by US Rx Care | Mar 17, 2020 | Uncategorized
One less-touted aspect of the Affordable Care Act is that it provides employers more tools for assisting employees with substance-abuse problems to seek help.
According to a study by the Substance Abuse and Mental Health Services Administration, 10% of America’s workers are dependent on one substance or another. The study also found that 3.1% have used illegal drugs either before or during a shift.
Also, 79% of heavy alcohol users have jobs, and 7% of them say they’ve had drinks while on duty.
Drug use and abuse have been on the rise — both illegal drugs and prescription painkiller abuse, the latter of which led a more than a 500% increase in people seeking treatment for addiction to doctor-prescribed opioids between 2007 and 2017.
As an employer, the costs are great if you have someone on staff who has a substance-abuse problem. It behooves you to ensure that the group health plan you offer your workers is comprehensive amid this growing problem.
Far-reaching costs
Addicted workers have been found to have:
- Lower or lack of workplace productivity;
- Higher health care costs;
- Increased absenteeism and presenteeism;
- Diminished quality control;
- More disability claims;
- Increased workplace injuries;
- Lower morale;
- Higher job turnover; and
- Employee theft.
Some employers have tried to help employees tackle their addictions or abuse problems by implementing workplace prevention, wellness and disease-management strategies. These programs improve health, which lowers health care costs and insurance premiums and produces a healthier, more productive workforce.
Under the ACA, anybody covered by a health plan has access to substance-abuse treatment. That’s because the law makes such treatment one of 10 benefits insurance plans must offer.
The ACA requires health plans to pay for prevention and early intervention.
Health care plans also have to comply with a “parity” law, which requires them to treat mental health issues the same way they do physical diseases.
What else can you do?
- You can start by adding addiction to your prevention, intervention, treatment and disease-management strategies.
- Use confidential screenings and assessments. There are a number of screening, brief-intervention and referral-to-treatment modules available to help people confront their drinking or drug use and get the help they need.
- Review your policy for coverage. If you have coverage for substance-abuse treatment, employees with addictions will be more apt to seek out help knowing the cost is at least partially covered.
And, importantly, make sure your substance-abuse benefit is robust, and that it covers a full continuum of care.
A strong benefit would include:
- Inpatient care;
- Residential treatment programs;
- Outpatient care; and
- Continuing care for those in need of treatment.
Far-reaching costs
Addicted workers have been found to have:
- Lower or lack of workplace productivity;
- Higher health care costs;
- Increased absenteeism and presenteeism;
- Diminished quality control;
- More disability claims;
- Increased workplace injuries;
- Lower morale;
- Higher job turnover; and
- Employee theft.
Some employers have tried to help employees tackle their addictions or abuse problems by implementing workplace prevention, wellness and disease-management strategies. These programs improve health, which lowers health care costs and insurance premiums and produces a healthier, more productive workforce.
Under the ACA, anybody covered by a health plan has access to substance-abuse treatment. That’s because the law makes such treatment one of 10 benefits insurance plans must offer.
The ACA requires health plans to pay for prevention and early intervention.
Health care plans also have to comply with a “parity” law, which requires them to treat mental health issues the same way they do physical diseases.
What else can you do?
- You can start by adding addiction to your prevention, intervention, treatment and disease-management strategies.
- Use confidential screenings and assessments. There are a number of screening, brief-intervention and referral-to-treatment modules available to help people confront their drinking or drug use and get the help they need.
- Review your policy for coverage. If you have coverage for substance-abuse treatment, employees with addictions will be more apt to seek out help knowing the cost is at least partially covered.
And, importantly, make sure your substance-abuse benefit is robust, and that it covers a full continuum of care.
A strong benefit would include:
- Inpatient care;
- Residential treatment programs;
- Outpatient care; and
- Continuing care for those in need of treatment.
by US Rx Care | Mar 10, 2020 | Health care costs
Employers, health insurers, regulators and hospitals are all raising concerns about the Trump administration’s rules issued last year that allow employers to fund health reimbursement arrangements (HRAs) that their workers can use to purchase health plans on the open market.
The Centers for Medicaid and Medicare Services, IRS and the Department of Labor issued the final rules in late 2019. They reverse one of the major pinch-points of the Affordable Care Act, which bars employers from paying employees to buy their own health insurance either on publicly run health insurance exchanges or on the open market.
The fine for breaching this part of the law is a hefty $36,500 annually.
The rules continue to receive pushback from small business groups, insurers, regulators and others, who say that employers who want to go this route are facing a bureaucratic nightmare.
