8 renewal considerations for 2020

Plan administrators have a lot to consider during open enrollment season. How are you preparing for 2020 open enrollment? Read the following blog post from Employee Benefit News for eight things to consider for renewals.


The triumphant return of the Affordable Care Act premium tax (the health insurer provider fee).

This tax of about 4% is under Congressional moratorium for 2019 and returns for 2020. Thus, fully insured January 2020 medical, dental and vision renewals will be about 4% higher than they would have been otherwise. Of note, this tax does not apply to most self-funded contracts, including so-called level-funded arrangements. Thus, if your plans are presently fully insured, now may be a good time to re-evaluate the pricing of self-funded plans.

Ensure your renewal timeline includes all vendor decision deadlines.

As the benefits landscape continues to shift and more companies are carving out certain plan components, including the pharmacy benefit manager, you may be surprised with how early these vendors need decisions in order to accommodate benefit changes and plan amendments. Check your contracts and ask your consultant. Further, it seems that our HRIS and benefit administration platforms are ironically asking for earlier and earlier decisions, even with the technology seemingly improving.

Amending your health plan for the new HSA-eligible expenses.

In July of this year, the U.S. Treasury loosened the definition of preventive care expenses for individuals with certain conditions.

While these regulations took effect immediately, they won’t impact your health plan until your health plan documents are amended. Has your insurer or third-party administrator automatically already made this amendment? Or, will it occur automatically with your renewal? Or is it optional? If your answer begins with “I would assume…,” double-check.

Amending your health plan for the new prescription drug coupon regulations.

As we discussed in July of this year, these regulations go into effect when plans renew in 2020. In short, plans can only prevent coupons from discounting plan accumulators (e.g., deductible, out-of-pocket maximum) if there is a “medically advisable” generic equivalent.

If your plan is fully insured, what action is your insurer taking? Does it seem compliant? If your plan is self-funded, what are your options? If you can keep the accumulator program and make it compliant, is there enough projected program savings to justify keeping this program?

Is your group life plan in compliance with the Section 79 nondiscrimination rules?

A benefit myth that floats around from time to time is that the first $50,000 in group term life insurance benefits is always non-taxable. But, that’s only true if the plan passes the Section 79 nondiscrimination rules. Generally, as long as there isn’t discrimination in eligibility terms and the benefit is either a flat benefit or a salary multiple (e.g., $100,000 flat, 1 x salary to $250,000), the plan passes testing. Ask your attorney, accountant, and benefits consultant about this testing. If you have two or more classes for life insurance, the benefit is probably discriminatory. If you fail the testing, it’s not the end of the world. It just means that you’ll likely need to tax your Section 79-defined “key employees” on the entire benefit, not just the amount in excess of $50,000.

Is your group life maximum benefit higher than the guaranteed issue amount?

Surprisingly, I still routinely see plans where the employer-paid benefit maximum exceeds the guaranteed issue amount. Thus, certain highly compensated employees must undergo and pass medical underwriting in order to secure the full employer-paid benefit. What often happens is that, as benefit managers turnover, this nuance is lost and new hires are not told they need to go through underwriting in order to secure the promised benefit. Thus, for example, an employee may think he or she has $650,000 in benefit, while he or she only contractually has $450,000. What this means is the employer is unknowingly self-funding the delta — in this example, $200,000. See the problem?

Please pick up your group life insurance certificate and confirm that the entire employer-paid benefit is guaranteed issue. If it is not, negotiate, change carriers, or lower the benefit.

Double-check that you haven’t unintentionally disqualified participant health savings accounts (HSAs).

As we discussed last December, unintentional disqualification is not difficult.

First, ensure that the deductibles are equal to or greater than the 2020 IRS HSA statutory minimums and the out-of-pocket maximums are equal to or less than the 2020 IRS HSA statutory maximums. Remember that the IRS HSA maximum out-of-pocket limits are not the same as the Affordable Care Act (ACA) out-of-pocket maximum limits. (Note to Congress – can we please align these limits?)

Also, remember that in order for a family deductible to have a compliantly embedded single deductible, the embedded single deductible must be equal to or greater than the statutory minimum family deductible.

Complicating matters, also ensure that no individual in the family plan can be subject to an out-of-pocket maximum greater than the ACA statutory individual out-of-pocket maximum.

Finally, did you generously introduce any new standalone benefits for 2020, like a telemedicine program, that Treasury would consider “other health coverage”? If yes, there’s still time to reverse course before 2020. Talk with your tax advisor, attorney, and benefits consultant.

