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.


Are you ready for self-funding? Three tools to help you decide

Switching to a self-funded plan can seem like a daunting prospect to many HR directors, but there are also many significant benefits to switching. Read on for three tools to help you decide if you’re ready to switch.


When your health plan is fully insured, it’s easy for your finance department to budget for the cost — you just pass on the health insurer’s annual renewal premium amount to them and that becomes the annual budget number. But you and your broker may have come to suspect that you are leaving money on the table by continuing on a fully insured basis, and you may want to test the self-funded waters.

By now, you may already know there are significant benefits to self-funding, but actually making the switch is a scary prospect for HR directors.

Before you can transition to a self-funded plan, you need to be financially stable and willing to take a bit of a risk. As a safeguard, you also need to familiarize yourself with the two forms of stop-loss insurance. One caps the impact on any one covered member’s claims (individual or specific stop loss), and the other caps your total annual claim liability (aggregate stop loss). Your broker can guide you on which stop loss levels and which stop-loss coverage periods are right for your population when transitioning from fully insured to self-funding.

Beyond these stop-loss safeguards, size will dictate how you pay. If you have fewer than 100 covered employees, you may be able to pay the same amount monthly, just as you do with your fully insured premium. This monthly payment equals projected claims plus an aggregate margin, a monthly administration fee and the stop loss charge. This eliminates unpredictable monthly payments for a small self-funded group.

However, for larger groups of over 100 employees, moving to self-funding will mean paying claims as they are processed (which means uneven claim payments), plus stop loss and administration.

To help you determine if you’re ready for self-funding, you may want to analyze your plan in a few different ways.

1. Look back: A look back analysis is just what it sounds like — a view of how your plan would have performed over the last couple years had you been self-funded, compared to how it did perform under a fully insured model. This should be an easy enough task for your broker to take on, especially if they have sought out self-funded quotes from claim administrators and stop-loss carriers on your behalf. In addition, they should know what your actual claims costs were. The result is that you’ll know whether you would have saved money or not.

2. Look forward: You may already know what your upcoming fully insured renewal looks like. But even if you don’t have hard numbers yet, you can work with your broker to determine a strong estimate of what your proposed premiums will be. Then, your broker should get a self-funded quote, which includes the expected and maximum claims, plus the administrative fees and stop-loss premiums. This is your expected self-funded costs for the upcoming policy period. Compare that estimate to your fully insured renewal costs. (Make sure the self-funded costs are on the same “incurred claims with runout” basis that the fully insured costs would be, for a fair apples-to-apples comparison.)
3. Probability. While the “look forward” analysis compares your fully insured costs to your expected self-funded costs, it is based on “expected” claims. The risky part of self-funding is that your actual claims will not ultimately materialize exactly as expected. There are some more sophisticated tools that combine group-specific data (such as your claims history, demographics and the proposed fixed costs) with a fairly large actuarial database to come up with thousands of possible outcomes.

By charting all of these outcomes, you can produce likelihood percentages of where your actual claims will come in at — versus the “expected” level, and versus the fully insured renewal rate. Not all brokers have this tool on hand, and as a result, there may be a cost associated with producing one. The output from this tool may appeal to your colleagues in the finance department.

Other considerations

During your analysis, you may want to set your self-funded policy year liability based on incurred claims (plus fixed costs), even though your actual paid claims within that policy year may be less due to the lag between when provider services occur and when you actually fund them. The lag is a cash-flow advantage but it does not represent a reduced claim liability.

Finally, don’t lose sight of the cost of high claimants, an important part of planning if you choose the self-funding route. Will your past high claimants continue into your renewal period? Are you aware of new high claimants on the horizon? Stop-loss carriers generally insure only “unknown risks,” not “known risks.” If a plan member has an expensive chronic condition, such as kidney failure, a stop loss carrier may “laser” that individual and set a higher individual stop-loss threshold. It’s important that you know what’s excluded and factor in any uncovered catastrophic claimants into your analysis.

In the end, it may turn out that self-funding is not a good fit, or possibly that this year is just not the year for it. But whether it is, or it isn’t, it is comforting to know that you’ve done your due diligence and have documentation supporting the decision you’ve reached.

SOURCE: DePaola, Raymond (5 October 2018) "Are you ready for self-funding? Three tools to help you decide" (Web Blog Post). Retrieved from https://www.benefitnews.com/opinion/ready-for-self-funding-three-tools-to-help-you-decide


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Level-funded plan uptake trickling down market

What are level-funded plans, and why are they becoming so popular? Allow this article to break down the facts for you.


A brighter light is being cast on level-funded group health plans as benefits decision-makers tackle open-enrollment season. Several industry observers say the trend is more pronounced given that the Affordable Care Act remains largely intact — for now.

There has been an ebb and flow to these self-insured underwritten plans over the past 18 months, says Michael Levin, CEO and co-founder of the healthcare data services firm Vericred. But with a fixed monthly rate for more predictability, he says they can drive 25% to 35% savings relative to fully-insured ACA plans that must comply with the medical loss ratio for a certain segment of the market.


Level funding typically leverages an aggregate and/or specific stop-loss product to cap exposure to catastrophic claims. These plans are offered by an independent third-party administrator or health insurance carrier through an administrative-services-only contract.

It’s best suited for companies with a very low risk profile comprised of young or healthy populations, according to Levin. And with low attachment, stop-loss coverage in most states, he explains that the plans have “very little downside risk from the group’s perspective.” Two exceptions are California and New York whose constraints on the stop-loss attachment point “essentially preclude level-funded plans from being offered” there, he adds.

The arrangement is trickling down market. “We’ve heard from carriers that will go down to seven employees, plus dependents, while others cut it off at 20 or 25,” he says.

David Reid, CEO of EaseCentral, sees a “resurgence of level funding” across more than 38,000 employers with less than 500 lives that his SaaS platform targets through about 6,000 health insurance brokers and 1,000 agencies. His average group is about 30 employees.

He’s also seeing more customers using individual-market plans rather than group coverage through Hixme’s digital healthcare benefits consulting platform. Under this approach, health plans are bundled with other specific types of insurance and financing as a line of credit to fill coverage gaps. Employer contributions are earmarked for individual-market plans, which are purchased through payroll deduction.

Read further.

Source:
Shutan B. (17 November 2017). "Level-funded plan uptake trickling down market" [Web Blog Post]. Retrieved from address https://www.employeebenefitadviser.com/news/level-funded-plan-uptake-trickling-down-market?feed=00000152-175e-d933-a573-ff5ef1df0000

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