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How benefit advisers can hold healthcare plans accountable for their prices

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Brokers and consultants already know that much of the growth in health benefit costs is not driven by insurer and TPA rate increases, but rather by the increase in the price and volume of healthcare services. While some of these costs are due to growing survivability rates for serious diseases and therapeutic improvements, much are avoidable, such as expenses associated with unnecessary care and unnecessarily expensive care. Evidence of variability of costs is found in the fact that unit cost and utilization can vary wildly from health system to health system, even within the same market.

Read more: 4 drivers of healthcare costs — and what advisers should do

Just because macro healthcare economics is the primary driver of overall health costs, doesn’t mean that health plans are powerless to control price increases. Even though health plans can and do negotiate rates directly with health systems in their networks, too often they don’t do everything they can to offer exceptional value to their customers. They don’t ask the right questions of health systems, they don’t practice thorough utilization management, and they don’t contract exclusively with providers who focus on high-value care. In other words, they don’t work hard enough to eliminate unnecessary costs or to bring prices down. Instead, they treat them as a given and pass those costs on to their customers.

Navigating these economic realities is challenging, and employee benefit advisers have their work cut out for them as they try to find the health plans that offer the most value for their clients. In order to discern which health plans offer the best bang for member bucks, benefit advisers need to understand the economics of healthcare today, and in particular, the economics of the market in which they operate. They can do this by asking hard questions of health plans and digging into data in order to determine healthcare cost and utilization differences between networks in their area.

Too often, benefit advisers take the whole healthcare market as a given, especially due to the popularity of broad preferred provider organization (PPO) networks, which include almost every system in an area. But the reality is that economics vary dramatically from system to system, so employee benefit advisors need to understand local economics in order to effectively evaluate network differences and find value. They can do this by:

  • Heavily and skeptically questioning carriers and TPAs to understand their networks and participating providers. Examples of questions to ask include: Tell me your opinion about different health systems in your network? How much do negotiated fees vary for outpatient services, professional services, etc.? Why is a specific expensive provider part of your narrow / high-performance network?

It’s also important to ask when a contract with a specific health system is up and if it will be renegotiated soon, since a new contract could include very different rates from the current one. Note that some of the time, carriers will discuss rates as a function of Medicare, but because Medicare DRG rates can vary dramatically from hospital to hospital, an adviser needs to understand Medicare base rates.

  • Analyzing claims. Every adviser has plenty of these available to them, and they should be analyzing those claims to determine which providers are lower cost and which are higher cost. In particular, it’s important to look at outpatient rates, facility rates, and professional rates, by specialty. It’s also important to compare the same diagnosis codes across providers. For example, claims could reveal that a hypothetical Dr. Jones operates on 100 patients out of 100, while a hypothetical Dr. Smith operates on only 50 patients out of 100 with the same condition. To figure out why this discrepancy exists, we would have to dig deeper since some doctors or practices may cater to only high-risk patients. Claim data can help shed light on health plan information that is not typically available to the public as health plan rates are often proprietary but appear on claims.

Taking all of these steps will help benefit advisers achieve something essential: holding health plans accountable for their prices. If a health plan doesn’t aggressively hunt for high value providers and reward them, you should ask why. And if you don’t like their answer, you probably identified a plan that isn’t a good fit for your clients because it doesn’t deliver on what matters most: quality care offered at an affordable price without compromising coverage.

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