Helping Employers Achieve the Benefits Balance

Employers Benefits Balance

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Balance.

An even distribution of weight enabling someone or something to remain upright and steady.

A condition in which different elements are equal or in the correct proportions.

The definitions make it sound easy—spreading the load around so no one person or group is under duress.

But balance is quite elusive.

We strive for it in all aspects of our lives.

Employers are no exception.

Employers Benefits BalanceThey struggle with it in the workplace, especially as it pertains to benefits.

CEOs, CFOs and HR directors are caught in the tugs of emotion and cost spreadsheets.

MedCost helps employers in their pursuit of balance.

Balancing medical care and cost management. Balancing the ideal with the reality.

Other benefits administrators can’t match our integrated clinical programs that combine member care with effective claims management.

And big name insurance companies, well, they use a scale. Scales are not negotiable. They don’t allow employers to make choices.

Achieving Employers Benefits Balance

MedCost helps self-funded companies balance self-care, the health of their company, with the care of others, their employees.

We enable companies to achieve the benefits balance™ that’s right for them.

MedCost. That balance is built right into our name.MedCost

(This is a transcript of the video, “Helping Employers Achieve the Benefits Balance.”)

Employers Benefits Balance

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*More Information for VA Employers
*More Information for NC Employers
*More Information for SC Employers

 

How to Help Employees Become HEALTHY & WHOLE (Video)

Ready to Balance the Care of Your Employees
with the Financial Health of Your Company?
HEALTHY & WHOLE

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  • Annual health care costs in America are $3.2 trillion.
  • Employers average 5.3 unplanned sick days per year.
  • That productivity lost is more than 1 and 1/2 hours of an 8-hour day.

When disease management and wellness programs combine, employers average $30 per member per month in decreased health care costs.

HEALTHY & WHOLE

That’s why we’ve developed a comprehensive program called HEALTHY & WHOLE.

HEALTHY & WHOLE encompasses physical, emotional, financial and social health – and
greater job satisfaction for employees.

The goal is to help employers balance the care of employees with the financial health of your
company.

HEALTHY & WHOLE Includes Disease Management

Our nurse health coaches provide hands-on support, helping members reduce blood
pressure, glucose levels and lose weight.

And for complex conditions, case managers provide expert help for families in very difficult
situations.

Over 73% of businesses offer corporate wellness to attract and retain talent, and strengthen
company culture. Another advantage is to encourage enrollment in consumer-directed health
plans, a growing trend.

HEALTHY & WHOLE Supports Lifestyle Changes

HEALTHY & WHOLE addresses not only members with chronic diseases, but the 75% who
need support with lifestyle changes.

Lifestyle changes – even small ones – create measurable outcomes of better health, productivity and bottom line.

The Results of Corporate Wellness Programs

HEALTHY & WHOLE

http://www.nahueducationfoundation.org/materials/WellnessBrochure.pdf

Implementing corporate wellness programs dropped claims costs -28%, doctor visits -17% and hospital admissions -63%.

This same study showed disability costs down -34% and injury incidence down -25%.

An employer we worked with said that he is passionate about having happy employees. If they
are happy, they will be productive and engaged.

A Program That Benefits Employees and Companies

Lifestyle coaching. Financial education. Fitness. Nurse health coaching. Long-term medical
conditions. HEALTHY & WHOLE serves everyone’s needs, including your company’s.

We want to see everyone HEALTHY & WHOLE. That’s why it’s important to us to balance the care of your employees with the financial health of your company.MedCost

HEALTHY & WHOLE

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(This post is a transcript from the video, “MedCost HEALTHY & WHOLE.”)

For more information on wellness consultations for employers, email Kati Davis.

 

10 Terms You Need to Know in Self-Insured Health Plans

Confused by all the “insurance-speak” in your company health plan? Here’s a quick guide for phrases in benefit plans for self-insured employers.


self-insured

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Self-Insured: What Does It Mean?

1 Self-Insured: Also called self-funding. Employers choose this model of funding to pay for health claims from company assets and employee premiums. Self-insurance allows employers to pay only for actual claims, instead of the fixed premiums of fully-insured plans. A 2013 study by the Kaiser Family Foundation noted three of five covered employees are in self-insured health plans.[1]

2 ERISA: Employee Retirement Income Security Act of 1974, passed by Congress to establish federal regulations for self-funded benefit plans. Self-funded employers avoid fees such as the Health Insurance Provider Fee,[2] Risk Adjustment Fee[3] and Federally Facilitated Exchange User FeeSelf-funded employers also avoid certain state premium taxes.