Once all decisions are made, spend some time with your existing Wrap Document and Wrap Summary Plan Description.

For employers using these documents, it’s easy to forget to make annual amendments. And, it’s easy to forget, depending on the preparer, how much detail is often in these documents. For example, if your vision vendor changes or even if your vision vendor’s address changes, an amendment is likely in order. Ask your attorney, benefits consultant, and third party administrators for help.

SOURCE: Pace, Z. (Accessed 9 September 2019) "8 renewal considerations for 2020" (Web Blog Post). Retrieved from https://www.benefitnews.com/list/healthcare-renewal-considerations-for-2020


Cadillac tax may finally be running out of gas

The Cadillac tax, a part of the Affordable Care Act, may be in for a change. This tax was supposed to take effect in 2018 but has been delayed twice and recently, the House voted to repeal this tax entirely. Read this blog post to learn more about this potential change.


The politics of healthcare are changing. And one of the most controversial parts of the Affordable Care Act — the so-called Cadillac tax — may be about to change with it.

The Cadillac tax is a 40% tax on the most generous employer-provided health insurance plans — those that cost more than $11,200 for an individual policy or $30,150 for family coverage. It was supposed to take effect in 2018, but Congress has delayed it twice. And the House recently voted overwhelmingly — 419-6 — to repeal it entirely. A Senate companion bill has 61 co-sponsors — more than enough to ensure passage.

The tax was always an unpopular and controversial part of the 2010 health law because the expectation was that employers would cut benefits to avoid paying the tax. But ACA backers said it was necessary to help pay for the law’s nearly $1 trillion cost and help stem the use of what was seen as potentially unnecessary care. In the ensuing years, however, public opinion has shifted decisively, as premiums and out-of-pocket costs have soared. Now the biggest health issue is not how much the nation is spending on healthcare, but how much individuals are.

“Voters deeply care about healthcare still,” said Heather Meade, a spokeswoman for the Alliance to Fight the 40, a coalition of business, labor and patient advocacy groups urging repeal of the Cadillac tax. “But it is about their own personal cost and their ability to afford healthcare.”

Stan Dorn, a senior fellow at Families USA, recently wrote in the journal Health Affairs that the backers of the ACA thought the tax was necessary to sell the law to people concerned about its price tag and to cut back on overly generous benefits that could drive up health costs. But transitions in healthcare, such as the increasing use of high-deductible plans, make that argument less compelling, he said.

“Nowadays, few observers would argue that [employer-sponsored insurance] gives most workers and their families’ excessive coverage,” he wrote.

The possibility of the tax has been “casting a statutory shadow over 180 million Americans’ health plans, which we know, from HR administrators and employee reps in real life, has added pressure to shift coverage into higher-deductible plans, which falls on the backs of working Americans,” said Rep. Joe Courtney (D-Conn.).

Support or opposition to the Cadillac tax has never broken down cleanly along party lines. For example, economists from across the ideological spectrum supported its inclusion in the ACA, and many continue to endorse it.

“If people have insurance that pays for too much, they don’t have enough skin in the game. They may be too quick to seek professional medical care. They may too easily accede when physicians recommend superfluous tests and treatments,” wrote N. Gregory Mankiw, an economics adviser in the George W. Bush administration, and Lawrence Summers, an economic aide to President Barack Obama, in a 2015 column. “Such behavior can drive national health spending beyond what is necessary and desirable.”

At the same time, however, the tax has been bitterly opposed by organized labor, a key constituency for Democrats. “Many unions have been unable to bargain for higher wages, but they have been taking more generous health benefits instead for years,” said Robert Blendon, a professor at the Harvard T.H. Chan School of Public Health who studies health and public opinion.

Now, unions say, those benefits are disappearing, with premiums, deductibles and other cost sharing rising as employers scramble to stay under the threshold for the impending tax. “Employers are using the tax as justification to shift more costs to employees, raising costs for workers and their families,” said a letter to members of Congress from the Service Employees International Union.

Deductibles have been rising for a number of reasons, the possibility of the tax among them. According to a 2018 survey by the federal government’s National Center for Health Statistics, nearly half of Americans under age 65 (47%) had high-deductible health plans. Those are plans that have deductibles of at least $1,350 for individual coverage or $2,700 for family coverage.

It’s not yet clear if the Senate will take up the House-passed bill, or one like it.

The senators leading the charge in that chamber — Mike Rounds (R-S.D.) and Martin Heinrich (D-N.M.) — have already written to Senate Majority Leader Mitch McConnell to urge him to bring the bill to the floor following the House’s overwhelming vote.

