reference-based pricing

2018. What a Year.

It’s that time of year again. Festivus parties have ended. Holiday cards have been sent. A new year has begun. And we’re taking a step back to look at everything 2018 brought for Maestronites.

We started the year off with a bang with our acquisition by AXA. Joining forces with a worldwide insurance leader added even more fuel to our mission to make employee health and benefits people-friendly again.

Shortly after the acquisition, we launched our health plan management approach to self-funded benefits. By incorporating a people-friendly reference-based pricing model, we were able to partner with 170 new employer clients, like Leith Automotive, Secure Health and Phoebe Putney who were looking to change the healthcare game by lowering costs and improving health outcomes for their employees. 

Passionate about the value HR leaders offer to organizations, we equipped them with resources to help them not only land a seat in the C-Suite, but better position them to successfully collaborate with their C-Suite team. After all, HR is uniquely positioned to help drive down one of their organization’s largest expenses – healthcare.

In 2018, we continued to expand our partnership with Aflac® to offer their brokers and employers a robust benefits administration solution called voluntaryEDGE™. This partnership with Aflac has made it possible to simplify and streamline the complete benefits experience for employers looking to provide comprehensive voluntary benefits packages, including accident, hospital, critical illness, vision, dental, disability and cancer insurance, to employees.

We on-boarded 65 new Maestronites, including more customer advocates, a new Chief Financial Officer and data analysts, to help us meet our employers’ needs. (Spoiler Alert: We’re still hiring.) To house these new hires, we moved our Detroit Maestronites to a bigger and better office and we began breaking down walls to expand our corporate headquarters in Chicago.

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4 Points to hit when talking benefits with your CFO

By Sheryl Simmons, Chief Human Resources Officer

As an HR leader, it’s essential to collaborate with all members of your C-Suite. Doing so is not only important to your organization’s success, but it also helps you share your unique insight and be seen as a key member of the C-Suite table. What better opportunity to display your value than by tackling the healthcare dilemma? After all, it’s imperative that your business crafts a strategy to tackle the skyrocketing costs and poor employee experiences with healthcare. Your CFO is already keenly aware of this. Partnering with them to strategize your organization’s approach can likely be a win-win for all, but it’s essential that you begin by learning to speak your CFO’s language for a successful partnership.

1 Treat benefits like an investment opportunity.
When speaking with your CFO, focus on demonstrating the investment opportunity a modern benefits approach can offer your organization. Let them know that your company is in the healthcare business. In fact, every U.S. company is in the healthcare business. Healthcare is the second or third largest expense for most employers. General Motors spends more on healthcare than steel. Starbucks spends more on healthcare than coffee beans. Once your CFO is on-board for a partnership, lay out the strategic, business-focused reasons for implementing a modern benefits approach.

2 Give them the 411 on cost-saving solutions.
Provide a high-level view of the variety of new, cost-saving healthcare solutions available in the market. Be prepared to answer why you selected the options for your company, as well as why you don’t see the others as a good fit.

Keep in mind, your CFO is not entirely fluent in HR speak and that’s okay. Share your knowledge. Get comfortable speaking from a financial viewpoint about the modern solutions organizations are using to combat rising costs like:

  • People-friendly reference-based pricing models that increase access to quality care AND lower healthcare costs
  • Pharmacy benefit management vendors that provide transparent contracting
  • Medical management that is integrating throughout the employee experience

3 Find the numbers. Know the data.
If you have access, dig into your claims data to show the breakdown of your current healthcare costs. It is highly probable that a small population of your employees are driving the majority of your healthcare costs. These are the numbers you need to bring to your CFO. If you don’t have this data available to you, hit your CFO with the fact that just 5 percent of Americans are driving over half of the cost of U.S. healthcare.

Use this information to forecast how new approaches to benefits can lower your healthcare costs. For example, implementing a self-funded solution that offers holistic care management can help improve the health conditions of employees who need it the most, while also offering wellness initiatives to maintain the health of your healthier employees.

4 Show them the money.
It’s fair to say that your company’s bottom line is top of mind for your CFO. In fact, 65 percent of CFOs claim “cost management” as their top priority. With that being said, you must be able to show them true numbers on how a new self-funded solution can provide real cost-savings for your company’s bottom line.

