UnitedHealth will begin passing drug discounts to plan participants

This article was published on March 13, 2019 on BenefitsPro written by Max Nisen.

The health-care policy environment is shifting in a dangerous way for insurance giants. A seemingly small change in how drugs are paid for could be the beginning of a response.

UnitedHealth Group Inc., the largest U.S. health insurer, announced Tuesday that its pharmacy-benefit management arm OptumRX will mandate that all new employer health-plan clients pass the drug discounts it obtains for them directly to plan participants. That’s a big shift from the current system, under which OptumRX and other PBMs negotiate prices with drugmakers and hand the resulting rebate checks to clients to use as they wish. PBMs profit from this arrangement, and have an incentive to favor heavily rebated drugs. That pushes drugmakers to hike prices, and patients are exposed to artificially inflated costs.

UnitedHealth’s new policy means lower drug costs for more people. But it has broader implications. It smartly preempts Trump administration efforts to reform rebates, and shows that the industry can make needed changes ahead of pushes for an even bigger government-led overhaul of the way they do business.

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Increasing costs and unhappiness with the status quo are motivating the administration’s regulatory effort to end rebates in Medicare. It is also thinking about forcing insurers to reveal the hidden prices they negotiate with hospitals, which would wreak havoc on their ability to negotiate. Consumer dissatisfaction also behind broader reform efforts championed by Democrats, such as Medicare for All. Such plans are distant threats, but they are present and existential enough to weigh on shares.

Making the switch to so-called point-of-sale rebates for new clients is a big and unique step for UnitedHealth, and it builds on its January transition of a different subset of its business. While the impact will be small at first as existing clients can stick to the old system, the new model could eventually impact as many as 18 million Americans, according to a research note from Royal Bank of Canada analyst Frank Morgan.

UnitedHealth says people already on its point-of-sale plans save an average of $130 per eligible prescription and that medication adherence is up by as much as 16 percent. People are happier and healthier when they can afford to take their medicine, and are more likely to avoid larger medical costs down the line.

If the administration’s efforts on rebates succeed, UnitedHealth will face less disruption and have more experience in making a new business model work. Slower rivals such as CVS Health Inc. and Cigna Inc’s Express Scripts – which offer point-of-sale rebates as an option but don’t mandate it – may suffer. Already in February, CVS attributed part of its weak 2019 guidance to the impact of shifting drug-pricing trends on its PBM as drugmakers held back on price hikes under political scrutiny.

Plans that offer point-of-sale rebates have a chance to focus more on reducing overall costs for both patients and payers, especially when integrated with an insurance plan. This isn’t going to make insurers and PBMs beloved overnight, or produce instant systemic cost-savings. But UnitedHealth is taking a needed and bigger step toward a better and more patient-friendly system.

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Getting Creative Can Attract Talent

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With unemployment for college-educated people age 25 and above at just 2.2%, it’s been a long time since we’ve seen a jobs market this tight. To attract and retain workers in this environment, growing companies are offering more than just competitive health benefits, and this is especially true for smaller companies forced to compete with larger companies.

Executive search firms have shared examples of employers going above and beyond their health plan by offering additional compensation to cover a candidate’s projected out-of-pocket medical expenses going forward. Technology-related firms in competitive markets are adding wellness benefits like on-site clinics or pre-arranged access to nearby fitness centers. For early to mid-career employees, companies are expanding their family leave or flex-time policies to provide easier transitions for young parents returning to work.

Flexibility and More

Whether it be more paid time off or arranging your work day to meet outside demands on your time, flexibility is becoming increasingly important, especially when you’re dealing with millennials or X-ers. Equally important to young workers is the culture present at an organization and the opportunity to make a difference – to know that what they are doing is helping their community or the world at large.

From unique apprenticeship programs at manufacturing and industrial companies to help with retiring outstanding student debt, more employers are looking for creative ways to gain an edge that will appeal to qualified, prospective employees. In a really tight job market, it pays to be creative.

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How Can Your Health Plan Be More Personal?

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Investment bank Morgan Stanley recently hired a Chief Medical Officer. General Motors made the Detroit-based Henry Ford Health System the only in-network option for 24,000 salaried employees in southeast Michigan. And, Apple joined many other large employers in using on-site clinics to provide more personalized care. These tactics are being used to address a combination of risk factors contributing to costly chronic conditions like diabetes, heart disease and obesity.

