Self Funding Magazine
Self Funding Magazine
EDITORIAL
TABLE OF CONTENTS Self Funding Magazine
Editor-in-Chief
Jonathan Edelheit
Assistant Editor Jenny Dodson
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SURVIVING HEALTH CARE REFORM: 10 CRITICAL ISSUES EMPLOYERS SHOULD ADDRESS WITH THEIR BROKERS by Adam Bruckman
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HEALTH PROMOTION VERSUS DISEASE MANAGEMENT A CORPORATE LIFESTYLE APPROACH by Dr. David Koivuranta
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TABLE OF CONTENTS
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LETTER FROM THE EDITOR SELF FUNDING AGENDA AND PARTICIPANT LIST ANNOUNCED by Jonathan Edelheit
06 THE NEW WILD WEST by Ray Desrochers
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PHARMACY BENEFIT MANAGER CONTRACT LANGUAGE THAT AFFECTS PLAN SPONSORS COSTS by Daniel Opinante
INSURANCE EXCHANGES: 17 HEALTH LET’S DO THEM RIGHT by Dennis Triplett CHANGE IN PAYERS’ FRAUD, 21 DRIVING WASTE AND ABUSE RECOVERY EFFORTS by Gary Stuart
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UTILIZATION REVIEW A DEPENDABLE COST CUTTING by Suzanne Berman
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OFFICE HEALTH THROUGH COLD AND FLU SEASON by Dr. Kathy Gruver
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WOULD YOU PAY YOUR CREDIT CARD BILL BEFORE REVIEWING IT? by Dr. Kristin Begley
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BENEFITS THAT REALLY MATTER: WHAT FEMALES WANT
Copyright © 2011 Self Funding Magazine. All rights reserved. Self Funding Magazine is published monthly by Global Health Insurance Publications. Material in this publication may not be reproduced in any way without express permission from Self Funding Magazine. Requests for permission may be directed to info@SelfFundingMagazine.com. Self Funding Magazine is in no way responsible for the content of our advertisers or authors.
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EDITOR’S LETTER
Self Funding Agenda and Participant List Announced
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his year we have worked extremely hard to totally redesign this years Self Funding Conference and Employer Healthcare Congress. We stripped everything down to the shell, and gave it a complete upgrade from speakers and agenda topics, to new networking software, and excitingly, to a new city. We are going to Chicago, in a true convention center, and everyone is ecstatic for the conference to move to Chicagoland and to be centrally located in the United States.
The results have been amazing for us. The industry has seen the changes and spoken. Our attendance is up 93% compared to last year around this same time, and it keeps growing day by day. To View the 2011 List of Attendees, visit the conference website, www.selffundingconference.com/2011-list-of-attendees1.html Part of that, I believe, is our investment in bringing in some of the brightest and best keynotes possible. This is an area where we focused heavily and tried to get innovative keynotes that are well known experts. We searched for those who not only inspire, but provide key insight we all need to stay motivated and to succeed in our business, passions and personal lives. All of our KeyNote speakers are outstanding, but I believe my favorite would have to be John Casey, Director of International Benefits for Google with his topic, Creating the Healthiest Employee in the World. Google is at the cutting edge of innovation and everything they do is usually inspiring and successful. I can’t wait to see how they are changing the curve and making their employees healthier, more productive and lowering their costs. I am very passionate about the power of social media. It is a very important topic for me to bring to the forefront for our attendees. Most of us know social media but don’t really understand it or know how to use it effectively. Social Media is being used for everything today; even enrolling and educating employees for benefits programs. I diligently searched and was able to get Mitch Joel, who Mashable.com (the top rated social media website out there), rated Mitch as one of the top social media experts in the world and his book, Six Pixels of Separation was rated one of the top 5 social media books to read. As most companies in US healthcare and benefits initiate their plans in social media, this will be an eye opening and critical session Our outside the box keynote speaker this year is Bill Rancic, Season 1 Winner of Donald Trump’s The Apprentice. Bill competed on national television and is a true entrepreneur. We have brought Bill in specifically to discuss the challenges we are facing in the healthcare and insurance industry today and he will be teaching us the importance of becoming “adaptable.” Adaptability is critical for all of us to survive, and I couldn’t imagine a more important topic for us to be addressing, especially in the face of all the changes and obstacles our industries are facing with PPACA and the economy. This year we are also adding in Global Benefits and have some of the largest multinational employers and insurance companies presenting on the growing trend of international benefits and providing case studies to attendees. We have put a lot of effort into our Employer VIP program and even upgraded it to include Agents and Third Party Administrators. There have been so many requests for VIP Passes, sometimes it can be difficult to manage! Attendees will see a major difference in the number of employers, agents and TPA’s coming this year that qualified for our complementary passes and other benefits. I really want to thank everyone who has made our magazines and the conference so successful. More importantly, you have helped us accomplish, in just three years, what many of our competitors who have been around for 20 years, have been unable to surpass. With your support, you have made us the the biggest benefits conference in the country for employers, agents, TPA’s and insurers.
Jonathan Edelheit
President Employer Healthcare Congress www.employerhealthcarecongress.com
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n the days of the Wild West, pioneers set out to discover a new frontier. Ahead of them lay challenges, potential dangers and possible wrong turns. They pressed on, however, in the hope that they would find a better life, a new home or even gold at the end of their journey! Today, healthcare payors also face a new frontier. Numerous challenges, dangers and possible wrong turns lay ahead, as the previously paved roads and the business-as-usual approaches of the last century are left behind. The rapidly evolving healthcare economy is shaping up in a way that is reminiscent of the Wild West. Payors that don’t join the caravan will find themselves left in the dust, unable to compete in this new world. What’s driving this new healthcare frontier? Out of control costs, the large number of uninsured and underinsured people in the United States and the realization that we need to do more to involve everyone in the process. The cost of healthcare as a percentage of the nation’s GDP is rising at an alarming rate. According to the “U.S.
