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May the FORCE be with you: Top lessons from Star Wars to help combat health benefits costs

Are you a Star Wars fan like us?

Star Wars fans celebrate May 4th every year across the country by wearing costumes and sharing GIFs and memes on social media.

“May the FORCE be with you” is a statement said by Obi-Wan Kenobi throughout his life as a Jedi.

The phrase, “May the FORCE with you, was used to wish luck or goodwill, generally when individuals parted ways, or the object of the expression was facing some sort of imminent challenge.

Obi-Wan’s greatest defeat was losing his one-time friend and apprentice, Anakin Skywalker, to the dark side where he eventually became the evil Sith Lord Darth Vader.

This month the dark side is going to be the “status quo” to approaching health benefits and some might compare Darth Vader to the BUCAHs (although the H won’t be around much longer).

Even if you are not a fan of the famous saga, this renowned phrase will resonate when it comes to health benefits and the challenges that employees and their families have every day with costs and understanding how to use their healthcare benefits.    

This month we empower employers, and their advisers, to seek out the FORCE and focus on the VALUE that can be created in changing the status quo, just like YODA did.

YODA was a legendary Jedi Master and stronger in his connection with the Force. Small in size but wise and powerful, he trained Jedi for over 800 years.

The Transparent Health Benefits movement is the YODA of health benefits, growing into an unstoppable FORCE when facing the challenge of transforming the status quo.

This month we will follow the YODA principle

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What you’ll learn? These EPIC takeaways:
Y- YES, YOU are the only person that can start the CHANGE that creates the IMPACT.
O - Optimizing your Rx program with transparency. 
D - Direct members to the highest VALUE care.
A -    Alternative Reimbursement- you can’t pay LESS for healthcare until you start paying LESS for healthcare.

Y - only YOU can make it happen. The change starts with YOU.

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Only you can fight the dark side, Luke Skywalker!

THE STATUS QUO STRATEGY DOESN'T WORK.  

COME TO THE FORCE

During 2023, organizations will add, change, or end strategies and partnerships in order to enhance employee experiences, lower costs, and increase the value of their benefits.

Employers are recognizing that healthcare doesn’t have a time machine…meaning you can’t impact something that has already happened.

Being proactive and changing the way people THINK about accessing healthcare is the ONLY way we will actually change anything and join the force of TRANSPARENCY.

According to a survey by Willis, Towers, and Watson this past February 2023, nearly 90% of employers say they are planning to make changes to their vendors either this year or next, which includes adding, enhancing, or ending certain services. Changes may also include working with a different vendor.

High-performing health and well-being vendors are now vital to employers. They have become a critical component of competitive benefit and well-being programs and strategic to their portfolio.

However, in an effort to meet the needs of their employees and improve workforce health, employers are taking a close look at the value and cost savings their vendors promise. What’s more, they are ready to make changes as needed.

Employers ranked their top areas of focus for vendor solutions over the next two years, with mental health finishing first, general wellbeing coming in second, and financial wellbeing slotting fifth.

When it comes to navigation and advocacy programs, 40% of employers are set to make changes to areas such as clinical guidance and expert medical opinion.

Nearly 9 in 10 employers (88%) said they plan to make changes to their vendors during 2023 to modify services offered.

Employers are recognizing that normal #BUCAH (Blue Cross, United Healthcare, CIGNA, Aetna, Humana) style plans don't help members with advocacy: becoming better healthcare consumers.

 

The healthcare industry has promoted the word "consumerism" for years, which, in its pure definition, is the protection or promotion of the interests of consumers.

 

Consumerism in our industry SHOULD be about making people better healthcare consumers by giving them the tools, resources, and, more importantly, the structure of how a health plan works and learning how to advocate for higher quality healthcare services at a lower cost.

 

Employees "spend their money differently than their employer's".

 

This has been how the industry has addressed “consumerism”.

 

But that really accomplished increasing out-of-pocket costs in attempts to make employees and their family members, “think twice" about accessing healthcare. The data is now clear that this has created more of a DELAY in healthcare versus better consumerism; and certainly has not saved anyone any money.

Lead the charge and call on the FORCE to help create the pathway to a better tomorrow.

Become the Y of the YODA approach, only YOU can make it happen.

The change starts with YOU.

O - Optimizing your Rx program with transparency.

