-range employers were more concerned with employee satisfaction levels. Very large employers identified employee health and well-being as their main objective.
One interesting finding was that regardless of objectives, a high percentage of employers expressed concern that their health benefits were falling behind those of industry peers. If you share that concern, be aware that even though expectations vary by industry and workforce demographics, the days of doing things because “that’s the way we’ve always done it” are over.
Stay Open to New Ideas
Top workplaces are committed to innovation in every part of their operation and health benefits are no exception. By self-funding, most use claims data to respond to member needs and take advantage of new opportunities. Health concierge services, price transparency tools, bundled pricing and the trend to low or no deductibles and copays are just a few of the ways health plans are innovating to rein in rising costs and help employees get the care they need – important objectives of a high quality health plan.
Whether you refer to it as Reference Based Pricing, Medicare Reference, Cost Plus or something else, the important thing is to understand what it is and why it’s being used to lower health plan costs.
Health plans with reference based pricing provide high quality coverage at a lower cost by using Medicare fee schedules as a base. Then they negotiate with hospitals and physicians to determine an acceptable percentage margin over and above Medicare. Margins often fall within a range of 25% to 65%. The absence of PPO networks takes many of the “unknowns” out of play. Rather than operating at the mercy of networks that traditionally save their largest discounts for the largest health plans, reference based pricing takes the mystery out of network discounts by fixing fees for covered services. In addition to lower out-of-pocket expenses, members also gain the flexibility they need to search for a physician that meets their needs rather than settling for a smaller network in order to save on out-of-pocket expenses.
Experience Makes the Difference
Administration is always important when a health plan is self-funded. But reference based pricing requires much more than claims administration. Supporting a health plan with reference based pricing requires a TPA with the skills to make providers comfortable with this form of reimbursement and the resources to protect the plan against issues such as balance billing.
Many employers fear reference based pricing because of balance billing, which can occur when the established fee does not pay a provider’s bill in full and the provider chooses to bill the unpaid balance to the member directly. Even though resourceful TPAs point out that concerns about balance billing are often overblown, they typically integrate measures to protect members against it. In most cases, these include adding the services of attorneys or consultants to enforce the terms of the reimbursement agreement or negotiate a payment settlement with hospitals that may not be subject to negotiated reimbursement rates.
Experienced TPAs know that the competitive landscape for providers can often determine the potential for referenced based pricing in a given community. While it may not be appropriate for all employer groups, the ability to control future healthcare costs certainly makes it worth exploring.
Communication and helping plan members get the most out of their health plan should be an all year round endeavor. Surveys continue to indicate that even highly educated employees describe benefits, insurance and the enrollment process as “very confusing.”
Consider academic research by the Commonwealth Fund and a recent study by Accenture. While one points to higher deductibles and co-pays as the leading financial barrier to medical care, the other cites low health literacy as a hidden cost adding billions in administrative expense to our healthcare system. While it may never be possible for your plan to do away with co-pays and deductibles, high performance TPAs are doing many things to help plan members make more informed healthcare decisions. Here are a few ideas.
1. Simplify Summary Plan Descriptions – Remember that these are more than compliance documents. They are communication pieces and need to be written so that regular people can read them. Make it easy for employees to find information on eligibility, how they enroll, what the plan covers, what isn’t covered and how to file a claim. Move as much legal information as humanly possible to the end.
2. Put an End to Boring Content – To make things easier on the eyes and draw attention to information people care about, use different kinds of headings and add visuals or infographics to any benefit-related communications. Include links to your TPA’s website or other websites that employees can learn from. You don’t need a Hollywood producer to use video clips and after all, video is pretty much all that younger people look at these days. Seriously!
3. Create a Decision Support Taskforce – It sounds challenging, but look outside HR to recruit a team of individuals who feel comfortable with your health plan and healthcare in general. Let people know they can reach out to these individuals with questions about plan options, coverage, how to file a claim, provider networks, etc. People will appreciate this, especially your younger employees, who studies show are particularly confused and stressed over everything insurance related.
Improving your communications can make people feel much more confident about the decisions they have to make. You don’t have to tackle everything at once and even a little progress will improve morale and help people avoid making decisions they may regret later.
The Centers for Medicare and Medicaid Services project that the $3.6 trillion our nation spent on healthcare in 2018 could approach $6 trillion by 2027. If that number has you wondering how your health plan (and our economy) can possibly survive such an increase, you’re certainly not alone.
Fortunately, you and your employees have an employer-sponsored health plan to depend on. And if your plan is self-funded like most, you have the freedom to determine how best to spend your healthcare dollars and the flexibility to respond to member’s needs. So rather than worrying about things that are out of your control, let’s look at steps others are taking to get more bang for their benefits buck.
Health Savings Accounts have become a must for employers pushing high deductible health plans. Contributing $500 or more to HSAs softens the impact of higher deductibles, and helps plan members cover out-of-pocket expenses and save for future healthcare expenses.
Covering the cost of Preventive Drugs at 100% is another option to consider. More and more employers are finding that waiving these copays can help speed recoveries and avoid some serious health problems that can cost everyone more down the road.
More Personalized Communication is the only way to deal with the reality that even with the availability of web portals, mobile apps and online transparency tools, health benefits are complex and confusing. Employers simply must do more to help members find out about their health benefits and understand them better. A public facing website could be a great way to not only explain your offerings to members, but also help to attract and retain qualified talent.
Direct Primary Care and requiring the use of Alternative Sites of Care for certain high-cost surgeries or second opinions are also discussed in this newsletter. TPAs have been recommending these strategies to many self-funded health plans in recent years and both are beginning to show positive results, depending on the makeup of the employee population.