And one of the biggest concerns is that employers will use the opportunity to move older and sicker workers from their group health plans to exchanges, in order to reduce the cost burden on their plans.
Complexity a major issue
The National Federation of Independent Business has said that small businesses that want to offer workers an HRA integrated with an individual-market health plan are facing a lot of complexity.
“NFIB recommends that your departments plan to release… a publication that explains in plain English, step-by-step, how small businesses can establish, administer, and comply with the rules,” the group wrote.
HRAs are tax-sheltered accounts funded employers that typically are offered to reimburse employees for out-of-pocket medical expenses. This rule expands how those HRAs can be used. HRAs have been tax-advantaged only if they are coupled with an ACA-compliant group health plan. They cannot be used now to pay premiums for individual-market health insurance.
Under the rule, employers could provide an HRA that is integrated with individual health insurance coverage. The rule does include provisions to prevent employers from steering workers or dependents with costly health conditions away from the employer group plan and toward individual coverage.
Employers also could offer a different type of HRA, funded up to $1,800 a year, that could be used by employees to pay premiums for short-term plans that don’t comply with ACA consumer protections.
Employers could not offer the same employees the choice of either a traditional group plan or an HRA-funded individual-market plan. But they could offer a group plan to certain classes of employees, such as full-time workers under age 25, and an HRA plan to other classes, such as part-time employees.
Fears many may be shunted from group plans
Other concerns that are being raised include those by the American Academy of Actuaries that self-insured employers, in particular, may use the rule to shunt less healthy employees out of their group health plans, which in turn could result in worsening the ACA individual-market risk pool.
The Federation of American Hospitals expressed concern that the proposal would shift people out of the employer group market into the less stable individual market, which offers thinner benefits and less support for consumers.
The conservative National Federation of Independent Business supports the new rule but is concerned that it will be a complex process to set this type of arrangement up, especially for small businesses.
The liberal Center on Budget and Policy Priorities said the proposal to let a special type of HRA be used to buy short-term plans could be challenged legally, because the ACA and the Health Insurance Portability and Accountability Act (HIPAA) prohibit group plans from discriminating based on health status, as short-term plans are allowed to do.
by US Rx Care | Mar 4, 2020 | Uncategorized
As the outbreak of the 2019 novel coronavirus gains momentum and potentially begins to spread in North America, employers will have to start considering what steps they can take to protect their workers while fulfilling their legal obligations.
Employers are in a difficult position because it is likely that the workplace would be a significant source of transmission among people. And if you have employees in occupations that may be of higher risk of contracting the virus, you could be required to take certain measures to comply with OSHA’s General Duty Clause.
On top of that, if you have workers who come down with the virus, you will need to consider how you’re going to deal with sick leave issues. Additionally, workers who are sick or have a family member who is stricken may ask to take time off under the Family Medical Leave Act.
Coronavirus explained
According to the Centers for Disease Control, the virus is transmitted between humans from coughing, sneezing and touching, and it enters through the eyes, nose and mouth.
Symptoms include a runny nose, a cough, a sore throat, and high temperature. After two to 14 days, patients will develop a dry cough and mild breathing difficulty. Victims also can experience body aching, gastrointestinal distress and diarrhea.
Severe symptoms include a temperature of at least 100.4ºF, pneumonia, and kidney failure.
Employer concerns
OSHA — OSHA’s General Duty Clause requires an employer to protect its employees against “recognized hazards” to safety or health which may cause serious injury or death.
According to an analysis by the law firm Seyfarth Shaw: If OSHA can establish that employees at a worksite are reasonably likely to be “exposed” to the virus (likely workers such as health care providers, emergency responders, transportation workers), OSHA could require the employer to develop a plan with procedures to protects its employees.
Protected activity — If you have an employee who refuses to work if they believe they are at risk of contracting the coronavirus in the workplace due to the actual presence or probability that it is present there, what do you do?
Under OSHA’s whistleblower statutes, the employee’s refusal to work could be construed as “protected activity,” which prohibits employers from taking adverse action against them for their refusal to work.
Family and Medical Leave Act — Under the FMLA, an employee working for an employer with 50 or more workers is eligible for up to 12 weeks of unpaid leave if they have a serious health condition. The same applies if an employee has a family member who has been stricken by coronavirus and they need to care for them.
The virus would likely qualify as a serious health condition under the FMLA, which would warrant unpaid leave.
