Vertical Integration Driving Costs Higher

medical-moneyA recent study in the State of Texas revealed that when health systems acquire physician practices, patient costs go up. The study was in response to a wave of consolidations across all facets of healthcare, from institutions to individual physician practices. Results showed that the share of physician practices owned by hospitals in Texas rose from 14% in 2012 to 29% in 2016.

When two years of claims data was analyzed, it showed that PPO members spent nearly 6% more when treated by doctors in hospital-owned practices, versus physician-owned practices. A breakdown revealed that higher costs were attributable to additional services being provided rather than higher fees. Higher costs for imaging, durable medical equipment and operating and recovery room use were common contributors, with no evidence of improved quality shown.

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Older Workers and Medicare

medicareIt’s doubtful that many technology companies are concerned about employees nearing age 65. Other employers, however, may want to brush up on Medicare eligibility in order to help older workers understand their options and avoid any potential gap in coverage. Here are just a few Medicare-related concerns:

  • For employees who will lose access to employer-sponsored group health coverage at age 65 or who choose to sign up for Medicare upon becoming eligible, the Initial Enrollment Period (IEP) is 3 months before to 3 months after the month they turn 65.
  • Medicare-eligible workers who leave employment with a retiree health plan or COBRA coverage are classified as “former workers” and therefore need to enroll in Medicare during their IEP.
  • Employees who have enrolled in Social Security before their 65th birthday will automatically be enrolled in Medicare Parts A and B. In order to avoid paying for 2 health plans, they may need to inform the Social Security Administration that they do not want Medicare Part B at this time.
  • Finally, for companies with fewer than 20 employees, Medicare becomes primary coverage. Workers and/or their spouses who are 65 or older must enroll in Medicare Parts A & B.

While employees must enroll in Medicare on their own, a little help from HR can go a long way. When questions about Medicare eligibility and enrollment arise, never hesitate to encourage a visit to a local Social Security Administration office or Medicare.gov.

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Surprise Bills

A survey of individual healthcare consumers shows that the lack of cost transparency is taking a big toll, with more than half of respondents saying they have passed on doctor visits or prescriptions because of cost. The vast majority of those foregoing treatment cite the cost of higher deductibles and copays as the top concern along with consistently rising prescription drug costs.

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Should Employers Care About Student Loans?

A Study by TIAA and the MIT Age Lab shows more than 44 million Americans account for some $1.5 trillion in outstanding student loans. Most borrowers are students, but surveys show that plenty of parents and family members are on the hook as well. While their circumstances vary, all are dealing with some level of financial stress.

Fortunately, an increasing number of employers are taking a more holistic view of wellness. And while most have long recognized the connection between stress and lost productivity, many are waking up to the fact that financial pressures are contributing to the stress.

Financial Education to the Rescue
SHRM says that to deal with the growing problem, more companies are enlisting the services of financial advisors. While counseling won’t directly attack their debt, it often helps families learn to cope with the problem. More large employers are allowing employees to convert a portion of their unused paid time off to debt reduction.

As an employer, anything you do to help will contribute to the overall financial well-being of your people. Just like other components of your wellness strategy, making employees more financially secure will enhance their overall quality of life while improving the culture and productivity of your organization.

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Moving Patients Can Be a Win-Win

From hospitals to insurers, you’ve probably heard many say that the goal is to provide the right healthcare, at the right time, in the right place. When it comes to the infusion of high-priced specialty drugs, location can make a huge difference. As an example, the variance in the cost of hospital-administered multiple sclerosis drugs can be staggering. One third party administrator saved a self-funded health plan more than $30,000 by moving a patient from a local hospital to a beautiful treatment facility in the Cayman Islands. The patient not only received their prescription in a beautiful, clean, state-of-the-art facility, but air travel and lodging were included.

Other cases compare the administration of specialty drugs in independent physician offices and patient’s homes rather than hospital outpatient settings. Savings ranged from $16,000 to $37,000 annually and the patient received the same level of personalized care without the hassle of a hospital visit. While the patient’s condition and circumstances always take precedence, finding a more appropriate location for treatment can make a positive difference for the plan and the patient.

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Using Social Media More

The Binary Foundation reports that more than half of surveyed adults have used social media networks to search for healthcare providers – a six-fold increase since 2017. More important, 75% of respondents were influenced by online ratings and reviews, with many calling these reviews somewhat or very reliable. Only 9 percent said they do not use online platforms when selecting a provider, compared to 48% in 2017.

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Can Chronic Disease Management Really Work?

healthWith the Centers for Disease Control and Prevention projecting that 83 million people will soon have three or more chronic diseases, the number of employers working to manage chronic conditions like diabetes, high blood pressure and coronary artery disease is staggering.

Not only do the average medical costs for a diabetic exceed $16,000 per year, but the loss of productivity is estimated to add an additional $1,700. How can your health plan cope?

Begin with Good Information
Reviewing claims data, diagnostic tests and prescription drug data is a critical starting point. Once plan members with chronic illnesses are identified, care managers, nurse navigators or health coaches can talk with them to learn about their lifestyle, ask about medications, nutrition, their family situation and other factors that may be impacting their condition.

Chronic disease management is not a one-step process. It involves partnering with a member’s physician and other professionals to understand the patient’s needs and develop a personalized care plan. This level of personal involvement will not only help the member receive the care they need but also help them better understand how to use their health plan to their benefit.

Experience shows that 80% of a company’s healthcare spend is often attributed to 20% of plan members. Chronic illness is likely the reason, making disease management a critical part of high-quality healthcare plans.
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Bundled Payments for “Baby Bundles”

Pregnant-WorkerAnother major insurance carrier has cooperated with selected healthcare providers in two states to introduce a bundled payment program for maternity care. Like bundled payment programs used by Medicare and commercial carriers for total joint replacement, the bundled maternity program reimburses the care provider for an entire episode of care, including prenatal, delivery and postpartum services, with one overall fee. Insurers are encouraged with the positive outcomes, citing early access to care and open lines of communication as significant advantages of this approach.

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More Large Employers Offer On-Site Clinics

Some mega-employers manage clinics on their own while others outsource to clinic vendors or healthcare systems. Many provide clinics within their own facilities, but some offer near-site locations and even share a near-site clinic with other companies. Regardless of which model is preferred, more organizations with 5,000 or more employees are deciding that on-site or near-site clinics can make primary care more convenient and affordable for everyone.

Some of these clinics offer pharmacy services and many have expanded to offer services such as physical therapy, telehealth and even behavioral health. One benefit that clinic operators often emphasize is that by making primary care convenient to employees, and in many cases their family members, fewer employees will neglect primary care because of cost or the inability to take time off to see a doctor.

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Is Direct Primary Care the Future?

A fee-based model that gives individuals unlimited access to a primary care physician without their insurance being billed is being heralded as the right prescription for healthcare. Most patient needs, such as consulting, tests, drugs and treatment are included, and no insurance billing is involved.

Sources estimate there are about 1,000 direct primary care practices in the continental United States. While most patients pay for the service out-of-pocket, more and more employers are choosing to offer this as a benefit and sharing in the cost.

TPAs and advisers supporting the trend caution that direct primary care is not a replacement for insurance, but rather a great supplement to an existing health plan. By removing the barrier of costly copays and deductibles, employees can forge a much closer relationship with their doctor, making them far less likely to choose a costly emergency room or urgent care clinic when the need for medical care arises. Direct primary care is an option that is growing and one we’d be happy to talk with you about at your convenience.

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