AmeriBen, the large-employer TPA who works with many Blue Cross plans around the country, hosts an annual management conference bringing together some of the most innovative unbundled large employers in the U.S. to discuss strategy and best practice. Because each of these employers has opted out of the traditional “ASO”—or bundled carrier—benefits insurance option, they are able to experiment with new vendors, plan designs, and approaches that are beyond the typical scope of benefits strategy. What follows are 10 of the most interesting topics discussed in the fall of 2015.
TEN: Eliminate Ineligible Members During Enrollment
Most employers are shocked to learn that 3-5% of their membership is ineligible for the plan. These ex-spouses, cousins, and aged-out children avoid detection and, according to Nucleus Research, cost about $3,500 each per year to your plan. The typical solution, an eligibility audit, is costly, time consuming, and disruptive. Benefit Focus, an enrollment vendor, recently published a breakthrough solution: require members to snapshot and upload documents proving marital status/age during enrollment.
NINE: Value Based Benefits for Engaged Disease Management Members
Disease Management helps chronically ill (and expensive) members become compliant with maintenance treatments. Unfortunately, it is famously difficult to engage these members, let alone contact them, with typical engagement rates falling in the single digits. Some employers are creating incentives for these members to engage with nurse managers, from waiving copays on prescription drugs, to reducing deductibles, to preferred plan designs, and are getting a great response.
Because the savings on telemedicine are so significant, most plans pay for the visits completely to incentivize use. The challenge is with high deductible plans, where 1st dollar coverage for traditional healthcare benefits is prohibited. Some legal circles have found justification for carving out the Telemedicine as a separate benefit, thus allowing the plan to provide blanket, fully paid coverage. (Warning: this strategy is controversial and most legal counselors will advise against it; we simply had a couple of large employers whose legal teams are comfortable with the strategy and find success with it).
SEVEN: Increase the Number of Pre-Certification Conditions
Quantum Health, an established market leader in member engagement, uses this strategy to have many more opportunities to engage the population and see what medical procedures are being purchased. When a provider calls in to certify a treatment, a plan can determine the medical necessity, in/out of network use, and the price and quality score of the provider. This gives the plan opportunity to make adjustments or ask necessary questions in follow-up calls to the member.
SIX: Triple High Deductible Health Plan Enrollment through Decision Engineering
Plans save around $2,000 for each member who buys a high deductible health plan, and because of this plans are eager to encourage adoption. Unfortunately, when a high deductible plan is introduced, the adoption rate is usually dismal. Benefit Focus, an exchange enrollment vendor, just published research suggesting that adoption rates for HDHPs triple when at least two options are presented instead of one (even if the difference between them is slight). With two options, it feels less like a novel plan and more like an established alternative.
FIVE: Identify Outlier Provision Thresholds and Add Them to Case Management Watch List
When large claim costs reach a certain threshold, the typical discount is not applied and a new contract provision changes the way the claim is paid. Frequently, these provisions multiply the amount due, making a large claim that much greater, to financially devastating effect. Savvy companies are discovering the most damaging outlier provisions within their network and managing around them to proactively avoid crossing these damaging thresholds.
FOUR: Using Smarter Narrow Networks
Traditional direct contract networks establish a strong discount with a single provider, but unfortunately, no single provider is high quality in every department. Furthermore, if a much lower cost provider might be available nearby, even the additional discount could result in a more costly procedure. Imagine Health, an innovator in the Narrow Network space, uses a breakthrough strategy to avoid these two pitfalls. By doing an RFP over a geographic region, they eliminate underperforming systems, departments, and providers on quality scores, and then transparently broadcast the competitive price of procedures and require RFP participants to perform 20% below average.
THREE: Integrate Members Into a Mobile Hub
The solution delivering the best results for a population does not come in a box, but is a coordinated effort of several best-in-class strategies. Unfortunately, this makes things confusing for members who don’t have time or attention devoted to learning the resources provided to them. The simplicity on the other side of this complexity is delivered by a new breed of technology that coordinates all vendors into a single application and interface. Jiff, the leader in this space, uses artificial intelligence to customize the interface for each member and deliver and incent solutions that matter to that individual. This solution dramatically improves member experience and boosts engagement as much as 200% or more for most vendors.
TWO: “Narrow Network” Your Specialty Drugs
Specialty drug costs are skyrocketing with year-over-year increases in the double digits. One strategy to help curb trend is to assign a “preferred” specialty drug in each major treatment category (where 2+ drug options are competing). This simple strategy can help get exclusively lower prices than what would otherwise be available through channeled volume and reduced competition for the seller of the drug.
NUMBER ONE: Stack a Virtual Narrow Network Atop an Existing PPO Network
Healthcare Bluebook is about to release a quality/price matrix on most impatient procedures that will allow consumers to compare high/med/low on quality next to high/med/low on cost for a full value calculation. A plan design that successfully encourages members to use this tool for decision making would essentially be able to place it atop any PPO network and reap huge rewards, without significant additional costs, contracts or negotiations. The impact to overall healthcare cost could quickly exceed 20% of medical spend.