 

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Prescription Drug (Rx) is the fastest growing and most used portion of the health benefits programs. Employer health benefit costs continue to increase year over year and Rx typically makes use of 20-25% of the total cost but is trending at over 20% year over year.

This staggering trend has continued to grow as the BUCAH carriers and the “Big 3” PBMs have “vertically integrated”. Like kids dressing up as Chewbacca or Prince Lea for Halloween, this disguise has only allowed for opaque pricing schemes, greater “dodge” of the intent of the ACA’s “minimum loss ratio” (MLR) rule, and more financial ruin for employers and employees across the country. The “death star” cherry on top, over 80% of employers are utilizing one of the ”big 3” PBMS--- are you still surprised Rx prices are out of control?

On top of this, drugmakers raised prices in the United States on more than 350 unique drugs in early January 2023, according to data analyzed by healthcare research firm 3 Axis Advisors.

The increases were expected to come as the pharmaceutical industry prepares for the Inflation Reduction Act (IRA), which allows the government's Medicare health program to negotiate prices directly for some drugs starting in 2026.

 

However, these rising prices impact ALL employers who are forced to take on more of the financial burden but are limited on how much they can shift costs to members. Whether fully insured or self-funded, rising drug prices, lack in transparency, and misaligned incentives create the dark side of the Rx space.  

 

Here’s the good news- 1%-3% of members are making up 30%-50% of the cost and most of those members are on medications that have alternative sourcing options AND/OR Manufacturer Assistance Program (MAP).

MAP programs are usually sponsored by pharmaceutical manufacturers and are promoted as a “safety net” for Americans who have no health insurance or are underinsured.

The goal of these programs is to provide financial assistance to help these patients access drugs for little or no cost.

This is where adding transparency and partnering with organizations that specialize in helping members access these MAP programs is the key to success.

Work With Transparent Pharmacy Benefit Managers

Pharmacy benefit managers, or PBMs, make a significant amount of money in an opaque pricing and reimbursement model. PBMs utilize the Average Wholesale Price, which is neither based on the price to manufacture OR the price paid for prescription drugs.

Instead, the AWP is completely arbitrary, allowing PBMs to inflate the figure and offer ‘discounts’ to health plans, employers, and, therefore, impacting employees and family members… simply to make more of a profit.

To circumvent this, consider working with transparent pharmacy benefit managers that operate on pass-through or transparent contracts. This means their sole income should be derived from disclosed fees NOT through the countless number of ways the “Big PBMs” make their revenue.

With these partners, you are made aware of where every single dollar of your pharmacy spend is going.

Do you have this today… WHY NOT?

With the proper structure and partners, an employer can lower their Rx cost by 50% with LITTLE change.

Are you ready to join the FORCE?

D - Direct members to the highest VALUE care.

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What if employees were better healthcare consumers? What if they had the tools they needed — as well as the desire — to actually shop for the best healthcare prices along with what was best for their health?

Increasing awareness of the disparity between healthcare costs — hospital procedures, clinic visits, lab work, prescriptions, and more along with the variance between the quality of the healthcare providers and facilities would —create more active healthcare consumers.

↑QUALITY + ↑ ADVOCACY = ↓COST.

A study conducted by policygenius.com discovered that only 4% of Americans could correctly describe terms such as deductible, copay, coinsurance, and out-of-pocket maximum.

Consumers simply haven’t been trained to focus on price shopping for healthcare. Weighing one price against another to make a more informed decision is not something we all do automatically, the way we do for virtually any other product or service.

There is a correlation between the tools and resources available to consumers to shop for EVERYTHING else like mortgages, cars, and even houses. Consumers use every available tool such as reviews, price calculators, and the top of all of them, they shop by brand, quality, and cost comparisons to ensure they are buying things that fit their budget and needs.

Even when they don't understand the terms and conditions of buying a mortgage, house, or even car, consumers still shop, ask questions, and make themselves more knowledgeable buyers. This happens EVERY SINGLE DAY.

WHY NOT SHOP FOR HEALTHCARE? 📢📢

According to a Harris Poll, is that 88% of Americans believe the government should require hospitals and insurers to disclose prices.

If it will lead to better results and people are asking for more transparency and access to data, why are so many employers, and their advisers, not pushing the change?

