Friday, October 17, 2014

Will Employers Favor Private Exchanges Over Coverage Sponsorship?

Originally posted 10/17/14 on The Health Affairs Blog

By Brian Klepper

Over the past couple years, health care exchanges probably have consumed more of corporate benefits managers’ time and psychic energy than any other topic. An outstanding question is whether the rank and file of American businesses will drop the hassle that employer-sponsored coverage represents, or default to private exchanges.

Private exchange offerings typically move employees from their companies’ previous self-funded health plans to fully-insured individual arrangements, purporting to offer more flexibility and choice that can adapt to the wide-ranging needs of employees and employers, while creating a more competitive health plan marketplace.

Several recent surveys have reported that employers plan to move aggressively to private exchanges. In a survey last year of more than 700 businesses, the Private Exchange Evaluation Collaborative, a group of regional business health coalitions working with the consulting group PwC, found that 45 percent of employers have implemented or are considering using a private exchange for active employees before 2018. Similarly, a February Aon Plc survey found that, while 95 percent of employers say they expect to continue offering health care for the next 3-5 years, and 5 percent of employers currently use a private exchange, 33 percent say they may consider using one in the future.

My organization, the National Business Coalition on Health (NBCH), is an umbrella for regional business health coalitions around the country, representing about 4,500 employers, unions and local governments and some 35 million people. Working with Benz Communications, an employee benefits communications firm, we surveyed 333 benefits managers, mainly in middle-market (1,000-5,000 employee lives) technology and service firms in the Western and Southeastern US, about how they intend to manage their health plans going forward.

More than half (55 percent) of the respondents indicated they will “never” stop sponsoring employee health plans in favor of giving employees money to buy coverage through a private exchange. Just 5 percent – this number syncs with other surveys – say they already use a private exchange to provide employees’ health benefits. About 8 percent say they’ll consider moving within the next three years.

It remains to be seen whether private exchanges can outperform conventional self-funding arrangements over time. New data from private exchanges – see here and here – claim 5-plus percent health plan cost savings, but we don’t know whether those numbers will be seen across the sector, or whether they’ll be sustainable.

Analyst and former health insurance executive Robert Laszewski has been openly skeptical, arguing that these structures do little to make health care cost less and much to make it cost more. In addition to the added costs of state mandates and risk management that individual, fully insured plans must deal with, individual products have higher health plan “expense factors,” meaning the costs of handling an individual an individual rather than a group policy. He notes:

Individual products operate on an expense factor of as much as 20 percent and small group plans as much as 15 percent. Moving away from self-insurance and to an individual choice platform will increase the expense factor leaving the employee less money for benefits.

There are other issues as well. While, admittedly, employer and union health plan sponsors have not, as a whole, been assertive health care purchasers in the past, they represent powerful market potential to reward organizations that deliver high value and withhold that support from those that do not. The US’ regulatory environment has effectively been “captured” by the health care industry, and a steady stream of information has made it clear that our health care delivery and finance systems are characterized by excesses that make our costs double those of other developed nations. One important question is whether, by moving the center of health care power from group to individual purchasers, we abrogate our ability to push back effectively against a health care industry already pre-disposed to excess.

I cannot explain why the NBCH/Benz survey results suggest much lower purchaser inclination to move to private exchanges. But they raise the possibility that there is an alternative view of what is possible in health care, and that self-funding and a willingness to continue trying to control the health care value monster remains alive and vibrant.

Brian Klepper is the CEO of the National Business Coalition on Health.

Monday, October 13, 2014

New FAQ Provides Updated Guidance on Reference-Based Pricing Under PPACA

NBCH thanks the American Benefits Council for the information provided in this post.

A new “frequently asked question” (FAQ) document was released jointly by the U.S. Departments of Labor (DOL), Health and Human Services (HHS) and Treasury on October 10, updating prior guidance on the application of Patient Protection and Affordable Care Act (PPACA) cost-sharing limitations for plans using “reference-based pricing.”

The new FAQ sets out specific factors that the departments will consider when evaluating whether a plan that uses reference-based pricing (or a similar network design) is using a “reasonable method” to ensure that it provides adequate access to quality providers at the reference base price.