“At a time when healthcare expenses continue to go up, and Congress remains divided on many issues, the repeal of the Cadillac tax is something that has true bipartisan support,” the letter said.

Still, there is opposition. A letter to the Senate on July 29 from economists and other health experts argued that the tax “will help curtail the growth of private health insurance premiums by encouraging employers to limit the costs of plans to the tax-free amount.” The letter also pointed out that repealing the tax “would add directly to the federal budget deficit, an estimated $197 billion over the next decade, according to the Joint Committee on Taxation.”

Still, if McConnell does bring the bill up, there is little doubt it would pass, despite support for the tax from economists and budget watchdogs.

“When employers and employees agree in lockstep that they hate it, there are not enough economists out there to outvote them,” said former Senate GOP aide Rodney Whitlock, now a healthcare consultant.

Harvard professor Blendon agrees. “Voters are saying, ‘We want you to lower our health costs,’” he said. The Cadillac tax, at least for those affected by it, would do the opposite.

SOURCE: Rovner, J. ( 19 August, 2019) "Cadillac tax may finally be running out of gas" (Web Blog Post). Retrieved from https://www.employeebenefitadviser.com/articles/obamacare-excise-tax-may-be-at-an-end 


Mastering Healthcare Cost Transparency Within Your Self-Funded Benefits Plan

Finding high-value healthcare providers for your employees is a constant struggle. After interviewing our Executive Vice President, Scott Smeaton, he gave us insight on a strategy for conquering cost transparency while maintaining quality care.

Working with Hierl Insurance for over 24 years, Scott shared how his endeavors working with selffunded plans has led him to believe the best strategy is one that starts at the employee-level.

Filling the Transparency Gap

First, let’s define what a high-value healthcare provider is: A high-value provider is a physician and / or facility that consistently demonstrates better patient outcomes at a lower than average cost. This is accomplished by meeting the highest quality standards i.e. low infection and readmission rates, quicker recovery rates, and high patient satisfaction scores, among others, at a lower than average cost.

These high value providers perform more procedures (volume) in facilities where they have greater control of the outcome (low overhead, low infection rates), and often provide “bundled” pricing where the patient knows how much the procedure will cost before the work is ever done.

Have you, in the last year, bought a big-ticket item without knowing the cost? This is the question Scott starts with when speaking to a company’s employees. Often, no one can raise their hand. Why? Historically, the information hasn’t been available. As an industry, we still have a ways to go. We’re moving in the right direction, working with innovative partners focusing on what patients need to make better healthcare decisions.

As a society, it’s common sense – whether you’re buying a car, a TV, or a house – to do some research as to the quality and cost of a product or service. “That ability to access those numbers and identify cost and quality measures has not been available in healthcare,” Scott explained. This gap is beginning to be filled, though primarily in direct-to-provider contracting exclusive to certain specialties.

Because healthcare information can be overwhelming, businesses struggle to find the most appropriate venue for sourcing the lowest costs without relinquishing the highest quality of care.

“We’ve found that the lower cost providers actually have higher quality of care due to the volume of services they offer,” Scott explained. Hierl partners with third parties to identify these providers. “A great example is an orthopedic specialist we work with. They have finetuned their procedures and their processes so much that they receive the highest quality ratings, yet they are the lowest cost providers, in their area. They tell you what it’s going to cost with a bundled price, before the procedure is performed,” Scott mentioned.

Hierl partners directly with high value providers, designing employee benefits programs that offer incentives to employees who use those providers. When buying big-ticket items like a car, it’s often reasonable to assume the more the car costs, the higher quality and value you are going to get from it. In healthcare, it’s essentially the opposite. Take Lasik Surgery, for example. Fifteen years ago, Radial Keratotomy (RK), which was a precursor to LASIK, was performed with a scalpel by a surgeon and cost roughly $8,000. In 2017, the average cost of LASIK was $2,088. Now, the procedure is much more effective due to improved technology.

With high value providers, such as the orthopedic specialist mentioned previously, that “high value” comes from the fact they are typically operating in freestanding clinics and surgery centers. This means there is lower overhead compared to being in a hospital setting, and they are run by specialized teams that can give their patients more attention. “High volume of services, low overhead costs, and high-quality care – those are the key ingredients we look for in the providers we recommend to our clients,” explained Scott.

