MargaretAnn Cross

Very effective if used properly, these panels are not yet widespread. However, that could change as industrial customers demand more input.

MargaretAnn Cross

Whether you're the physician administrator for a large group practice or the CEO of a multihospital health system, when dozens of letters from large employers begin to cross your desk asking you to reopen negotiations with a managed care plan, you're likely to listen.

That's the thinking of a coalition of businesses working with Aetna. The employers want to make sure that Aetna and providers work out their differences so that the networks of doctors and hospitals their employees use remain stable.

"If you end up sending 50 to 70 letters, providers are going to pay attention," says Darrell Sawyer, manager of benefits administration at Smurfit-Stone Container, a packaging manufacturer based in Chicago.

Sawyer is a member of the executive committee of the Aetna Customer Advisory Group, an independent organization made up mostly of human resources professionals from about 90 companies that contract with Aetna. The group meets twice a year with Aetna executives, and the letter-writing effort, which companies take on when Aetna's negotiations with doctors and hospitals stall, is one example of how they work together.

Employer representatives on Aetna's panel and other health plan advisory boards also are offering their help, ideas, and opinions on insurers' ventures into disease management, technology expenditures, new product development, and more. By participating, employers get access to top health plan executives, early news as to what the company is up to, and the chance to learn from other employers. For their part, managed care organizations gain a direct line of communication with the companies that purchase their products.

"It is very expensive to win and lose customers, so it's smart business for insurers to listen to these groups," says Linda Havlin, a Chicago-based partner with Mercer Human Resources Consulting.

Employer advisory panels aren't widespread, but their numbers are likely to grow, Havlin contends. "These groups can be very effective if they are used appropriately. And, it's a message from the health plan that says, 'We continually want to get customer input as to how to best serve client and employee needs.'"

Closer cooperation

Business leaders would welcome more opportunities to work with health plans in this way, says Gregg O. Lehman, PhD, president and CEO of the Washington-based National Business Coalition on Health. NBCH polled 90 business coalitions nationally on whether its members participate in advisory panels or boards of MCOs. Ten percent responded; of those, just one could identify a member company that had a representative sitting on the board of a managed care organization (see "Employer Rep More Than Just a Token," on page 40).

"That's going to change," Lehman says. Because a greater number of businesses today are gathering data on health plan quality issues before contracting with insurers, employers and insurers are working more closely than ever. "It's a matter of time before coalition executives will be asked to sit on employer panels to actually advise health plans."

The customer advisory boards at Anthem Blue Cross and Blue Shield of Virginia, formerly Trigon Blue Cross Blue Shield, were redesigned about four years ago to include employers of all sizes, from small-business purchasers with up to 14 employees to companies with thousands of workers.

"We look upon the boards as standing focus groups," says Donna DeWitt-McGee, Anthem's director of market analysis. "We want to hear their thoughts on our products and policies." The company has two boards, one for each side of the state, which meet two to three times a year and discuss everything from covering genetic testing to how to improve an explanation-of-benefits form and what features should be on Anthem's Web site.

"I feel that my employees have a voice," says Laura Dietrick, assistant director of benefits at the University of Richmond, which has 1,400 employees.

The Aetna Customer Advisory Group has spearheaded many changes at Aetna over the years, says Russell D. Fisher, senior vice president of national accounts and Aetna global benefits. The group, founded by employers, suggested that Aetna go to an electronic referral process in its HMO, for example, and has given input on how to structure a new consumer-driven product. Aetna's top management, including Chairman John W. Rowe, MD, and President Ronald Williams, have attended the group's meetings.

"It's really helped us understand what we need to do and how we need to change as we go forward," Fisher says.

In working with employers, however, managed care organizations have to make sure that communication is productive and they have to resist the urge to turn meetings into a sales pitch, says Mercer's Havlin. "Insurers really have to think about where employers can provide input best and what tools they need to comment on the effectiveness of how the plan is running. You don't want a meeting to just be a general gripe session. It's hard to manage these groups when their conversation is based on innuendo or the last person who walked in their office with a claims complaint."

It is important to keep the dialog focused but open, agrees Anthem's Dewitt-McGee. "We try to make it free-form enough that we can allow for some very valuable discussion, but we do try not to get on specific claims issues or anything along that line."

Sharing broader health care ideas with other human resources professionals and learning how they've met challenges also is important, says Smurfit-Stone's Sawyer. "The most significant thing for me is the exchange with other members."