Filling Voids in Wellness Programs

We all know how hard it is to change lifestyle habits. While traditional wellness programs can offer great tools and improved access, more and more employers are realizing that to boost engagement and keep it from fading over time, you must tailor a program to the needs of each individual.

This level of involvement, sometimes referred to as condition management, includes more personal involvement and communication. Providing guidance and support on nutrition, exercise, stress management and other concerns can help at-risk employees overcome the challenges that have kept them from enjoying their best life.

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Ever Asked a Hospital What a Procedure Costs Them?

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Can the cost of a hip replacement in Philadelphia really vary from $11,000 to $125,000?

From white papers to published books, much has been written about how difficult it can be to find out what a hospital stay or outpatient procedure will cost. And as Anna Wilde Mathews observed in her article Lifting the Veil on Pricing for Health Care, the mystery surrounding healthcare pricing stems partly from the fact that hospitals and other providers generally don’t publicize how much they’re paid for services, which varies depending on who’s footing the bill.

Much has changed recently. And while it is difficult for websites like healthcarebluebook.com to quote exact pricing, they do suggest what a reasonable price should be based on what insurance carriers have paid hospitals for certain procedures in a certain geographic region.

It’s easy to understand why hospitals are reluctant to share price information. Consider the results of a study on hip replacement surgery published by JAMA Internal Medicine. According to Dr. Joseph Bernstein, professor of orthopedic surgery at the University of Pennsylvania, while more than half of the 120 hospitals surveyed could not provide a cost for the surgery, those that did quoted prices ranging from $11,000 to $125,000.

How can your health plan achieve price and quality transparency? Treat healthcare expenses like other business expenses! Self-fund with Medicare Reference Based Pricing and partner with a TPA that has the willingness and know-how to hold providers accountable.

These are today’s keys. These are the things we do for our clients each and every day. To take control of your healthcare costs, give us a call at your convenience.

Tell Us How You Feel!

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Who Owns Your Claims Data?

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You Can’t Manage What You Don’t Measure!

With a self-funded healthcare plan and a good, independent TPA, access to claims data is standard operating procedure. Even more important, a good TPA like Diversified Group has the expertise to convert your data into intelligent, actionable strategies to manage your plan, monitor performance and modify plan design to control costs.

In contrast, employers with fully insured health plans seldom see their claims data. Even self-funded plans managed by large carrier-owned ASO divisions are often unable to receive claims data on a regular basis.

Analyzing claims data with state-of-the-art tools helps identify, analyze and manage potentially high dollar claims. This capability alone saves many of our clients more than 20% annually. Hospital stays can be monitored, claim costs can be unbundled to detect fraud and abuse and discounts can be negotiated without compromising the quality of care received. Even the rising cost of specialty (bio-tech) pharmaceuticals can be managed when risks are identified early on.

If you’re not receiving claims data and analysis, you’re operating in the dark and it’s time you had a conversation with your broker or TPA. After self-funding your health plan, we consider analyzing claims data to be “Cost Control 101”!

Tell Us How You Feel!

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2018 Massachusetts EMAC Payment Update

In August of 2017, Massachusetts passed H.3822 “An Act Further Regulating Employer Contributions to Health Care”. The purpose of the act is to reinforce the finances of the Commonwealth’s Medicaid and Children’ s Health Insurance (CHIP) programs (MassHealth). Since the implementation of the Affordable Care Act, many states have seen health coverage shift from private employers to the state’s Medicaid program. Primarily due to expanded Medicaid eligibility, many more employed individuals are taking subsidized care through the exchanges and Medicaid versus their employer’s plan. Currently Massachusetts covers 1 in every 4 residents on MassHealth.

To help ease some of this fiscal burden, effective January 1, 2018, the Commonwealth has instituted a temporary, two year, two tiered assessment on employers expected to collect $400 million over 2018 and 2019.

Employer Assessments:

    • Tier One – An increase in the Employer Medical Assistance Contribution (EMAC)* rate currently paid by employers, resulting in a maximum per employee annual contribution of $77 in 2018 and 2019 instead of the current $51;
    • Tier Two – A separate, targeted EMAC payment requiring employers to pay an additional 5% of wages on the first $15,000 in annual earnings ($750 maximum per employee) for each non-disabled employee who is enrolled in a state-subsidized health plan, MassHealth or ConnectorCare – regardless of whether the employer offers a group health plan or whether the employee is a full or part-time employee.

