Is This Test Really Necessary?

New lists help guide medical discussions

by David Wetzler, Senior Benefits Consultant
  

At a time when the health care and health insurance industries are under intense scrutiny, nine U.S. medical societies have developed lists of "Five Things Physicians and Patients Should Question" to improve care and eliminate unnecessary tests and procedures.

The intent of the initiative is to help patients choose care that is supported by evidence showing that it works for patients like them; is not duplicative of other tests or procedures already received; won’t harm them; and is truly necessary. The effort has been championed by the Choosing Wisely initiative of the American Board of Internal Medicine (ABIM) Foundation*, as well as Consumer Reports.

For example, number one on the list of The American Academy of Family Physicians is:

• Don't do imaging for low back pain within the first six weeks, unless red flags are present. Red flags include, but are not limited to severe or progressive neurological deficits or when serious underlying conditions such as osteomyelitis are suspected. Imaging of the lower spine before six weeks does not improve outcomes, but does increase costs. Low back pain is the fifth most common reason for all physician visits.

Choosing Wisely is part of a multi-year effort of the ABIM Foundation to help physicians be better stewards of finite health care resources. It continues the principles and commitments of promoting justice in the health care system through a fair distribution of resources set forth in "Medical Professionalism in the New Millennium: A Physician Charter.”

The new lists are being issued at a time when many payers (employers, Medicare, Medicaid, states and local governments) are struggling to reduce their health insurance costs. But such efforts run the risk of the payer being accused of rationing care. Such a charge was leveled at Medicare in 2010 when it opened a National Coverage Determination on the prostate cancer therapy Provenge (sipuleucel-T).  And many questioned the FDA’s late 2011 decision to revoke the breast cancer indication for Avastin (bevacizumab). 

We would love to hear what you think about these lists.

1. Do you agree that certain tests and procedures are, in fact, overused and unnecessary?
2. Do you think accusations of rationing may follow from publication of these lists, or is this a rational step to reduce costs and promote meaningful conversations with our physicians?
3. Should employers make these lists available to their plan participants?

Feel free to email me your thoughts, at dwetzler@SRABenefits.com. 

*To learn more about the ABIM Foundation, visit www.abimfoundation.org.

Medical Loss Ratio Rebates a Messy Game

Refunds due in August - but don't hold your breath
by SRA Benefits

The Kaiser Family Foundation just released a study estimating that insurers will provide policyholders close to $1.3 billion in medical loss ratio (MLR) rebates in August of this year. SRA Benefits studies of Missouri and Kansas insurers suggest that several carriers will be issuing rebates in our markets but some policyholders expecting refunds might be surprised when no money arrives.

The PPACA (National Healthcare Reform) provides that insurers must issue rebates to policyholders if their ratio between expenses and what they actually pay providers is better than the new law allows. For small group and individual plans insurers cannot keep excess premiums when they pay less than 80% of premiums to medical providers; they cannot keep excess premiums when they pay less than 85% of premiums for large groups. The rest must be refunded to policyholders. However, with this first round of rebates, what is counted and how it’s counted creates a confusing array of issues that each insurer’s actuaries and accountants must address.

Preliminary information and disclosures from insurers to the National Association of Insurance Commissioner (NAIC) show a wide range of results for our local markets by type of plan, insurance company and state. SRA also found a wide range of differences in how insurers are interpreting the regulations as well as significant challenges due to ways in which carriers are structured for tax and business purposes. This is not a reflection of insurers with evil intent but a reflection of very complicated accounting and legal issues. Because there are so many variables, each insurer will likely make different decisions as to the regulations based on their individual situation.  In addition, the information publicly available today through the NAIC is different than the actual forms and submissions that will ultimately be submitted to Health and Human Services (HHS). 

Insurers are scrambling to make last minute revisions before final submissions are due to the Federal government June 1, 2012. Once the announcements come out, the lucky policy owners will be waiting for their refunds in August of this year. 