3 SPD: Summary Plan Description that lists health plan terms and conditions, written for a particular employer or organization. The SPD defines the benefit coverage and exclusions. MedCost ensures that coverage and exclusions mirror the stop loss contract. If the stop loss contract does not mirror benefits offered, the employer may have to pay claims that were not covered by the stop loss carrier.

Fixed Vs. Variable Cost

self-insured

4 Fixed Cost: Predetermined fees that are paid as part of a health plan, regardless of actual expenses. Fully-insured plans are 100% fixed cost, paid out in set premium rates to the carrier. Self-insured fixed costs range from 18%—21% of total plan costs for administrative fees and stop loss insurance.

5 Variable Cost: Also called soft dollars, which may translate into potential savings for a self-funded employer. Prudent employers deposit funds for the total estimated employee claims into a reserve account in the company’s name. These dedicated funds remain in the employer’s account for future medical expenses if not spent during a plan year. MedCost provides professional underwriting services to help employers ensure that they are adequately covered for both expected and unexpected claims.

6 Corridor: Also known as claims or risk corridor, or margin. Underwriters include this as a cushion to cover unexpected claims. Generally this amount is around 25% for self-funded plans and 20% for fully-insured plans. Expected claims plus risk corridor (for variable expenses) determine the maximum liability (or attachment point).

Stop Loss Insurance

7 Stop Loss Insurance: Coverage designed to protect self-funded employers from the risk of catastrophic claims beyond a predetermined liability. MedCost underwriters recommend policies with consistency between the stop loss policy and the employer’s SPD, to avoid any gaps in coverage when claims are submitted.[4]

8 Specific Stop Loss Deductible: The limit of liability under stop loss coverage on an individual employee covered under an employer’s heath care plan. The employer chooses this amount based on total group size and selected risk tolerance.

Stop Loss Coverage Specific Example

Self-insured
Jane Smith suffers from renal failure and undergoes kidney dialysis. Her claims total $300,000. Jane’s employer is self-funded and has purchased specific stop loss with a $75,000 deductible.

Total Claim $300,000
Employer Deductible $75,000
Amount Reimbursed by Stop Loss Carrier $225,000

9 Aggregate Stop Loss Deductible: This amount is the self-funded employer’s overall or group liability under a stop loss policy. Underwriters typically project expected claims plus a 25% margin to determine an employer’s maximum liability (or attachment point).

Stop Loss Coverage Aggregate Example

self-insured

  • Includes claims paid that do not exceed the specific deductible
  • When underwritten appropriately, expenses should approach the amount of expected claims ($4 million), rather than the maximum liability ($5 million)
Expected claims $4,000,000
25% Margin $1,000,000
Maximum Claims Liability $5,000,000

10 Benefits Administrator: Also called a third party administrator (TPA) or administrative services organization (ASO). Employers typically contract with an administrator to handle benefits plan documents, claims payments and provide other services. Experienced administrative companies like MedCost can preserve significant savings for employers through careful management of resources, with customized benefits and targeted products to meet employer needs.

We’ve spent over 30 years in the industry. We know health care choices are complicated and not getting any simpler.

Questions?

Have questions? Contact your health care consultant or Jason at MedCost for more resources.


 

[1] “2013 Employer Health Benefits Survey,” Kaiser Family Foundation, August 20, 2013, http://kff.org/report-section/ehbs-2013-section-10/

[2] “Affordable Care Act Provision 9010, Health Insurance Providers Fee,” http://www.irs.gov/Businesses/Corporations/Affordable-Care-Act-Provision-9010

[3] “Explaining Health Care Reform: Risk Adjustment, Reinsurance, and Risk Corridors,” Kaiser Family Foundation, January 22, 2014, http://kff.org/health-reform/issue-brief/explaining-health-care-reform-risk-adjustment-reinsurance-and-risk-corridors/

[4] For more information, download Stop Loss Coverage White Paper: Maximizing Benefits, Limiting Risk

2017 Employer-based Premiums Contrast with ACA Increases

By Phil Galewitz, Kaiser Health News

2017 employer-based premiums

Family health insurance premiums rose an average 3% this year for people getting coverage through the workplace, the sixth consecutive year of small increases, according to a study released Tuesday.

