Summary of The Alliance
Employer Benefits Roundtable
December 1, 2015
Table of Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Steerage and Medical Tourism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Value-based Insurance Design VBID/Wellness . . . . . . . . . . . . . . . . . . . 9
Telehealth/telemedicine and Onsite Clinics . . . . . . . . . . . . . . . . . . . . . . 14
Consumer-directed Health Plans and the Excise Tax . . . . . . . . . . . . . . 21
Prescription Medications Including Rx and Specialty Rx Tiers . . . . . . 27
Searching for more information on benefit plan design? . . . . . . . . . . 33
Introduction On December 1, 2015, approximately 60 employers, agents and industry professionals gathered at Monona Terrace to
discuss hot topics in benefit plan design.
Staff members from The Alliance facilitated 10 small group discussions and attendees shared their best practices,
concerns and questions. Following the small group discussions, highlights were shared with the larger group.
This event was the first roundtable discussion facilitated by The Alliance. The report is a synopsis of the notes gathered
from this event.
Five topics were discussed: steerage & medical tourism, value-based insurance design (VBID)/wellness,
telehealth/telemedicine & onsite clinics, consumer-directed health plans & the Excise Tax and prescription medications
including Rx & specialty Rx tiers. Each of the five topics discussed has been given a section, as noted in the table of
contents.
All of the notes generated for a topic were used to create the word cloud at the beginning of each section. The more
frequent a word appeared in the notes, the larger the size of the word in the word cloud. The word cloud is followed by
the discussion questions given to event attendees. Each section concludes with a synopsis of the notes generated
from the selected topic.
3
Steerage & Medical Tourism
4
Steerage & Medical Tourism What incentives does your company use to steer employees to specific health care providers
for specific services?
> Most, but not all of the employers represented at the roundtable discussion offer
steerage and medical tourism incentives.
> Examples of incentives based on steerage at the
point-of-decision.
MRI/diagnostic (incentive offered to employees to go to highest
quality/lowest cost providers) [Noted by four groups.]
Through QualityPath and promoting consumerism to steer toward
the highest quality/lowest cost providers
Having lab work done at a contracted laboratory facility instead of
at a hospital
Contracted providers for selected high-value procedures
(QualityPath program and other employer-sponsored programs)
Offer gift cards or offer no co-pay for prescriptions
> Employers want to learn more about steerage options
This topic is still very new to employers – would like more
education on this topic.
Need more information on plan design for steerage and
medical tourism.
Would like The Alliance to offer more steerage programs/expand
QualityPath
> Examples of incentives
based on steerage plan
design.
Offer services at preventive
service rates
Only use positive incentives
Increased employer
contributions $
Offer a contracted service for
second opinions
Steer toward your local area
and share the savings with your
employees
Offer $1,000 gift card incentive
Continued coverage for
complications
Medical tourism to providers
outside the United States
5
Steerage & Medical Tourism What barriers have you encountered when considering or implementing a steerage program?
> Employee barriers
Lack of consumer “caring” to participate
Challenges in communicating programs
effectively to employees
Limited time to spend educating
employees/consumers. Only have one hour
annually (open enrollment) to talk about
steerage. Explaining what is medical
consumerism and why it is important, takes 45
minutes of that hour.
Employees want to stay local for procedures.
Many are not comfortable with going to an
unfamiliar health care system.
Common for employees to want to keep
existing relationships with providers and not
transfer to a new one.
Employees are wary of medical steerage
directly from their employer. Medical steerage
requests mined from medical data, such as
patients with an osteoarthritis diagnosis, are
more favorably received by employees when
sent by The Alliance.
> Geographic location barriers
Employees are hesitant to travel out of their
regional area for health care. They typically
prefer to stay locally. [Noted by four groups.]
Employers and employees prefer to stay with
local providers. [Noted by several groups.]
Geography. Employees living outside of the
primary Alliance network. Employer’s
insurance contains multiple provider networks.
Want to support the local economy. And
employers want the local economy to support
them too.
> Coordination barriers
Complexity
Steerage at the correct time (point of decision)
Doctors sometimes discourage seeking other
medical providers outside of a doctor’s own
network.
6
Steerage & Medical Tourism Does your company offer a medical tourism option? If so, are your employees using it?
Why or why not?
> Many of the employers noted that they are enrolled in QualityPath
> Some employers have steerage programs to their own onsite clinics or specified
local providers
> One employer noted a medical tourism program they sponsored in Mexico
> Some employers noted that they do not currently sponsor steerage or medical
tourism programs
7
Steerage & Medical Tourism
Synopsis
> What kinds of incentives do you use?