Flexibility in Cost Transparency Begins with Self-Funding

Perks such as gym memberships and free lunches have become common practice for companies looking to brand themselves as a great employer. However, it is important to understand these tactics aren’t the answer when it comes to employee experience but rather an engagement strategy. Modern employees want to work in a great environment and want to know their contributions are valued through benefit offerings like discounted healthcare.

For anyone looking to unlock the power of employee engagement through benefits, the time to act is now. With the number of companies catching on to the importance of customer experience, it will not only help you gain an edge on your competition but make your company a favorable place to work – the definition of a ‘win-win’ .

The plans that get the most value from this third-party vendor initiative are self-funded plans, due to their flexibility. “That’s not to say we can’t work with fully insured companies,” Scott insisted. “We have found being self-funded really allows the employer to access the ‘cream of the crop’ or the third-tier beyond typical in-network and out-network providers and facilities, which are those high value specialists.” Aiding employer and employee education through third-party care coordinators and plan incentives, Hierl’s benefits plans are next-level.

We give businesses focus and control over their healthcare expenditures. When it comes to shop-able services, or nonemergency services needed, our care coordinators will ensure you partner with the best high value, low cost provider possible. Scott emphasized, “We are a pilot of health plan partners – a conductor of sorts, pulling all the moving pieces and parts together for our clients to guarantee a more focused, transparent result of their healthcare spending.”

To speak with Scott, contact him today at (920) 921-5921 or by email at ssmeaton@hierl.com.


Creating an ‘urgent care first’ mindset for employee benefits

Urgent cares are popping up everywhere, making getting quick healthcare easier and more convenient for patients. Read this blog post to learn why it's important to guide employees to adopt an "urgent care first" mentality.


Urgent care centers are popping up everywhere, which means getting quick healthcare is easier and more convenient for patients. But these centers could also help employers minimize expensive emergency room claims. That’s why it’s important to guide employees to adopt an “urgent care first” mentality.

The concept of urgent care has been around since the 1970s, but rising healthcare costs, especially for ER care, have spurred an increase in centers across the U.S. over the last decade. In fact, from 2014 through June 2017, the number of urgent care centers rose by nearly 20%.

Urgent care centers provide care for health problems that aren’t life-threatening, but can’t wait for an appointment with a primary care provider. No one wants to suffer with a sore throat all weekend. Many urgent care centers are staffed with doctors and nurses, and provide more advanced capabilities than what’s typically available at a primary care doctor’s office. For example, some urgent care centers give stitches, provide X-rays and even MRIs.

Patients can also get treatment at urgent care for conditions they’d typically see a primary care doctor for, such as the flu or a fever, mild to moderate asthma, skin rashes, sprains and strains, and a severe sore throat or cough — illnesses that produce unnecessary high claims if treated in an ER.

Still, when a severe sore throat and high fever strike on a weekend and the doctor’s office is closed, employees may gravitate to the ER because they’re sick and need help right now. That’s where the urgent care first mindset becomes good medicine. It typically costs the employer (and often the employee) far less if that sore throat is treated in an urgent care facility.

The high cost of ER care is enough to make anyone run a high temp. From 2009 to 2016 (the most recent data available), the average amount that hospitals billed insurance carriers for an emergency room visit more than doubled, from $600 to $1,322. By contrast, urgent care typically costs about $150 per visit. Members often pay a lower copay for urgent care visits, too.

The urgent care first mindset is starting to take hold. New data analysis from Aetna shows that as urgent care centers began to proliferate, ER visits for minor health issues dropped 36%, while the use of urgent care and other non-emergency health settings increased 140%.

However, the same study shows that plans only saw a decrease in ER visits if there were several urgent care centers in the geographic region where their employees lived. Awareness is key.

Fostering an urgent care first mentality

Employers can’t just include urgent care in a benefits plan and expect employees to use it. They need to design the plan to encourage use and follow up with plenty of education.

Education about the benefits of primary care versus urgent care versus the ER should take place during open enrollment and throughout the plan year so members understand the medical necessity and financial implications of each option. Including the closest urgent care centers to employees, as well as a list of services they provide, can help encourage them to adopt an urgent care first mentality.

A word of caution: not every nearby urgent care center is actually in-network. It literally pays for employees to keep a list of nearby in-network centers handy when that inevitable weekend sore throat strikes.

Reminders about urgent care before spring allergies, summer vacations, fall school physicals and flu season can also help encourage their use.

