Emerging Trends in Health Plans - IFEBP · medical billing, claims, appeals and health insurance...

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Emerging Trends in Health Plans

John R. PovinelliSenior Vice President, Benefits ConsultantSegal ConsultingPhoenix, Arizona

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Agenda

• What Brings Us Here?• Concierge Medicine• Reference Based Pricing• Patient Advocacy• Pharmacy Gifting—Specialty Medicine• Big Data (Data Analytics)• On-Site Clinics• Transgender Coverage• Telemedicine• Member Communications

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What Brings Us Here?

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9.7%9.5%

7.6% 7.5% 7.3%5.7% 6.5%

6.8%

7.8%

7.6%

9.4% 9.7% 8.3%

7.8%

8.4%

6.7%

7.6%

6.9% 8.0%7.5%

9.7%

10.2%

8.7%

8.0%

6.7%

6.1%

6.3%

6.4%6.8% 6.7%

7.7%

4.0%

3.6%

4.5%

3.0%

3.1%

1.9%

4.2%3.5%

4.4%

7.4%7.9%

6.4%

5.0%

5.5%

5.5%

10.7%

11.2% 11.3% 11.6%

5.5%4.7%

3.0%3.1%

2.6% 2.8% 2.9%

3.0%3.5%

4.1%

1%2%3%4%5%6%7%8%9%

10%11%12%

2008 2009 2010 2011 2012 2013 2014 2015 2016 2017PPO (without Rx) POS (without Rx) HMO (without Rx)2

Source: 2017 Segal Health Plan Cost Trend Survey1 All trends are illustrated for actives and retirees under age 65, except for MA HMOs.2 Prescription drug trend is combined for retail and mail order delivery channels

Ten-Year Summary of Selected Medical, Prescription Drug Carve-Out and Dental Trends:

2008 – 2015 Actual and 2016 and 2017 Projected1

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1. Participant out-of-pocket expenses

2. Tinkering with eligibility and contributions

3. Regional choices

4. Consolidation

5. Narrow networks and on-site clinics

6. Value Based Plan Designs

7. Value Based Provider Payments

8. Gradual expansion

9. Growth in remote medicine

Major Trends

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Plan Sponsors Will Adapt and Designs Will Change

• Employees place great value on health benefits

• Cost advantages under a self-insured funding• Innovative solutions to control spending• More choices • Efficient participant cost share• ACA modification

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What Brings us Here?

So What’s Next?• Maximized value, Minimize costs• Modify health care delivery using creative

solutions– Concierge Medicine– Reference Based Pricing– Patient Advocacy– Pharmacy Gifting—

Specialty Medicine– Big Data (Data Analytics)

• Communicate

– On-Site Clinics– Transgender Coverage– Telemedicine– Communications

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Concierge Medicine

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Concierge Medicine

What is Concierge Medicine?• A relationship between patient and physician • Patient pays physician directly • Services above normal office visit• Not considered insurance

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Fee for Care

Concierge Medicine

Three general categories:

1

Fee For Extra Care2

Hybrid3

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Concierge Medicine

• Average PCP has 2,500 patients• Concierge docs have fewer than 600 • Not part of annual medical

plan membership fee • Fees not reimbursed

under FSA or HSA

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Concierge Medicine

Why Concierge Medicine?• Remedy to more patients seeking care • More time with physician • VIP services• Reach your doctor 24/7• Coordinated care

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Concierge Medicine

So What’s Next?• This is not for everyone• Annual fees can be substantial• Differentiates “have” and “have nots” when it

comes to equality and care for all• Addresses member concerns regarding the ability

to buy-up to access• Communicate

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Reference Based Pricing

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Sponsors pay a fixed amount or limit contributions Savings come when

Providers accept reference based pricing1

Plan design requires patients pay the difference 2

Providers in community begin to reduce prices3

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• Increase in the volume of services • Vary widely in price and member can control • Does not work well for services patient has little

control over• Cost savings• Member education

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So What’s Next?• Identify price volatility in current utilization• Is there sufficient access to alternative providers?• Consider communications and understanding

– Substantial education– Small steps

• Communicate

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Patient Advocacy

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Patient Advocacy

• Understanding complex health conditions, medical billing, claims, appeals and health insurance

• Patient Advocate: – Find clinical research– Locate providers– Review billing– Negotiate fees– Pursue appeals– Schedule appointments– Coordinate senior care

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Patient Advocacy

• Can be family members or friends• Have popped up across the US• Integrate and employ utilization

management• How patient advocate

reimbursed?