Average 2017 Family Premiums: $18,764

The average total cost of family premiums was $18,764 for 2017, according to a survey of employers by the Kaiser Family Foundation and the Health Research & Educational Trust. That cost is generally divided between the employer and workers. (Kaiser Health News is an editorially independent program of the foundation.)

2017 employer-based premiumsWhile overall premium increases remain modest, workers are picking up a greater portion of the tab — this year $5,714 for family coverage, about a third of total cost.

Employer-provided coverage for a single person rose on average 4%, to $6,690. Those individuals pay $1,213 on average.

Still, the employer market looks remarkably stable compared to the price increases seen in the Affordable Care Act’s insurance marketplaces for people who buy their own coverage. Premiums on those plans spiked on average about 20% this year, and many insurers dropped out because of financial concerns.

Average ACA Premiums Up 20% in 2017

For all the media attention and political wrangling over the Obamacare exchanges, their share of the market is relatively small. They provide coverage to 10 million Americans while 151 million Americans get health insurance through their employer.

The continued slow rise of employer health premiums identified in the Kaiser survey surprised some analysts who have expected the trend to end as the economy picked up steam, leading to a jump in use of health services and health costs.

Drew Altman, CEO of the Kaiser Family Foundation, said it’s “health care’s greatest mystery” why health insurance costs have continued their slow pace even as the economy has picked up the past few years. “We can’t explain it.”

2017 employer-based premiums

Employee Deductibles Have Nearly Doubled Since 2010

Another unexpected result was that workers’ deductibles — the health bills that workers must pay before their insurance coverage kicks in — remained stable this year at $1,221. Since 2010, as companies sought to keep premiums in check, deductibles have nearly doubled. Higher deductibles can limit premium increases because costs are shifted to workers and it gives them greater incentive to cut spending.

“Increasing deductibles has been a main strategy of employers to keep premiums down and we will have to watch if this plateauing is a one time thing … or if this portends a sharper increase in premiums in future years,” said Altman. “It could be deductibles are reaching their natural limit or could be the tighter l2017 employer-based premiumsabor market” that’s causing employers to back off, he added.

Meanwhile, a second employer survey released Monday by Mercer, a benefits consulting firm, suggests a modest increase in health costs coming next year, too. Employers said they expect their health costs to increase by an average 4.3% in 2018, according to the survey.

To deal with higher medical costs — notably big increases in the prices of prescription drugs — employers are using multiple strategies, including continuing to shift more costs to workers and paying doctors and hospitals based on the value of the services rather than just quantity of services.

Jeff Levin-Scherz, a health policy expert with benefits consultant Willis Towers Watson, said there is a limit on how much employers can shift costs to their workers, particularly in a tight labor market. “Single-digit increases doesn’t mean health care costs are no longer a concern for employers,” he said.

Trend: Employer-Based Coverage Has Dropped

The 19th annual Kaiser survey also found that the proportion of employers offering health coverage remained stable last year at 53%. But the numbers have fallen over the past t2017 employer-based premiumswo decades.

The survey highlights that the amount workers pay can vary dramatically by employer size. Workers in small firms — those with fewer than 200 employees — pay on average $1,550 more annually for family premiums than those at large firms. The gap occurs because small firms are much more likely than large ones to contribute the same dollar amount toward a worker’s health benefits whether they’re enrolled in individual or family coverage.

More than one-third of workers at small employers pay at least half the total premium, compared with 8% at large employers.

That’s the case at Gale Nurseries in Gwynedd Valley, Pa., where health insurance costs rose 7.5% this year. Its 25 workers are paying nearly half the cost of the premium — at least $45 a week for those who choose the base coverage plan. Employees also have deductibles ranging from $1,000 to $2,500.

A decade ago, the nursery paid the full cost of the premium.

“It’s crazy — we keep paying more and getting less,” said comptroller Candy Koons.

At the Westport (Conn.) Weston Family YMCA, health insurance premiums rose about 7% this year, leaving its 50 full-time employees to pay a $156 premium for individual coverage.

“It’s not problematic, but it’s one of our bigger costs associated with payroll,” said Joe Query, the human resources director.

 

Kaiser Health News is a national health policy news service that is part of the nonpartisan Henry J. Kaiser Family Foundation.