The too-low ER copay

Plan design is another important piece of the puzzle to help steer employees to the right level of care for their needs. It’s not that unusual to see a $100 copay for an emergency department visit. While no one wants to discourage ER visits for true emergencies, it makes sense to adjust the plan design to encourage primary and urgent care visits instead. That may mean a $20 copay for primary care, a $40 copay for urgent care and a $200 to $250 copay for ER visits — which is waived if the plan participant is admitted to the hospital.

For high-deductible health plans paired with a health savings account, the savings can be even more drastic; patients may pay $200 for an urgent care visit versus $1,200 for an ER visit.

The combination of education and plan design can help curb unnecessary ER visits, which could help employers control healthcare increases from plan year to plan year. For health issues that crop up during off hours, the urgent care first mindset is good for both employers and employees, who will ultimately save time and money.

SOURCE: O'Conner, P. (5 July 2019) "Creating an ‘urgent care first’ mindset for employee benefits" (Web Blog Post). Retrieved from https://www.benefitnews.com/opinion/creating-an-urgent-care-first-mindset-for-employees


How to Sweeten Your Healthcare Offerings to Attract + Retain Employees

Employees are the heart of any great business, and key employees and leaders are essential to long-term success. Once acquiring what you feel like is a complete team, some employees may be exploring other options and walking away. You may also find yourself struggling to attract younger generational employees.

But why is this?

For any employee, benefits are no longer a perk in business; they’re an expected part of compensation.  For any employer looking for ideas on how to ensure their business meets the wants and needs of their employees, Tonya Bahr, one of our expert Benefits Advisors, has outlined three benefits sure to help.

Benefit #1: Gym Memberships

As the old saying goes, “healthy employees are happy employees.” More companies are encouraging healthy habits in and out of the office. The typical employee would like to have the ability to join a gym and work out. This helps negate a general sense of feeling too consumed by work and life, while putting action to their desires. Joining a gym of their liking through the use of a company stipend or expense is a huge plus for many employees and will aid in long-term employee retention.

Benefit #2: Focus on Family

Nobody is without a life away from work. The considerate employer is no stranger to the normal work-life balance and is flexible to offer employees time off when their attention is needed elsewhere – typically family matters. Parents who need to attend a child’s event, a mother who requires maternal leave or those tending to the needs of their elderly loved ones desire a company that doesn’t have a fixed focus on strictly work itself.

Benefit #3: Community Involvement

Numerous studies have found employees increasingly value brands that emphasize doing good around them. From encouraging employees to volunteer on their days off and promising rewards or hosting in-house events, the ways in which your organization can spread a good name into the community is nearly limitless, not to mention, a fun and active way to market your business to prospective employees.

Better Benefits Strategies with Hierl Insurance…

When it comes to Employee Benefits, the experts at Hierl bring an element of strategic innovation to the conversation that others simply are not.  We take pride in the experience we provide our customers focusing in on a clear, defined, proven process and diligent communication to deliver real results that are meaningful to your unique vision and goals as an organization.

The industry has gotten complicated. With an ever shifting landscape, keeping up can be exhausting and trying to plan ahead can seem daunting.When you partner with Hierl, you gain a team of innovative, kind-hearted, strategically focused, big picture experts that work diligently to ensure your outcomes are meaningful where it matters most to you.

For more information, contact Tonya Bahr at 920.921.5921 or tbahr@hierl.com. You can also visit our website for more information on our collective services.

Employee Benefits


At Hierl, we know you are more than just numbers on a spreadsheet. You are a unique, diverse population of real people with real needs and real objectives.

Discover the Extra Mile

One overlooked way to promote well-being: Target oral health

How is your company promoting well-being? Research shows an association between gum disease and conditions like diabetes and coronary artery disease. Continue reading for how employers can promote well-being by targeting oral health.


With the cost of employer-sponsored healthcare benefits approaching $15,000 a year per employee, according to the National Business Group on Health, innovative companies are looking for new and creative ways to get maximum value from their benefits dollars.

By embracing benefits strategies focused on overall health, companies can help their current employees be healthier and more productive and attract and retain the workers they need to succeed in today’s competitive labor markets.

And although wellness programs or health apps might first spring to mind, there’s an overlooked way to promote employees’ health: oral care.

Guided by research that shows associations between gum disease and conditions like diabetes and coronary artery disease, forward-thinking dental insurers are developing products that emphasize the importance of regular oral care, particularly for workers with those conditions — and smart companies are jumping on board.

Products that emphasize the importance of maintaining oral health are an important step in integrating care. Over the next several years, leading-edge insurers will create new ways to engage patients in conversations about their dental and overall health, as they seek to encourage behavior changes and improve health outcomes. To help improve oral and overall well-being, insurers will need to share oral care information with their members through targeted emails, text messages and phone calls.