Health Care Costs” report by the Kaiser Family Foundation, “expenditures in the United States on healthcare surpassed $2.3 trillion in 2008, more than three times the $714 billion spent in 1990, and over eight times the $253 billion spent in 1980.” Chronic disease, an aging population and outof-control administrative expenses are considered by many to be big drivers of the unprecedented cost of today’s healthcare. As the annual cost of care continues to grow, it has become clear that our current healthcare model simply isn’t sustainable. As a result, similar to the pioneers that headed for the new frontier all those years ago, many payors are now beginning to explore other options as they too head in new directions. New ideas – some novel approaches, some revamps of previous attempts to reduce costs while delivering higher quality care – are beginning to take shape as the twenty-first century healthcare caravan begins. Last year’s passage of the healthcare reform bill has set in motion a series
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of sweeping changes that affect the way medical care will be delivered and paid for over the next decade and beyond. Funding and managing the new generation of healthcare services are fundamental challenges to achieving the bill’s goals of improved care access, quality and costefficiency. The initiative calls on all parties – patients, providers, payors and the government – to ensure that maximum value is received from every dollar spent. Let’s look at some of the changes that will help to shape what is sure to be a wild ride. Today’s static, one-size-fits-all healthcare model is being replaced by new models that stress individualization, personalization and customization, based upon the unique needs of each member. These new models will, in many cases, shift ownership, responsibility and risk to providers, employers and even the members themselves, as we finally begin to closely link everyone involved in the healthcare delivery cycle and have individuals take on a greater role in managing their care. One option that is gaining significant traction and momentum is ValueBased Benefit Design (VBBD), now more commonly referred to as
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Value-Based Healthcare. This model is focused on the idea of having highly personalized benefits that incentivize specific healthy behaviors for individuals who have or are likely to develop chronic diseases. Using this new approach, for example, a value-based plan would offer people at high risk for a heart attack reduced or eliminated co-pays for certain prescribed medications and physician visits, and may even offer premium reductions or other incentives if certain health and wellness objectives are consistently met. In some cases, physicians are also incented based on how well they perform. This is a dramatic shift away from more traditional approaches, as it focuses on proactively managing the people that are most at risk as a way to create and maintain a happier and healthier patient population while keeping the overall cost of care in check. While still too new to fully determine their total return on investment, a number of early adopters of value-based health plans are already reporting lower or more stable costs, increased productivity and enhanced member satisfaction. One thing has become clear, however, when reviewing the results of these programs: payors that want to compete using these new options must first embrace nextgeneration technology platforms that will enable them to achieve increased levels of flexibility, agility, transparency and interoperability in order to ensure that they will be able to address the
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complexities that are associated with many of these offerings. There are a number of other new models that are also appearing as part of the Wild West brigade, including Accountable Care Organizations (ACO), a new generation of Consumer-Directed Health Plans (CDHP) and Patient-Centered Medical Homes (PCMH). While each of these options also has important advantages, disadvantages and differences, most of them have at least one thing in common – a shift in risk. Using many of these new approaches, payors will now share risk with providers, employers and even members, as each of these groups takes on more responsibility for the quality and cost of care. One of the most crippling weaknesses of many of the legacy healthcare technology platforms is their inability to easily integrate with other systems in a way that enables the exchange of data both across and between organizations. While payors already collect a myriad of information from a wide variety of different sources, most of it resides in hard-to-access silos that were never intended to support the level of business transparency that is required to operate in the current healthcare environment. Payors need to be able to easily aggregate and analyze data, in real-time, and then convert it into actionable intelligence that will support optimal decision making by everyone involved in the healthcare delivery cycle. They must also be able to provide members and providers with instant access to information related to benefits, provider networks, health conditions, and the current status of deductibles, limits and OOP maximums.
complexity that most organizations are simply not ready to deal with given the fact that many of their existing platforms and applications were not designed with any of these items in mind. As we move from the 17,000 diagnosis and procedure codes of ICD9, to the more than 155,000 codes that are now part of ICD-10, many payors are finding themselves in a situation that is reminiscent of Y2K. Hundreds or in some cases thousands of database fields, often in multiple systems, need to be expanded to accommodate the increased length and complexity of the new codes, and existing data needs to be migrated and merged to ensure that claims that are processed using the new standard will be paid correctly. Many of the payors that have realized the importance of using modern technology platforms to address these twenty-first century healthcare business needs have already begun the transformation. Those that haven’t yet joined the caravan will continue to face enormous challenges, as the world of healthcare continues to increase in complexity and they find themselves unable to compete in the rapidly evolving healthcare marketplace.
Similar to the Wild West “showdowns” of the past, we are now seeing new showdowns between the old and the new healthcare technology platforms, and the old and the new healthcare business models. Today’s healthcare pioneers will use a new generation of tools to drive their success, as they move away from the antiquated, hard to maintain legacy platforms and the multitude of s u r r o u n d Changes related to healthcare reform and new systems that regulations are also part of the Wild West journey. are currently The move to the ICD-10 standard, for example, is holding them quickly approaching and will introduce a level of back. Payors
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About the Author Ray Desrochers is a senior technology and business executive responsible for leading HealthEdge’s day-today operations and for ensuring the successful growth of the company. A graduate of the University of Massachusetts, Ray has been a frequent speaker at technology events and conferences around the world.
that want to stake their claim in this new world must have systems that will allow them to quickly adapt to new models, easily address market changes, eliminate waste and manual processing, and offer significantly enhanced levels of transparency and support. Like the days of the Wild West, opportunity is everywhere, especially for those who are willing to do what it takes to be successful. Changes are sure to bring challenges for everyone – providers will find new and more efficient ways to participate in the healthcare cycle, patients will play a more active role in keeping themselves healthy and managing the cost and quality of their care, and payors will offer new options that will help to further support reform. Reaching the “new world” of twenty-first century healthcare will not be easy, but it will offer unlimited benefits for those that can endure the challenge.
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he pharmacy benefit management (PBM) industry is on the verge of significant transition. The PBM market place is being consolidated as two of the largest players merge to a form an organization serving over 100 million members. While there is considerable discussion concerning what the implications of the acquisition are in terms of market dynamics, pharmacy negotiation power and client pricing, there are often overlooked implications that will have significant impact on plan sponsor pharmacy benefit costs. One such aspect is common PBM contract language that may seem innocuous but in reality may
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give the PBMs financial advantages that do not translate to savings for plans sponsors. After conducting thousands of pharmacy benefit audits, as well as PBM request for proposals, we have found that most plan sponsors do not understand how PBM contract language can affect the PBM’s discount guarantees, and ultimately their pharmacy plan costs. The following is a summary of some of the common PBM contract language we suggest every plan sponsor become familiar. We will focus on explaining the impact of the following three sections
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frequently found in a PBM service agreement.
package size submitted through retail channel. By comparing the top 500 generic medication’s • Mail service discounts based on 100 unit actual unit costs (cost per pill) for retail versus package size mail service unit costs, we determined that the • Exclusion of Single Source Generics from actual unit costs for mail service are the same the generic discount guarantee as the retail generic unit costs. The difference • Inclusion of Zero Balance Due claims for discount guarantees
Mail Service Discounts Based on 100 Unit Package Size:
between retail and mail from a unit cost basis is Most PBMs include contract language which only 1 percent (see table X). states that mail service discount guarantees In this example we determined for this client are based on 100 unit package sizes (or that the actual generic costs for mail service are lower). Package size language may be found virtually the same as retail generics. The PBM in the pricing section or as a definition within mail service discount guarantee set forth in the the PBM service agreement. The language PBM contract based on 100 unit package size is contrary to how mail service pharmacies is greater than the retail discount guarantee, but purchase medications. The goals of mail service the costs are the same. pharmacies to purchase medications in the largest package size available to take advantage Unfortunately most of the larger PBMS have of volume price points where greater discounts structured their mail service operations to are offered by the pharmaceutical manufacturer. utilize 100 unit package size, and are resistant Through the use of this language, PBMs can to removing the 100 unit package size language. increase the Average Wholesale Price (AWP) Plan sponsors with high mail utilization should discount offered to the plan sponsor by as much consider the requirement of MAC (maximum allowable cost) pricing for mail service generics. as 3.5 percent for generic medications. PBMs develop aggressive MAC pricing to be To support this conclusion, we compare the used to price retail generic claims to prevent average package size for retail claims to the the retail pharmacy from using similar pricing. average package size used for mail service With that said, requiring the PBM to use the claims when auditing client data. Below is a same MAC pricing at mail service will lessen the impact of the 100 unit package size language sample analysis. and generate greater cost savings for the plan sponsor.