This can be done by showing a comparison of the cost trend of traditional benefit strategies. Fully-insured employers can expect to continue to see a 20 percent increase in their benefits, while self-insured employers that offer traditional PPO networks, can expect a 5.5 percent cost increase for the future. However, employers that are implementing creative healthcare solutions like a health plan management approach to self-funded benefits are experiencing an average decrease in healthcare costs of 20 percent in their first year.

If you’re already in the process of researching vendors that offer these modern approaches, be sure that you’re also making it a requirement for them to provide you with an ROI analysis. If they can’t provide this for you, do you truly trust them to partner with you?

You can find more tips and resources to help you grab a chair and collaborate with the entire C-Suite at YourHRSeat.com.

Traditional vs. People-friendly reference-based pricing

By Ray West, Chief Growth Officer

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If you’re familiar with reference-based pricing (RBP), then you’re also likely aware that many early adopters did not have the best experience. They were promised RBP was a surefire strategy to prevent overpaying for medical claims. However, employers experienced an alarming amount of noise from their employees, who were struggling to cope with balance billing and fear of medical debt. Since then, some vendors have evolved the RBP game to include a people-friendly approach.

The traditional reference-based pricing model.
When RBP emerged approximately ten years ago, the model leveraged median prices in geographical locations as a reference-point for how much an employer would pay for provider services. RBP vendors then began holding strict reference points to Medicare for all service types. This created a “take it or leave it” message for providers, leaving them understandably frustrated.

This traditional model also left employees in the dark. As if the healthcare experience isn’t complex enough, employees were receiving bills from their providers for the balance their health plan was refusing to pay (aka, a balance bill). These bills came as a surprise to employees and vendors were providing little to no education or support to help guide employees on how to resolve these balance bills.

Eventually RBP vendors began to grow more flexible with their payment models by incorporating additional data to determine what was an appropriate amount to pay. Up-front and real-time member education became a part of their offering. Some even began offering employee assistance with balance bills.

The people-friendly reference-based pricing model.
Today, employers are able to implement a modern reference-based pricing model that eliminates over-paying for claims, but also offers complete transparency and the support employees need – the people-friendly reference-based pricing model. This new model improves the experience for everyone involved:

  • Providers receive fair-market reimbursement
  • Employers get connected with providers and see significant healthcare savings and transparent claims data
  • Employees get the support they need to navigate the complex healthcare system

People-friendly reference-based pricing still has Medicare at its core. However, it’s no longer a rigid, one-size-fits-all approach. Instead, these vendors directly reach out to providers and negotiate a fair-market reimbursement using Medicare as a reference-point. This ensures providers are being paid fairly for services and reduces the risk of employees receiving a balance bill.

It’s important to note that people-friendly reference-based pricing is not solely based around Medicare. These vendors offer employers a proactive provider disruption analysis, which helps identify the doctors an organization’s employees are used to seeing. This will often lead to provider outreach and contracting with providers to guarantee the provider will accept the negotiated pricing, essentially replacing traditional PPO networks with RBP networks.

The education and support offered by people-friendly reference-based pricing sets it far apart from the traditional reference-based pricing model. Vendors will navigate employees to high quality and low-cost providers in their area. One way they do this is by implementing copay incentives – offering lower copays for medical services if they visit pre-negotiated providers. In addition, employees are given education on how to react if they receive a balance bill. They’re also given the support and guidance necessary for handling a balance bill to eliminate the worry of medical debt.

Here’s a look at what the people-friendly RBP process can look like for an employee:

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If you’re working with an RBP vendor or thinking of implementing one, don’t settle for just any vendor. To determine if they’re truly people-friendly, ask them these simple questions:

  • How do they handle balance billing?
  • Will they be a co-fiduciary for the plan and provide legal services if needed during balance billing?
  • How do they support employees in learning how to navigate the healthcare system?
  • Are they flexible to your needs?

Learn more about how employers are changing the healthcare game by implementing innovative solutions to drive down their healthcare costs by visiting GameChangerHR.com.