Additionally, because individuals dealing with a complex treatment plan may put off receiving oral care while they address their medical issues, they could benefit from plans featuring a case manager, or a “dental champion.” Working in conjunction with medical case managers, a dental champion can help employees understand how receiving regular oral care can influence their overall health. They also can ensure a company’s workforce is getting the oral care they need, helping them find providers and arrange appointments.

Savvy employers recognize that any realistic effort to limit the increase in healthcare costs begins by addressing chronic ailments. According to the Centers for Disease Control and Prevention, six in 10 Americans live with at least one chronic disease, like heart disease, cancer, stroke or diabetes.

By promoting overall health — including regular oral care — employers can encourage positive lifestyle changes that help their employees reduce the likelihood of many chronic problems. Those who brush and floss their teeth regularly, receive frequent cleanings and checkups and deal with oral issues at early stages are taking steps to improve their overall health.

Because everyone’s individual situation is different, insurers and employers will need to include a more personalized approach, engaging members in conversations about their dental health and how it contributes to attaining their overall health goals.

SOURCE: Palmer, T. (13 June 2019) "One overlooked way to promote well-being: Target oral health" (Web Blog Post). Retrieved from https://www.benefitnews.com/opinion/promoting-wellbeing-through-dental-health


CMS Publishes 2020 Benefit Payment and Parameters Final Rule

The Centers for Medicare and Medicaid Services (CMS) has released its final rule and fact sheet regarding benefit payment and parameters for 2020. Read this blog post from UBA to find out which topics this final rule addresses.


The Centers for Medicare and Medicaid Services (CMS) published its final rule and fact sheet for benefit payment and parameters for 2020. Although the final rule primarily affects the individual market and the Exchanges, the final rule addresses the following topics that may impact employer-sponsored group health plans:

  • The 2020 maximum annual limitation on cost sharing is $8,150 for self-only coverage and $16,300 for other-than-self-only coverage.
  • For fully-insured plans, any indication of a reduction in the generosity of a benefit for individuals that is not based on clinically indicated, reasonable medical management practices is potentially discriminatory.
  • Amounts paid toward cost sharing using direct support by drug manufacturers (for example, coupons) to insured patients to reduce or eliminate immediate out-of-pocket costs for specific prescription brand drugs that have a generic equivalent are not required to be counted toward the annual limitation on cost sharing.
  • Federally Facilitated Small Business Health Options Programs (FF-SHOPs) may operate a toll-free hotline rather than a more robust call center.

The final rule is effective on June 24, 2019. The final rule generally applies to plan years beginning on or after January 1, 2020.

SOURCE: Hsu, K. (13 June 2019) "CMS Publishes 2020 Benefit Payment and Parameters Final Rule" (Web Blog Post). Retrieved from http://blog.ubabenefits.com/cms-publishes-2020-benefit-payment-and-parameters-final-rule


What HR pros should know about clinical guidelines

Clinical guidelines are designed to optimize patient care in areas such as screening and testing, diagnosis and treatment. Read this blog post for what HR professionals should know about these guidelines.


Your employees and their family members frequently face tough questions about their healthcare: How do I know when it’s time to get a mammogram? When does my child need a vision screening? Should I get a thyroid screening? If I have high blood pressure or diabetes, what is the best treatment for me?

For the providers who care for them, the key question is: How do we implement appropriate, science-backed treatments for our patients, testing where needed, but avoiding potentially harmful or unnecessary (and expensive) care? The answer is to seek guidance from and use clinical guidelines —along with existing clinical skills — wisely.

Clinical guidelines are sets of science-based recommendations, designed to optimize care for patients in areas such as screening and testing, diagnosis and treatment. They are developed after a critical review by experts of current scientific data and additional evidence to help inform clinical decisions across a spectrum of specialties.

Based upon this process, guidelines are then released by a number of sources and collaborations, including academic and non-profit healthcare entities, government organizations and medical specialty organizations.

From preventive care to treatment protocols for chronic conditions, guidelines provide a framework healthcare providers use with patients to help guide care. However, it’s important to note that clinical guidelines are not rigid substitutes for professional judgment, and not all patient care can be encompassed within guidelines.

The impact on healthcare and benefits

Clinical guidelines are used in myriad ways across the healthcare spectrum, and providers are not the only ones who utilize them. Insurers also may use guidelines to develop coverage policies for specific procedures, services and treatment, which can affect the care your covered population receives.

