DECEMBER - 2022HR TECH OUTLOOK8In MyOpinionIn MyOpinionDo you know the saying, "don't hate the player, hate the game"? While healthcare should not be a game, most employers and benefits teams must work within the current healthcare system; operating with insurance companies, third-party administrators (TPAs), and prescription benefit managers (PBMs) - can prove challenging.Managing health claim expenses is not an easy task, and many large employers take it on by choosing a self-funded arrangement for group health insurance. This means employers are on the hook for claim liability ­ until the deductible is met and stop-loss insurance kicks in to offer financial protection for claims exceeding this amount.The current predicament we are in - our collective inability to manage our own personal healthcare, as evidenced by recent headlines indicating Americans' average life expectancy saw the sharpest two-year decline in nearly 100 years, directly influences how our healthcare system operates. Prioritizing personal healthcare improves insurance rates and employee benefits, ultimately building a happier, healthier workplace.Let's review the contracts, coverage, and cost-sharing employers should consider having in place to best support employees' health journeys.Optimize Your ContractsAdministration contract optimization for medical and pharmacy policies can ensure your organization is getting the most value. Within traditional medical network management, evaluate the network discounts based on your population's demographics by requiring your health plan network provider to establish a discount guarantee. Want to push the envelope a bit? Reference-based pricing allows for payment based on a percentage of Medicare Allowed Cost, which is significantly lower than billed charges less discount. A word to the wise, careful consideration of this model is key as there are pros, such as significant cost savings, and cons, such as employee friction, including potential balance billing. Have a large population that is geographically dense? Consider direct contracting, leveraging large population steerage to drive deeper discounts.The frequency with which the pharmacy landscape changes can cause whiplash. The terms within a PBM contract alone can make or break your pricing deal. Do you continue with traditional rebates or move to a pass-through rebate model in exchange for an administration fee? Do you explore an open pharmacy network or a narrow network in exchange for more favorable pricing terms? Including an annual market check within your PBM contracts may help your organization get better terms even 12 months after your initial contract is inked. Coverage and Cost-Sharing ProvisionsSome what trickier is setting the right coverage and cost-sharing provisions. What is your company's philosophy about offering healthcare coverage? Do you want to ensure employees can have anything covered for low out-of-pocket expenses? A better question might be whether you want to be at, above, or below the median offered to employees within your preferred benchmark (geography/employer size/industry). Do you want your benefits to show you as an employer of choice? Or is it simply a check-the-box offering? Consider where you fall for the type of plan(s) you offer, the coverage levels within the plan(s), and the employee cost-sharing.Kate Genovese, SVP, Employee Benefits Strategist, Risk Strategies CompanyByPUTTING PERSONAL HEALTHCARE FIRST BENEFITS EMPLOYERS AND RATESKate Genovese
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