Large self-insured employers spend hundreds of billions of dollars annually on health benefits struggle to manage trend and reduce employee health risk. Consultants and carriers provide uninspiring choices from cost shifting to adoption of private exchanges.
Despite the outlay of billions only two things are certain for employers—employee engagement declines and administrative expenses increase. With national health expenditures eclipsing 17 percent of the gross domestic product, new players or vendors are flooding the market with products, technologies, and services with a promise to employers to reverse the slide of employee engagement and the escalation of health care costs. While some industry estimates project 30 percent of health care cost as waste, health care payers through evidence-based approaches must sort through these options.
Each patient and episode of care is supported by hundreds of individuals and thousands of transactions across the health care system. Although patients and their physicians continue to sit at the center of these interactions, the evolution of medicine and the emergence of new technologies confuse the traditional relationship. Patients and doctors are confronted with an array of new resources (e.g., patient advocates, disease managers, wellness coaches, retail clinicians, free-standing labs) to supplement traditional interactions with nurses, pharmacists, specialists, and hospitals that aim to improve health outcomes and potentially reduce costs.
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Picture a tortoise trying his level best to cross the road. He symbolizes a knee replacement or a gall bladder surgery patient. Picture 25 to 30 heavy packages strapped to this poor tortoise's back. The burden is more than he can bear. What's in these packages? Well, it's all of the health care vendors who want a piece of this longitudinal episode of care.
Let's look at this for a minute. First, the employer's benefit administrator must attend to the patient's benefits, eligibility, and enrollment in a health network that has corralled participating providers at jewelry store discounted prices.
Second, the patient must shop for a provider, possibly taking advantage of some type of quality rating system or transparency tool. If he is fortunate he has a health coach or an advocate to walk him through the event. Hopefully, he participates in your wellness program and has managed his recently diagnosed diabetes through his chronic condition manager. He will have to consult his PBM for any medications and make sure they are on the formulary list.
His procedure will be tracked by the health plan and any hospitalization will be case managed. His utilization will be benchmarked against norms and his employer population to be evaluated for any cost drivers and savings opportunities. Did we leave any one out from this process? Yes, the actual physicians and ancillary clinical services like imaging, lab, and durable medical equipment. We also have turned the patient into an administrator–navigating through a maze of disintermediated third parties is more critical than the clinical care and far side of the road.
We readily accept the necessity of this system and willingly add an extra package or two to the struggling tortoise. It is much too complicated to line-item veto unnecessary vendors and processes.
Who will help this beast of burden cross the road to his simple destination of feeling better? Right now everyone is too busy working on his episode of care and ensuring that he has all the help he needs. Finding the appropriate mix of clinical and operational resources and processes is critical in health care for eliminating unnecessary care and administrative costs.
By understanding claim and utilization data, employer payers are ideally positioned to help their dear tortoise. Through a data-driven process payers can separate unnecessary interventions, redundancy, and waste from programs that advance health and the patient-physician relationship.
When it snows health care costs and a state of health care emergency is declared, only essential workers should travel the road with the patient and physician. Employer payers must support the physician-patient relationship and take care not to overburden that encounter with barriers to the health and welfare of their employee plan participants.
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