Don’t hold your breath until you actually get a refund in the mail. With different rules between state and federal regulations, some policy holders may be excluded or in a different pool than they believe. As an example, you may have small group rates and benefits but be a large group under the law.  And insurers may choose to reduce future premiums in lieu of cash refunds. As your broker, SRA Benefits stands ready to help you understand the refund process and its implications to your company.

Why would you need advice?  If you happen to be a lucky employer and qualify for a refund it will be your turn to figure out what to do with it.   Once employers find out the options and requirement on what is to be done with the money, they will have a glimpse of the challenges insurers face.

IRS Issues New 2012 W-2 Reporting Requirements

For Many Companies, Cost of Health Care Coverage Must Be Included 

By David Wetzler, Benefit Consultant

Many employers will soon be required to report to employees the cost of their group health plan coverage. According to the IRS, the purpose of the reporting is to provide useful and comparable consumer information to employees on the cost of their coverage.

The IRS recently issued guidance (IRS Notice 2012-9) to help with the mandatory reporting that is scheduled to begin with 2012 W-2 forms. 

As the deadline gets closer, however, many employers are having trouble figuring out how they are supposed to calculate the reportable cost.

 Here are some highlights of the latest IRS guidance.

• If an employer issues W-2 forms for less than 250 employees in the preceding year, it is exempt from the W-2 reporting requirement. 
• Corporations which are wholly owned by federally recognized Indian tribal governments are exempt. 
• The aggregate reportable cost generally includes the portion of the cost paid by the employer and the portion of the cost paid by the employee, regardless of whether the employee paid for it through pre-tax or after-tax contributions. 
• Employers who are subject to the reporting requirements include federal, state and local government entities, churches and other religious organizations. 
• The aggregate reportable cost will be reported on Form W-2 in box 12, using code DD. 
• For employees who are terminated during the year, an employer may "apply any reasonable method of reporting the cost of coverage provided under a group health plan" for the employee, provided that the method is used consistently for all employees receiving coverage under that plan who leave their jobs during the plan year and continue or otherwise receive coverage after the termination of employment. 
• An employer is not required to report any amount in box 12 using Code DD for a departing employee who has requested to receive a Form W-2 before the end of the calendar year. 
• An employer does not have to issue a W-2 reporting healthcare cost to retirees who are not otherwise required to receive a W-2. 
• An employer is not required to include the cost of coverage under a dental or vision plan if it satisfies the requirements for being excepted benefits under the Health Insurance Portability and Accountability Act (HIPAA). Generally, to be excepted benefits for this purpose, the dental or vision benefits must either:

 1. Be offered under a separate policy, certificate, or contract of insurance (that is, not offered under the same policy, certificate, or contract of insurance under which major medical or other health benefits are offered); or

  2. Participants must have the right not to elect the dental or vision benefits, and if they do elect the dental or vision benefits they must pay an additional premium or contribution for that coverage. 

• The amount of money placed in a healthcare flexible spending account is not required to be included in the reportable costs as long as the amount comes solely through employee contributions from salary. 

• Reporting requirements do not apply to amounts contributed to an Archer Medical Savings Account or to any health savings account of an employee or an employee's spouse. 
• Coverage of employee assistance programs (EAPs) is not required to be reported if no premium is charged. This also applies to wellness programs and onsite medical clinics for COBRA participants. If a premium is charged, then an employer must include the cost in W-2 reporting. 
• Other types of coverage NOT subject to the reporting requirement include: 
• Coverage only for accident, or disability income insurance, or any combination thereof; 
• Coverage issued as a supplement to liability insurance; 
• General liability insurance and automobile liability insurance; 
• Workers' Compensation or similar insurance; 
• Automobile medical payment insurance; 
• Credit-only insurance; and other similar insurance coverage, specified in regulations, under which benefits for medical care are secondary or incidental to other insurance benefits. 

These are only some of the rules associated with the new healthcare reporting requirements. For more information, consult with your tax advisor or an SRA Benefits consultant.