It's great, Dietrick says, "just to be able to sit in a room with other employers and hear what they have to say."

Employer rep more than just a token

Penny Kelch, manager of benefits and compensation at Snyder's of Hanover, a snack-food company based in Hanover, Pa., does more than advise the PPO her company contracts with. As a member of the board of directors, she votes --on the MCO's rates, which doctors it credentials, and strategic planning matters.

"We provide direction and a lot of input as to what we expect from the PPO," says Kelch, one of three employer representatives on the 12-person board of directors at South Central Preferred, a York, Pa.-based, not-for-profit PPO that contracts with physicians in eight counties. Other board members include six physicians; the CEO of the PPO's parent organization, WellSpan Health; and two members of WellSpan's board of directors.

The goal is "to have a forum where employers and those who provide health care services can sit down and talk about their concerns," says Jim Cochran, South Central's chief operating officer.

Employers and physicians have been on different sides of issues but have worked through them, Cochran says. In the early days of the PPO, for example, physicians balked when employers wanted to credential chiropractors, who today are part of the network. Later, physicians asked employers to sponsor more preventive care initiatives. Now employers are required to have wellness programs in place to get the best discounts from the PPO.

The debates have enlightened both sides, Cochran says.

"I understand now that doctors are not making money if they are not seeing patients every 15 minutes and they are spending three hours a day filling out paperwork," Kelch says. "You have a better understanding of the whole process when you are able to communicate back and forth."

Yet employers on managed care boards also have to remain prudent buyers of health care, says Linda Havlin, a Chicago-based partner with Mercer Human Resources Consulting. If the managed care company wants to hire more people or invest in new technology, the employer representative on the board has to look with a critical eye and ask, "How is this going to lower administrative costs, improve customer service, and lower health care costs?" she says. "The employer representatives really have to take the tough business perspective and remember that they are truly an independent eye on the effectiveness of that health plan's operation."

MargaretAnn Cross is a freelance writer in Ann Arbor, Mich. She specializes in health care.

Managed Care’s Top Ten Articles of 2016

There’s a lot more going on in health care than mergers (Aetna-Humana, Anthem-Cigna) creating huge players. Hundreds of insurers operate in 50 different states. Self-insured employers, ACA public exchanges, Medicare Advantage, and Medicaid managed care plans crowd an increasingly complex market.

Major health care players are determined to make health information exchanges (HIEs) work. The push toward value-based payment alone almost guarantees that HIEs will be tweaked, poked, prodded, and overhauled until they deliver on their promise. The goal: straight talk from and among tech systems.

They bring a different mindset. They’re willing to work in teams and focus on the sort of evidence-based medicine that can guide health care’s transformation into a system based on value. One question: How well will this new generation of data-driven MDs deal with patients?

The surge of new MS treatments have been for the relapsing-remitting form of the disease. There’s hope for sufferers of a different form of MS. By homing in on CD20-positive B cells, ocrelizumab is able to knock them out and other aberrant B cells circulating in the bloodstream.

A flood of tests have insurers ramping up prior authorization and utilization review. Information overload is a problem. As doctors struggle to keep up, health plans need to get ahead of the development of the technology in order to successfully manage genetic testing appropriately.

Having the data is one thing. Knowing how to use it is another. Applying its computational power to the data, a company called RowdMap puts providers into high-, medium-, and low-value buckets compared with peers in their markets, using specific benchmarks to show why outliers differ from the norm.
Competition among manufacturers, industry consolidation, and capitalization on me-too drugs are cranking up generic and branded drug prices. This increase has compelled PBMs, health plan sponsors, and retail pharmacies to find novel ways to turn a profit, often at the expense of the consumer.
The development of recombinant DNA and other technologies has added a new dimension to care. These medications have revolutionized the treatment of rheumatoid arthritis and many of the other 80 or so autoimmune diseases. But they can be budget busters and have a tricky side effect profile.

Shelley Slade
Vogel, Slade & Goldstein

Hub programs have emerged as a profitable new line of business in the sales and distribution side of the pharmaceutical industry that has got more than its fair share of wheeling and dealing. But they spell trouble if they spark collusion, threaten patients, or waste federal dollars.

More companies are self-insuring—and it’s not just large employers that are striking out on their own. The percentage of employers who fully self-insure increased by 44% in 1999 to 63% in 2015. Self-insurance may give employers more control over benefit packages, and stop-loss protects them against uncapped liability.