Generally, reference-based pricing is a system under which the plan pays a fixed amount for a particular drug, procedure or other service (for example, a knee replacement), which certain providers will accept as payment in full. If an individual uses a provider that does not accept the reference price, the individual pays the difference between the reference price and the actual price of the service.

Wednesday, October 8, 2014

EEOC Files Second Lawsuit Challenging an Employer Wellness Program

NBCH thanks the American Benefits Council for the information provided in this post.
On October 1, the U.S. Equal Employment Opportunity Commission (EEOC) announced a lawsuit challenging a wellness plan sponsored by a Flambeau, Inc. (a Wisconsin-based manufacturer with 1,600 employees) as violating the Americans with Disabilities Act (ADA). The EEOC lawsuit in EEOC v. Flambeau, Inc. alleges that the company's wellness plan required employees to complete biometric testing and a health risk assessment (HRA) on a day appointed by the employer. The complaint further alleges that an employee, who was on medical leave on the appointed day, did not complete the HRA or biometric testing, and was denied by the employer when they tried to complete the required HRA and biometric testing subsequently. The employee's health insurance was allegedly terminated for failure to complete the wellness requirements and the employee was informed that he could apply for "medical insurance" and pay the entire COBRA premium rate.

The EEOC's suit, filed in the U.S. District Court for the Western District of Wisconsin, argues that the biometric testing and health risk assessment constituted "disability-related inquiries and medical examinations" that were not job-related and consistent with business necessity as defined by Title I the ADA, which prohibits disability discrimination in employment, including making disability-related inquiries.

This is the second lawsuit filed by the EEOC in recent months (and its Chicago District Office, specifically) challenging a wellness program under the ADA. In August, the agency filed suit against Orion Energy Systems, alleging that the company fired an employee (after first making her responsible for her entire health insurance premium) when she would not submit to a medical exam and inquiry related to a wellness program. That lawsuit involves a participation-based wellness program requiring the completion of an HRA. The employee who declined to complete the HRA was permitted to enroll in the health plan, but was required to pay the full cost of the coverage ($413 per month for employee-only coverage). The employee objected to the penalty and allegedly was fired for not participating in the wellness program. The EEOC is alleging that this wellness program is not "voluntary" and thus violates the ADA. EEOC v. Orion Energy Systems was filed in the U.S. District Court for the Eastern District of Wisconsin.

The EEOC announced in its most recent semi-annual regulatory agenda that it intends to issue regulations later this year addressing wellness programs under the Americans with Disabilities Act (ADA) and the Genetic Information Nondiscrimination Act of 2008 (GINA). 

Tuesday, October 7, 2014

Health Affairs October Issue Focuses on Specialty Drugs

The October issue of Health Affairs - released today - takes on the topic of specialty drugs, highlighting a number of studies that look at the high costs associated with the increasingly prevalent use of these pharmaceuticals.

Check out the contents of the October issue online.

Most Employers Reject Private Exchanges According to NBCH and Benz Communications Survey

NBCH teamed with Benz Communications this summer to conduct the 2014 Inside Benefits Communication survey to learn how companies are strategizing and implementing benefits communications through the lens of the Affordable Care Act, compliance mandates and industry trends.

The ACA excerpts of the survey are being released today in the infographic below, and in the accompanying news release and executive summary report.

More than 300 employers across the country participated, spanning a wide cross-section of industries, employer sizes and geographic locations.

The full survey report, including detailed analysis of benefits communication investments, will be released at NBCH's annual conference on November 11.

Thursday, October 2, 2014

The Next Chapter of Obamacare

Robert Laszewski

Posted 9/09/14 on Health Policy and Marketplace Review

Welcome back from the summer.

It's been pretty quiet lately on the Obamcare front.

So quiet, that there has been a flurry of articles recently over how Obamacare has dropped to a second or even third tier issue and will hardly matter come election-time.

Wishful thinking.

Obamacare has largely been out of the news cycle for a couple of months but that is about to change.

A few thoughts.

Tuesday, September 30, 2014

Forty Percent of Payment to Physicians and Hospitals in the Commercial Sector Today is Designed to Improve Quality and Reduce Waste

Catalyst for Payment Reform (CPR) today released the 2014 National Scorecard on Payment Reform. The 2014 version of this annual Scorecard indicates commercial health plans have dramatically shifted how they pay physicians and hospitals, with 40 percent of their payment now designed to encourage health care providers to deliver higher-quality and, in some cases, more affordable care.