US Won't Define Required Healthcare Benefits

States will set rules within wide categories

By David Wetzler, Senior Benefit Consultant

In a major surprise on the politically charged new health care law, the Obama administration said that it would not define a single uniform set of “essential health benefits’’ that must be provided by insurers for tens of millions of Americans.


Instead, starting in January 2014, each state will have the power to determine what health benefits must be covered by health insurance policies offered within its borders.


Essential health benefits may vary within 10 broad categories which include preventive care, emergency services, maternity care, hospital and doctors’ services, and prescription drugs.
The move could lead to significant state-by-state variations in what would be covered under the health care program, much like the current differences in state Medicaid programs and the Children’s Health Insurance Program.


On December 16, 2011, the Department of Health and Human Services (HHS) issued a bulletin outlining proposed policies and the approach it intends to pursue in rulemaking for defining Essential Health Benefits (EHB). Per the Patient Protection and Affordable Care Act (PPACA), beginning on January 1, 2014, non-grandfathered Individual and Small Group plans offered inside and outside the Exchanges must cover the EHB. In addition, PPACA prohibits the use of lifetime and annual limits on the dollar amount of EHB.


In developing the regulation, HHS stated that its aim is to balance comprehensiveness, affordability, and State flexibility. It is, therefore, proposing to allow each State to select an existing health plan as a “benchmark” to establish the services and items included in the Essential Health Benefits package for 2014 and 2015.


States will choose from one of four health insurance plan options as a benchmark:

• the largest plan based on enrollment in any of the three largest small group products in the State
• any one of the three largest State employee health plans
• any one of the three largest Federal employee health plan options
• the largest HMO plan offered in the State’s commercial market 

HHS will propose that the default for States choosing not to set a benchmark will be the small group plan with the largest enrollment in the State. For 2016 and beyond, HHS would reassess the proposed benchmark process.


The bulletin did not address cost sharing, e.g., deductibles, copayments, and coinsurance, which will be covered in future guidance. Cost-sharing rules will determine the actuarial value of the plan. It also does not address how this state-by-state approach is to be applied to the ban on lifetime and annual limits for plans that cover people in multiple States.


However, the bulletin did reaffirm that Essential Health Benefits must include items and services within the following 10 benefit categories: 

1. ambulatory patient services;
2. emergency services;
3. hospitalization;
4. maternity and newborn care;
5. mental health and substance use disorder services, including behavioral health treatment;
6. prescription drugs;
7. rehabilitative and habilitative services and devices;
8. laboratory services;
9. preventive and wellness services and chronic disease management; and
10. pediatric services, including oral and vision care

Opponents of health reform have said that the PPACA removes the authority of states to regulate health insurance. This move may be the administration's response to those criticisms.

This document is for general informational purposes only. While we have attempted to provide current, accurate and clearly expressed information, this information is provided "as is" and SRA Benefits makes no representations or warranties regarding its accuracy or completeness. The information provided should not be construed as legal or tax advice or as a recommendation of any kind. External users should seek professional advice from their own attorneys and tax and benefit plan advisers with respect to their individual circumstances and needs. This message has been sent to you to provide information that may be helpful to your business and to provide an opportunity to give us your requests and general feedback.

Employees Seek Health Care Information 24/7

Social Media Plays Key Role 

By Piotr Zygmunt, Benefits Consultant

More and more consumers are turning to social media for health care decisions. According to the Dayton Business Journal, 41 percent of people said they use social media as a health care resource.  In fact, 94 percent said they turned to Facebook for medical content for diet and exercise tips.  In addition some respondents even said the information was likely to impact their future health decisions.   In response to this, companies in the health care industry are taking the appropriate steps to make their social media presence known.

Consumers are using these social media sites for multiple purposes, such as:

• Viewing health education videos;
• Getting diet and exercise tips;
• Learning about upcoming health events;
• Increasing awareness of diseases, and
• Discovering health statistics.