Employees are joining the FORCE and becoming more involved in determining the cost of their healthcare.

The pandemic has prompted many Americans to become more engaged healthcare consumers. This is good news for the system, including for employers who provide health insurance to more than 50% of the Americans in this country. When people are better at buying healthcare, they have the opportunity to be healthier and to save themselves and their employers’ money.

Employers end up spending more than $230 billion a year in excess healthcare costs as a result of improper education on how to make the most of their medical coverage.

Teaching employees how to be better healthcare consumers is an important step toward reducing costs for employees and employers alike.

Price transparency is merely the first step in helping consumers make smarter choices about their healthcare.

Giving employees, and their families, an advocate to help them navigate the healthcare system, understand the quality and cost metrics, and support them with asking ALL of the questions necessary will not only lower healthcare costs, but improve outcomes and make members happier with the benefits they are given--- a win for both employers and advisers.

As the industry takes steps to become more like the retail industry, employers and insurers have an opportunity to engage and fulfill the great healthcare expectations of the employees as consumers.

A - Alternative Reimbursement

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How do current health plans allow members to pay less for services?

Have your employees paid cash for a service or prescription drug (Rx) and found that the cash price is lower than using your insurance?

The next question would be, who decides the price of healthcare services today?

Two entities:

Neither entity has a vested interest in saving anyone any money:

  • The health insurance carrier
  • The Provider (doctor, hospital, etc.)

Although they would like you to think that the other is the bad guy, the truth is they need each other to co-exist.

What can employers do? Give up? Of course not!

The BUCAH “Vader” PPO networks don't live up to their commitments and want to keep you stuck in the dark side.

When prices aren’t transparent, it’s difficult, if not impossible, for employees, and their families, to budget accordingly.

Essentially, the PPO discount scheme guarantees that all employers pay an average of double or triple the cash pay price.

This is the place where Alternative Reimbursements can bring you to the FORCE.

How to Use Alternative Reimbursements in Your Health Plan?

Employers are afforded more clarity, stability, and predictability in the costs of healthcare services thanks to the alternative reimbursement plans that establish these conditions.

The potential for cost savings for employers is at 30–60%. All with giving employees, and their families, $0 cost care… YES, you read that right- FREE!!

But why would providers accept less payment?

Here's why. The current system pushes employees and their families to bear thousands in out-of-pocket expenses. Providers, healthcare, systems, etc. have to “chase” these out-of-pocket expenses and, on average, wait 60-90 days for payment. Add this to the natural “opposing forces” of each side, and it typically costs a hospital $.30-$.50 to collect every dollar of out-of-pocket cost. dollar.

The insurance companies are unnecessary for these forms of alternative reimbursement strategies; therefore, you're trimming some fat from the system.

We can achieve better pricing and higher quality providers for the everyday employee without a large insurance company involved.

Using more direct and transparent arrangements, a typical employer has a better chance of securing competitive rates and superior service from their providers.

Reimbursement strategies that employ alternate forms of payment create a more expedited and streamlined collection method of payment for the service provided allowing employers to offer a better benefit to their #1 asset.

BOTTOM LINE: BREAK THE MOLD BY JOINING THE FORCE

LET THE PAST DIE--- it’s not been working, so let’s not be scared to try something different and the data is there to show us.

Employers need to go beyond incremental changes in a system that is no longer delivering adequate health or financial security for their employees. To adopt a mindset of “health as an investment,” employers should begin by understanding their employee populations’ needs and preferences.

Achieve this by implementing the YODA approach:

Y- YES, YOU are the only person that can start the CHANGE that creates the IMPACT.

O- Optimizing your Rx program with transparency.

D- Drive (or direct) members to the highest VALUE care.

A- Alternative Reimbursement- you can start paying LESS for healthcare until you start paying LESS for healthcare.

Employers and advisers need to take an innovative mindset to bring forth the solutions that enable the FORCE OF THE FUTURE.

All healthcare players involved in saving money and the lives of employees must embrace speed to deliver the first minimum viable solutions to employers and members within 6-to-12 months.

Employers deserve a health benefits Jedi team focused on transparency and with the ability to increase business results by identifying the needs of employers and their workforce; it is important to drive the creation and continuous growth of YODA, this new model of breaking the mold by joining the FORCE.

 

 

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