The National Scorecard on Payment Reform uses data submitted by commercial health plans on a voluntary, self-reported basis to eValue8, the National Business Coalition on Health’s annual request for information to health plans. The plans responding to the Scorecard questions represent 65 percent of the commercially-insured lives in the U.S.

You can read more about the 2014 Scorecard here and access the complete Scorecard online.

Friday, September 26, 2014

NBCH Member Coalition News: Washington Health Alliance

The first statewide report in the nation to measure Choosing Wisely® recommendations finds that patients in Washington may be exposed to care that they don’t need—and potential harm. The report, Less Waste, Less Harm: Choosing Wisely in Washington State, offers county-by-county results for nine different Choosing Wisely recommendations.

The results are based upon claims data representing 3.3 million lives in Washington state and was issued by the Washington Health Alliance (the Alliance) in conjunction with the Washington State Choosing Wisely Task Force, a group of more than 20 medical leaders from the largest health care organizations in the state. The Task Force is co-sponsored by the Alliance, the Washington State Medical Association (WSMA) and the Washington State Hospital Association (WSHA).

Read the full press release here.

Thursday, September 25, 2014

Employers and Key Stakeholders Focused on Improving Health and Health Care, Reducing Waste and Costs, and Payment Reform at NBCH Annual Conference

WASHINGTON– September 26, 2014 – The National Business Coalition on Health (NBCH) will bring together more than 400 purchasers, business and health coalitions, plans, providers and other stakeholders for its 19th Annual Conference – Employers Transforming Health Care: The Power of Collaboration. The event will be held at the Marriott Wardman Park in Washington, November 10-12, 2014 and features Shawn Leavitt, Senior Vice President, Global Benefits, Comcast, as opening keynote.

NBCH is a national, non-profit, membership organization of 54 business and health coalitions, representing over 4,500 employers and 35 million employees and their dependents across the U.S.

“Most health care purchasers have been remarkably passive in the face of skyrocketing health costs,” said Brian Klepper, PhD, Chief Executive Officer, NBCH. “By contrast, NBCH has taken an activist agenda and this meeting will display approaches that have consistently delivered far better health outcomes at lower cost. We believe that purchasers are hungry for these types of approaches that can recover health costs while improving results and drive better value throughout all of health care.”

Speakers for this event include:
  • Mary Bourland, VP, Medical Documentation, Medical Director of Compliance, Mercy Health Systems
  • Dan Crippen, Executive Director, National Governors Association
  • Jonathan Dugas, Director of Clinical Development, The Vitality Group
  • A. Mark Fendrick, Director, Center for VBID, University of Michigan
  • Grant Gordon, Co-Founder & CEO, Artemis Health AnalyticsDavid Gruber, Managing Director, Director of Research, Alvarez & Marsal Healthcare Industry Group
  • Ann Kirby, Assistant Benefits Manager, Hines
  • Robert Laszewski, President, Health Policy & Strategy Associates, LLC
  • Christian Moreno, Vice President, Health Risk Solutions, Lockton Dunning Benefits
  • Tyneeta Morris, Director, Human Resources, Greyhound Lines, Inc.
  • Mario Schlosser, Co-CEO and Co-Founder, Oscar Insurance Corporation
  • Joe Thompson, Arkansas Surgeon General, Arkansas Center for Health Improvement
  • Sally Welborn, Senior Vice President Global Benefits, Walmart Stores, Inc.

Registration is complimentary for all employers affiliated with an NBCH member coalition. For additional details and to register for the conference, visit NBCH’s website:

About the National Business Coalition on Health
National Business Coalition on Health (NBCH) is a national nonprofit membership organization of purchaser-led health care coalitions, representing more than over 4,500 employers, unions and local governments, and approximately 35 million employees and dependents across the United States. NBCH and its members are dedicated to value-based purchasing of health care services through the collective action of public and private purchasers. NBCH seeks to accelerate the nation’s progress toward safe, efficient, high-quality health care and the improved health status of the American population.

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Note to editors: A limited number of passes are available for accredited media upon request.