2 Obstacles to Managing Drug Costs (Video)

To Manage Employer Prescription Costs, Get the Right Drug for the Right Condition

Employer Prescription Costs

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Zafeira Sarrimanolis, MedCost Pharmacist and Clinical Consultant,knows the value of reviewing pharmacy usage patterns for clients, to identify opportunities to contain costs.

“From a more clinical perspective, the key to managing drug costs is making sure that the right people are using the right drug for the right medical condition,” she said.

Obstacle #1: Not Adhering to the Formulary

“What is a formulary?” asked Michael Cornwell, Director of Sales and Underwriting. “A formulary is a guide that the Pharmacy Benefit Manager puts out that says these brand drugs are the preferred versus the non-preferred versus generics.

“For example, the average cost of a generic today is about $28-$29. The average cost of a brand drug is probably in the $167 range.

employer prescription costs“Members do not always know what drugs are on the formulary,” said Ms. Sarrimanolis. “Certainly their providers don’t always know what drugs are on the formulary, so that’s where some of the confusion and disruption comes from.

“We try to fill a lot of these gaps through member education. Pharmacy Benefit Managers do a great job of outreaching to members through the mail, emails and on their websites. Unfortunately, members might not always understand that information.

“What we need to do is to encourage members to become smarter consumers and to make the best, most cost-effective choice for their own medication.”

The Pharmacy Benefit Manager’s Role

employer prescription costs

“A Pharmacy Benefit Manager, or PBM, serves multiple purposes,” Mr. Cornwell said. “One purpose is to process all the pharmacy claims. By doing that, benefits administrators like MedCost are able to collect the data and analyze it.

“Zafeira, as our pharmacist on staff, and our Care Management teams know what usage patterns are. We know what kinds of drugs people are taking.

“The PBMs certainly are negotiating discounts at the drugstore and contract rates for us to get the best prices that we can for the drugs that we take. PBMs can also provide data on clinical reasons to manage those drugs and make sure that they’re the most appropriate and cost-effective.

Obstacle #2: Not Educating Members

“One of the largest reasons that people are readmitted to the hospital is because they don’t adhere to directions to take their medication.

“Programs like step therapies ask: ‘Have you tried this drug before you try that one?’

“Prior authorizations ask: ‘Why do you need this drug?’ For example, you must have the proper genotype to be able to take certain treatments for Hepatitis C.

employer prescription costsPrior authorizations cause a lot of disruption to the member. You go to the doctor for a prescription.  You go to the drugstore and they say why do you need to take this drug? And you go back to your physician but they’re busy. It takes time, so it’s all disruptive at a time when you want your medication. It’s hard to understand.

Member education is extremely important. It would be nice if we could fill that gap to where physicians knew exactly what your formulary was at the point that physicians are prescribing that medication. Right now that doesn’t exist.

“Every 1% increase in generic utilization results in about 1.5% savings,” said Michael Cornwell.

“In drug costs, it becomes pretty significant. As Zafeira said, as the drug manufacturers continue to make more drugs (which is a good thing), it puts more challenges on us to make sure that the drugs are appropriate and cost-effective.

Using PBM Websites to Shop Employer Prescription Costs

employer prescription costs“We’re going to go through more disruption as a result of that. We’re going to have to get used to it. But there are a lot of new tools coming on the marketplace to try to help people shop for drugs,” Mr. Cornwell observed.

“The PBMs have websites where you can log in under your personal account with your PBM that is administering your drugs. You can put in the name of the drug and the details; and it will show you the best places the most price-competitive places, to buy that drug. It will also match up what your formulary is and if there are alternatives that are cheaper than the drug you have.

“The bigger issue is helping people to understand to be shoppers.”MedCost

(This post is a transcript from the video, “2 Obstacles to Managing Drug Costs.”)

employer prescription costs

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Too Few Patients Follow The Adage: You Better Shop Around

By Michelle Andrews, Kaiser Health News

shop medical costs

Despite having more financial “skin in the game” than ever, many consumers don’t make any attempt to compare prices for health care services, a newly released study found.

In a survey of nearly 3,000 adults younger than 65, about half of the roughly 1,900 who said they spent money on medical care in the previous year reported that they knew in advance what their costs would be. Of those who didn’t anticipate how much they would owe before receiving care, only 13 percent said they tried to predict their out-of-pocket expenses. An even smaller proportion, 3 percent, compared prices from multiple providers ahead of time.

