If you want employees making better health care decisions, then give employers the data they need to create effective health plan choices.
For years, insurers have perpetuated the myth that the data does not exist. Your client is too small, or the data is not credible, or privacy laws prohibit its release. Today's buzzword in health care is transparency, but somewhere along the line, change advocates forgot a key player - the employer.
Employers would never make a major purchase without data. Yet, for health care coverage, that is exactly what they are required to do. Employers know more about the office photocopy machine than they do about their health plan. Year after year, employers must tolerate double-digit increases without the data to know what the increase represents or more importantly, how to fix it.
Is it any wonder that health care reform became a rallying cry?
Myth-buster
Benefit advisers seeking health care data on behalf of their clients run into major resistance from insurers. The industry-wide practice denies employers access to health care data on their own health plans - data employers are entitled to and need for plan management.
Let's examine the reasons for withholding health care data. First: The client size is too small for tracking the data or, if there are data, they are too small to be credible. Regardless of client size, if the health plan incurs claims, there are claims transaction data.
Regarding data credibility, insurance professionals understand credibility. This is not a pricing or underwriting issue; it is a need for information. Non-credible data does not mean the data has no value. Even small amounts of data reveal trends that help employers develop strategies for spending their precious health care dollars.
You can never have too much data. Here is an example: The claim data for an employer-sponsored health plan reveals a higher use of the emergency room than urgent care. Even though the data is not statistically credible, it highlights the need for an adjustment to the plan design. The new plan design includes a disincentive for non-emergency care provided in the ER.
The second reason for withholding health care data is privacy concerns. HIPAA permits the release of protected health information under certain circumstances. The Health Information Technology for Economic and Clinical Health Act of 2009 expanded the HIPAA privacy and security rule. Business associate agreements and revisions to plan documents specify compliance with HIPAA regulations on the use and disclosure of PHI. With agreements in place, HIPAA permits insurers to release PHI. De-identified information that does not identify an individual is not subject to HIPAA privacy rules. While compliance is challenging, it is possible for insurers to produce HIPAA-compliant reports with meaningful health care data.
The full-view approach
Claims data provide a rear-view mirror perspective on what happened in the past and offer an ongoing measurement for comparison. Claims data remain a key analytical tool; however, insurers and employers need to shift from looking only in the rear-view mirror to full-view approach. A full-view analysis adds present issues identified through health assessments and health screenings, as well as plans for the future via employee engagement surveys.
Here's an example of the effective use of past, present and future data. Employees participate in their company's health assessment surveys and complete recommended health screenings. Through that process, health professionals identify several risk factors, including diabetes, high blood pressure and asthma. Both claims data and health assessments reveal non-compliance issues, where at-risk employees are not following physicians' prescriptions for care. The benefit adviser, insurer and employer collaborate on a strategy for improving compliance and removing barriers to care. The strategy includes a plan design change with incentives for compliance, ongoing education programs for the identified risks, and regular surveys for measuring employee engagement.
If employers have any hope of controlling health care costs, access to health care data is critical. Without the knowledge of their specific health care trends, employers' options are meaningless.
Informed decisionmaking
Data leads to information, which leads to the knowledge employers need to take action. Employers need access to data that is both real-time and detailed.
Greater transparency provides employers with not only total paid claims, but also the services provided and utilization trends. It allows for predictive modeling and the development of important health programs designed for the specifics of the employer's health plan.
Historically, cost control has focused on decreasing utilization, when it should focus on creating the right utilization. For example, instead of looking at the number of visits, analyze the types of visits.
Texas law on transparency
The timely release of health care data is equally important for employers in fulfilling their fiduciary responsibilities under ERISA. Texas was the first state to pass a law mandating health care transparency. The Texas law allows employer plan sponsors, including fully insured group plans, access to more detailed claims data. It requires an insurer response within 30 days of a written request from a plan sponsor. The law addresses privacy concerns by requiring proper certification from the employer plan sponsor that complies with HIPAA standards. It is a model worth considering as the new standard for insurers for delivering timely and detailed health care data to employers.
How insurers can help
Insurers do not like customers treating health insurance as a commodity. The complaint is there is no customer loyalty. If insurers want the relationship of a trusted adviser with long-term business relationships, greater transparency in health care data is a first big step.
The insurers have the data. Now they need to share it and collaborate with plan sponsors and the plan's benefit advisers in the battle against rising health care costs. Insurers can help in several ways.
First, recognize that not all claims are created equal. Insurers should change their thinking of claims in terms of volume and start thinking in terms of high- and low-value claims. A high-value claim is the right utilization, like a follow-up visit with the primary care physician to review lab results. Create plan designs that encourage high-value claims.
Second, insurers must blow up the cookie-cutter approach to plan designs. An effective plan design adjusts to the needs of the employer's utilization. If there is low compliance on prescription drug medication, for example, design the plan for incentives that encourage utilization. If copays are too high for targeted risk factors, lower them or remove them altogether. That is encouraging the right utilization. The savings are the lower incidence of heart attacks, strokes and other debilitating illnesses. Pitney-Bowes launched this concept, known as value-based benefit design, and it is gaining popularity because it works.
Third, in addition to sharing the health plan's data, share normative data and the insurer's best practices. Insurers have a tremendous amount of intellectual capital. They can "slice and dice" health care data to produce real value without sacrificing proprietary information. For example, one insurer developed a star-rating system for evaluating the performance of a 28-employee health plan. Four stars was the highest rating. Without releasing proprietary or protected health information, the insurer reported a rating of two stars for compliance with prescription drug medications. With the information, the employer, with the help of the benefit adviser, was able to develop an education program and look for alternative plan designs that encouraged compliance.
Employers have shifted from thinking of health care as an expense to recognizing it as an investment needing value. Insurers bring that value through greater transparency in health care data and a commitment to real change. EBA
Kahle is SVP and chief wellness officer for Intercare Insurance Solutions in San Diego.
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