Explore creative health plan design options that can reduce healthcare costs while still delivering a great benefit for employees.
Although healthcare utilization decreased across the board in 2020 and 2021 during the COVID-19 pandemic, health plan costs continue to rise for many employers. According to research from Willis Towers Watson, employers expect their healthcare costs to increase 5.2% in 2022, prompting them to consider healthcare cost containment strategies.
Instead of shifting costs to employees through high-deductible health plans (HDHPs) or cutting benefits altogether, many self-insured employers are implementing alternative plan designs. While these plans involve a more nuanced approach to contracting, benefits, and cost structure than typical PPO or HMO plans, they can drive cost efficiencies while still providing employees and dependents access to high-quality care options.
If your benefits program is willing to get creative, you can experiment with several types of plan design options. Let’s explore a few alternatives that are gaining traction among large, self-insured employers.
A center of excellence (CoE) is a specialized program that provides concentrated clinical expertise and resources focused on a specific condition or care type. Unlike traditional hospital or specialty care settings, CoEs deliver comprehensive patient care in an interdisciplinary fashion. For example, the University of Tennessee Medical Center in Knoxville has six CoEs covering a broad spectrum of specialties: women and infants, brain and spine, cancer, emergency and trauma, heart/lung/vascular, and orthopedics.
To become a certified CoE, a healthcare institution must apply through the National Association for Continence. Once the institution is certified, it’s inspected every three years to maintain CoE status.
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Direct contracting is an agreement between an employer and a provider group or hospital system to provide care for plan members in a specific geographic area. Unlike a traditional payer arrangement, where the carrier handles all the negotiations, your benefits team (and likely your broker/consultant as well) will determine reimbursement rates for specific services, prescriptions, and medical equipment.
Direct contracts can follow a traditional fee-for-service structure or employ alternative payment models such as pay-for-performance, shared savings, bundled payments, or global capitation.
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Narrow networks aren’t strictly defined, but these plans often have 25% or fewer participating local physicians compared to the approximately 70% found in broader PPO networks.
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If you’re looking for a plan design that will give you highly predictable costs, you may want to consider a reference-based pricing (RBP) strategy. RBP closely ties your payment rates to Medicare reimbursement rates—usually as a percentage of Medicare—so your costs stay consistent across providers.
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Tiered networks are like typical PPO networks, but divide providers into tiers based on the cost and quality of the care they provide:
Tier 1 offers providers who deliver high-value care (low cost, high quality). Employees will have the lowest cost-sharing amounts with this smaller pool of preferred providers.
Tier 2 offers a larger network of providers and facilities. With this PPO option, employees may pay a higher cost-sharing amount.
Tier 3 provides the most options when it comes to providers, services, and facilities, and includes out-of-network providers. Employees have the highest cost-sharing amounts with these providers.
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The bottom line is: You want to make the best plan design decisions for your benefits program. To do that, you must first understand your employees’ current health trends and utilization patterns. It helps to work with a consultant or third-party administrator who has the tools available to track those trends. Once you understand the trends, it’ll be easier to educate your employees on how to shop for care, avoid out-of-network penalties, and increase their satisfaction with your plan offerings.
After you’ve decided which alternative plans to offer, investing in a healthcare navigation platform to support employees in their search for new providers and staying in-network can help you and your plan members get the most out of your plan offerings.
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