To illustrate a key example of an intended impact of guidelines on health plan coverage, consider those issued by the U.S. Preventive Services Task Force, whose A and B level recommendations comprise the preventive services now covered at no cost under the mandate of the Affordable Care Act.

As another example, the National Committee for Quality Assurance, which accredits health plans and improves the quality of care through its evidence-based measures, uses the American Heart Association guidelines when creating its quality rules for treating high cholesterol with statin drugs.

Other examples exist among commercial coverage policies. For example, some cancer drug reimbursement policies use components from nationally recognized guidelines for cancer care.

Because science is rapidly changing, guidelines are often updated, leading insurers to revisit their policies to decide if they will change how services and medications are covered for their members. Providers and health systems may modify processes of patient care in response to major changes in guidelines and/or resultant changes in payer reimbursement.

Not all guidelines are updated on a set schedule, making it even more important for providers and organizations that rely on guidelines to stay on top of changing information, as it can have a direct impact on how they work. Attending conferences, visiting the recently established ECRI Guidelines Trust, and regularly reviewing relevant professional association websites and journals can help ensure needed guidelines are current. Lack of current information can affect care decisions and potential outcomes for patients. Those who have access to the most up-to-date, evidence-based information are able to work together to make well-informed healthcare decisions.

Why it matters for employers

As employers or benefits consultants, it’s critical to ensure that your health plan, advocacy or decision support providers, and other partners that depend on this information to guide their practices and decisions understand and follow current, relevant guidelines.

Further, by combining information from relevant guidelines and data from biometric screenings, health risk assessments, claims and other sources, it’s possible for clinical advocacy and other decision support providers to identify employees with gaps in care and generate targeted communications (through a member website and/or mobile app) to help them take action to improve their health.

Clinical guidelines are science distilled into practical recommendations meant to be applied to most patients for quality healthcare. By maintaining current, relevant guidelines, organizations and providers who work with your covered population can ensure that all parties have the key information they need to make the best decisions for their health.

SOURCE: Sivalingam, J. (18 March 2019) "What HR pros should know about clinical guidelines" (Web Blog Post). Retrieved from https://www.benefitnews.com/opinion/what-hr-managers-should-know-about-clinical-guidelines?feed=00000152-a2fb-d118-ab57-b3ff6e310000


To check or not to check: Managing blood sugar in diabetic employees

Over the last 20 years, there has been a growing prevalence of Type 2 diabetes in the United States. An estimated that 75% of patients with Type 2 diabetes regularly test their blood sugar. Read on to learn more.


Over the last 20 years, there’s been a growing prevalence in the U.S. of Type 2 diabetes, a chronic condition that significantly impacts employers, their employees and family members clinically, financially and through quality of life. With that comes an increase in the use of insulin for people with Type 2 diabetes to better control blood sugar to reduce long-term complications, which includes eye, kidney and cardiac disease, as well as neuropathic complications.

Most of these patients manage their condition with oral medicines versus insulin, and it’s estimated that 75% of patients with Type 2 diabetes regularly test their blood sugar, even though doing so may not be needed. Blood sugar testing is an important tool in managing diabetes as it can help a patient be more aware of their disease and potentially control it better. But it also can be painful, inconvenient and costly.

Blood sugar testing can be an important tool in managing diabetes, and there are two types of tests. The first is a test conducted at home by the patient that shows the blood sugar at a specific point in time. The second type is called HA1c (a measure of long-term blood sugar control) that shows the average blood sugar over the last two to three months. The value of at-home testing is now thought to be questionable.

In 2012, the Patient-Centered Outcomes Research Institute began a study to evaluate the value of daily blood sugar testing for people with Type 2 diabetes not taking insulin. The endpoint for the study was whether there was a difference in HA1c levels for those who did daily testing and those that did not. The conclusion of the study found that there were no significant differences between those two populations.

In response to these findings, the institute developed an initiative called Rethink the Strip that involves stakeholders including primary care practices, healthcare providers, patients, health plans, coalitions and employers. Given the cost for test strips and monitors for patients with Type 2 diabetes who test their blood sugar daily, it’s important to adopt an evidence-based patient-centered approach around the need for and frequency of self-monitoring of blood glucose.

As employees and employers cope with the costs associated with blood sugar testing, there are several strategies that should be considered to better manage this issue. They include:

1. Support shared decision-making. Like all interventions within healthcare, it’s important to weigh both the benefits and the risks of daily blood sugar testing in a thoughtful manner between the patient and their provider.

