Monday, December 30, 2019

Fiduciary Responsibility in Healthcare Plans

Healthcare management in the United States has been slowly declining-- from the lack of services that are offered to patients, to the steady increase in price for office visits and procedures. We outlined the state of the American healthcare system in a previous post (link to live post) and it seemed that since most Americans get their healthcare from their employer-- there was little to nothing they could do about rising costs and lack of care. 

That is until some major companies decided that they as large employers could do more, and took it upon themselves to find a better way for healthcare to operate in this country. They decided to use some powerful data analysis tools to prove that there was a way to keep costs low and ensure that patients are still getting the best possible care. When employers, providers, and insurance companies agree that this is a major problem-- and that they have a fiduciary responsibility to solve it-- healthcare will change for the better.

stethoscope and pen on note pad
Innovative companies are changing the way they manage their healthcare plans for the better.

Challenges Met By Innovative Companies

The landscape of the healthcare system is changing-- and thanks to some innovative companies who decided to take matters into their own hands-- it is for the better. Companies such as Walmart, Boeing, and Facebook decided that they had enough of the stagnant system that existed between employers, insurance companies, and health providers. They-- amongst others-- want to reduce their healthcare spending on what they see as a broken system.

Employers took it upon themselves to analyze their employee data-- and see what their particular situations were demanding. By opting to scrutinize this information, they can come up with a better, flexible, and more customized solutions for their employees. Not all companies have been able to shake up the healthcare system, it takes those with the desire to change what it isn’t working. They have taken on some of the largest problems facing the healthcare system, including:

Corporate and cultural inertia

People have been stuck in the same system for too long-- with little hope for change or a way out. This happens companies get accustomed to doing things a certain way and expecting a certain result. These types of systems are difficult to change-- and it is hard for employees to bring their concerns about something like healthcare to their human resources department or manager. 

Largely, it seems that employers just didn’t think it was their concern to be involved in the healthcare matters of their employees. Employees see that there’s no way for them to actively change the system, and thus resign themselves to dealing with it. This type of behavior is common and has lead to some of the major problems in healthcare.

Insurance carriers that do not control cost

Employer-sponsored healthcare plans are at the mercy of insurance companies that have very little incentive to control costs. When they know that most Americans get their insurance through their employers, there really is no other viable alternative to the prices of the premiums they are offering.

Cost for employers has risen exponentially for plans that seem to offer less for employees-- and with no hope of change coming from the insurance providers. When there is no real competition on the insurance market, prices can keep rising without discretion.

patients arm having blood pressure taken
Evaluating plans to make sure they offer the appropriate services at a fair price is an employer's fiduciary responsibility. 

Over prescribing pharmaceuticals

The over prescription of pharmaceuticals has cost employers a lot of money in recent years. In an era where patients go to multiple doctors on a regular basis it is difficult to manage the patient's prescription mix and instead of working with the patient to develop a plan of care it was much easier to prescribe pills. Once patients are on prescriptions, it is also hard “de-prescribe” them and take them off it. These quick fixes have put a substantial burden on healthcare costs-- and sometimes even create more problems for the patient due to side effects or mixing medications.

Drug companies have also kept increasing the cost of pharmaceuticals-- which leads to increased out of pocket expense for employees. Companies who want to shake up their healthcare plan also want to change the mindset among their employees that prescription pills should be their first choice.

Low value primary care providers

Innovative companies have recognized this as a problem, and want to eliminate the quantity over quality mentality that can be found amongst some primary care providers. When a health facility is compensated based on the number of patients that they treat-- the patient’s well being is not the end goal.

When value-based medicine is practiced, each patient’s situation is considered-- and physicians and hospitals are paid based on patient health outcomes. This gives incentives to hospitals to provide the best possible care-- and learn from the patient data to better their experiences and treatment options.

Criminal claims

Abusing the healthcare system through fraud is a problem employers have had to deal with before-- and is something that needs to be eliminated through system wide changes. Fraud can take place at the member and provider level-- and can end up costing employers a lot of money. Companies have tried to adapt their healthcare policies to help prevent fraudulent claims by members-- they understand that if they have access to the services they require, there is less need to get them via fraudulent ways.

How Did They Do It?

These companies have to actively change the way in which their healthcare plans were managed-- and enacted these core principles to manage their fiduciary healthcare responsibilities.

Actively manage their plans

These companies run their healthcare operations like a business-- which means that the decisions made by CFOs are data driven and based on knowledge of the entire problem. They use the data of their employees to find the highest value for the most reasonable cost. Having more control over costs is very important-- and the types of companies changing the field of healthcare prefer a self-insured arrangement.

Insist on transparency with providers

It is imperative that there is a transparent relationship with providers. This ensures that employers know what costs are-- how to prevent their increases. Conflicts of interest can drive up costs-- and these companies are aware from past experience that insurance companies alone have little incentive to keep costs low. 

Employers want to see a return on their investment-- and they want to know that they’re getting high value healthcare for the price that they’re paying. Being open with providers allows them to manage their performance and adjust it according to data trends.

doctor in scrubs with scissors on table
Companies have instilled certain best principles to help manage their healthcare costs.

Contract with primary care providers interested in patient wellbeing

Employers who have changed their healthcare management have also insisted on using PCPs that are value based as opposed to volume based. The performance data of the PCPs is expected to be shared with these companies-- so that they can continue to monitor that they are working to provide excellent patient care. 

When the hospital is able to track the performance of physicians, it can track their progress on patient care. After routine assessments, physicians can change their practices to better suit the needs of their patients-- and continue offer high-value care for them.

Utilize Centers of Excellence

Centers of Excellence are a great way for employers to save on healthcare costs. When their employees use them for procedures, they know that they’re getting the best possible care from experts in their field. These institutions such as the Cleveland or Mayo Clinics have data to backup their claims to be the best at what they do-- there is solid evidence that these places are going to do the job right the first time. 

These centers are also more likely to say no to unnecessary surgery-- which is something a volume-based hospital would not do. This can save employers lost of money on healthcare-- and keep patients from undergoing procedures they do not need.

Manage costs of chronic diseases

Some of the highest healthcare costs can come from the management of chronic diseases. By partnering with a center of excellence, leading companies can provide their employees with excellent care from the leaders in the field. 

Help employees manage their benefits

Healthcare plans can be extremely confusing to employees-- there are all kinds of websites and insurance lingo that can be confusing to understand, and most just don’t bother to go through them at all. Innovative employers believe that their employees should be actively engaged in their healthcare plan-- and be able to understand it. 

That’s why they typically offer concierge services to assist when employees have questions or problems arise when they use their benefits. They also give them access to their own data in one convenient site-- so whenever they have an issue or need their information, they have easy access to it.

The parties involved with the U.S. healthcare system have a fiduciary responsibility to ensure that the employees are receiving the care that they deserve-- and that providers and insurance companies are held accountable for their practices. If this means that the best practices need to be updated, it appears that the time is right to start that change for the better.

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