PBMs for Better or Worse

variouspillsWith enrollment in Medicare Part D and specialty drug costs exploding, it’s no surprise that forecasts predict 7 percent annual growth for PBMs over the next several years. Two trends noted in the report were the continued acquisition or startup of PBMs by insurance carriers and the need for employers to better understand their options when comparing proposals.

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Is Reference Based Pricing Saving Money?

healthcareWhen the independent think tank finds that on average, prices paid to hospitals by younger, healthier policyholders were 100 percent higher than what Medicare would have paid for the same procedures, it’s easy to understand the impact that payment contracts based on what Medicare pays can have on health plan costs.

In contrast to traditional fully insured plans, self-funded health plans with reference based pricing (RBP) enable consumers to learn the cost of treatment before they receive it. This is the advantage of basing provider payments on publicly available cost and quality data rather than arbitrary network discounts. And because Medicare varies its pricing by geographic region, providers are compensated fairly, and medical price inflation can be controlled.

From Big to Small

While very large employers were early adopters, the model is becoming far more commonplace among smaller groups that partially self-fund. TPAs are helping some of these plans realize overall savings in the 20 percent range and for a plan with 300 members, this can mean annual savings of $1 million or more.

In a marketplace that has lacked transparency and accountability for far too long, Medicare reference is proving to be not only a market disruptor, but an approach that can help employer-sponsored health benefits thrive. Contact us if you want to learn more about how a RBP plan could work for you.

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How Much Do You Know About Costs?

In 2017, according to the Centers for Medicare and Medicaid Services, healthcare spending for every man, woman and child in the U.S. totaled nearly $11,000 – more than any other wealthy country. The interesting thing is that very few of us really know what goes into this number or who pays the bills. Here are a few facts you may find interesting.

  • The average cost of employer-based health insurance for a family in 2019 was $19,616.
  • The Census Bureau reports that 91.5% of Americans have health insurance coverage.
  • In 2017, the average ER visit cost about $1,400 – an increase of 176% in 10 years.
  • Federal, state and local governments currently pay for about 45% of all healthcare services.
  • From 2000 to 2016, spending on prescription drugs rose by 69% – more than any other component.
  • The Kaiser Family Foundation reports that in the past year, 50% of Americans put off needed healthcare because of cost.

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Price Transparency Efforts Continue

price-transparency-2In a recent decision by the U.S. District Court for the District of Columbia, the AHA lost its bid to avoid having to disclose rates hospitals negotiate with insurers. While an appeal is expected, this is a win for the administration, which is committed to  providing patients with understandable information about the cost of medical services.

The rule approved last year required hospitals to post a list of standard charges and rates they charge for diagnostic-related groups (DRGs). These charges were, however, posted as “chargemaster rates” – a format that meant little to the general public. By requiring that hospitals post median prices negotiated with commercial health insurers, CMS believes that providers will be forced to compete on price and that consumers will be better able to make informed choices.

In other developments, the Trump administration was stopped from requiring that drug companies disclose prices in their TV commercials. The President also brokered an agreement with drug companies and insurers to limit Medicare recipients’ copays on insulin to $35 a month. This will go into effect in 2021.

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HSA Limits Increase for 2021

stethoscope and moneyInflation-adjusted limits for contributions to health savings accounts and high deductible health plans for the coming year were just announced. According to the announcement, eligible individuals with self-only HDHP coverage will be able to contribute $3,600 to their HSA in 2021, an increase of $50 from 2020. Those with family coverage will be able to contribute $7,200 in 2021 and those who are 55 years of age or older will be able to make an additional “catch-up” contribution of $1,000 to their HSA.

While minimum deductibles for HDHPs will remain the same for 2021 plan years at $1,400 for self-only coverage and $2,800 for family coverage, the maximum limits for out-of-pocket expenses will increase to $7,000 for individual coverage and $14,000 for family coverage.

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Calls for Expanded COBRA Coverage

self-fundingWith nearly 40 million workers laid off or furloughed as a result of the Coronavirus, many organizations have urged Congress to expand COBRA coverage. Most of their concerns are focused on encouraging Congress to subsidize COBRA premiums for these workers so that existing health conditions will not get worse because care is delayed.

To date, the Department of Labor and the IRS have extended the time period workers have to decide to enroll in COBRA. With the President’s order setting the end of the national emergency for COVID-19 at June 29th, individuals would have until August 28th to enroll in COBRA. DOL and IRS have also given workers 30 days beyond the end of the national emergency to pay their COBRA premiums for March, April, May and June. Should the Administration decide to extend the national emergency, these timelines would be adjusted accordingly.

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How a Premium Dollar Is Spent

premium-dollarAmerica’s Health Insurance Plans, a national trade association whose member companies provide insurance coverage and health-related services to consumers and businesses, has released a study revealing the breakdown of today’s healthcare premium dollar, as follows:

  • 23.3 cents of every premium dollar is used for prescription drugs
  • 22.2 cents cover the cost of physician services
  • 20.2 cents are used to pay for office and clinic visits
  • 16.1 cents are used to cover hospital stays
  • 13.5 cents are applied to care management, administrative expenses, business expenses, provider management and other fees
  • 4.7 cents of every dollar go to taxes, and…

AHIP reports that on average, 2.3 cents of every premium dollar make it to the bottom line as net profit.

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Older Workers and Medicare

It’s doubtful that many technology companies are concerned about employees nearing age 65. Other employers, however, may want to brush up on Medicare eligibility in order to help older workers understand their options and avoid any potential gap in coverage. Here are just a few Medicare-related concerns:

  • For employees who will lose access to employer-sponsored group health coverage at age 65 or who choose to sign up for Medicare upon becoming eligible, the Initial Enrollment Period (IEP) is 3 months before to 3 months after the month they turn 65.
  • Medicare-eligible workers who leave employment with a retiree health plan or COBRA coverage are classified as “former workers” and therefore need to enroll in Medicare during their IEP.
  • Employees who have enrolled in Social Security before their 65th birthday will automatically be enrolled in Medicare Parts A and B. In order to avoid paying for 2 health plans, they may need to inform the Social Security Administration that they do not want Medicare Part B at this time.
  • Finally, for companies with fewer than 20 employees, Medicare becomes primary coverage. Workers and/or their spouses who are 65 or older must enroll in Medicare Parts A & B.

While employees must enroll in Medicare on their own, a little help from HR can go a long way. When questions about Medicare eligibility and enrollment arise, never hesitate to encourage a visit to a local Social Security Administration office or Medicare.gov.

Surprise Bills

A survey of individual healthcare consumers shows that the lack of cost transparency is taking a big toll, with more than half of respondents saying they have passed on doctor visits or prescriptions because of cost. The vast majority of those foregoing treatment cite the cost of higher deductibles and copays as the top concern along with consistently rising prescription drug costs.

HSAs Become More Flexible

hsaCurrently, patients with high deductible health plans and health savings accounts have to pay for treatment of chronic illnesses out-of-pocket until they have reached their required deductible. According to IRS Notice 2019-45, those with chronic conditions such as diabetes, high blood pressure or asthma, will reduce their financial burden prior to reaching their health plan deductible.

The notice, which becomes effective on January 1, 2020, states that the service or item needed must be low cost and supported by medical evidence showing that it will prevent the chronic condition from getting worse or causing other related health issues.