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Medical and pharmacy benefit trends
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Employee Benefits Consulting
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  • Tasked with forecasting healthcare reimbursement changes / budgetary impact across the employer spectrum
  • Several leading EBCs are operating their own web-based health insurance exchanges
  • Healthcare reform initiatives require constant clinical, financial, political analysis to align present and future  healthcare benefit plans and administration; EBCs usually overlooked in pharma / medical device marketing strategy

Employee Benefit Consulting Overview

Several firms listed above specialize in pharmacy benefit consulting. These include ArmsRx, KMR Pharmacy Advisors, PBIRx, Pharmacy Benefit Consultants, Pharmacy Outcomes Specialists and Pharmaceutical Strategies Group / PSG. They focus on formulary management, prescription benefit plan design, pharmacy claims auditing, rebate management, medical versus pharmacy benefit coverage, retail/mail order/specialty pharmacy administration and other clinical / financial matters.  Through auditing and other means, they assess if the correct copays, dispensing/administrative fees, pricing and other financial or clinical claims adjudication edits are functioning as intended. They can also detect fraud, over-prescribing and other issues. While managing the employer and employer dynamics of prescription drug benefit management, they are also collaborate with employer and managed care organizations to maintain alignment with the U.S. Department of Labor plus other Federal and State agencies that have a leading role in the oversight of employee and retiree benefits regulation.

Third Party Administrators / TPAs

In some instances, TPAs are a company's go-to partner for employee benefits. They not only provide the day-to-day claims administration and processing of healthcare, payroll, workers comp and other financial payment or risk management functions, they actively support medical, pharmacy and other benefit plan budget and coverage decision making. They are typically well integrated with self insured or commercially insured companies and other organizations in terms of finances, budget controls and accounting which involves standard as well as ad hoc reporting capabilities necessary to generate data to monitor and forecast results. CoreSource, Corvel, Crawford, Esis, Gallagher, Helmsman, Meritain, Sedgwick, UMR and York are some of the largest TPAs in the nation with wide capabilities that work with private and public companies on a regular basis. 

Pharmacy Benefit Management

The larger employee benefit consulting firms like AON, Mercer, Segal, Willis Towers Watson, Xerox Human Resources also deploy staff members specializing in prescription benefit management as part of their overall healthcare benefits consulting practices covering active employees, dependents, retirees, medical, dental, vision and other programs plus compensation, profit-sharing and other administrative / human resource functions. These staff members are often pharmacists / PharmDs with established experience with clinical outcomes and commercial / cost aspects of prescription medications including brand, generic, oral, injectable, infused, topical formulations as well as strategic tiering of prescription drugs within benefit formulary structures, coinsurance and deductibles to maximize opportunities for economic care. These measures apply to the medical benefit i.e. hospital care and outpatient services drug utilization as well as the retail, mail order and specialty pharmacy prescription drug program participation.

Retrospective, Present and Future Clinical and Financial Data 

While the concept of "Big Data" and its associated analytics and management has been a comparatively recent trend in many industries, it has been a routine part of the employee benefit consulting and managed care / health insurance realms for decades including early disease management programs, population health outcomes and improvement initiatives. Actuarial and risk management professionals have routinely engaged Big Data to assess past, present and future trends.  The cloud, accelerated analytic capabilities and advanced programming packages have made it easier / faster for them to execute queries and subsequently base decisions and direction on.

Obamacare In 2019

Transitioning through 2017 and 2018, in 2019 Obamacare has fully crossed over into the President Trump era.  There was significant change underway for employee benefit programs.  The Employer Mandate Compliance requirements of the ACA was in full swing. Employers with 100 or more full-time/full-time equivalent employees are required to offer minimum essential coverage to at least 70% of full-time employees and dependents.

Prior to 2017, in 2016 compliance was required at 50 or more full-time/full-time equivalent employees and at a 95% threshold. A compliant offer of affordable minimum value coverage will resolved penalty exposure. Behavioral healthcare is also part of the requirements based on the Mental Health and Parity and Addiction Equity Act. There must be parity between medical/surgical and mental health/substance abuse coverage.