Incentives based on steerage plan design
Incentives based on point-of-decision steerage
> What kinds of barriers have you encountered?
Employee barriers
Geographic location barriers
Coordination barriers
> Medical tourism examples.
Onsite clinics
QualityPath
One example of an international medical tourism
program in Mexico.
> Employers asked to learn more about
steerage & medical tourism and how to
better promote these programs to employees.
8
How do your health care benefits compare?
Contact Member Services at [email protected] or 800.223.4139 to request a benefits and coverage analysis report customized to your industry, geographic location or company size. A free benefit of your membership with The Alliance.
Value-based Insurance Design VBID/Wellness
9
Value-based Insurance Design VBID/Wellness If your company is using value-based insurance design (VBID), briefly describe what you’re
doing. (VBID is defined as differential coverage for evidence-based treatments and services
and/or steerage to high-value providers.)
> VBID is primarily used for
disease management
Individuals with multiple
health factors are identified
as potentials for company-
designed VBID coverage
Use to manage chronic
conditions
Use to steer to local hospital
No cost sharing for
maintenance meds/chronic
conditions
Disease management
program = free/low-cost
prescription medications
Value-based care for chronic
conditions – based on
population’s need –
preventative maintenance
rather than expensive crises.
> Wellness programs include …
Biometric screenings tied to premium reduction. [Noted by three groups.]
Wellness programs are becoming more outcomes-based
Offer $ for wellness participation, health status
No monetary incentive. Individual health coaching.
Workplace wellness champions
Activity-based wellness
Farm to table incentive
> VBID/wellness insights
Most of the employers at the roundtable event have some type of
VBID/wellness program integrated into their plan, but not all. Many are
struggling to make VBID work most effectively for their population.
Need clear communications/education to explain why VBID/wellness is
beneficial.
Employees can lose sight of benefit when it is monthly reduction in
premiums. Consider cash.
How to best integrate VBID/wellness for the entire family? Spouses can
sometimes be the most expensive on plan.
10
Value-based Insurance Design VBID/Wellness How do you think VBID could help your company manage chronic conditions?
> Weight loss
> Early detection from regular physicals
> Company/culture sponsorship
> Provide a consistent message/plan
> Proper incentives
> Self-funded realizes largest gains
> Adherence to meds
> Increased engagement & Rx compliance
> Incentives increase participation
> Educate/early identification
> Cost savings, but difficult to quantify the ROI
> Healthier workforce – reduced absenteeism
> One-on-one nurse available for
personal education
> Onsite options work well
> Providing incentives for employees to
use quality providers at a good price
> Increase employee health
> Outcome-based to increase productivity
> Steer employees and inform them of
resources for their chronic conditions
> Encourage employee to look at other
resources too (community services)
> Discount, don’t increase cost
> Should be voluntary
> Designed for employees and spouses
11
Value-based Insurance Design VBID/Wellness What are the barriers to VBID/Wellness adoption at your company?
> Education of employees,
leadership team or both
Education to employer & employee
Not at right time
Employer lack of understanding
what does it look like/new concept
Education “too much info” (EE)
Adherence
Lack of buy in from the company
and employees
Difficult to convince leadership
EEOC, Communication, employee
buy-in
Employees think you are getting
too involved in their health care
“Big brother”
Perception of being singled out.
> Employee motivation
People don’t want to be told what they should do or not
do to be healthy = “pay me and I will contribute”
People don’t want you involved. Heath care is personal.
Tied to their PCP
Personal issues
Motivation
> Complexity of program
Overwhelming number of options with limited resources
and time
Incentives are more complex with HDHP.
High turnover employers
Multiple locations & consistency
> Medical Costs
Rapid changes in costs
ROI calculations
12
Synopsis
> How are employers using value-based insurance design
(VBID)/wellness?
Used primarily for disease management.
Wellness programs can include a variety of options, but biometric screenings
are the most popular.
Most of the employers noted that they have a VBID program in place,
but are struggling to make VBID more effective for their population.
> How could VBID help your company manage chronic conditions?
Give incentives for participation
Early identification before problems become chronic
Education/communication to explain what the terms VBID and wellness mean
and why they are important
Emphasis on evolving VBID offerings to be “outcomes-based”.
> What are the barriers to VBID/wellness adoption at your company?
Education of employees, leadership team or both
Employee motivation
Complexity of program
Medical costs
Value-based Insurance Design VBID/Wellness
How do your health care benefits compare?
