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The Truven Health Blog


The latest healthcare topics from a trusted, proven, and unbiased source.


Will Your Benefit Plan(s) Trigger ACA’s “Cadillac” Tax? Start Planning Today.


By Tom Halvorson/Thursday, June 11, 2015
A recent Wall Street Journal blog outlined the efforts some CFOs are taking to prepare for the ACA’s so-called “Cadillac Tax” provision.  But is it enough? A survey from Aon Hewitt found that a quarter of employers have not yet determined the impact of the “Cadillac” tax on their benefit plans, and more than one-third reported that their executive leadership and finance teams have limited or no knowledge of the implications of the tax for their organizations.

It’s critical to effective planning for budgeting, collective bargaining, and benefit strategy that employers understand which plans — current and future — are likely to incur the tax and when each plan’s costs may be likely to cross the excise thresholds. The earlier employers can quantify the impact of the tax, the sooner plans can be put into place to mitigate or defray the expense.

According to Truven Health Analytics latest research,* which analyzed recent MarketScan® claims data* for more than 13 million active employees, non-Medicare retirees, and their families in more than 2,500 self-funded plans to identify real-world healthcare spending trends, 15% of active employee plans are projected to incur the tax upon its activation in 2018, and by 2020, more than 19% of plans are expected to incur the tax. We estimate the tax would result in a cost increase of up to $480 per employee per year (PEPY) for plans expected to incur the tax.

Our study also found that early retiree plans are projected to exceed the statutory thresholds at a much higher rate than active employee plans. Eighty-one percent of early retiree plans for U.S. employers are likely to incur the “Cadillac” tax, and this rate is projected to increase to 84% by 2020. For the plans that we’ve projected will be impacted by the “Cadillac” tax, there will be an annual increase of $1,609 PEPY, or 6.8% of total costs.

We conducted similar research for industry groups such as health systems, universities, and public employers, and these analyses revealed that nearly 40% of active employee plans for health systems and more than 25% of active employee plans for universities in this study are projected to incur the “Cadillac” tax by 2020.

By implementing a combination of benefit design changes, premium contribution alterations, and health risk interventions, you can mitigate the impact of this new tax in 2018 and beyond. Early awareness is key. For more information on the effects of the Cadillac Tax, read our research brief. And contact us to learn how our modeling tools can help. 


Tom Halvorson
Director, Practice Leadership


*The study was executed using data from the Truven Health MarketScan® Commercial Claims and Encounters Research Databases, which consists of medical and drug data from employers and health plans. It contains data for more than 59.9 million individuals annually, encompassing employees, their spouses, and dependents who are covered by employer-sponsored private health insurance.



The Hidden Impact of Drug Formularies on Member Health


By Kristen Lybrook /Wednesday, October 22, 2014
A recent Action Brief from the National Business Coalition on Health described prescription drugs as the third largest healthcare expense in the United States. As plan sponsors continue to search for opportunities to manage rising prescription drug costs — including option-limiting strategies such as narrow pharmacy networks and formulary options — the larger Pharmacy Benefit Managers (PBMs) have implemented a closely related strategy: exclusion of products from their standard formularies.


 
The PBMs assert the exclusion of products from the formulary has had a positive impact for plan sponsors:

  • Increased rebate payments due to greater leverage with pharmaceutical manufacturers.
  • Exclusion of “me-too drugs” that are structurally very similar to existing drugs, but with a high price and little, if any, clinical benefit.
  • Control of products linked to manufacturer copay coupons that reduce member cost sharing but increase the plan’s cost.

However, plan sponsors must also consider the impact of excluding therapies on a member’s medication adherence and overall health outcomes. When a claim is rejected at the pharmacy because the drug is excluded from the formulary, the member must pay out-of-pocket or ask their physician to prescribe an alternate medication. The increased cost or additional effort can be a barrier for members and may cause them to abandon the prescription, which can compromise their health and lead to costly complications.