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Patient Advocacy

So What’s Next?• Identify member’s ability to navigate the health

care system• Can you effectively teach them?• How much is that worth (benefit value)?• What do we insource, outsource, and educate?• Communicate

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Pharmacy Gifting

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Pharmacy Gifting

Helping financially needy patients purchase medications and supplies• May qualify for drug, diagnosis, and dosing• PBMs can assist with paperwork

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Pharmacy Gifting

Getting Help to Pay For Medication• With or without medical plan coverage • Average person is overwhelmed in drug expenses• Provider, patient require to complete an

application• Doctor's signature required

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Pharmacy Gifting

So What’s Next?• Identify pharmacy gifting program within your PBM

portfolio• Identify risks and rewards for the members and the

Trust• How does the program work?• What is required by the member?• Understanding is critical• Communicate

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Specialty Pharmacy

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Specialty Pharmacy

• Handles and services requirements of specialty drugs

• Provides Mechanism to manage specialty drugs• Products treating specific disease states

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Specialty Pharmacy

What is a “Specialty Drug”1

• High cost pharmaceuticals• Special administration requirements• Special handling• Special clinical support• Potential for significant waste

1 The Biopharmaceutical Pipeline: Evolving Science, Hope For Patients. January 2013.

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Specialty Pharmacy

• Increases are driven by:1

– Patient demand– Chronic conditions– Number of available treatments– New uses/FDA indications for existing drugs– Increasing cure rates– New discoveries by drug companies

Specialty Focus: Drug Spend Growth

1 UnitedHealth Center for Health Reform and Modernization. The Growth of Specialty Pharmacy Current Trends and Future Opportunities. 2014

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Specialty Pharmacy

• Minimizing the cost and maximizing care• Specialty solutions

– Channel management—Medical and retail strategies– Clinical treatment protocols or therapy management– Formulary or preferred step management– Network management

Specialty Focus: Drug Spend Growth

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Specialty Pharmacy

5%6%

3%5% 5%

14% 13%

18%19% 19%

0%

3%

6%

9%

12%

15%

18%

21%

2013 2014 2015 2016 2017

Prescription Drug(Rx) Carve Out* forActives and RetireesUnder Age 65

Projected SpecialtyDrug/Biotech

Prescription Drug Trends: 2013 through 2017

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So What’s Next?• How much do we spend on specialty drugs?• What is the rate of prescription drug increases and

specialty drug increases?• Are specialty programs readily available via your

PBM?• Evaluate member and financial impact—Prescriptions

over what thresholds?• Communicate

Specialty Pharmacy

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Big Data(Data Analytics)

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Big Data (Data Analytics)

• Large volume of health care data• Requires manipulation• Identify trends and patterns• Make predictions• Common components:

– Volume– Velocity– Variety

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• Efficiency and productivity • Generally less expensive• Can be manipulated and grouped • With high powered analytics

you can determine:– Root causes– Risks assumptions– Fraudulent behavior – Disease intervention

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• Financial management• Benefit design and network management• Medical and Rx quality adherence• Health and wellness program design• Regulations and compliance• Vendor performance and contract adherence

Analytic Capabilities

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So What’s Next?• How does my plan compare to others?• Where we lag, what are my alternatives?• Where are my opportunities to improve?• What market dynamics should I be prepared for?• Communicate

Taking Action With:• Plan design• Network (specific network providers)• Additional vendor partners• Communication• Utilization management tools

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On Site Clinics

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On Site Clinics

• Retail Clinics• Urgent Care Clinics• Primary Care Clinics

Range of Models/Options

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On Site Clinics

• Lower costs • Easier access to care and services• Patient Centered Medical Home• Clinic staff knows what the benefits are

Advantages to Membership

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On Site Clinics

• Located on campus • Care delivered by nurse practitioners with

physician oversight• Primary care often includes

basic care• Generic prescription

drug dispensing• Treats non-covered

for a small fee

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On Site Clinics

• Need 1,000 to break-even• Need 2,500 to achieve economies of scale• Membership located within 20 mile radius• Sensitive to local pricing • Largest cost is staffing• ROI* ranges from 1.5:1 to 4:1

* Actual ROI will vary and is dependent on many factors in a given employer’s situation.