Exclusion of Single Source Generics (SSG) from the Generic Discount Guarantee:
This client example demonstrates that the average generic package size submitted through mail In the next 5 years the pharmaceutical service is 42 percent smaller than the average marketplace will see a significant increase
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utilization of generic medications as a result of many highly utilized brand medications losing their patent protection. Once a brand medication is available as a generic, the unit cost savings does not occur immediately. Generic medication pricing is much like any businesses where supply and demand plays a crucial role in price. Once a brand medication loses its patent protection, it is typically the existing brand manufacturer that launches the first generic version. If the new generic, only has one manufacturer, that manufacturer will establish the cost of the generic at a price point only slightly lower than the existing brand. Once a generic medication is introduced, it will take between 9 to 18 months before the generic costs will decrease significantly as generic prices are dependent upon the number of generic manufacturers competing in the market. Since the unit cost of a new generic is not much lower than the existing brand medication, PBMs prefer to exclude these new generic medications from their overall generic effective discount guarantee. The reality is, the PBMs are not going to obtain the same AWP discounts for new generic medications as they would for generics that have been in the market place for years where competition is prevalent. Further, with the large market share these medications represent, if PBMs do include SSG in the client’s discount guarantee, they will struggle to meet the guarantee.
If the PBM generic pricing terms included SSG, the PBM will realize an approximate 13.2% reduction in the overall effective generic discount guarantee (Refer to Table X).
It is obvious why PBMs want to exclude SSG from their overall generic effective discount guarantee. The PBM language excluding SSG from the overall generic effective rate is not the problem. Our concern with this language is how SSG are defined. Most PBM contracts allow the PBM to define what is a SSG, and how long the SSG are excluded from the discount guarantee. In our experience we have found large variations with regards to SSG definitions, and in many cases, SSG are not defined at all.
Plan sponsors should understand that through 2015 they can expect their generic utilization to increase approximately 10 percent. Currently we see plan sponsors generic utilization at approximately 70 percent. In 2015 generic utilization should approach 80 percent. It is commonly understand Looking specifically at the brand medications that that the majority of the PBMs traditional revenue is are losing their patient protection in 2011 to 2015, the pricing spread for Generics. In the next 5 years, the impact is significant. By reviewing client clams plan sponsors need to focus in generic discount data, we project plan sponsors can expect over 30 language, and how it will impact their costs. percent of their existing brand claim utilization to transition to generic medications in the next five Our recommendation to plan sponsors is require your PBM to provide a definition of SSG years (Refer to Table X).
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medications, a list of the SSG drugs that will excluded from the discount guarantee with regular updates, and the length to which SSG are excluded from the generic discount guarantee. Only by defining SSG, monitoring which SSG drugs are excluded from the generic discount guarantee and auditing to determine of the PBM accurately applied the SSG provisions of the contract, will a plan sponsor be able to validate their PBM’s generic discount guarantee.
increasing traffic to their retail pharmacy locations. Many if not most of these medications result in a zero balance due claim because the $4 member copay is less than the plan sponsors copay.
By including these claims, the PBM is taking credit for the retail pharmacies decision to offer these medications at or below their acquisition cost. The savings impact of ZBD claims is not a result of the PBMs discount negotiations with retail pharmacy Inclusion of Zero Balance Due Claims for chains, savings is strictly a function of plan design and retail pharmacy pricing practices. As a result Discount Guarantees: ZBDs should be excluded from the calculation of Zero Balance Due Claims (ZBD) are defined as PBM discount guarantees. claims were the member cost share (copay) pays the full cost of the prescription drug claim and the plan In reviewing client data, we estimate that ZBD claims sponsor is billed $0. As an example, if the cost of a may represent as much as 25 percent of retail claims generic drug is $4 and the member’s copay is $5, the and 11 percent of mail service claims. The impact copay would cover the entire cost of the drug and to plan sponsor AWP discounts is between 1.5 and the plans sponsor would incur no claim cost under 2.0 percent and primarily applies to retail generic most benefit plans. The volume of ZBD claims are medications (Refer to Table X). a function of the plan sponsor’s plan design. As member copays increase, the number of ZBD claims also increase. Conversely, plan sponsors with benefit plan designs with low member copays have fewer ZBDsclaims. For many years, it was the industry norm to exclude ZBD claims from calculating PBM discount guarantee. The rational is if an auditor determined a ZBD claim paid in error, there are no damages to the plan sponsor because the plan sponsor paid $0 for these claims. The inclusion of ZBD claims in calculating plan sponsor AWP discount guarantees, have become the norm. In the past few years many retail pharmacies are provided $4 generic programs. The retail pharmacies have offered these medications in some instances at or below their cost for the purpose of
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About the Author Daniel Opinante is the president of Seneca Consulting Group, a national pharmacy benefit consultant and auditing firm.has been very active in educational initiatives designed to help unveil the complexity of the pharmacy benefit industry. As the featured speaker of the national PBM educational series “Taming the Tiger”, Mr. Opinante has had the opportunity to present his “PBM 101: Pricing and Revenue Models” throughout the Country. Mr. Opinante has had the privilege of supporting education and awareness of PBM business models at many industry venues. As a speaker at the National Self Funding Conference, Health and Welfare Conference for Mid- Sized Employers, Made In America Taft Hartley Benefits Summit, the National Association of Police Officers (NAPO), and Health Care Administrator Association (HCAA), Mr. Opinante is dedicated to offering his experience to provide plan sponsors with a unique understanding of the pharmacy benefit industry. \ Since ZBD claims only benefit the PBM, and in most cases are not representative of the PBM network negotiated discounts, we recommend plan sponsors require the exclusion of ZBD claims from the PBM AWP discount guarantees.
Summary The Pharmacy Benefit Management service agreement language highlighted in this article is an example as to how often ignored contract terms can affect AWP discount guarantees and plan sponsor costs. Now and in the future it is important for the plan sponsors when reviewing potential PBM vendors, understand how PBM contact language can affect their plan costs, and the savings generated by the PBM discount guarantees.
Prior to establishing Seneca Consulting Group, Mr. Opinante had a successful 10 year management career for a New York based Pharmacy Benefit Manager. Mr Opinante provides valuable guidance for plan sponsors as to how to maximize their benefit dollar Contact Mr. Opinante by email or phone Dan@senecaconsulting.com 631-577-4092
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egardless of the ongoing debate, healthcare reform is now the law of the land, and we need to begin the process of developing meaningful consumeroriented products and solutions. After all of the political wrangling and “cleanup” changes to the 2010 law, the critical issue will remain:
health care overhaul are scheduled to take effect, including: federal coverage mandates, premium subsidies for income-qualifying consumers (133 to 400 percent of the federal poverty level) and new platforms to help individuals and small businesses buy health insurance.
Creation of state health insurance How well prepared are we to execute on expanding exchanges in 2014 — expected to bring health insurance to add tens of millions more some 30 million uninsured Americans under the people? umbrella of privately provided health insurance — is one of the keys to determining the direction In 2014, the most significant changes of the health benefits will take in the future.
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Quality of implementation will drive success or failure of the exchanges. If the exchanges fail to satisfy a broad range of consumers and employers, disappointment could propel the nation toward a single-payer government system. If the exchanges succeed, tens of millions of newly-covered individuals will have access to health care, and we may all come to embrace the concept.