The IRS will be implementing auditing initiatives to verify employer compliance.  As 2016 was the first year of composite reporting, some leniency was expected as some errors in the implementation and administration of the ACA measures was expected to carry over from 2015.  However, the IRS more closely audited employers to assess "good faith" compliance with the ACA standards.  There may be significant penalties for those who do not demonstrate they have taken assertive steps to implement and manage the required benefit changes.  2018 required thorough alignment with the ACA standards moving forward. Further challenges have surfaced in 2019 as many leading health plans have exited the lowest premium Obamacare plan market entirely due to administrative and profitability issues. 

Medical and Pharmacy Benefit Cost, Care, Complexity

To gain maximum value, reduce costs and understand the changes and complexities of healthcare benefits, employers and other organizations are relying on brokers and employee benefit consultants for wider, deeper analytics and increasingly competitive rates. Clients are seeking ongoing guidance in managing changes required through healthcare reform measures which impact care, costs and coverage. They are looking to employee benefit consultants to help them manage rising healthcare costs which impact their employees and dependents as well as the profitability and financial well-being of their organization; this encompasses:

  • Staying within annual corporate budgets
  • Helping manage medical and pharmacy benefit plan vendors like health insurance companies, prescription benefit managers, vision and dental plan companies, disability and others
  • Monitor ongoing employee health plan member utilization and associated costs of benefits on the budget
  • Minimize impact on employees in terms of sharing the cost burden of healthcare and pharmacy benefits as benefits are updated annually
  • Assess trends and forecast healthcare and pharmacy changes, government policy and regulations plus other factors that may have a financial impact on their benefits costs and program designs and project their impact on present and future employee benefit decisions
  • Determine suitability of wellness programs and other employee engagement measures designed to improve their healthcare and lower company benefit costs
  • Collaborate on RFP design, vendor candidates, bid response evaluation and selection of new healthcare, pharmacy, vision or dental plan programs 
  • Advise company on annual open enrollment communications and processes to avoid miscommunication and ensure transparency in regards to increased premiums, copays, coinsurance and other cost sharing changes due to higher expenses as well as medical plan or pharmacy plan coverage changes 
  • Provide guidance on correcting and reinforcing measures to assure employee and dependent healthcare data privacy measures

6 pivotal risk management concerns employee benefit consultants collaborate with clients on:

  • Catastrophic care costs and potential for stop-loss insurance to fall short of expectations
  • Specialty pharmacy drug costs aligned with biotech, orphan drug and other unique but expensive therapies
  • Developing and improving competitive benefit programs to attract new talent and retain existing employees while incurring minimal additional budget demands on company finances
  • Benefit changes required to comply with local, State and Federal benefit requirements and regulations which contribute to increased costs and material costs to the company's annual plan and forecast projections
  • Reduction in benefit provider competition due to vendor consolidation or market exits so a smaller pool of potential benefit companies exists to choose from or leverage against each other in rate negotiations
  • Developing precise strategies in the event the company generates less than expected revenue and struggles to meet corporate objectives, investor earning expectations, etc. and benefits budgets are at risk

As companies acquire or merge with other companies, benefit consultants and brokers play integral roles during the process. It is crucial employee benefit costs are accounted for in the finances of merger and acquisition transactions. Once deals have been completed, benefit coverage continues and differences between the legacy and new organization benefit designs must be accounted for.  Healthcare benefits, which can include medical, pharmacy, dental, vision, rehabilitation, disability and other care facets, continue to be more closely managed.
Managed care organizations and health insurance companies are seeking to offer more services as a marketing / revenue driver but continually are seeking ways to cut costs and risks for themselves and their customers as part of their overall retention strategy to win new business and maintain existing clients for as long as possible.
... This is a list of leading Employee Benefits Consulting Firms and Health Insurance Brokers; scroll down for managed care presentations, employee benefit trends ....
... Digital marketing, the ACA and other factors are changing the way healthcare insurance is marketed; visit the resources below to get more insights ...
... Employee Benefit Consultants (EBCs) have significant roles in how new and existing medications are managed in prescription benefit plans which impact market access; learn more from the resource below ...

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