Large employers plan to continue offering health coverage to workers, according to the 18th annual Towers Watson/National Business Group on Health Employer Survey, but the struggle to minimize costs continues. This year, the survey looks at how this challenge is taken up by employers that, of the 583 respondents, “are in the top tier of respondents whose costs have increased over four years at a much lower rate than the … median.”

Companies that have controlled health costs well now plan to …
Examine health care benefits, employee subsidies, and out-of-pocket costs in a “total rewards” framework 39%
Manage company subsidy as part of a “total rewards” budget rather than a separate health plan budget 30%
Increase employee contributions in tiers, with dependent coverage at higher rate than single coverage 24%
Structure employee contributions based on employees taking specific actions 23%
Adopt new payment methodologies that hold providers accountable for the cost of episodes of care, replacing fee for service 22%
Offer telemedicine for professional consultations 22%
Fund account-based health plans in accord with wellness or health management behavior 22%
Offer specialty provider networks 20%
Track outcomes quantitatively from all vendors 20%
Contract directly with physicians, hospitals, and/or ACOs 18%
Provide access to a private or corporate health exchange 18%

“The actions of our best performers may well provide a playbook that others can follow to achieve their goals,” the study says. “This is especially true for those whose strategies and tactics have led to less-than-desirable financial and health results.”

One thing the most successful companies are doing is “integrating their contribution strategy with their health management and wellness activities. Many more companies are tying their wellness incentive strategy to their [account-based health plan] contributions.”

More employers are not just taking the workers’ word for it regarding whether they’re making necessary lifestyle adjustments.

“More recently, companies have been expanding biometric outcomes to include achievement of specific body mass index levels and target cholesterol levels. Today, 16 percent of companies align their rewards/penalties with specific biometric targets (other than tobacco use), and another 31 percent are considering this strategy for 2014.”

Wellness incentives to expand; requirements to be tougher

2011 2012 2013 2014
Use financial rewards for people who participate in health management programs/activities 54% 61% 62% 81%
Use penalties for people not completing requirements of health management programs/activities 19% 20% 18% 36%
Require employees to complete a health risk appraisal and/or a biometric screening to be eligible for financial incentives 35% 42% 54% 75%
Require employees to validate participation in healthy lifestyle activities to receive a reward or avoid a penalty (e.g., proof of fitness center use or engagement with a primary nurse case manager) _ 23% 33% 59%
Reward or penalize based on tobacco use 30% 35% 42% 62%
Reward or penalize based on biometric outcomes such as achievement of weight control or target cholesterol levels 12% 10% 16% 47%
Apply rewards or penalties and/or requirements under health management programs/activities to employees and spouses alike 19% 23% 31% 59%

Source: “Reshaping Health Care: Best Performers Leading the Way,” Towers Watson/National Business Group on Health, March 2013

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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.