Designing exchanges for success
A major theme of health insurance exchanges is that they are market oriented. The goal is for consumers to enter an open marketplace, see their health insurance options and make purchases. Sounds simple. However, for an exchange to be successful, the design must generate enough competition and choice to drive significant participation. We urge all stakeholders including business This would thereby mitigate adverse selection leaders, regulators and consumer groups to join and reduce administrative costs —critical the planning and implementation, to ensure factors for achieving long-term sustainability. success when the health insurance exchanges go “live.� To date, much of the attention on exchange design has focused on the regulatory requirements. But states and the industry need to provide equal emphasis on how well the exchanges will work for users. Attracting and retaining a large number of enrollees is the ultimate determinant for success. Based on extensive experience serving health plans and consumers, we encourage policy makers to focus on these four success factors for the exchanges:
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• Integration of core competencies to ensure a cost-effective, seamless flow of eligibility, enrollment and payments
Creating centralized marketplaces Concepts for the state exchanges range from minimalist websites listing hyperlinks for eligible insurance plans to one-stop shopping places that enable consumers to compare, select, enroll and pay for their health plans, all on one platform. We believe centralized markets are the way to go. Each state or region’s exchange should offer one-stop service for consumers, employers and insurance brokers. An exchange should be integrated—not a shallow, fragmented portal sending consumers off in all directions to gather information from insurers.
Emphasizing consumer experience Much of the insurance exchange discussion so far has been about regulatory issues. While fairness and other concerns are important, we believe consumers should be the focal point in designing exchanges.
• One-stop centralized marketplaces with transparent information on all aspects of health insurance
We urge policy makers to select robust technologies that support seamless end-to-end processes. Non-subsidized individuals and small employers will be more likely to embrace exchanges that include these characteristics: • Simplicity and ease of use
• High-quality consumer experience with • Plain English rather than legalese emphasis on simplicity and ease of use • Array of competitive choices to meet • Broad range of products with design and price variations diverse needs of consumers, small employers and brokers
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• Clear navigation path from shopping to with industry to draw upon relevant systems payment to service expertise in the various fields, including:
Providing competitive choices
• Insurance companies—risk, claim and provider management systems
Much as a retail store attracts customers by offering a broad line of merchandise, health • Administration and technology firms— robust, easy-to-use presentation, insurance exchanges should provide a diverse transactional and customer service platforms range of health benefit plans and ancillary products to meet the needs of consumers, small • Financial institutions—payment systems, employers and brokers. best practices and efficient disbursements If states take an overly controlling position that limits options, users will find the exchanges Doing health insurance exchanges right unattractive. Consumers or employers are not will come from investing time and energy all alike, so the new marketplaces should enable to design them well. Success will require choices among an array of options, such as drawing upon all of the skills in industry to traditional insurance, managed care plans and design an exchange that will attract large pool of participants into a competitive marketplace consumer-directed options. that is simple to use, provides a wide array of Consumer-Directed Health Care (CDHC) choices and is in one integrated service delivery plans should have a presence in these exchanges. model. This category includes Health Savings Accounts (HSAs) and Health Reimbursement About the Author Arrangements (HRAs), which are generally Dennis Triplett is Chief paired with higher deductible policies. Executive Officer of UMB Healthcare Services, a division Consumer-directed plans, with their emphasis of UMB Financial Corporation, on individual decision making, demonstrably headquartered in Kansas City, improve health care costs, efficiency and MO. Dennis has responsibility for UMB’s wellness. These important outcomes should be addressed among the options offered in the new strategic direction in health care banking and manages the sales and marketing activities as exchanges. well as product development and relationship management. He developed UMB’s Medical Integrating core competencies Savings Account product in the late 1990s and Given the complexity of health insurance grew that into their multipurpose card product decisions, it is critical to incorporate all core supporting a variety of spending accounts competencies to make each exchange a fully including HSAs, FSAs and HRAs. functioning system. States should design exchanges in partnership
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H
ealth insurers and the federal government don’t see eye-to-eye on many facets of the Patient Protection and Affordable Care Act (PPACA). But when it comes to preventing fraud, waste and abuse (FWA), private payers are in full support of provisions designed to enhance data sharing efforts and impose stricter
penalties. The need is clear: As much as 10 percent of healthcare spending is lost to abuse, according to recent studies , with the federal government alone losing more than $70 billion to improper Medicare and Medicaid payments, according to the Department of Health and Human Services (HHS).
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True, the new rules written into the PPACA are largely devoted to eradicating FWA in Medicare and Medicaid, but health insurers will no doubt benefit from increased screening and data sharing efforts designed to prevent FWA, rather than trying to recoup payments later determined to be the result of a billing error or fraudulent activity (i.e., pay-and-chase).
70 percent of private payers, according to the National Health Care Anti-Fraud Association (NHCAA) – must understand that under new circumstances, prepayment FWA avoidance programs are a vital component of payers’ strategies to lower costs and improve profitability.
Challenges Payers Face Now and in
Prevention. It’s a model that some private the Future healthcare payers have already employed, assisted by analytical technologies that detect Annually, FWA drains between $68 and $226 claim anomalies. Those that haven’t – about billion from the United States’ healthcare
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system – and taxpayers’ pockets. The causes of these erroneously paid claims are many. Along with mistakes introduced during the revenue cycle, organized crime rings steal patient IDs and create fictitious services and procedures that defraud payers, mar medical records and even endanger patients’ health and safety. Further complicating the scene for payers are complexities on the horizon for healthcare providers. These changes are not just the children of reform, but also include the previously directed mandates to implement ICD-10 diagnosis coding. ICD-10 will require providers to change their systems to reflect new codes for thousands of diseases, symptoms, injuries and abnormal findings. If providers are
not prepared to submit claims using ICD-10, and payers are not prepared to accept these updated codes, the door is left wide open for more errorfilled claims in inappropriate payments. Without a comprehensive payment integrity solution that includes advanced prepayment detection tools, many erroneous claims – including those submitted for medically inappropriate procedures or services that were never performed – will slip through the cracks. Further, using only traditional pay-and-chase tactics, health plans will rarely recover the amount originally paid on the fraudulent claim. A significant percentage will likely be lost in fees, staff resources and settlement costs.
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Prepayment FWA Detection: Case for Advanced Analytics
The one more layer to a multifaceted payment
Payers that have implemented a prepayment FWA model are leveraging analytic tools to identify potential claim discrepancies. These solutions typically combine predictive, data-driven analytics, rules-based analytics, integrated code edits, clinical aberrancy rules and provider verification to catch potentially fraudulent or erroneous claims. The analytical tools are designed to examine how claims are being paid according to rules and codes in an effort to detect common patterns and trends. From this data, the software identifies claim outliers prior to or during adjudication.
integrity program, it also gives clinical context to the analytics, allowing even more certainty that a claim may be aberrant.
A programmatic payment integrity approach has emerged as the new best practice. Progressive payers are combining technology with expertise offered by knowledgeable investigators with backgrounds in law enforcement, criminal justice, private investigation, claims investigation, statistics and analytics. These individuals are tasked with reviewing and analyzing historical claims data, medical records, suspect provider databases and high-risk identification lists while also conducting patient and provider interviews. This integrated, holistic approach to fraud While a rules-based approach can identify detection and prevention combines predictive, a predetermined set of known schemas, a data-driven analytics with expert analysis and data-driven analytical solution examines investigation, to help payers meet regulatory hundreds of variables in various combinations guidelines, reduce unnecessary payments due to simultaneously, allowing it to detect previously FWA and recover erroneously paid claims. unidentified and emerging schemes that rulesAnalytics: Proven based analytics alone may not recognize Prepayment – enabling the payment integrity solution Benefits to the Bottom Line to intelligently evolve. As it evolves, the subsequent models provide new actionable and HealthMarkets, a health and supplemental contextual information so investigators and insurance carrier covering more than 350,000 analysts can make rapid, informed decisions. lives in 44 states, has been reaping the rewards Intelligent evolution of detection models is of a comprehensive FWA prevention program by critical given the complexity and rapidity of implementing a broad payment integrity solution. fraud scheme proliferation. The organization has realized significant results Furthermore, solutions that combine data from through dedicated prepayment analysis efforts multiple sources provide a more complete conducted over the last two years. view of potential FWA by providing a conduit between clinical edits and predictive analytics In 2007, the payer processed 4,154,322 claims – to determine clinical aberrancy rules. Unlike flagging 178 as potentially fraudulent via manual traditional clinical edits or fraud-based rules, fraud detection efforts, lacking the resources aberrancy rules look across multiple data to make FWA prevention activities a more variables and time to identify claim anomalies, effective and automated process, HealthMarkets which trigger an alert requesting additional didn’t pay 175 of the scrutinized claims, saving review of the claim. Not only does this provide an underwhelming $50,000—less than 1/100
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of a percent of the overall value of claims paid that year. After implementing a prepayment analytics solution in 2009 that enabled the organization to systematically detect erroneous and fraudulent claims, HealthMarkets achieved $9.5 million in savings in the first year alone.
