Not surprisingly, one of the key ways employer-sponsored health care can adapt and overcome today’s challenges is cost mitigation. But first, employers must understand employer health care ecosystems, most of which are composed of several parts. Generally, the components are:
- a collection of doctors that members have access to at an agreed-upon rate (professional network)
- a collection of medical facilities that members have access to at an agreed-upon rate (facility network)
- a methodology that ensures medical procedures are necessary and meet coverage criteria (precertification and prior authorization via utilization management)
- a means to interact with ongoing and costly member illnesses (case management and disease management)
- the rules by which a claim is to be paid and how the member is to properly access the medical benefit (summary plan description or SPD)
- a claims administrator and payer that adjudicates and pays claims to the terms the employer has set in the SPD (insurance carrier or TPA)
Merely having these components in the overall health care ecosystem is not sufficient to effectively manage costs, as these specific components are the catalysts in which costs proliferate. However, employers have the capacity to amend, replace, remove, add and create new ecosystem components to address specific needs, objectives or opportunities in their employee benefits landscape.
The primary cost-mitigation options that are marbled within the health care ecosystem are segmented into different categories. Learn about these and more in our latest State of Health Care Guide.
When an employer’s health care ecosystem is constructed to be nimble enough to align cost, quality and access parameters, the corollary effects compound in a manner that yields synergistic benefits to both employer and employee. Cost-containment solutions reduce and manage overall risk to the plan, which produces lower overall premium and budgetary pressure. These solutions lead to more innovative plan design, which creates steerage incentives to drive employee-patients to better overall outcomes. In order for an employer’s health care ecosystem to achieve these outcomes, the employer’s plan should include tactics that:
- Protect against unnecessary spending due to fraud, waste and abuse (FWA)
- Provide structured and reasoned access to primary care
- Guide minor acute care to efficient and low-cost sites of care (telemedicine, urgent care)
- Construct a care coordination methodology that handholds patients through health care navigation and care-delivery decisions for both routine and complex matters, as well as creates a 360-degree composite view of the patient as a unique individual
- Promote value-based care for situational diagnoses (low back pain, diabetes, dialysis)
- Align benefit deliverables with evidence-based medicine and proper diagnosis for high-dollar and catastrophic conditions (birth abnormalities, cancer, autoimmune conditions)
- Account for health care system outliers and have a plan to negotiate and contest their impacts on overall health spend
- Manage the pharmacy contracting and purchasing process to ensure the best overall drug procurement strategy
- Collect and analyze ongoing data to deduce patterns, trends and opportunities regarding overall ecosystem performance