Contact Member Services at [email protected] or 800.223.4139 to request a benefits and coverage analysis report customized to your industry, geographic location or company size. A free benefit of your membership with The Alliance.
13
Telehealth/Telemedicine & Onsite Clinics
14
Telehealth/Telemedicine & Onsite Clinics How do you offer telehealth/telemedicine and/or onsite clinics to your employees?
> Company A covers telemedicine at 100%, they use Teladoc and love it.
> Company B does not currently offer telemedicine, but is looking into it. They tried to obtain
telemedicine through their nurse practitioners via their onsite clinics, but ran into licensing issues
between states. However, they do offer virtual visits through their onsite clinics.
> Company C offers telemedicine consultations for a $5 co-pay, 24/7, no limit on number of visits,
and payment is made by credit card.
> Agent A has a client that uses telehealth: $20 co-pay and an annual limit of three visits.
> Company D uses Amwell for telehealth services.
> Company E uses Virtualwell for telehealth services.
> Company F offers telemedicine visits using Amwell for a $5 co-pay.
> Company G uses a nurse helpline through their pre-authorization company.
> Company H offers health coaching outreach to patients with high-cost potential.
> Company I uses Teladoc and United Health Care for telemedicine visits (via phone or video) for a
$10 co-pay. They have also added a behavioral health option to their telemedicine plan.
> Company J uses a nurse line and Teladoc
> Company K currently has a nurse line. They cancelled Teladoc due to low participation rate.
> In 2015, 11 percent of Alliance members offered onsite clinics.
15
Telehealth/Telemedicine & Onsite Clinics What kinds of benefits are there to offering telehealth/telemedicine and/or onsite clinic options?
> Convenience/efficient use of resources
No driving to doctor’s office
Better access to health care, especially in rural areas
Avoid urgent care/ER visits – avoid long waits for patients
> Lower cost for both employees and employers
> Reducing the barrier of waiting time and/or appointments empowers employees to talk to a primary care provider
sooner. Otherwise they may defer making an appointment and a small problem turns into a big problem – with big
medical bills.
> Save time and money
> Reduced absences
Reduced sick days/PTO
> ROI
Increase health plan quality
16
Telehealth/Telemedicine & Onsite Clinics What kinds of challenges do you see to offering telehealth/telemedicine
and/or onsite clinic options?
> Patient experience
PCP Relationship
Loss of personalization with doctor
Consistent medical staff, turnover and people management
Skeptical of true evaluation of symptoms
Overall understanding of medical analysis
Several times resulted in additional doctor visits
> Plan design/location
Disease management
Fill gaps
Choice
Better in a larger metropolitan area
Conflict with steerage to clinic
> Cost
Initial investment/cost
Bending to the trend of costs
No differential in cost
17
Telehealth/Telemedicine & Onsite Clinics Tell us about your onsite clinic?
> Company A offers an onsite clinic at all of their locations. The clinics are only open
for selected hours, this is their way to get employees in. (Getting people enrolled is
hard due to a generational gap.)
> Many employees at company B do not have a Primary Care Provider. This is
thought to be why company B has seen such success with their onsite clinics.
They allow all employees, spouses and dependents (8 to 26 years old) to access
the onsite clinics. They do this to increase utilization to show their c-suite that
people are using it. (You have to have insurance to use the clinic, not necessarily
through the employer. And all services at this clinic are at no cost.)
> Company C would like to create an onsite clinic.
> Reasons why we do not have an onsite clinic
Population too small. We can’t afford an onsite clinic.
Too difficult to offer an onsite clinic with hours available to all shifts at all locations.
Costs and liability issues are too high.
Cost to build an onsite clinic would be higher than the savings.
Not sure about short-term and long-term ROI. 18
Telehealth/Telemedicine & Onsite Clinics How likely are you to offer telehealth/telemedicine and/or onsite clinic options within the
next two years.
1 of 3 Approximately one of three
roundtable attendees …
• Currently offer telehealth/telemedicine and/or an onsite clinic or are highly considering adding this to their plan design.
• Are somewhat interested in adding telehealth/telemedicine and/or an onsite clinic to their plan design.
• Have low or no interest in adding telehealth/telemedicine and/or an onsite clinic to their plan design.
19
Telehealth/Telemedicine & Onsite Clinics Synopsis
> Telehealth/telemedicine and/or
onsite clinics plan examples.
Telemedicine visit examples were given
with co-pays ranging from $0 to $20 per
visit.
In 2015, 11 percent of Alliance members
offered onsite clinics.
