Abstract
This case study describes the collaboration between a self-insured employee benefits team and a national health insurance provider to control costs while maintaining program quality and promoting population health. In 2015, Quest Diagnostics well exceeded the full-year expense target for their ∼60,000-life Group Health Insurance (GHI) program. Through proactive changes, physician executive leadership, health plan collaboration, disease-specific population health initiatives, and plan design, Quest GHI annual employer health care cost trend subsequently improved from a year-over-year trend of 5.7% for 2014 to 2015, to 4.6% for 2015 to 2016, to −1.0% for 2016 to 2017, and most recently, 0.3% for 2017 to 2018. The actuarial value of the GHI plan did not decline, and employee cost share also remained unchanged in 2017 and 2018 versus 2016 for the high-performance network option. There was a 3% premium increase for the Preferred Provider Organization option in 2018. A third-party analysis for full year 2017 showed Quest GHI to be 11% more efficient than the mean GHI for programs with a comparable benefit and employee contribution. Early results in 2018 show improvements in the health status of the health plan membership. This article describes an approach for self-insured employers to proactively collaborate with a health plan and pharmacy benefits manager to practice the Triple Aim of improving the patient health care experience and population health while reducing per capita health care spending.
Highlights
In the United States, more than 178 million (56%) Americans receive insurance coverage through an employer; of these, approximately 60% have insurance from a self-insured employer.[1]
Physician executive leadership, health plan collaboration, disease-specific population health initiatives, and plan design, Quest Group Health Insurance (GHI) annual employer health care cost trend subsequently improved from a year-over-year trend of 5.7% for 2014 to 2015, to 4.6% for 2015 to 2016, to -1.0% for 2016 to 2017, and most recently, 0.3% for 2017 to 2018
In Quest Diagnostics’ experience, solutions must be organized by disease state and incorporate multiple elements, including early identification, engagement, correct diagnosis, care pathways by episode that track to best evidenced-based care, care delivery in the lowest cost setting, and continuity of care facilitated by an appropriately situated provider supported by health plan care management staff resources
Summary
In the United States, more than 178 million (56%) Americans receive insurance coverage through an employer; of these, approximately 60% have insurance from a self-insured employer.[1]. Self-insured employers need to obtain additional value to offset the trend of higher health care costs. Companies with a self-insured strategy take on the risk for coverage of medical and pharmacy costs for their employees. An important benefit is that self-insured companies pay claims as they present rather than paying a fixed ‘‘fully-insured’’ rate that would include an approximately 2%–3% catastrophic premium. This article describes how a self-insured employer applied the Triple Aim[12] (ie, better experience of care, better population health, a negative per capita cost trend) as a management strategy to directly and proactively engage collaboratively with a national health plan (Aetna) and pharmacy benefits manager to achieve a subsequent yearover-year reduction in employer and employee annual cost trend without compromising quality and access to care. The intent of this article is to describe insights into a novel and successful approach to benefit other self-insured employers encountering similar challenges
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