It wasn’t that survey respondents were ignorant of price differences or didn’t care about them. More than 90 percent said they believed that prices vary greatly among providers, and 71 percent said that the amount they spent out-of-pocket was important or very important when choosing a doctor.

Yet most respondents said they didn’t comparison shop or even ask how much they would owe in copayments or other cost-sharing expenses before they turned up for an appointment.

Researchers conducted the online survey in February and March of 2015, dividing respondents into three groups: uninsured, insured in a plan with an annual deductible higher than $1,250 for single coverage or $2,500 for family coverage, or insured in a plan with a lower deductible or no deductible. The results were published in the August issue of Health Affairs.

Three-quarters of the study participants said they did not know of any resource that would allow them to compare costs, while half said that if a website showing such information were available, they would use it.

“If price shopping is an important policy goal, it will be necessary to increase the availability of information on price and decrease the complexity of accessing the information,” the researchers wrote. They noted that patients trying to figure out pricing information and their share of the cost must often know specific procedures’ billing codes, the difference between professional fees and facility fees, and the details of how their insurance plan is structured.

“Our results emphasize that simply passing price transparency laws or regulations (as over half of states have done) appears insufficient to facilitate price shopping,” they added.

Most respondents said they did not think there was a relationship between lower cost and lower quality.

shop medical costsOne reason for the lack of shopping activity may be that consumers value the ongoing relationship they have with an existing doctor and don’t want to disrupt that, said Neeraj Sood, professor of public policy at the University of Southern California in Los Angeles and one of the study’s authors.

Another possible explanation is that despite efforts by states, employers and insurers to make price information readily available, shopping for health care services is nowhere near as user-friendly and intuitive as buying something on Amazon or Expedia.

“Maybe right now these tools are so primitive that even though there is a financial incentive to shop, people aren’t doing it,” Sood said.

People surveyed were most likely to search out prices before going to a retail or urgent care clinic compared with other care facilities. Consumers who received physical therapy or lab and imaging services were more likely than others to comparison shop for providers, the survey found.

 

Please visit khn.org/columnists to send comments or ideas for future topics for the Insuring Your Health column. Kaiser Health News, a nonprofit health newsroom whose stories appear in news outlets nationwide, is an editorially independent part of the Kaiser Family Foundation.

The 3 Keys of Stop Loss Insurance (Video)

stop loss carriers

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“Stop loss carriers are definitely not the same,” said Jeff Thornburg, Senior Manager for MedCost Underwriting. “Stop loss insurance should not be treated as a commodity. Price is important. It should be considered. But the quality of the carrier and their policy are actually more important than the price.

“As long as you are getting a good price, you want to drill down into the policy. The first key is:

1. Be sure your policy is going to mirror, or virtually mirror, stop loss carrieryour plan document, to avoid any gaps in coverage.

“When there’s a gap, there’s a denial. You might as well consider denied claims as additional premium. So if you bought the cheaper policy that had more exclusions, and you had a denial, you quite possibly ended up paying more than if you had just bought good quality stop loss from a good quality carrier.”

Senior Underwriter Jeff Woodburn explains the second key: look for these qualities to choose the best carrier.

2. What differentiates the good stop loss carriers from inferior ones?

             *Financial stability
             *The ability to be efficient in paying claims
              *Ease of doing business

“For example, a premature baby incurs a tremendous amount of expense,” said Mr. Woodburn, with over 10 years in the industry. “As you know, that is a totally unexpected expense. But when these unexpected events occur, that is when your stop loss insurance kicks in to cover expenses that exceed a certain threshold. This threshold is predetermined when we’re putting the health plan together for a prospective group.”

Mr. Thornburg has seen how important the third key is from his 28 years handling stop loss insurance.

3. Choose your benefits administrator wisely.

“As a self-funded employer, you’re going to have the same claims, regardless of which stop loss carrier you choose. Your claims are going to happen whether you are with Benefits Administrator A, B or C.

“In evaluating different benefits administrators, it’s important to nail down who is going to manage those claims the best. To limit the liability of the employer while still giving good service and excellent benefits to the employees.

“This is what it comes down to at the end of the day. Who is going to best manage your claims?”MedCost

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stop loss insurance

IRS Reposts Revised Form 720 for PCORI Fee: Deadline 7/30/17

Michael BerwangerBy Michael Berwanger, JD, Director, Quality Management & Compliance

The IRS recently reposted the April 2017 version of Form 720 (Quarterly Federal Excise Tax Return) on its website.* While the form’s primary purpose is to serve as the quarterly return for various federal excise taxes, it also is used to report PCORI fees imposed under health care reform. (For more information on PCORI, see  “PCORI Fee for Self-Funded Employers”.)