*EMAC is a MA payroll tax paid by employers. Its purpose is to help finance the cost of subsidized care for low income MA residents. The EMAC was effective 1/1/14 to replace the MA Fair Share Contribution when it was repealed in lieu of the ACA. EMAC applies to employers with 6 or more employees in a quarter. Contributions to EMAC are paid on the first $15,000 of each employee’s wages.

The program will be administered by the Department of Unemployment Assistance (DUA). The DUA will match quarterly wage reports with MassHealth and ConnectorCare records to determine which employers owe the assessment and how much. The amount owed will appear on the employer’s DUA statement in the section showing the employer’s Unemployment Insurance liability. Payment is due on or before the last day of the month succeeding the quarter in which wages were paid and reported. Employers can check to see if the state’s calculations match their own records online after the EMAC Supplement is calculated.

For more information/FAQs from the DUA, click here.

HIRD Form is Back
Employers will be required to annually submit a new version of the HIRD (health insurance responsibility disclosure) form, also beginning in 2018 to verify information that is currently self-reported by individuals who apply for public health insurance programs. The new Massachusetts healthcare coverage form is an annual report on the employer’s offer of health insurance to its employees, including information on eligibility, cost, benefit design and employee contributions. The final version of the form and regulations governing its completion will be available in early March for employers to use in their 2018 healthcare reporting. More guidance on the form and when/how to file will be forthcoming. Employers who knowingly falsify the form or fail to file it face a penalty of $1,000-$5,000, according to state law.

Employees Are Spending More for Health Care, Using Less. Put a Stop to It!

Paying more for less is never a good thing, especially when it comes to employee health care costs. And while many people have become almost numb to this trend, Diversified Group is doing more than ever to help self-funded health plan clients fight back. With cost transparency tools contained in programs such as Pharamasense and RealTimeChoices, Diversified is providing employers and members the tools needed to compare out-of-pocket costs as well as quality.

Read on for a full article from BenefitsPro that discusses how employees are spending more on health care, but using it less.

Employees’ health care spending up, usage down

This article was published on January 24, 2018 on BenefitsPro, written by Jack Craver.

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Working Americans are using less care and paying more for health care.

Despite reducing their consumption of health care services, Americans with employer-sponsored insurance spent more than ever before on health care in 2016, according to a new study by the Health Care Cost Institute.

Spending is going up simply due to price increases for prescription drugs, operations and doctor’s visits.

Spending for those with employer health plans increased 4.6 percent in 2016. The previous year, spending increased 4.1 percent. In the prior two years, spending increased by less than 3 percent annually.

“Working Americans are using less care and paying significantly more,” Niall Brennan, president of HCCI, tells the Wall Street Journal. “That has huge implications for the health-care system, for the overall stability and growth for our economy as a whole.”

The study also examined how prices have increased for medical services and medication between 2012 and 2017. It found that spending on surgeries increased by an average of 30 percent during that time, while spending on administering drugs, such as chemotherapy, increased by 37 percent.

These spending increases coincided with a decline in the use of the services. Surgeries declined by 16 percent and the on-site administration of drugs declined by 4 percent.

The biggest increase, however, was for prescription drugs. The cost of brand-name drugs more than doubled, rising 110 percent during the five year period. That came despite a 38 percent decline in the number of prescription days filled.

When taking into account generic drugs, the spending increase on medication was still significant: 27 percent. Of course, many of the most notable price increases in recent years have involved generic drugs.

The dramatic increases in spending for prescription drugs helps explain why the American College of Physicians took the step two years ago to recommend that doctors prescribe generic versions whenever possible, reasoning that the high prices of branded drugs make it less likely that patients will fill their prescription.

High drug prices have also led a group of hospitals to team up to manufacture their own drugs, in an attempt to bypass a pharmaceutical industry that they believe has gone off the rails with its pricing.

Fittingly, on Wednesday the American Psychological Association released findings from a survey showing that roughly two-thirds of Americans say that the cost of health insurance is a source of stress in their household. Smaller majorities also report that changes to federal health care policy and the cost of medications cause them stress.

While the APA study found a high level of stress across all demographic groups, Hispanics and those who live in cities are far more likely to say they’re worried about them or a loved one losing access to health care services. Fifty-five percent of millennials said they are stressed by the lack of access to mental health services, compared to only 25 percent of baby boomers and 14 percent of older adults.

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