prior to payment, there is always a need for discerning and experienced fraud investigators and analysts, many of whom have uncovered millions of dollars of fraudulent or abusive claims. The leading technology vendors employ investigative personnel with these broad backgrounds and expertise in FWA that can Despite demonstrating significant results in fully outsource a payer’s investigative unit or their FWA prevention efforts, technology augment the team already in place. alone isn’t enough. HealthMarkets has learned that, although a payment integrity program Adapting for the Future must include the best and latest IT solutions, there needs to be balance in technology and Ongoing industry challenges, including claim staff. For a comprehensive plan, payers may processing complexities, healthcare reform need fraud analysts and investigators, certified and competition often force payers to impose claim coders and a medical director or other increased premiums and coverage limitations medical personnel. Even when fraud is detected for patients. Payers that once presumed they
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could not afford to invest in fraud prevention About the Author now realize that federal mandates, market forces and internal financial pressures make Gary Stuart is executive vice it critical to identify and prevent unnecessary president of payer services for claims payments. Emdeon, a leading provider of healthcare revenue and Detecting erroneous claims prepayment is a payment cycle management strategic way for payers to reduce liabilities and clinical information and improve their overall financial health. exchange solutions, connecting payers, However, health insurers often don’t have the providers and patients in the U.S. healthcare depth of information gleaned from analyzing system. www.emdeon.com multiple payers’ claims data. Traditionally employed pay-and-chase approaches to FWA management have not proven to be comprehensive enough, compelling payers to consider switching to prepayment solutions to achieve payment integrity. Effective prepayment FWA solutions that draw upon multi-payer/multi-provider/multigeography data and sophisticated analytics are emerging to fill the void. Further, by leveraging the power of predictive analytics to continuously identify new forms of FWA, and by prioritizing suspicious claims for maximum financial benefit and fewer false positives, payers can take tremendous steps toward effectively combating FWA and minimizing lost healthcare dollars.
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hange is inevitable for self-insured employers. More control over insurance programs means keeping up with a fastchanging legislative environment that’s inherently out of an employer’s hands. So as states grapple with both healthcare and workers’ compensation reform, employers wait in the wings to figure out their next move. Recently, many steps have been made to protect the patient that keep self-insured employers on their toes. Just last year, the Patient Protection and Affordable Care Act (PPACA or PCA) of 2010 was passed as an answer to public pressure for healthcare cost containment, and also as a way to prevent Americans from incurring financial ruin due to medical costs. Similarly, workers’ compensation laws – administered on a stateby-state basis – have been designed to protect workers and employers from excessive costs
due to injury liability and litigation. While these mandatory requirements may seem restrictive to self-insured employers who value control, employers can take the reins back by developing compliance strategies to limit their risk and maximize cost savings. One tool that helps achieve both objectives is Utilization Review (UR). By preventing injured workers from receiving unnecessary treatments, including expensive surgery, excessive medication or unwarranted physical or occupational therapy, UR remains an invaluable piece in the medical cost containment puzzle.
GOING BEHIND THE SCENES OF THE UR PROCESS In order to objectively keep claims under control, UR is employed during the period between injury and return-to-work. UR is the process of
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gathering medical information to determine whether or not a requested treatment is medically necessary, and it can be managed by an employer’s claims department, given the appropriate certifications and resources, or through a state licensed, third-party UR company. The UR process begins when a treating provider submits a request for a treatment and related documentation for either concurrent treatment (during), prospective treatment (pre-certification), or retrospective treatment (after). A pre-certification for emergency treatment is not required, but may be subject to a retrospective review, depending on the state. The UR organization reviews the request for treatment, typically using nationally-recognized evidence-based guidelines – built on documented research data – and either authorizes, denies, modifies
or delays a treatment. The UR organization’s first line of reviewers – a pre-clinical reviewer (PCR) and a registered nurse (RN) – will either: (1) authorize the treatment, or (2) forward a treatment request to a peer reviewer, which is a licensed medical provider often of the same specialty as the requesting provider. After examining all submitted documentation and attempting to speak directly to the requesting provider on the phone, the peer reviewer will make his or her final determination. If a recommended treatment is disputed, the peer reviewer will offer a clinical explanation of the decision and provide appropriate treatment
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• Allowing workers to get the appropriate care they need so they can go back to work recommendations to the requesting provider that follow commonly accepted evidence-based guidelines. Fourteen states regulate the UR process in order to maintain a system that fairly and objectively authorizes, modifies or denies treatment requests. The aims of the implemented polices include: • Setting deadlines for determinations to facilitate fast decisions that get patients through the healthcare system quickly
• Ensuring reimbursement to providers for medically necessary services
ADVOCATING FOR THE PATIENT AND FOLLOWING THE RULES Many states have adopted the timeframes and guidelines set by the Utilization Review Accreditation Commission (URAC) – a nonprofit organization that sets national standard policies for companies involved in the UR process. According to the URAC website, the policies are developed by various stakeholders, including providers,
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healthcare organizations, insurers and the public interest. An organization must be compliant with the policies and procedures set by URAC to be accredited by the organization. Requirements for accreditation also include two quality improvement projects at any given time and onsite visits to determine URAC compliance.
compensation claims is complicated by regulatory compliance matters and can leave an employer financially vulnerable. Self-insured employers that invest in the UR process as an integral component of managing claims, particularly large claims, can cut down on excessive and unnecessary treatments, thus reducing costs. More importantly, the UR process expedites the return of a productive worker by directing injured workers only to treatments that are needed and related to their work injury. In a constantly changing landscape, UR acts as a reliable guiding force to help you manage your employees’ health and medical costs.
Specific rules and guidelines for the UR process set by each individual state legislature supersede URAC’s recommendations and standards. For example, URAC’s deadline for a prospective treatment request determination is 15 calendar days from the date of receipt. A UR organization reviewing a workers’ compensation claim in California has five business days to complete the UR review. It’s the UR organization’s About the Author responsibility to keep up-to-date on the statespecific rules and changes. Suzanne Berman is a Utilization Review Nurse in If there’s not enough medical information to the Medical Review Unit of make a treatment decision, most states give a Rising Medical Solutions, a one-time deadline extension. Since decisions Chicago-based medical cost are almost always backed by evidence-based containment and care management company. research, a treatment request is often delayed Prior to Rising, Berman gained critical clinical due to limited documentation. The UR process expertise working as a Surgical Staff Nurse at allows requesting providers to advocate for Northwestern Memorial Hospital, where her patients through the appeal process, in either specialty was Orthopedic and Trauma. She’s an expedited or standard appeal. If a requesting a Registered Nurse in Illinois and Texas, and provider disagrees with the UR determination, a member of the Association of Peri-Operative they are given the opportunity to make their Registered Nurses. Berman has a master’s case by either submitting additional medical degree in Public Policy and Administration from documentation or requesting to speak directly Northwestern University, and holds a Bachelor with a new peer reviewer. of Science in Nursing from the University of Pennsylvania.