Please note, the portion of the form related to the PCORI fees is unaffected. While Form 720 is filed quarterly for other federal excise taxes, the PCORI fee reporting and payment are only required annually, by July 31 of the year following the calendar year in which the applicable policy or plan year ended. The change noted at the beginning of the form is related to the excise taxes.

IRS form 720As background, PCORI fees, used to fund research on patient-centered outcomes, apply to plan and policy years ending before October 1, 2019. They are payable by insurers and sponsors of self-insured health plans, and are calculated by multiplying the applicable dollar amount for the year by the average number of covered lives. As announced in IRS Notice 2016-64, the fees owed in 2017 are as follows:

  • For plan years** ending on or after October 1, 2015, and before October 1, 2016: $2.17 per covered life
  • For plan years** ending on or after October 1, 2016, and before October 1, 2017: $2.26 per covered life

If you have already filed and used the form posted prior to the most recent update, please contact a tax professional on whether refiling is necessary.MedCost

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*If you downloaded the Form 720 (Rev. April 2017) before July 3, 2017, please note that
on page 2, under IRS No. 33, the rate is corrected to 12% of the sales price, not 12%
of the sales tax.)

*’*Plan year’ is generally the 12-month period stated in the Summary Plan Description, or for plans filing a Form 5500, the plan year stated in that filing. NOTE: The plan year may be different from the benefit year or the renewal period.

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This blog post should not be considered as legal advice.

Controlling Specialty Drug Costs (Video)

Specialty Drug Costs Can Be Managed with These Strategies
specialty drug costs

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“It’s interesting that a lot of these specialty drugs are designed for a very small percentage of the population that have a certain disease state,” said Michael Cornwell, MedCost Director of Sales and Underwriting.

“There may be less than 200,000-300,000 people in the country that need that particular drug. That’s one of the reasons specialty drugs are so expensive.”

MedCost Pharmacist Zafeira Sarrimanolis agrees. “It’s an exciting time in the drug manufacturing world, because all of these new medications have been coming out over the past ten years or so for medical conditions that really weren’t treatable before.

“For example, hepatitis C medications previously were not very effective and really hard for patients to tolerate. Now we have new medications on the market that are practically a 100% cure rate for patients.

specialty drug costsThese drugs are also a lot easier for them to take and tolerate. Part of the problem with that is the price tag on some of those new medications.”

“One of the largest reasons people are readmitted to the hospital is because they don’t adhere to the medication,” said Michael Cornwell. “Programs like step therapy ask you to try a clinically appropriate drug before you try a similar but more expensive one.

Prior authorizations probe a physician’s reasoning behind prescription choices. A lot of these specialty drugs are really for a pretty small percentage of the population. So when you look at a population as a whole, the people taking those drugs are usually between 1%-1½% of your population. That’s the good news.

“The bad news is they’re very expensive. Probably the biggest growth area in the specialty arenas are the cancer drugs. There’s a whole pipeline of new cancer treatments hitting the marketplace. But in that pipeline, member education and aid in helping and consulting is a good thing too. It allows us to have some personal outreach try to help these people manage their disease state.MedCost

(This post is a transcript from the video, CONTROLLING SPECIALTY DRUG COSTS.”)

 

5 Factors in Employer Prescription Drug Costs

Why are employer prescription drug costs spiraling higher every year?

“There are a combination of factors,” said Zafeira Sarrimanolis, PharmD, MedCost Pharmacist and Clinical Consultant. “This is a major problem for employers who do not want to make employees unhappy by instituting clinical pharmacy programs in their health plans.”

employer prescription drug costs


What Are the Factors in Employer Prescription Drug Costs?

  1. Manufacturer Price Hikes.

    Costs for drugs like EpiPen® and Humira® have been widely publicized.[i] Prices are escalating 16-17% per year. Manufacturers are also promoting new uses for existing high-cost drugs, even though there are already FDA-approved, lower-priced drugs for the same conditions already on the market.

