| Health & Medical Innovation | Employee Benefits
| Health & Medical Innovation | Employee Benefits
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The Self-Insured Employer Marketplace
The Self-Insured Employer Marketplace
Let's talk about your high cost medical and Rx claim strategies.
For a plan of 10,000 members costing the employer sponsor $50 million: 300 people account for $28 million. Understanding who is high cost this year, and who will be high cost next year will help shape critical medical cost strategies.
High medical cost solutions for a working family population warrant targeted strategies. The concentration of expenses for this year’s medical costs is found claimants spending more than $25,000/year. Condition-specific solutions are often required for back surgeries, cancers, neonatal care, extended substance abuse treatment, auto-immune disorders, and complications of hospitalization.
Your data can help identify conditions that would benefit from disease-specific carve-out point solutions that can enhance what your members get from their health plan. Members with diabetes need specific solutions for diabetics. Members with cancer need cancer-specific strategies. Likewise for orthopedic surgeries, behavioral health conditions, cardiac care, asthma support and reproductive health.
Utilization data can help understand how members are (or are not) accessing health care services. A plethora of new and enhanced alternatives can supplement where and how members seek routine care and preventive screening. Underutilization and avoidance of health care put your members and your health plan costs at tremendous risk down the road.
High-cost claims analytics can help employers determine what care management carve-outs make sense for their members. Care management carve-outs are increasingly in demand for certain chronic conditions, post-op care; high-risk pregnancies; pre-term infant home care; cancer hospice, rare diseases and many other clinical scenarios. When your data shows inadequate care metrics through low utilization, gaps in care, or migration to higher-risk categories, condition management solutions are worth considering.
Second medical opinions, virtual centers of medicine and specialty telemedicine are revolutionizing how employer health plan members can access top medical expertise. It has never been easier to go beyond your health plan's network and provide plan members with access to top oncologists, neurosurgeons, rheumatologists, and internal medicine sub-specialists.
Medical and Rx data analytics can provide valuable information on where, when and how your members are receiving service. Many strategy considerations will benefit from understanding claimant health care access. Considerations for plan design, coverage of retail primary care, provider network assessment and hospital-based outpatient services warrant deeper claims data analytics.
Risk stratification and risk migration claims data analytics offer valuable insights into the health profile of employees and covered members in your plan. These data can be coupled with wellness programs metrics, such as, participation rates, utilization and outcomes data to help employers determine the efficacy and progress of their wellness interventions.
210 pages of charts and graphs is actually quite easy to produce.
Identifying the handful of key findings that have an actionable solution is harder. This requires seasoned familiarity with the data set, as well as an up to date understanding of available marketplace solutions.
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“Why should I pay for this if it isn’t covered by the insurance company?”
If an employer’s medical insurance company doesn’t cover a diagnostic or therapeutic service, why should the employer consider buying it separately?
The answer is found in the corridor between “medical necessity” and what can be argued is genuinely “medically necessary.” In order to prove that your product/service is medically necessary, you first need to understand the medical insurance company’s medical necessity policies for your technology.
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“The benefits of Point Solution carve-outs are in their ability to offer better options for managing cost and benefits offered by experienced vendors. Those third-party vendors can customize their programs to meet the specific needs of your benefit programs.”
For the self-insured employer, third-party carve outs and other vendors usually make up a significant part of the health management program offered to employees and their spouse/partners and dependents.
Whether your firm has an enterprise solution for your employer clients' clinical claims data analytics, or you rely on carriers or third-parties vendors- it is ultimately up to you to provide recognized value as a trusted advisor.
At RON LEOPOLD CONSULTING we help brokers with the clinically rich data they need to interpret and help them bring relevant, marketplace-ready innovative solutions to their employer clients.
Self-insured employers need a clinically-savvy advocate on their side. Whether you are meeting with your health plans, or determining the progress of key point solutions, the data you face can almost always benefit from a seasoned clinician familiar with claims data reporting.
At RON LEOPOLD CONSULTING we help employers extract value from their carrier reports and measure the progress of your Point Solutions.
210 pages of charts and graphs......but what is this telling you? Employers and their trusted advisors increasingly require a clinically-trained data expert to find genuine meaning and actionable recommendations from their claims data.
Your CFO is watching cost trends. Looking at cost stratification is as important as risk stratification. Percentage of "zero dollar" members may represent inadequate access to care. Higher than benchmark spend on very expensive claims may provide insights to more aggressive medical and pharmacy cost solutions.
Every major condition has a story. The solutions for different diseases and conditions vary greatly, and often require specialized clinical resources. Members with cancer, diabetes, back injuries or high risk maternity each require approaches that leverage expertise in their respective areas.
3% of your claimants drive 56.5% of your dollars. In other words, for 10,000 members, 300 people are driving well over half of your expenditure. How much of that is specialty pharmacy? Which members are potential stop-loss risks? What targeted strategies should you consider?
Underutilization of primary care, preventive services and behavioral health may eventually drive greater costs than overutilization of emergency departments and medical specialists.
The long game, for employers, is mitigating higher risk. The value of health risk solutions, such as wellness and lifestyle programs, are seen in the migration of members from higher risk strata, to lower risk strata. These programs can mitigate member population risk migration and offset further costs.
Measuring quality of care requires an ability to measure gaps in care for members. Overutilization, or misuse of key diagnostics and treatments can also assist in identifying foci of lower quality care.
RON LEOPOLD CONSULTING
Ronald S. Leopold, MD, MBA, MPH
Copyright © 2022 Ronald S. Leopold, MD, MBA, MPH - All Rights Reserved.
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