In a new survey that was conducted by the National Research Corporation, one in every five Americans use social media for healthcare information, specifically Facebook, YouTube, and Twitter. What can companies do to help their employees access health care information?  Think electronic media.  Here’s a few things to consider:

• Develop a company-customized web portal for benefit plan information;
• For multi-site locations, use video for sharing enrollment processes; 
• Use company-sponsored social media tools to promote wellness initiatives;
• Consult with your broker for other ideas, and to help ensure the necessary privacy/legal parameters are in place when sharing health-related news.

Industry experts agree that the use of social media for delivering information 24/7 to individuals will continue to grow.  Companies will be ahead in the health care communication game by planning a social media strategy for their employees as well.

Lifetime ‘Dose’ of Excess Weight Linked to Diabetes Risk

Type 2 diabetes epidemic in the U.S. may loom even larger than previously predicted. 

By David Wetzler

President, Benefits Consultant

It's long been known that obesity increases diabetes risk, but a new study finds that the amount of excess weight someone carries -- and how long it's carried -- can make that risk even higher.

That's especially worrisome given the growing number of obese children and teens who will spend more years of their lives obese than prior generations, researchers from the University of Michigan Health System warn in a university news release.

"The relationship between weight and type 2 diabetes is similar to the relationship between smoking and the risk of lung cancer," said the study's lead author Dr. Joyce Lee, a pediatric endocrinologist at the University of Michigan C.S. Mott Children's Hospital. "The amount of excess weight that you carry, and the number of years for which you   carry it, dramatically increase your risk of diabetes."

Researchers examined information on roughly 8,000 teens and young adults and calculated how far above a certain body mass index (or BMI, a calculation based on weight and height) they were and for how long. The study found those with a BMI of 25 or higher (overweight) or 35 and higher (30 and up is obese) for a greater length of time had a higher risk of diabetes. 

For example, individuals with a body mass index of 35 for 10 years were considered to have the equivalent of 100 years of excess BMI -- a considerable cumulative "dose" of excess weight. 

What is the economic consequence to the taxpayer and employers?

The disease will cost the nation almost $3.4 trillion in the 10 years through 2021, with more than 60 percent paid for by the U.S. government, according to a study conducted by United Healthcare.  Employers will bear the brunt of the remaining costs – especially as health care reform forces employers to increase their contributions to escalating insurance premiums which will be driven in part by the rising costs of treating the disease. 

More information

The U.S. Centers for Disease Control and Prevention provides more information on the health consequences of obesity.

To help keep employees fit, SRA Benefits consultants on wellness programs for businesses.  Contact info@SRABenefits.com.

One Bright Spot in the Health Care World: Wellness Programs

by Robert Falke, Benefits Consultant

Health Care Reform is still full of uncertainty and is making many employers nervous. Some, however, are taking advantage of one bright spot: wellness.

 
As the Department of Health and Human Services (HHS) pushes out new regulations from the Patient Protection Affordable Care Act (PPACA) and we inch closer to the implementation of mandated State Health Exchanges, employers are, rightfully, concerned about their health care costs.  Without firm confidence of the exchange system, some employers are choosing to address costs by helping change employee’s habits and improving their health.

The PPACA allows employers to offer incentives to employees who participate in wellness plans and/or meet certain health standards.  While the current incentive cap is 20 percent of the cost of coverage, the law increases the reward amount beginning in 2014, when rewards may be up to 30 percent of the employee’s cost of coverage.    The participating employees see an immediate “carrot” in the form of lower monthly contributions.  The employer’s benefit will accrue over time as health claims and related expenses decrease with improved employee health. 

Now is a prime time for companies to consider wellness initiatives. Building a wellness plan, however, takes some planning and follow-through to get good return on your investment.  One important decision is how you will structure your incentive.  Some questions to ask:

• Are you going to use a carrot or a stick approach?
• What wellness attributes will be measured?
• How are you going to communicate the plan and incentive to your employees?
• How are you going to keep your employees engaged long term? 

SRA Benefits has a history of developing plans with proven results in bending the cost curve and ultimately affecting the cost of the medical plan.  We help clients take full advantage of the PPACA regulations and develop a results-based incentive program that can not only impact medical claim costs, but can impact employee satisfaction.  Aren’t those bright spots worth investigating?