GETTING EMPLOYEES BACK TO WORK BETTER AND STILL SAVING MONEY
The goal of UR is to ensure that treatments are medically necessary and appropriate first and foremost. The administration of workers’
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ealth care reform has America’s employers scrambling to ensure they will be in compliance, scratching their heads about certain provisions and secretly wondering if their company is prepared for what comes next. Is your broker taking an active role in this process? Even more important, how do you determine if his or her firm is
equipped to help you navigate this uncharted territory? This new era demands sophisticated expertise and technology from employee benefit advisers. These 10 critical questions – and your broker’s responses - can help make sure the right captain is at the helm to guide your company into the future.
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1. What assistance should brokers provide their clients in response to health care reform? Today’s innovative brokers are at the top of their game, serving as guides to help employers navigate through health care reform. This legislation has made a complex industry even more complicated. Savvy businesses are turning to brokers who have invested in personnel and communications platforms that deliver the right information on a timely basis to their customers. Webinars, e-mail advisories, newsletters, handbooks, Q&As and updated timelines about the topic are now mandatory resources that employers should receive.
2. Compliance assistance has become an enormous challenge for companies. What kind of support is available? Compliance assistance is essential and has become one of several important services employers should expect. Keeping up with regulatory requirements is a challenge, particularly for small businesses. Leading brokers are committed to regularly alerting clients about all regulatory/compliance matters to keep them informed and help manage organizational risk and exposure. Annual compliance reviews (e.g., HIPAA, ERISA, COBRA, HCR, etc.) should now be routine, as well as assistance with IRS paperwork and filings, including Form 5500 preparation. The goal is to eliminate confusion related to compliance (and any potential deficiencies) with upfront education and counsel about copious state and federal issues.
3. What are the three most important questions employers should ask their brokers NOW? • Ask about strategies and offerings to address long-term health insurance affordability issues. There are many options to consider including self-funding, consumerdriven plans and voluntary products. The best brokers spend time getting to know their clients and help design a strategy with customized plans to address an employer’s needs and budget over a period of several years.
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• Inquire how the firm stays abreast of continually changing regulations related to health care reform – and what tools and resources are available to clients. Push to understand all the services offered and how the broker differentiates their services from other advisers in the market. • Explore how they help educate customers’ employees about wellness and preventive care – so that these individuals can become better health care consumers. Access to online information and resources, health risk assessment tools, a customer advocate center and communication materials are excellent indicators that you are receiving maximum value.
4. What do you predict will be the greatest challenges for employers and when will they occur? What solutions and resources can guide them through these obstacles? Employers are challenged to find a long-term strategy that provides affordable health insurance for their employees. Brokers must identify ways to address this crisis and help clients bend the cost-curve on employee benefits. Data analytics, consumer-focused approaches, integrated benefits (voluntary products), defined contribution expertise, transparency tools and a high-performing technology platform are among the tools and offerings that brokers will need to properly address this issue. Without a strong adviser providing creative and innovative solutions, businesses will continue struggling to provide affordable employer-sponsored benefit options.
5. What do you predict will be the greatest challenges for employees, and when will they occur? What solutions and resources can guide them through these obstacles? Today’s economy presents monumental challenges for the American workforce. At the same time, health insurance policies have become increasingly difficult to understand. Employees -- not just their employers -- need more from a
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broker: more expertise, more guidance and more tools. Firms that have invested in technology, resources and training for their customers’ employees set themselves apart from the pack. Leading consultants not only design comprehensive plans, but offer a communication platform to help roll out and advise individuals about their benefits options. More frequently, through voluntary products and defined contributions plans, employees will make their own decisions about what insurance to purchase for themselves and their families. Top brokers will provide services and information about these options to each worker through technology, educational tools and enrollment capabilities. Advisers clearly need to address these issues and are already devising solutions that go well beyond the employer.
6. What innovative approaches are brokers taking to ensure their clients are well informed about reform updates? The Patient Protection and Affordable Care Act (PPACA) was passed on March 23, 2010. With more than a thousand pages of rules, regulations and effective dates, businesses are faced with the daunting task of digesting the act’s complexities. Leading consultants in the employee benefits industry are committed to helping their customers comply with these mandates, as well as other regulatory and legislative requirements. The industry’s best brokers are well-equipped to serve as trusted advisers. They provide their clients with a wide array of health care reform communication tools, including frequent advisories, webinars, seminars, newsletters, handbooks, tax credit assessments and calculators – and comprehensive online resources.
7. Escalating costs remain a challenge and many predict health care reform will not resolve this issue. What are your thoughts on the matter, and what approaches do you recommend to help control costs? Escalating insurance costs remain a reality. No one can accurately predict the future, but it is likely that health
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premiums will continue to rise unless major changes are made by all stakeholders in our health care system – insurers, providers, employers and employees. Wellness, lifestyle management and employee engagement are crucial to bringing rising costs under control. Innovative brokers are rolling out tools to help clients and policy holders embrace these concepts, and many are utilizing advanced technology and analytic tools to help employers and their employees with key decisions about plan options. The right decision-support tools can more effectively evaluate plan alternatives and establish a longterm strategy. Better information equates to improved decision-making, less internal analysis and optimal plan results, which maximizes value for everyone involved. The right technical tools can quantify the value differences among plan features, enabling employers to make solid, cost-saving business decisions based on clear, actionable information.
8. How can I determine if a broker is capable of guiding my company through this transformation? First and foremost, make sure your broker truly understands your business, your culture and your financial situation. Ask around. Get references. Ensure the firm has the capability to communicate well, plan ahead and effectively implement and follow through. Ask about their technology platform. In addition, you want a representative who makes employee benefits simple – and minimizes surprises. Top-notch advisers are skilled at helping employers and employees do more with less. The right mix of benefits at the workplace has a direct impact on employee health, satisfaction and financial security. Seek a client service model that enhances closer relationships between you and your employees. It’s also important to keep in mind that health care reform will require more from your adviser, so determine whether their firm has the resources, capital and expertise to thrive during these changing times and can meet your new and evolving needs.
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9. Health care reform is still evolving. About the Author What’s the latest news from Capitol Adam Bruckman is president and CEO of Hill? Health care reform is definitely a moving target. Courts across the nation are challenging it, politicians are battling over it, and insurers are trying to influence the interpretation and implementation of several provisions. Some recent amendments deal with changes to certain aspects of health care reform, but not much seems to be happening right now as the focus on Capitol Hill is soundly on our country’s debt and deficit.
10. There are still threats of repealing health care reform. What do you predict will happen, and how will it impact employers? No one can predict the ultimate outcome. Instead of taking a “wait-and-see” approach, employers should prepare, remain educated and stay abreast of the ever-changing health care reform landscape. A great broker will help any business do just that.
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Atlanta-based Digital Insurance, an employee benefits agency specializing in insurance for small businesses and mid-sized companies. He can be reached at abruckman@digitalinsurance.com or 770-250-3025.
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ave you ever wanted more time? More time to get things done and more time for you to live life? Just having an extra hour in the day or an extra day in the week would make life a bit easier wouldn’t it?
