Employee Benefit News
Medical officer warns employers against exchange-only health benefits model
Posted December 18, 2012 by
By Raymond Fabius, MD, CPE, FACPE at 11:40AM.
In conjunction with this monthfs EBN cover story, gBuyer beware,h which examines consumer readiness
for purchasing their own health care coverage via public and private exchanges,
Dr. Raymond Fabius, chief medical officer at Truven Health Analytics, penned
this guest blog post questioning the wisdom of shifting to the exchange-only
model. Read his arguments against moving away from the employer-sponsored health
care system, and share your thoughts in the comments. —Kelley M. Butler
Sears Holdings and Darden Restaurants shook up the health care industry
recently, when they announced a new approach to providing health care coverage
to employees. Under the new plans, employees will be given a fixed sum of money
each year to choose their coverage and insurer from an online marketplace.
The logic behind the approach is simple: By creating a marketplace, employees
will be able to comparison shop and insurers will compete harder to get workers
to select their plans, ultimately lowering health care costs. Unfortunately, the
realities of health care consumerism do not follow simple logic.
Consider the recent health care experiences of Johnson & Johnson,
Navistar and PPG — companies that all have found that providing more
comprehensive benefit designs to their employee populations have actually helped
to reduce overall health care costs. In Johnson & Johnsonfs case, after
analyzing the cost of treating chronic conditions related to obesity, high blood
pressure, high cholesterol and tobacco use among its employee population,
implementing a preventive wellness program saved the company $565 per employee
per year — between $1.88 and $3.92 for every dollar spent to implement the
program. Similarly, Navistar and PPG were able to reduce overall medical costs
by increasing their investment in wellness, risk reduction and disease
management.
These types of population-specific nuances can get lost when benefits are
designed exclusively around short-term cost-cutting. By implementing what
amounts to a privatized health care exchange for their employees, Sears and
Darden are succumbing to a tempting, but potentially dangerous, assumption that
a health care market will behave like a stock market. But health care is not
governed by efficient market forces. All available information is not
gpriced-inh for health care consumers.
In fact, our research on moving employer-sponsored health care coverage onto
an exchange-based benefit design shows that there is no short- or long-term
financial advantage. Using insurance claims and wage data from 33 large
employers with 933,000 employees, we were able to project employer health care
costs for 2014-2020 under a number of different exchange-based scenarios, each
with varying levels of employer/employee contribution.
Ultimately, we found that moving employees onto a government-subsidized
insurance exchange would increase the financial burden as much as $17,268 per
employee per year, which is $9,000 more per employee per year than they
currently spend. This estimate was based on the assumption that the employer
would make the employee gwholeh by providing after-tax wage increases to
subsidize the additional costs for employees to purchase insurance through the
government insurance exchange. We also modeled a scenario in which the employer
did not subsidize the employeefs additional costs at all, which resulted in a
cost-shift to employees of more than $16,000 per year.
How can moving employees onto an exchange-based model increase total
healthcare costs by thousands of dollars a year? There are several areas where
employers can lose efficiency and incur significant unexpected costs if they
donft ask the right questions.
Chief among these is a major loss in purchasing power. By effectively
fragmenting employees across a marketplace of insurers, early adopters of
consumer-choice plans will lose their chief source of leverage in negotiating
bulk discounts with health plans. Employers moving onto an exchange-based design
also must evaluate the incremental additional cost of carrier risk, margin and
exchange administration fees. Based on our model, the estimated cost of lost
purchasing efficiency by moving to an exchange is $2,990 per employee per year
on an allowed cost basis including administrative service and margin costs.
The second major driver is a lost opportunity to manage population health and
productivity for the long-term. Whereas Johnson & Johnson, Navistar and PPG
were able to achieve cost reductions by analyzing and tweaking their benefit
design based on the behavioral realities of their employee populations,
companies that shift the benefit selection process to their employees lose the
kind of aggregate, company-wide analytics that can influence truly effective
benefit design. Critical measures such as chronic disease management and its
relationship with absenteeism and the impact of wellness programs on population
health are incorporated into effective top-down benefit design. When plan choice
is left up to workers themselves, will they always choose the most effective
plan for managing their unique health care needs?
Beyond these issues, there are still several unknowns surrounding the
treatment of private insurance exchanges in accordance with the Patient
Protection and Affordable Care Act.
Still, with its laser focus on short-term cost-reduction, the insurance
exchange approach likely will gain followers among employers. Our data show
large employers with traditional benefit designs in place spent $10,120 per
employee per year on medical and pharmacy payments in 2011. Without any
changes in benefit design, that number is projected to rise 4.9% to $10,615 per
employee in 2012 and 5.1% to $11,156 per employee in 2013. Amid the current
economic struggles, any new approach that looks like it will decrease that
burden while keeping companies compliant with PPACA is tempting.
As more companies consider following the lead of Sears and Darden, it will be
critical for those involved in the benefit design process to carefully evaluate
the real-world cost of an exchange-based approach. This involves digging much
deeper than bottom-line premiums. Long- and short-term population health,
employee productivity and maintenance of chronic disease will be the true
metrics against which effective plan design is measured. By focusing on cost
alone, we are ignoring an important half of the health care equation: good
health.
Raymond Fabius, MD, CPE, FACPE, is chief medical officer at Truven Health
Analytics, a provider of healthc are data and analytics solutions and services.
He can be reached at raymond.fabius@truvenhealth.com.