On Site Economics

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On Site Clinics

So What’s Next?• Assessment of need

– Access to primary care and wellness– Facilitate efficient health care delivery

• Consider demographic opportunities and obstacles

• Final advantages and costs• Benefit value• Communicate

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Transgender Coverage


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Starting with the 2017 plan year, allow coverage for transgender

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So What’s Next?• Identify what is and what is not currently covered• Identify (covered entity) status and applicability• Obtain compliance council regarding what must be

covered and what might be required• Amend plan and adopt coverage guidelines• Notify TPA and PBM of coverage changes for

transgender services• Communicate

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Telemedicine

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Telemedicine

Telemedicine is the exchange of medical information using electronic communication

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Telemedicine

• Consultation takes place via phone, email or video call

• No appointment needed• Complements traditional healthcare• Concept is still evolving• Has appeal in remote

communities

What is it? How does it work?

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Telemedicine

Savings come in form of:• PCP office visits• Convenience of care• Urgent care• Steerable ER

Avoided Costs

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Telemedicine

• An important healthcare cost containment tool • AMA:

– 70% of office visits can be done over phone – 50% of ER visits are non-emergencies

Cost Savings to Plan Sponsors

Sources: Cigna – MD Live

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Telemedicine

• Needs assessment– Access– Current utilization

• Characteristics (opportunities for improvements)• Cost structure (likely member adoption?)• Consider partners

– Independent– Leverage existing vendor relationship

• Communicate, communicate, communicate

So What’s Next?

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Member Communications

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Some fundamentals:• Should be honest, direct, simple, clear• Don’t leave members in the dark• Be clear, and over communicate• Never insult a members’ intelligence

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• Inform• Educate• Ensure understanding• Recruit• Connect• Motivate• Retain

What You’re Trying To Do

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Integrate, Facilitate, Complement

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From your Home Screen to your Home Page in one touch.

One really simple thing . . .

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• Communicate on time and on point• When messages are difficult or complex—Break it down • Never forget to stress “What’s in it for me?”• You must know how to connect with your audience(s). If you don’t

know, find out.• Access

– Ongoing Availability– Time sensitive communication

• You create the message—You control the message• Know your objectives. Inform? Educate?

Drive action?• Don’t be afraid to “think outside the box.”

So What’s Next?

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Session #H09

Emerging Trends in Health Plans

• Costs continue to rise• There are many leading-edge

practices to address rising costs• Determine which of these

practices may work for your population

• Learn as much as you can about your members’ needs and where efficiencies can be embraced.

• Learn as much as you can about initiatives and implement with confidence

Website Resourceshttps://www.ifebp.org/inforequest/ifebp/0165821.pdf https://www.ifebp.org/inforequest/ifebp/0165163.pdf

62nd Annual Employee Benefits ConferenceNovember 13-16, 2016Orlando, Florida

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2017 Educational ProgramsHealth and Welfare

63rd Annual Employee Benefits Conference October 22-25, 2017 Las Vegas, Nevadawww.ifebp.org/usannual

Certificate SeriesFebruary 27-March 4, 2017 Lake Buena Vista (Orlando), FloridaJuly 24-29, 2017 Denver, Coloradowww.ifebp.org/certificateseries

Health Care Management ConferenceMay 1-3, 2017 New Orleans, Louisianawww.ifebp.org/healthcare

Certificate of Achievement in Public Plan Policy (CAPPP®)Part I and Part II, June 13-16, 2017 San Jose, CaliforniaPart II Only, October 21-22, 2017 Las Vegas, Nevadawww.ifebp.org/cappp

Related ReadingVisit one of the on-site Bookstore locations or see www.ifebp.org/bookstore for more books.

Self-Funding Health Benefit PlansItem #7563www.ifebp.org/SelfFunding

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Emerging Trends in Health Plans - IFEBP · medical billing, claims, appeals and health insurance...

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