| Health & Medical Innovation | Employee Benefits
The Self-Insured Employer Marketplace
The Self-Insured Employer Marketplace
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.
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.
Employer-sponsored insurance covers almost 155 million people in the U.S.
It is estimated to be a $1 Trillion marketplace.
For every employer the business stakes around health outcomes, medical costs and access to medical care are extremely high.
What is the product or solution you have to offer and how does it fit into an employer's ecosystem? How is it better than what they may already have. Why doesn't their medical carrier(s) provide this? How are you different? How is this solution different? How is it better? What else do you need to consider?
Does what you do currently work for the self-insured employer marketplace? What additional processes and functionalities need to be considered to satisfy employer client needs? What about employees and their families: how can you assure employers that plan member user experience will be positive?
In a single sentence: What is your value proposition? What is the problem you are solving for the self-insured employer client? What about the employee or plan member? Can it be measured? What is the return on investment (ROI) or value on investment (VOI)? How can it be easily measured?
Who should you sell to? What kind or employers should you target? How do you effectively reach them? What do you need to do to sell successfully? Where are the best channels? Who are the stakeholders and key players that might get your foot in the door?
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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.
Just because you can do it, even do it very well, and you think it's very cool.......that doesn't mean that a self-insured employer will buy it. You may have a new diagnostic test for early detection of a disease or condition. You'll need to be prepared with answers. How will it be deployed? Who will pay for it? How much does it cost? Is your pricing flexible? What happens when a test is positive?
Just because you have a slick app......just because the challenges you address have been in the news recently......just because it's relevant to something that is important to an employer.....your health care innovation solution needs to work. You have to be able to show it works. Be credible. Demonstrate value.
You may be surprised how savvy self-insured employers and their key advisors actually are. You know your product but it will be up to them to determine whether and how it might fit into their platform. Your job is to explain what your healthcare innovation can do and how it might work with their platform. It's easier for you prospect to say "No thanks." What triggers might change their minds?
Self-insured, or self-funded plans, currently cover an estimated 94 million of the nation's 156 million employees. The 2020 Kaiser Family Foundation Survey of Employer Health Benefits reports that 67 percent of employed, insured workers are covered under self-insured, or self-funded, arrangements. Under these arrangements, the employer, n
Self-insured, or self-funded plans, currently cover an estimated 94 million of the nation's 156 million employees. The 2020 Kaiser Family Foundation Survey of Employer Health Benefits reports that 67 percent of employed, insured workers are covered under self-insured, or self-funded, arrangements. Under these arrangements, the employer, not an external insurer, directly bears the financial risk for the cost of employee health care.
"Self-funded employer groups already bear the risk for the increased costs of their health plans. The health plans that take on administrative services only (ASO) contracts should look for ways to increase their value to these organizations, not just encourage them to take on greater costs. The popularity of self-funding with large employ
"Self-funded employer groups already bear the risk for the increased costs of their health plans. The health plans that take on administrative services only (ASO) contracts should look for ways to increase their value to these organizations, not just encourage them to take on greater costs. The popularity of self-funding with large employers puts pressure on health plans to differentiate themselves, especially as enterprise employers are looking for new options."
[Forbes Technology Council; Sept 2020]
"A return-on-investment (ROI) mindset would lead employers to optimize where they spend resources related to the mix of the employee base. For example, effectively treating depression and anxiety could lead to a 4:1 return (that is, $4 back for every $1 spent) in improved employee health and productivity at work."
[McKinsey; "Innovating employee health: Time to break the mold;" Sept 2021]