Member out-of-pocket costs are also negatively impacted when a PBM chooses to reduce therapy options to one brand product in a class. For 2015, the two largest PBMs have limited the formulary option for diabetic test strips to one brand product line. Although plan sponsors will see an increase in rebates, members enrolled in a Consumer Driven or High Deductible Health Plan will likely face higher out-of-pocket costs at the pharmacy to comply with the formulary.

The member may choose to go outside of the benefit to purchase lower-cost supplies; however, the costs won’t count toward meeting deductibles or out-of-pocket maximums. Further, utilization data for the claims will be lost because the claims will be rejected at the point of sale. Thus, any medication adherence or disease management program reporting you produce will be understated, making it seem like members are non-compliant when they are making choices based on paying a lower cost.

To ensure you fully understand the impact of any formulary changes made by your PBM, consider:

  • Conducting an independent review of your PBM’s formulary to evaluate whether the changes being made are clinically appropriate.
  • Gaining a thorough understanding of the cost impact of formulary changes to both you as the plan sponsor and to your members as consumers.
  • Asking what support is available to encourage impacted members to start on a new therapy and monitor that they continue to take them.
  • Providing members with resources (letters, articles, newsletters) to help them make informed decisions about medications.

Kristen Lybrook
Account Director


Consumer Engagement Grows as CDHPs Gain Popularity


By Chris Justice/Wednesday, October 8, 2014

Consumer-Driven Health Plans (CDHPs) are one of the fastest growing benefit options offered to employees – and soon may become the dominant plan type. In fact, a recent Kaiser/HRET survey found that CDHP enrollment has gone from just 4 percent of all employees who were given that option in 2006 to 20 percent in 2013. 

In order to ensure CDHP members can effectively engage in their healthcare, employers must provide participants with timely access to consumer information tools to help them understand the range and cost of treatments available through plan providers and also information about provider quality. In the absence of this kind of help, CDHP participants are faced with a daunting task to make effective care decisions.

In addition to employees becoming more educated about their own healthcare, the companies they work for are offering new options that provide incentives and potential savings for the enrollees, as well as the employer itself. As part of a recent survey of Truven Health MarketScan™ data contributors, 64 percent of companies stated that they currently offer one or more CDHP options, and 76 percent stated that they will offer one or more in the future. The majority of these options consist of CDHP or high-deductible health plan (HDHP) with a health savings account (HSA) feature. 

This type of growth is leading to a new paradigm in which more patients are taking on a greater role in treatment decision-making. For instance, under a traditional PPO plan in the past, it was very likely that a breast cancer diagnosis would result in a set course of action. However under a well constructed CDHP, the patient can make assessments based on the price she is willing or able to pay, the quality of treatment and providers, and even the best locations to receive the necessary treatment. With the help of her doctors and advisors, she can decide what’s best for her. She is engaged in her own plan for her health and treatment. 

As this substantial shift continues, employers have the ability to empower their employees by providing the opportunity for them to be engaged in their own healthcare decisions, leading to cost-savings for the employee — and the organization.   

To learn more about achieving year-round engagement with your employees, please access this complimentary insights brief from Truven Health Analytics.

Chris Justice
Senior Director of Practice Leadership


Although Not Typical, Walmart’s Employee Benefit Costs Worth Noting


By Anita Nair Hartman/Tuesday, September 16, 2014
Anita Nair-Hartman imageA recent CNBC article discussed Walmart’s announcement that it will spend far more than anticipated on employee health coverage and have to trim its earnings forecast for the year. The retailer expected more workers to seek coverage under the Affordable Care Act’s (ACA) mandated coverage requirement, but the actual number topped their projections. Although this news has gotten a lot of attention, National Business Group on Health research indicates that most employers aren’t expecting as large of a jump in healthcare costs as Walmart, and Truven Health research supports this. As the CNBC article points out, Walmart’s employee base has some unique characteristics -- including low-wage workers in states where Medicaid expansion didn’t occur, forcing them to chose Walmart (rather than Medicaid) coverage. These aren’t typical employer circumstances.