> What are the benefits?
Convenience/efficient use of resources
Lower cost for both employees and
employers
Reduced absences
ROI
> What are the challenges?
Patient experience
Plan design/location
Cost
> Experience with onsite clinics?
Employers with onsite clinics have experienced
challenges. However, once employees are educated about
how and why to use an onsite clinic, usage has increased
dramatically and for one employer has reduced urgent
care/emergency room charges due to the fact that many
employees had previously not had a designated PCP.
> Employers are split about offering
telehealth/telemedicine and/or onsite clinics.
Employers surveyed at the event encompassed a range of
thoughts on this subject from high interest to no interest.
20
How do your health care benefits compare?
Contact Member Services at [email protected] or 800.223.4139 to request a benefits and coverage analysis report customized to your industry, geographic location or company size. A free benefit of your membership with The Alliance.
Consumer-directed Health Plans & The Excise Tax
21
Consumer-directed Health Plans & The Excise Tax Does your company currently offer a consumer-directed health plan (defined as a high-
deductible health plan with a health savings account)? If so, what do you offer? If not, why not?
> Approximately two out of three employers at the roundtable event currently offer at least
one high-deductible health plan (HDHP) with a health savings account (HSA)
> Structure of consumer-directed health plans differ by industry and by company
> Employers view consumer-directed health plans as an opportunity to …
Offer insurance at a lower premium.
Educate about health care consumerism.
Encourage employees to take an active role in their health care.
> Barriers to offering a consumer-directed health plan ….
Onsite clinic offering HSA complicates patient cost sharing
Too complicated
Difficult to kick start this
22
Consumer-directed Health Plans & The Excise Tax What role will consumer-directed health plans play in helping you minimize or eliminate your
exposure to the excise tax?
> More HDHP plan options
> Higher deductibles
> Create an educational opportunity to become a better health care consumer Consumers need to understand why it is beneficial to them to take an active role in their health care choices
Explain how much health care costs
Explain what quality data is available and how to use it effectively
Empower consumers to ask questions and make conscious choices
Have a full understanding of the parameters of the plan and changes for the new plan year
> Steer consumers toward more effective health care choices Switching from brand name to generic drugs where possible
Reduce unnecessary emergency room visits
MRI options
Use insurance cost calculators to estimate the cost before scheduling a procedure
23
Consumer-directed Health Plans & The Excise Tax What are your main concerns about offering a consumer-directed health plan?
> Employee education and creating a culture of health care consumerism
How to best educate employees?
Complexity of plan impacts adoption
Technology can be a barrier
> How to design a better health plan for the future
Embedded deductibles, flexible spending account (FSA), health reimbursement account (HRA), health spending
account (HSA), flex plan ... lots of choices.
> Uncertainties about the changing landscape of the ACA
Too many unknowns
Excise tax “not real” until it happens
> What if …?
Maximum out of pocket reached and they run the bill up?
How do we keep health care providers accountable?
Employees trust in their provider for health care information more than their employer?
> Onsite clinics work well for some companies. But are they a good fit for your workplace?
24
Consumer-directed Health Plans & The Excise Tax What other steps are you taking to prepare for the excise tax?
> Many are waiting for outcome of next election
> Ongoing employee communication
> Education
> Monitoring their report from their broker
> Incremental changes
> Excise tax analysis
> Determining the total cost since they have onsite clinics
25
Consumer-directed Health Plans & The Excise Tax Synopsis
> Approximately two out of three employers at the roundtable event currently offer at least
one high-deductible health plan (HDHP) with a health savings account (HSA).
> How will consumer-directed health plans help minimize/eliminate exposure to the excise tax?
There will be more HDHP plan options
Higher deductibles
Create an educational opportunity to become a better health care consumer
Steer consumers toward more effective health care choices
26
> Main concerns about offering a consumer-directed health plan
Employee education and creating a culture of health care consumerism
How to design a better health plan for the future
The changing landscape of the ACA
Coordination between employer, employee and providers to obtain a
better quality of care at a more cost-efficient price
Should we consider an onsite clinic?
> Employers are preparing for the excise tax in a variety of ways, but
the ACA landscape is constantly changing. We need more
information as employers and we need to educate our employees.
How do your health care benefits compare?
Contact Member Services at [email protected] or 800.223.4139 to request a benefits and coverage analysis report customized to your industry, geographic location or company size. A free benefit of your membership with The Alliance.