  2. Increased Use of Prescription Drugs.

    The number of people taking cholesterol drugs is up from 6.5% (1999-2002) to 13.1% (2009-2012). Similar increases are seen in other common chronic conditions, including depression which increased 6.4% to 9.0% over the same period.[ii]

employer prescription drug costs

 

3.Specialty Drugs.

New, expensive medications for diseases such as cancer and multiple sclerosis are constantly hitting the market. Specialty drugs account for about 1% of total prescriptions but 35-45% of pharmacy spend, averaging $3,400 per drug per month.[iii]

4. Patent Expirations.

In 2016, Crestor, Zetia and Benicar all had patent expirations. The increased competition from generic equivalent drugs is decreasing costs across the board. Unfortunately for high-cost injectable medications like Humira, the introduction of generic versions is not as simple.

5. Advertising.

An estimated 80 drug commercials per hour are shown across TV outlets.employer prescription drug costs[iv] Radio, magazines, newspapers and social media also contain prescription drug ads that prompt individuals to ask doctors about specific drugs.

It’s an exciting time in the drug industry with the influx of new drugs coming on the market,” said Michael Cornwell, MedCost Director of Sales and Underwriting. “But it also presents challenges for us in the industry since controlling these costs is not always user-friendly.”

 

Employer Strategies for Controlling Prescription Drug Costs

 

Pharmacy Benefit Managers

Working with a Pharmacy Benefit Manager (PBM) supports cost management for employers in the pharmacy portion of their health plans. A PBM negotiates discounts and rebates from drug manufacturers, which are then returned back to the employer. PBMs also contract with pharmacies and process pharmacy claims.

The PBM controls pharmacy costs for employers through development of a preferred drug list (or formulary) and clinical programs. MedCost as a benefits administrator works closely with PBM partners to get the best rates for employers, customizing a pharmacy plan for each client’s unique population.

Formulary Management

Preferred drug lists are arranged in tiers, or cost levels, of generic, preferred and non-preferred medications. A PBM Pharmacy & Therapeutics Committee of industry experts follows a clinically-driven formulary decision-making process to define the preferred drug list. Some drugs are excluded from coverage in favor of clinically-similar alternatives that treat the same disease.

Exclusions can save as much as 15% of prescription drug costs in an employer’s health plan.

Prior Authorization

Prior authorizations require a doctor to provide additional clinical information to determine whether the health plan covers that drug. Employees, providers and health plan administrators dislike the inconvenience of waiting for approval of drugs. But this strategy is key to ensure that members take safe, clinically-appropriate and cost-effective drugs.

“There’s a human factor,” said Michael Cornwell. “We do not want to be disrupted in using familiar medicines. But employers cannot save money without these strategies.”

Step Therapy

Step therapy requires initial use of a lower-cost, clinically-similar drug for a medical condition, before a higher-cost drug for the same condition is covered by a health plan.

Summary

When 1% of prescriptions drive 40-45% of an employer’s pharmacy spend, avoiding wise management is no longer optional”, said Zafeira Sarrimanolis. “Part of my role as a MedCost Pharmacist is to emphasize the importance of cost-management strategies to our employers and consultants.”

“I also work closely with our clients to help employers understand the importance of educating their employees about these changes and why they are needed.”

“It’s all about making sure each employee gets the right drug for the right medical condition at the right time. That’s how we control pharmacy costs.MedCost

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[i] Brad Tuttle, “21 Incredibly Disturbing Facts about High Prescription Drug Prices,” Money Magazine, June 22, 2016, http://time.com/money/4377304/high-prescription-drug-prices-facts/ (accessed April 26, 2017).

[ii] “Health, United States, 2015,” National Center for Health Statistics, Centers for Disease Control and Prevention,   https://www.cdc.gov/nchs/data/hus/hus15.pdf#079 (2009-2012), (accessed April 26, 2017).

[iii] “The Growing Cost of Specialty Pharmacy – Is It Sustainable?” American Journal of Managed Care, February 18, 2013, http://www.ajmc.com/payer-perspectives/0213/the-growing-cost-of-specialty-pharmacyis-it-sustainable (accessed April 26, 2017).

[iv] “Prescription Drug Costs Remain Atop the Public’s National Health Care Agenda,” Kaiser Family Foundation, October 28, 2015, http://kff.org/health-costs/press-release/prescription-drug-costs-remain-atop-the-publics-national-health-care-agenda-well-ahead-of-affordable-care-act-revisions-and-repeal/ (accessed April 26, 2017).