2. Managed benefit design. Employers should pay for daily blood sugar test strips in cases where it brings value (e.g., Type 1 and Type 2 patients who are taking insulin as well as patients that are either newly diagnosed or are going through a transition period, for example, post hospitalization or beginning a new medication regimen).

3. Involve vendors. To ensure alignment in all messaging to plan members, ask health systems and/or health plans and third-party vendors to align their communication, measurement and provider feedback strategies on when it’s appropriate for daily blood sugar testing.

These strategies can help employees with diabetes understand how their daily activities (nutrition, exercise and stress) and medications impact their condition. This benefits the employee in reaching treatment goals and feeling their best, while also helping employers and employees reduce the need for unnecessary and costly test strips.

SOURCE: Berger, J. (14 March 2019) "To check or not to check: Managing blood sugar in diabetic employees" (Web Blog Post). Retrieved from https://www.employeebenefitadviser.com/opinion/managing-blood-sugar-in-diabetic-employees?brief=00000152-146e-d1cc-a5fa-7cff8fee0000


Digital health revolution: What we’ve learned so far

The effectiveness of digital health devices is being called into question by recent studies. Digital health devices provide personalized feedback to users, helping improve their health. Read this blog post to learn more.


The promise of the digital health revolution is tantalizing: a multitude of connected devices providing personalized feedback to help people improve their health. Yet, some recent studies have called into question the effectiveness of these resources.

While still evolving, many compelling use-cases are starting to emerge for digital health, including a set of best practices that can help guide the maturation of this emerging field. In the near future, many people may gain access to individual health records, a modern medical record that curates information from multiple sources, including electronic health records, pharmacies and medical claims, to help support physicians in care delivery through data sharing and evidence-based guidelines.

As these advances become a reality, here are several digital health strategies employers, employees and healthcare innovators should consider.

Micro-behavior change.

Part of the power of digital health is the ability to provide people with actionable information about their health status and behavior patterns. As part of that, some of the most successful digital health programs are demonstrating an ability to encourage daily “micro-behavior change” that, over time, may contribute to improved health outcomes and lower costs. For instance, wearable device walking programs can remind people to move consistently throughout the day, while offering objective metrics showcasing actual activity patterns and, ideally, reinforcing positive habits to support sustained change. Technology that encourages seemingly small healthy habits — each day — can eventually translate to meaningful improvements.

Clinical interventions.

Big data is a buzz word often associated with digital health, but the use of analytics and technology is only meaningful as part of a holistic approach to care. Through programs that incorporate clinical intervention and support by care providers, the true value of digital health can be unlocked to help make meaningful differences in people’s well-being. For instance, new programs are featuring connected asthma inhalers that use wirelessly enabled sensors to track adherence rates, including frequency and dosage, and relay that information to healthcare professionals. Armed with this tangible data, care providers can counsel patients more effectively on following recommended treatments. Rather than simply giving consumers the latest technologies and sending them along, these innovations can be most effective when integrated with a holistic care plan.

Real-time information.

One key advantage of digital resources, such as apps or websites, is the ability to provide real-time information, both to consumers and healthcare professionals. This can help improve how physicians treat people, enabling for more customized recommendations based on personal health histories and a patient’s specific health plan. For instance, new apps are enabling physicians to know which medications are covered by a person’s health plan and recommend lower-cost alternatives (if available) before the patient actually leaves the office. The ability to access real-time information — and act on it — can be crucial in the effort to use technology to empower healthcare providers and patients.

Financial incentives.

Nearly everyone wants to be healthy, but sometimes people need a nudge to take that first step toward wellness. To help drive that engagement, the use of financial incentives is becoming more widespread by employers and health plans, with targeted and structured rewards proving most effective. From using mobile apps and comparison shopping for healthcare services to encouraging expectant women to use a website to follow recommended prenatal and post-partum appointments, financial incentives can range from nominal amounts (such as gift cards) to hundreds of dollars per year. Coupling digital health resources with financial rewards can be an important step in getting — and keeping — people engaged.

The digital health market will continue to grow, with some studies estimating that the industry will exceed $379 billion by 2024. To make the most of these resources, healthcare innovators will be well served to take note of these initial concepts.

SOURCE: Madsen, R. (14 March 2019) "Digital health revolution: What we’ve learned so far" (Web Blog Post). Retrieved from https://www.benefitnews.com/opinion/digital-health-revolution-what-weve-learned-so-far?brief=00000152-14a5-d1cc-a5fa-7cff48fe0001