Prescription Medications Including Rx & Specialty Rx Tiers
27
Prescription Medications Including Rx & Specialty Rx Tiers On a scale of 1 (lowest) to 5 (highest), how concerned are you about the impact of
prescription drug price increases on the total cost of care?
2 of 3 Approximately two of three attendees rated their concern about the impact of
prescription drug price increases as a five on a five-point scale.
1 of 3 Approximately one out of three attendees rated their concern about the impact of
prescription drug price increases as a four on a five-point scale.
28
Prescription Medications Including Rx & Specialty Rx Tiers Does your company’s prescription medication benefit currently use tiers to determine the level
of coverage for particular types of medication? If so, do you have best practices to share?
> Many
employers
reported
offering
three, four,
or more
tiers of
prescription
coverage.
> Mail order
has been an
opportunity
to lower
prescription
costs.
Providing incentives for mail order
Providing incentive adherence
Max out-of-pocket for maintenance co-pay
Initial fill only 5, then rest if patient can
continue
Low generic co-pay to drive utilization
Using Navitus – consumer driven
Collaboration (Employee, employer, drug
manufacturer)
Case management to assist with coaching
(not condition specific)
Traditional – keep to step therapy
User PBM
VB – zero co-pay
3 tier: $10 generics, 30% brand names,
30% formulary with prior approval
4 tier: $5 generics, $45 preferred brand,
> Best practices shared … Company A added specialty pharmacy to their
plan in 2015, due to the high cost of Humira
Company B uses BidRx, an online service. Enter
your prescription and pharmacies bid on filling
your prescription. Some medications are free.
This allows transparency in pharmacy costs.
Company C pays for a percentage (co-insurance
fee) instead of charging a flat co-pay.
Company D offers a 30 percent co-pay up to a
maximum of $300/month. Maximums are a real
concern for specialty Rxs.
Company E offers a 20 percent co-pay – up to
50K paid at 100 percent.
Company F splits generics into two tiers for cost,
$10 & $30 (may exclude some drugs)
Company G educates employees on max
$1,000/individual and being good stewards (e.g.
injections in doctor’s offices)
Four tiers – specialty only by mail order, incent
mail order for three- month supply
29
Prescription Medications Including Rx & Specialty Rx Tiers Have you addressed specialty medication costs? If yes, how have you done so? If not,
do you plan to do soon? What steps do you plan to take? Will tiers play a role?
> Step therapy [Noted by multiple groups.]
> Mail order only if appropriate [Noted by multiple groups.]
> Partially fill an initial specialty prescription to ensure
no negative reaction [Noted by multiple groups.]
> In own tier with different cost sharing
> Authorization
> Mandatory therapy
> White bag vs. brown bag (liability issues – concerns)
> Change to co-insurance with a cap
> Program to manage distribution, $, alternatives
> Narrow network – may or
may not work
> Condition management
> Prior authorization
> Working with pharmacy
benefit manager to review
specialty medications
> Navitus trying to secure
discounts with pharmacy
providers
> CVS – Caremark, direct
nurses assigned
30
Prescription Medications Including Rx & Specialty Rx Tiers How have employees responded to the use of tiers? Can you share any communication tips?
> Concerns shared included …
Employees think they have to go against the doctor’s orders.
Huge majority of employees use generic drugs to save costs. What more can we do?
31
Prescription Medications Including Rx & Specialty Rx Tiers Synopsis
> All of the employers surveyed rated their concern about the impact of prescription
drug price increases as either a four or a five on a five-point scale.
> Many employers reported using three, four, or more tiers for prescription prices.
> Employers are taking a variety of steps to address the steep rise in specialty
medication costs.
> Employers had more concerns than communication tips.
> Employers are looking for more information, education and guidance about benefit
plan design for prescription medications.
32
How do your health care benefits compare?
Contact Member Services at [email protected] or 800.223.4139 to request a benefits and coverage analysis report customized to your industry, geographic location or company size. A free benefit of your membership with The Alliance.
Searching for more information on benefit plan design?
33
> Download our 2015 Alliance Summary of Benefits and Coverage Analysis at: http://www.the-alliance.org/uploadedFiles/Members/Products/2015_The_Alliance_Summary_of_Benefits_and_Coverage_Analysis.pdf
> Contact Member Services at [email protected] or 800.223.4139 to request your
free benefits and coverage analysis report customized to your industry, geographic
location or company size. This benefit is only available to members of The Alliance.
Request yours today and see how your benefit plan compares to those of your peers.
> Visit our events page and sign-up for our next Alliance Learning Circle:
http://www.the-alliance.org/members/events/.