Nonetheless, after years of low healthcare inflation, employee benefit costs have grown this year, and Wall Street is going to be keeping an eye on the impact to every company’s bottom line. For employers, monitoring benefits spend and strategy is more critical than ever. Equally important will be engaging employees in healthcare decision making, improving health and productivity through wellness programs, and remaining vigilant on fraud and waste.

Anita Nair-Hartman
Vice President Market Planning and Strategy

Large Employers Continue to Manage Their Healthcare Spend


By Michael L. Taylor/Tuesday, September 2, 2014
Mike Taylor imageA recent survey published by the National Business Group on Health (NBGH) found large employers haven’t stopped trying new ideas to control their healthcare spend. Various consulting firms have predicted anywhere from a 4% to 9% healthcare cost increase for 2014, with a sharper uptick in 2015, so these strategies are very important. The medical spend trend in the past several years has been more moderate due to a combination of lingering effects from the recession and payment reform. What strategies will employers use to control costs in the future? Here is a partial list (in no particular order):
  • Employers will continue to implement higher co-pays and deductibles. This has been occurring for 20 years with the employer typically paying 70-80% of the cost and employees picking up the rest.
  • The use of high-deductible health plans (HDHP) will continue to grow, with deductibles above $1000. HDHP include the full cost of all prescriptions as part of the deductible, and employers expect that strategy to drive more transparency around drug costs and a higher demand for generics.
  • Employers will more carefully consider the use of spousal surcharges. The logic is that if a spouse has other coverage because they work at another employer, the spouse should take that coverage. Spousal surcharges run more than $100 per month, and are intended to incent the spouse to seek other coverage.
  • Large employers haven’t given up on wellness programs. We will see continued interest in financial incentives to change behavior, with a minority of employers incenting outcomes such as weight loss, tobacco cessation and physical activity.
  • Many employers haven’t found value in disease management programs and are looking into other ways to help employees better utilize healthcare services. The future of disease management programs is unclear, but providers are working hard to target these programs to patients who are most likely to benefit.
  • “Specialty drugs” or “biologics” are a growing cost issue. As has been reported by many, the new Hepatitis drug costs $84,000 for a 12 week treatment. Specialty drugs consume roughly 25% of the drug spend, but are projected to rise to nearly 50% in the coming years. Employers will likely use step therapy and prior authorization programs to manage these costs.
  • Interest in narrow networks will continue to grow, including incentives to receive care at distant medical centers and “Centers of Excellence.” Large employers with many employees at one location are studying the feasibility of contracting with only a few hospitals by offering the hospitals a larger volume in return for a lower unit price. I believe this will be limited to certain procedures (cardiac bypass, hip and knee replacement) rather than full alliances.
  • Employers will continue to drive “pay for value, not volume” payment reform. This is a newer trend, but I believe it will grow substantially in the next several years. Employers want to know they are buying high quality healthcare, and not paying for wasteful unnecessary care.
  • Employers are still considering more transparency tools to help their employees understand cost, but many employers are looking to their health plans to provide these tools.
  • Most employers have shifted their retiree benefit plans (especially for the pre-65 retirees) to an exchange, rather than allowing the retirees to remain on their traditional plans.
  • Some employers are looking to public or private exchanges. These conversations are less likely to be occurring for those who employ large numbers of knowledge workers; most of this activity will likely take place among companies that employ low-margin service employers.
Our clients are studying many options. There is no single clear strategy; every employer has a different culture, and a unique approach to managing costs. These choices are difficult for employers to evaluate, because there are so many variables and confounders that it’s difficult to know what parts of the strategy are actually working. Employers are depending more and more on data and analysis to understand all these moving parts. The one constant among all the variables will be the need for data and thoughtful analysis.

Michael L. Taylor, MD, FACP
Chief Medical Officer

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