That’s the question many healthcare providers are asking now, in light of the fact that everyone from recognizable retailers to Internet titans have descended upon the industry to disrupt the way healthcare services are provided. It’s understandable for providers to feel bewildered by the newfound boldness of the healthcare consumer (what we used to call the “patient”); however, it’s important to understand that said boldness is not necessarily the consumer’s fault. As stated, other entities have come on the scene in recent years. They are intent on wreaking havoc on the way providers do business – and patients, hoping to save some money, are just doing their due diligence by researching all their options. Some of the ways that healthcare has become consumerized include new, non-traditional business models such as:
- Clinics setting up shop in grocery chain stores
- Medical tourism for surgeries and tests
- Online diagnostics and consultation
Of course, no one is saying these healthcare business models are recommended – but they are popular, and they cater to a new generation of patients that have grown up believing convenience is a right in their life, rather than a bonus. That belief would especially apply to their healthcare. Now that members of this generation are starting to have children of their own, they will naturally expect that their kids will have access to the same conveniences; in fact, they probably expect healthcare to become even more convenient as time goes on. As more and more providers begin to satisfy these expectations, the providers who fail to deliver the same convenience will be shut out.
So, how can providers make sure they don’t get left behind? True, it may not be practical to set up shop in a supermarket – but what about offering online access to medical records? This is a feature that many parents of young children appreciate. Extended hours are another amenity that providers can consider; it’s not non-traditional, but it’s certainly convenient, and it can help providers retain some of their more consumer-minded patients.
Providers that need guidance in the new, consumer-driven healthcare landscape may benefit from a consultation with a healthcare consultant. GM&A gladly speaks with providers that request this guidance; feel free to contact us today with your questions.
We recently addressed third party administrators that are hired by self-insured employers to process claims, also known as TPAs. Now, we’re here to explain a category of TPA called a pharmacy benefit manager, or PBM. A PBM is typically a TPA of prescription drug programs, tasked with the responsibility of processing and paying out prescription drug claims. Other responsibilities of a PBM include:
- Creating and updating the formulary (the list of medicines that may be prescribed)
- Contracting with pharmacies for patients and providers
- Negotiating prices, including discounts and rebates, with pharmaceutical manufacturers
Although this may be your first time hearing of them, PBMs are not uncommon at all; in fact, the majority of insured Americans receive prescription drug benefits that are administered by PBMs. Direct contracting companies like us like PBMs because we can help the pharmacy chains we contract with get better rates by negotiating with the PBM.
We can also discuss the prospect of our clients getting high quality, generic equivalent drugs and rebates, so that patients (covered employees who work for our employer clients) can get the medications they need at prices that are generally affordable for them. Likewise, our employer clients can pay a fairer price for prescription drug benefits so that their bottom lines will remain intact. This is just another benefit employers can take advantage of when they choose to use direct contracting for health insurance obligations. If you have any questions, feel free to contact GM&A today. We will be glad to explain the ways we can help employers like you negotiate pharmacy benefits.
As you may have heard, self-funded healthcare plans can be a very effective way to mitigate the escalating cost of healthcare in the United States. This is especially the case for large firms with 1,000 or more employees – firms that would otherwise be forced to reduce plan options in the new healthcare frontier we now find ourselves in.
So, how much money can a self-funded healthcare plan save a large employer? According to a Kaiser Permanente study, it may be able to save them up to $700 per employee every year. Yes, per employee! If the company indeed has 1,000 employees, that’s a savings of $700,000 a year. Even for a large, profitable corporation, that’s not pocket change!
As for mid-size firms that cover anywhere from 100 to 1,000 employees, they have been slightly less enthusiastic about choosing self-funded healthcare plans. As it turns out, only 58 percent have chosen to self-fund company healthcare, while 93 percent of companies with 5,000 or more employees choose to self-fund. Why the hesitation? It may be because the cost of administering a self-funded plan, combined with the premium payments necessary to cap their risk with stop loss coverage, is just too big a hill to climb. It may seem too costly, too complicated and just out of the company’s “league,” so to speak – and that’s fine. Self-funded healthcare plans are great, but they aren’t right for every employer.
One option these mid-sized companies may consider is a captive stop loss agreement, which requires them to pool their risk with other insurers in order to attain the critical mass and stability they need to keep benefits secure. This “group purchasing power” adds a much-needed level of protection against catastrophic losses, so it can be ideal for mid-sized businesses.
If you have questions about self-funded healthcare plans or captive stop loss agreements, contact GM&A to request a corporate healthcare consultation. We will be glad to see if we can help.
One question we are frequently asked is whether we work alongside healthcare consultants or third party brokers, if a company that is our client wishes to bring one in for any number of reasons. The answer is yes, we do. Here’s why: We see these professionals as colleagues and partners, not competition. Our business model only succeeds if our clients save money, so we are happy to work with anyone else a company has brought in to help them save money. We can work together to achieve the client’s goal, no matter what that goal is.
Sometimes, the objective of the consultant is to implement a wellness program that will reduce the company’s overall healthcare costs; this is becoming increasingly common, now that the government gives companies a “reward” of sorts in the form of a discount on health insurance premiums, deductibles and other costs; the discounts may be up to 30 percent or more, especially if the programs are designed to help employees quit smoking. This is another development that was introduced in the wake of the Affordable Care Act, so we have been doing this for the past couple of years as companies have begun taking advantage of it.
Other times, the aim of the healthcare consultant or broker is to help its client companies find the best possible health plan for the organization. They take into consideration factors such as the size of the company, demographics of employees (i.e. women of childbearing age, older adults, etc.), in addition to data on the nearest providers. No matter the reason a company has brought in a healthcare consultant or broker, we can work alongside these outside professionals to help the company attain its goal. If your organization is working with a broker or consultant to choose the best health plan, implement a wellness program or accomplish some other healthcare-related tasks, contact GM&A to see how we can help.
Much has been said over the past couple of years regarding the employer’s obligation to provide healthcare benefits, underscored by the Affordable Care Act and the political push back surrounding it. While it may be true that the law has been helpful to some who did not previously have health care coverage, there are plenty who disagree once they log onto Healthcare.gov and see the high cost of the plans in their state exchanges.
For employers, the government offers an option in the Small Business Health Options Program (SHOP); however, many small business owners are also dismayed to find that the cost of taking advantage of the program is far higher than what they expected it to be. And for local government organizations, the cost is surprisingly higher.
Take our client, the Tyler Independent School District in Tyler, Texas. Tyler ISD wanted a healthcare coverage option for its 17 elementary schools, six middle schools and two high schools. The state plan cost was so high that some in the district feared layoffs would be necessary in order to make up for the cost of providing employees with healthcare – and this was back in 2001, when the economy was stronger and it would be years before the Affordable Care Act was in the picture.
Even then, we were able to negotiate significant discounts with a local provider network for the Tyler ISD health plan. According to district officials, these discounts have resulted in millions of dollars being saved by the school district in the years since the plan was enacted – and, as one spokesperson told us, “The benefits of the state plan are less than our benefits,” and they come “at a higher cost.”
Health care consulting is a service that has become absolutely necessary in 2014. If your business or local government organization is unsure how to cover employees affordably and comprehensively, contact GM&A to see what we can do for you.