Time management is one of the biggest challenges we face as businesses and people. There are only so many hours in the day and only so many days in the week. In that given time frame, we must accomplish a certain number of tasks in order to be efficient and proficient at what we do. If we’re not good at what we do, even if we do it fast, it can take too long to get the necessary result or outcome right. If we’re slow at what we do, we might get the necessary result or outcome right but again it can take too long. Both instances are a problem. So what do we do? We schedule our work and our life in order to dedicate the time needed or the time allotted to accomplish all the things that have to get done and that need to get done. It seems reasonable to most people to operate in this fashion. However, as most people will attest, we always seem to run out of time to get things done and we never seem to have enough time to ourselves—which is what we really want! Is there a better solution? Yes, there is. It’s called freedom management. Instead of allowing time for all those necessary tasks and hoping that there is some time left over for us at the end, which there never is, it’s best to schedule that time for ourselves first and use the rest of the time to get things done. The leverage comes from using your freedom time to recharge, be happy and get focused so your productivity time is at optimum. As they say, all work and no play make you a dull person.
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And it works. If you give yourself four hours to get something done, you’ll use all four hours. If you give yourself three hours to do the same thing, you’ll get it done in three. A given task will always fill the time allotted and you will always operate at a level of efficiency and proficiency given the nature of a situation. Because you can control the nature of most situations, you can also control your tasks. So from now on, instead of cramming your free time into your schedule, schedule your free time first and then cram in the work. You’ll be surprised at the results when you actually accomplish more in less time. There is a valuable lesson in freedom management versus time management when it comes to health, especially in the workplace. Most people and businesses operate with a focus on their desired product, service and revenue at the expense of their health, wellness or lifestyle. Then, if and when a health issue arises, which it most certainly will, we dedicate resources to deal with the problem so we can get back to work.
As we know statistically and experientially, this costs businesses time and money. It also creates tension in the workplace and affects the corporate lifestyle of the company. Fortunately, there is a better way. Just like our example of trying to squeeze in more personal time with all the work we have to do, most people are living life trying to squeeze in all the healthy things they should do amongst all the work they have to get done. This is a challenge at best. Interestingly, if time is scheduled and built into our day through habits and defined initiatives, we can invest in our health while we work so that not only do we gain the health benefits but our work quality and quantity also improves. Again, this is supported by the current research and the case studies regarding wellness in the workplace. Once a health problem exists, it takes much more time and money to heal, recover and treat that problem then it would have to prevent it in the first place. Just like customer service, if there are procedures and systems in place to deliver
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the best experience for buyers and people who use About the Author our products, we can avoid the scenario where a customer encounters poor service or a bad product, operate Time Health Management which then takes considerable resources and a corporate health and wellness expenses to counteract. After all, a happy customer company. It is founded on over is a repeat customer willing to spend money! a decade’s worth of experience and knowledge derived from Similarly, a healthy employee is a performing treating employees suffering employee. The benefits, however, go beyond the from ergonomic stress, strain and disease. It’s workplace and affect the employee’s entire life. time to manage your corporate health, visit www. When the company plays such a pivotal and vital timehealthmanagement.com and contact us for a role in the health and welfare of its team, the rewards free business wellness evaluation. Learn why our are significant. The business is more productive with workplace wellness solutions make sense. For more lower costs on health claims while the employees information email drdave@timehealthmanagement. are happier and more in tune with life and work. com or call 416-697-7918. Ask us about our 5 minute onsite ergonomic and stress reducing This is what happens when there is a focus on system, perfect for every business. health promotion versus disease management. Yes, diseases, illnesses and injuries will happen and you will want to have a plan and the resources or benefits to deal with them when they do. However, this should not be the entire management plan or the selling feature to employees. It’s good to know you’re going to be looked after when and if something does happen to your health, but it’s even better to know that something is being proactively done to ensure that likelihood is being minimized. That’s the kind of company we all want to work for and with. In the end, disease management is nothing more than symptom treatment, crisis triage and a final product of things gone wrong. It’s a fight to make up for what could have been and what should have been and what will one day be true health promotion in the workplace. By adopting physical, chemical and emotional strategies for helping employees with nutrition, exercise, ergonomics, stress reduction, environmental adaptation and rest periods, the workplace will no longer be a place where we get drained, rather a place that energizes and revitalizes our lives for the better.
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he cold and flu season is right around the corner. Expect sneezes, sniffling and snot from the coworker who just borrowed your stapler. In an ideal world, people would not show up to work sick. But with the economy the way it is and people lax to miss work for fear of losing a paycheck or losing their job, we have to protect ourselves
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Funding Magazine Here are someSelf tips to keep you healthy in the work place this time of year:
Let’s start with the basics. Our mothers were right; hand washing can protect you from germs. Make sure you wash your hands with soap and hot water and get between your fingers and under your fingernails. I know a lot of office staff that keep hand sanitizer at their desks and disinfectant wipes close by in case you are covering someone else’s phone or using their supplies. Don’t get too germadverse though, because we do build up our immune system by being around germs. In between hand washing, avoid touching your face and eyes too. Taking a multivitamin containing extra vitamin C and Zinc has been shown to help prevent colds and speed their recovery time. Some people mega dose on Vitamin C, but we can only absorb a certain amount at a time (opinions vary on how much), so if you are going to take extra vitamin C, spread out the dose. Too much vitamin C can cause loosen bowels and gas, which is a good hint that you’ve had too much. I personally am a big fan of Airborne ™. I find it works for me and is worth a shot for you too. Herbs like Echinacea and Golden Seal have properties that can help speed healing of colds and flu. Garlic is another helpful
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herb and can be taken in your food or bought in a “de-smelled” supplement form like Kyolic™. There are numerous supplement formulas on the market to boost your immune system; I recommend trying some and seeing what you like best. Homeopathics are a safe and easy way to try to stave off illness. Homeopathy works on the principle of “like cures like” and you decide on the remedy based on a combination of very specific symptoms like: Is your nose stuffy on just the right side? Does your headache get better when you drink cold water? Are you craving salt? Is your face flushed? Are you cranky and want to be left
Selfa Funding alone? Answering series ofMagazine questions such as those can guide you to the right single remedy.
from intruding. If thoughts do penetrate, just acknowledge and dismiss them without judgment.
Combination remedies are also readily available and tend to mingle the most common remedies for the ailment. There are remedies simply named Cold and Flu and there is an effective combination called oscillococcinum™, which has worked for me in the past. You can inquire in your favorite health food store or contact a trained professional.