Reference Based Pricing and Worksite Wellness programs are options we have discussed at length in recent years and both can be extremely effective. To learn more about these options and for other ideas you may want to place on your radar screen, contact your account representative. Spring is the perfect time to start thinking about next year!
With unemployment for college-educated people age 25 and above at just 2.2%, it’s been a long time since we’ve seen a jobs market this tight. To attract and retain workers in this environment, growing companies are offering more than just competitive health benefits, and this is especially true for smaller companies forced to compete with larger companies.
Executive search firms have shared examples of employers going above and beyond their health plan by offering additional compensation to cover a candidate’s projected out-of-pocket medical expenses going forward. Technology-related firms in competitive markets are adding wellness benefits like on-site clinics or pre-arranged access to nearby fitness centers. For early to mid-career employees, companies are expanding their family leave or flex-time policies to provide easier transitions for young parents returning to work.
Flexibility and More
Whether it be more paid time off or arranging your work day to meet outside demands on your time, flexibility is becoming increasingly important, especially when you’re dealing with millennials or X-ers. Equally important to young workers is the culture present at an organization and the opportunity to make a difference – to know that what they are doing is helping their community or the world at large.
From unique apprenticeship programs at manufacturing and industrial companies to help with retiring outstanding student debt, more employers are looking for creative ways to gain an edge that will appeal to qualified, prospective employees. In a really tight job market, it pays to be creative.
You might be surprised to hear that millennials represent one third of the American workforce, but Pew Research Center confirms it. If your health benefit plan hasn’t adapted to the needs and lifestyles of these young people, you’re missing an opportunity to boost retention, build loyalty and enhance wellness.
For starters, it’s important to realize that 45% of young adults age 18 to 29 do not have a primary care doctor. They do, however, have a smartphone and you can bet they use it to access the internet constantly. With online sources like WebMD offering so much healthcare information, it’s no wonder that millennials are likely to self-diagnose and even treat one another at home before seeing a doctor. If young people can find much of the healthcare information they need in the palm of their hand, you can bet they expect to find benefits and enrollment information easily accessible as well.
They Want Information Now
Just like so many of us who have come to expect an immediate response to everything, millennials who do need a doctor expect the visit to happen quickly and easily. According to PNC Healthcare, this explains why 34% of millennials prefer to use a retail clinic rather than waiting several days to see a primary care physician in their office – a rate twice as high as baby boomers. It would also seem to point to an increased use of telemedicine.
Cost Matters to Millennials
Millennials face more than their fair share of financial pressures and take their finances seriously. Surveys show they are more willing to request a cost estimate prior to choosing a treatment option than baby boomers or seniors ever were. This not only makes cost transparency tools important, but it’s a very positive trend that should contribute to lower claim costs going forward.
Whether it be treatment options, provider access or cost of care, the demand for health and benefit plan information will only increase as more and more millennials enter the workforce. In order to respond to change, self-funded employer groups will need the resources of an independent TPA that can combine the right plan design with more personalized, interactive communications and more innovative ways for younger employees to access the more personalized care they will need going forward.
In late June, the Department of Labor introduced final rules on Association Health Plans (AHP), which will allow bonafide associations to offer healthcare plans to member companies. While we had hoped for a different approach to regulating these plans, association health plans will be regulated by states as MEWAs.
According to the final rules, an association that wants to establish a healthcare plan must already exist for another purpose. In other words, an association cannot be formed for the exclusive purpose of offering healthcare plans to its members. Another stipulation is that new self-funded association health plans cannot be established until April 1, 2019.
Association Health Plans will be exempt from the federal mandate on essential health benefits, but will remain consistent with popular Obamacare rules such as coverage of pre-existing conditions and bans on lifetime limits.
While reserve requirements will vary from state to state, we expect that these plans will be quite costly to establish and closely monitored by state regulators. Nonetheless, for large associations with significant cash reserves, we expect this option to make it possible for thousands of small businesses to lower their cost of employee health benefits.
With time running out on an opportunity for Congress to repeal and replace the Affordable Care Act and open enrollment season approaching, thousands of small and mid-sized businesses are likely bracing for another round of premium increases. A growing number of employers, however, will choose to avoid the uncertainty plaguing traditional group insurance markets by moving to a self-funded health plan – an option that provides an opportunity for savings and far more plan design flexibility.
Healthcare benefits continue to be perhaps the biggest obstacle facing small and mid-sized businesses. The Self Insurance Institute of America reports that between 2011 and 2016, the average annual deductible for employer-sponsored plans increased by 49% and the percentage of firms with fewer than 200 employees still providing health benefits fell from 68% in 2010 to 55% in 2016.
Self-funding on the other hand, has proven to be a far more responsible alternative for employers, enabling thousands to not only use their health benefit plan to attract and retain high quality employees, but to do so at an affordable cost. While self-funding has long been a staple for the nation’s largest employers, nearly a third of companies with 200 or more employees now offer at least one self-funded option.
Everyone Benefits from Flexibility
There are many reasons for the growth of self-funding, with flexibility and access to valuable claims data high on the list. Since self-funded plans are governed by ERISA, they avoid many of the costly mandates governing fully insured plans. To manage risk, stop loss coverage is obtained to cover claims that exceed anticipated levels. If claims are below anticipated levels, the plan retains the savings that would have been paid to an insurance carrier in the form of non-refundable premiums. Benefits can be customized to meet the unique needs of the group. When an independent TPA is engaged to administer the plan, claims data can be analyzed to identify chronic conditions and other key cost drivers. Services such as telemedicine and mobile transparency tools can be added to make physician access more convenient and more affordable. From plan design to data analysis, everyone benefits from the flexibility that a self-funded plan can provide. It’s the biggest reason why more small and mid-sized companies continue to move to self-funding with help from an independent TPA.