Tuesday, September 23, 2014

Bleak Future of Primary Care Access

Richard Young, MD

Published 9/22/14 in The Ft. Worth Star Telegram

Note from Brian: Richard Young, a primary care physician at John Peter Smith, a safety net health system in Ft. Worth, TX, has been an articulate and tireless explainer of the deeper health care dynamics that have undermined primary care and good health care for us all. See below.

Unfortunately, we have a preview in Dallas-Fort Worth and other communities of the effects of failed policies of Medicare/Medicaid, state government and insurance companies in how they value medical services and how they poorly support the first-contact primary care system.

Sunday, September 21, 2014

Developing A Coordinated, Considered Response to Predatory Health Care

Brian Klepper

In today's New York Times, Elizabeth Rosenthal describes the growing and egregious over-treatment and overpricing practices by physicians and health systems, abetted by health plans.

The excesses detailed in this article are at the core of our national health care quality and cost crisis. The best solutions are collaborative, considered actions by group purchasers, potentially the most empowered of health care's stakeholders.

When predatory anecdotes like these come to light, the benefits managers - or better yet, the CFOs - of local employers, unions and governmental agencies should immediately call the health plan and demand that the health systems, physicians and other providers involved be removed from the provider panel. (Small communities held hostage by a few dominant health care players are a separate topic that I'll address soon.)

As Tom Emerick, former VP Human Resources at Walmart has stated repeatedly, health care will not improve until purchasers demand different behaviors from health care vendors, focusing business on organizations that facilitate high quality care at reasonable cost, and publicly avoiding those that do not.

This is a serious issue that demands a coordinated response. It is at the top of NBCH's agenda. Join with us on this.

Wednesday, September 17, 2014

New Anthem Blue Cross plan takes on Kaiser

Taking aim at HMO giant Kaiser Permanente, insurer Anthem Blue Cross is joining forces with several big-name hospitals and their doctors to create an unusual health plan option for employers in Southern California.

The joint venture being announced Wednesday brings together seven rival hospital groups in Los Angeles and Orange counties, including well-known institutions Cedars-Sinai Medical Center and the UCLA Health System. The deal reflects the pressure insurers and hospitals alike are facing to hold down healthcare costs for employers and their workers.

Read the full article via the Los Angeles Times here.

David Lansky Addresses Pacific Business Group on Health's State-of-the-Art Travel Surgery Program

David Lansky, President and CEO of Pacific Business Group on Health, was recently interviewed by U.S. Domestic Medical Travel in regards to the coalition’s Employers Centers of Excellence Network (ECEN) which offers a state-of-the-art travel surgery program, and serves to provide patients with high quality, affordable healthcare. You can access the full interview here.

Tuesday, September 16, 2014

CMS to Continue Webinar Series on Reinsurance Contributions

NBCH thanks the American Benefits Council for the information provided in this post.

The U.S. Department of Health and Human Services (HHS) Centers for Medicare and Medicaid Services (CMS) will host the latest in a series of webinars on required Transitional Reinsurance Program (TRP) contributions under the Patient Protection and Affordable Care Act (PPACA).

Under PPACA, during the first three years that health insurance exchanges are operational (i.e., 2014 through 2016), health insurance issuers and plan administrators (on behalf of self-insured group health plans) will be assessed a per-enrollee fee to finance the three-year transitional reinsurance program. The fee is $63 per covered life for 2014.

HHS and CMS released guidance on the process for making TRP contributions in May, previewing "a streamlined process for the collection of reinsurance contributions" through This issuance was followed by an initial series of webinars to provide an overview of policy and operations for reinsurance contributions, followed by a second series to provide an overview of how a contributing entity can submit its annual enrollment count and make reinsurance contributions through

CMS has announced this latest webinar series to provide an overview of the "job aid" available to assist entities in the development of supporting documentation and detail how an entity can update reinsurance contribution filings through if an issue arises after submission. The new webinars will be held on the following days and times:
  • Wednesday, September 17, 2-3:30 p.m. ET
  • Friday, September 19, 2-3:30 p.m. ET
  • Wednesday, September 24, 2-3:30 p.m. ET
Registration will be on a first-come, first-serve basis, limited to three participants per organization. Registration will be limited to selecting only one of the event dates. You will need to log in to the official Registration for Technical Assistance Portal for more information.