Try to be as happy as you can. I’ve observed people who are always sick, you know them; they catch everything that comes around. And they always try to blame someone for “getting them sick”. I’ve noticed that these folks more often than not are basically unhappy people. Perhaps they don’t like their jobs, maybe their marriage is less than ideal, could be some depression. Whatever Keep drinking that water! Not only should we have the source of the unhappiness is, I think that if they a large amount of water for health in general, but can be happier, they will also be healthier. Illness it’s even more important when we are sick. Water is very often used as excuse to not face something can help thin out that mucous and keep our noses and for someone that is “always sick”; I’d ask them and lungs clear. Tea, broth and juice are good too! to examine what else is going on in their lives. It’s sometimes a really hard question to ask, but worth We have enormous power in our mind. I fully the work if you want to stay healthy and have a believe that we can talk ourselves in and out of long and productive life. being sick. If you are afraid of every germ and sure that so and so from you office is infecting you, Now, what about western medicine, what does it chances are you are going to catch it. Our attitude have to offer at this time of year? Not much frankly. and what we say in our minds strongly effects Right now people are rushing to get their flu shots. what happens in our bodies. Repeating to yourself These are recommended for older adults, children that you are healthy and well or that your immune and people with compromised immune systems. system is strong can actually prevent you from Every year the formula changes in an effort to battle catching the latest thing and boost your defenses. the virus of the year. Some people have found the flu shot makes them sick, and others get the De-stress yourself! So much research has been flu anyway. I have read numerous reports that the done on the effects of stress on the immune system. flu shot increases the risk for Alzheimer’s disease And let’s be clear, it’s not so much the stress, from the additives like mercury and aluminum it’s your reaction to the stress. If you can take which are contained in the vaccine. I’ve also seen things in stride and make sure you are allowing evidence that the vaccine doesn’t do anything at yourself some downtime to process all of what is all. Remember that the flu shot is a combination happening in your life, you can keep that immune of many chemical and natural compounds, some system healthier. I recommend what are called of which can have side effects. I’m not suggesting “minis”. They are small meditations that invoke you skip the shot, just be informed before you the relaxation response as opposed to the stress make any medical or natural health choice. response. On the inhale say in your mind “I am” and on the exhale say “at peace” or “pure love” or Antibiotics are another thing that just isn’t going “pure joy” or “truly well”. You get the idea. This to help you get rid of that cold. A cold is caused allows the body to relax as you concentrate on both by a virus, antibiotics work on bacteria. So, if it the breath and the words and keeps other thoughts develops into an upper respiratory infection or
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magine receiving your credit card bill every month, and the only information you’re provided is an amount due and a “pay by” date of 48 hours from now. The amount due doesn’t look too far off
from what it was on your last statement, so you shrug and just pay your bill – you can trust your credit card company, right? Let’s say you realize one month you should be responsible and decide to check your bill for accuracy. You contact your credit card company for a full statement complete with the charges you’ve made, but they tell you you’re not allowed to review your bill now but can conduct a spot audit at the end of the year. For the audit, only a couple weeks of a detailed account of your purchases will be provided and referenced for accuracy, and the weeks chosen will be at the credit card company’s discretion.
Sound ridiculous? Of course it is. We may scoff at this scenario and think
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no corporate entity can be this unaccountable with people’s hard-earned money. Yet a similar system has been used for prescription medication bills across the nation for decades now. Every two weeks, $12 billion of pharmacy benefit claims is paid to pharmacy benefit managers (PBMs) without review. Corporations, government entities, and unions – to name a few – receive their prescription claim bills every other week and often have only 48 hours to write checks to their PBMs for the amount due. Payers do not receive detailed statements of all the claims for which they are being charged, and even if they did, their HR departments certainly do not have the resources to review spreadsheets with millions of fields of data for accuracy—and certainly not within 48 hours. Compound this lack of oversight with the fact that errors and overcharges do occur. Insurance companies and PBMs play a crucial role in ensuring healthcare is available to people across the country. But while their functions are indeed valuable, the cost to payers of doing this kind of business is billions of dollars each year in preventable overcharges. You might ask why these errors even occur. The reasons center around the complexity of the current drug payment system in the United States. PBM contracts are long and complex, and the systems used to process
claims data are old and never move out of production. As a nation, we have come to accept margins of error. They seem to be inevitable. However, with skyrocketing healthcare costs stifling economic recovery and significantly impeding the ability of businesses to grow, the margin of error on drug spend has a direct impact on the level of success that companies, government entities, states, and the nation as a whole are so desperately looking to achieve or sustain. IMS Institute reports U.S. national drug spend to be at $307.4 billion for 2010. Looking at a reasonable margin of error anywhere from 2 to 5 percent, we as a country are spending $6 billion to $15 billion in errors. Our governments have put policies and measures in place to help protect health information and enforce responsibility and accountability through legislation such as Medicare Prescription Drug Improvement and Modernization Act of 2003 (Medicare Part D) and the Sarbanes-Oxley Act (SOX). But there is nothing in place to mandate transparency or drug spending accountability, despite great pressure on entities to comply in such
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a complex drug care system. Prescription drug costs continue to grow at 7 percent year over year and are on pace to double within ten years, so this issue will only grow in importance going forward. While credit card holders are generally not held responsible for errors on their credit card bills, payers are responsible for errors on their prescription claim invoices – PBMs assume no liability, so payers alone have the fiduciary responsibility to protect their plan members. As prescription drug costs continue to rise, reviewing the PBM bill with each invoice is an important step to providing immediate plan savings today and ensuring cost containment in the future.
About the Author Dr. Kristin Begley is responsible for developing and implementing strategic programs for pharmacy benefit management at Truveris.
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shift is taking place in workplaces across America. Women are repositioning their careers in and in the process, are looking for something different. Do you offer the benefits that they want? A logical first step is to understand which benefits women, and many times men, want. To answer this question, I conducted research, a qualitative phenomenological study, in 2009. From this independent research, five major themes emerged. You can provide your employees with many of these benefits, often at little or no cost.
Concern for Family Responsibilities Nearly a third of the women interviewed cited concern for family members as catalysts for job change. They wanted options that would allow them to tend to spouses, children, and parents. Approximately 25 percent of those expressing concern for family members would have stayed with a previous employer if more options had been available to them. Consider offering your employees time to address family needs. Workplace options that promote a balanced, healthy family life will also help you retain employees.
Desire for Increased Flexibility and Control Nearly half of all women who left their positions expressed a desire for increased flexibility and more control over their work including their work schedule. Many employees are interested in compressed work weeks, flexible hours, and telecommuting options. Recently I spoke to a male employee in his late 20’s. He was working late into the evening and I asked him if he was tired and wanted to go home. “No way!” he responded. “I get into my zone late into the day and my productivity spikes. I’d rather work tonight and be able to have Thursday morning off
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to play golf. It’s good for me and it’s good for [the company].” In addition to flexible work schedules, giving employees control over work assignments can also improve your ability to retain employees. If how the work completed is less important than the end product, consider giving your employees more freedom to determine the process they want to use to complete a task or work assignment.
Interest in Another Career Twenty-five percent of the women interviewed cited interest in another career as reason for their exodus. Many of these women were ready for a major shift in their type of work so it is possible that employers would have had difficulties keeping these employees regardless of what they would have done. Still, this makes a case for allowing employees to move from one area to another or one job assignment to another. A move from production to marketing might be what keeps one employee engaged while an opportunity to learn a new skill might be enough for you to retain another. Crosstraining also gives an organization more depth so everyone benefits.
The Business Environment
Dissatisfaction with the environment in their places of business caused at least 25 percent of the women interviewed to eventually leave their positions. Some of the women interviewed explained that desire for increased security played into their thought process regarding an exodus. Employees want to feel secure. Although employers may be limited in what Lack of Support they can offer employees in the way of security, Nearly one quarter of the women interviewed increased communication and an overall sense cited lack of support as a determining factor of stability can assist employers with this when they decided to leave their positions. endeavor. Often supervisory support was listed as a concern although in some cases support at home So what is the bottom line? Forty-five percent of was listed as a concern. Providing employees those interviewed indicated there was something with a supportive work environment where the their employer could have done to make them employee feels valued can be the difference stay. Forty-five percent – nearly half! What are between a content employee and an employee you doing to make your employees want to stay? who is not engaged.
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About the Author Dr. Carrie Stringham has been teaching undergraduate and graduate courses in human resources for more than fifteen years. Carrie is a consultant and trainer in the areas of human resources, healthcare administration, and organizational leadership and can be reached at www.stringhamresources. com.
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