Next Steps for Health Plans During and After COVID-19

Unless they had multiple members who contracted COVID-19, many health plans may have experienced a temporary reprieve from rising health care costs as plan participants delayed care while the country was shut down.

But any decline is likely temporary, explained the Mayo Clinic’s Cheryl Nienhuis, CEBS and Dana Baker, during their webcast “Capping Medical Plan Costs and Improving Care in the Aftermath of COVID-19.”

To begin with, plan members may start rescheduling their missed health care appointments and procedures as the country starts reopening. And that delayed care has the potential to increase long-term costs if participants’ health conditions have worsened.

Next Steps for Health Plans During and After COVID-19

Nienhuis and Baker provided some immediate steps that health plans can take to limit the impact of delayed care as well as strategies to address rising costs for the 2021 plan year.

Immediate Steps

Many plan participants have delayed three types of care during the pandemic.

Essential Care (Urgent Care)

“While the country was shut down, there were patients who did not go to the emergency department. We’ve seen a drastic decline in people coming through the ER” with heart attacks, strokes and other emergency conditions, according to the American College of Emergency Physicians, Baker said. The challenge is how to balance the risk of contracting the virus against the risk of not seeking care.

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Elective Care

During the shutdown, people delayed procedures such as hip or knee replacements as well as certain cardiac procedures. Now that states are reopening, it’s uncertain when or whether these procedures will be rescheduled. “There’s still some fear out there,” Baker said. The risk is that some of those elective surgeries, like a heart valve replacement, may now be urgent, she said.

Preventive Care

Many people have delayed routine preventive care such as mammograms, annual lab tests and vaccinations. The reduced level of vaccinations creates the potential for an outbreak of disease, Baker said. In Minnesota alone, there was a 70% drop in measles vaccinations compared with a year ago.

“It’s really important for those screenings to be done,” Baker noted. People who miss a screening or a lab test may see their diabetes worsen or develop cancer without knowing it. There also is the potential of people with medium health risks moving into the high-risk health category and low-risk people moving into the medium-risk category.

What Plan Sponsors Can Do

  • Communicate the safety measures that have been put in place at hospitals and clinics. The Centers for Disease Control and Prevention have issued safety guidelines, including limiting visitors and screening patients and employees for the virus.
  • Communicate the importance of seeking urgent and preventive care. “We really want to encourage people to go and seek care that is needed when it is needed,” Baker said. “If we can just share the importance of preventive care from a high-level standpoint, without getting into the employees’ personal business, that may be something really beneficial in order to help manage plan costs,” she said.
  • Tweak wellness programs. Some employees may not have been able to qualify for wellness program incentives, so employers may want to change the guidelines to allow them to qualify.

Steps that plans take now could flatten the cost curve for the 2020 plan year. “Just a simple communication may be beneficial as things reopen,” Baker said.

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2021 Strategies

Plan sponsors can begin planning now for changes for the 2021 plan year, including the following.

Analyze Plan Data

“We really want to start looking at what our data says from the past as well as what we want to focus on in the future,” Nienhuis said.

Data to analyze includes:

  • Medical plan diagnoses, costs and volume
  • Pharmaceutical costs
  • Preventive care utilization
  • Short-term disability.

“Now is the perfect time to analyze data to see if you need to make changes,” Nienhuis said. For example, she spoke with one employer group that saw a 37% spike in spine care costs in one year. That plan may consider strategies such as offering a second opinion service for spine issues or an ergonomic program to bend the cost curve.

Consider Direct Contracting

Through direct contracting, health plans can find the right partners to deliver the right diagnostics and care at the right time. Plan sponsors can research providers that are willing to work with them to increase quality of care, improve outcomes and reduce and avoid costs, Baker said.

Approaches include:

  • Centers of excellence (COEs). Health plans contract with a COE to provide a specific set of services for certain conditions, like cancer or spinal problems. One study from the Mayo Clinic showed that after 500 patients from one plan were referred to the Mayo Clinic COE, 53% of the members who had been approved for spinal surgery avoided it and instead received less invasive care.
  • Network design. Health plans steer members to specific providers through a tiered benefit design, which has different levels of member cost sharing depending on the tier. Some plans use narrow networks, which means that care is covered only when given by in-network providers.
  • Benefit design. Health plans steer members to specific providers by removing financial barriers such as copays, coinsurance and travel costs.

Improve Member Experience

Plans can use the following tools to ensure that plan members are getting access to the appropriate and lowest cost care.

  • Benefit platforms consolidate benefit plan information to help members easily learn about and access benefits.
  • Third-party administrators and case management services play a crucial role in identifying and referring patients. They also can help with education, outreach and travel arrangements.
  • Expert medical opinion services help plan members who are struggling with a difficult medical decision by confirming the diagnosis and treatment plan or offering a different diagnosis. They help prevent unnecessary procedures and steer members to high-quality providers.
  • Health advocacy services can help members navigate the system and resolve billing issues.

“Your goal will be to lower costs while you increase the quality of care and the timeliness of getting that care to your population,” Nienhuis said.

[Related Reading: Interest in Telemedicine Has Exploded During COVID-19: Here’s How It Works]

Learn More About the Impact of the Coronavirus on the Workplace

Visit the International Foundation Coronavirus (COVID-19) Resources page to find information for plan sponsors, including these upcoming free member webcasts:

Kathy Bergstrom, CEBS
Senior Editor, Publications at the International Foundation of Employee Benefit Plans


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