What to do
Here’s what health and safety experts are recommending you do now:
- Consider restricting foreign business trips to affected areas for your employees.
- Perform medical inquiries to the extent legally permitted.
- Impose potential quarantines for employees who have traveled to affected areas. Ask them to get a fitness-for-duty note from their doctor before returning to work.
- Educate your staff about how to reduce the chances of them contracting the virus, as well as what to do if they suspect they have caught it.
If you have an employee you suspect has caught the virus, experts recommend that you:
- Advise them to stay home until symptoms have run their course.
- Advise them to seek out medical care.
- Make sure they avoid contact with others.
- Contact the CDC and local health department immediately.
- Contact a hazmat company to clean and disinfect the workplace.
- Grant leaves of absence and work from home options for anyone who has come down with the coronavirus.
If there is a massive outbreak in society, consider whether or not to continue operating. If you plan to continue, put a plan in place. You may want to:
- Set a plan ahead of time for how to continue operations.
- Assess your staffing needs in case of a pandemic.
- Consider alternative work sites or allowing staff to work from home.
- Stay in touch with vendors and suppliers to see how they are coping.
- Consider seeking out alternative vendors should yours suddenly be unable to work.
by US Rx Care | Feb 18, 2020 | Uncategorized
As a new decade begins, the health insurance industry is on the cusp of making a leap towards improved, higher-tech management of health plan participants.
A recent paper by Capgemini, an insurance technology and consulting firm, predicts the following trends that will be taking shape in the health insurance industry and how they may affect businesses that are paying for their employees’ coverage.
1. Realigned relationships — Insurers are trying to shift risk between themselves and pharmaceutical companies in an effort to reduce drug outlays. The report says insurers are also working more closely with health care providers for early intervention in medical issues that may be facing participants. Addressing health issues early can reduce long-run treatment costs.
2. Fluid regulations — As we’ve seen, just because the Affordable Care Act became the law of the land, the regulations governing health care and health insurance have continued streaming out of Washington. If the last two years are any guide, this will continue to be the case. Also, the constitutionality of the ACA is now being litigated once again after an appeals court upheld a lower court’s ruling that the individual mandate is unconstitutional.
3. Increasing transparency — More stringent regulations, along with President Trump’s recent executive order to improve price and quality transparency, are forcing the health care industry and insurers to become more transparent in their pricing.
One of the biggest focuses is on the drug industry and the role of pharmacy benefit managers, the largest of which have been criticized for being opaque in their pricing, discounts and how they handle drug company rebates.
Also, insurers are increasingly providing detailed information regarding services covered under their health plans, claims processing and payments. Additionally, some insurers are helping enrollees to make more informed decisions before they use a health care service by providing digital tools to help them reduce out-of-pocket expenses.
4. Predictive analytics — Health insurers are using predictive analytics for risk profiling and early intervention for enrollees with health issues. Predictive analytics provide insurers with insightful assessments of potentially high-risk customers, in order to mitigate losses.
With advancements in technologies such as big data and connected devices, insurers now have access to vast amounts of customer data, which can be used to remind people it’s time for their check-ups, medications and other necessary medical services.
Insurers are using predictive analytics to identify and monitor high-risk individuals to intervene early and prevent further complications. This in turn can help reduce claims.
by US Rx Care | Feb 12, 2020 | Health care costs
Congress before the new year passed
legislation repealing the so-called “Cadillac tax” on generous group health
plans, as well as two other taxes, finally putting to bed an issue that has
plagued the Affordable Care Act since its inception.
Although it had not yet been implemented,
employers didn’t like the Cadillac and labor unions came out against it as
well. It was so unpopular that Congress voted twice to delay implementation,
which was originally set to start in 2018. The latest start date had been
pushed until 2022.
The Cadillac tax, an enacted but not yet
implemented part of the ACA, is a 40% levy on the most generous
employer-provided health insurance plans — those that cost more than $11,200
per year for an individual policy or $30,150 for family coverage. It was
designed to only tax the portion of the premium that was above the threshold.
Effect of repeal on group plans
The tax would have been levied on health plans, which are legal entities through which employers and unions provide benefits to employees. It would have been paid by employers, but its impact on employees would be indirect and would have depended on how firms and health plan managers responded to the tax in offering and designing benefits.
None of these
issues now need to concern employers offering group plans.
The tax was
eliminated as part of a $1.4
trillion year-end budget bill that President Trump signed in order to keep the
government open. Here are all the ACA-related taxes that the legislation
eliminated:
- The
Cadillac tax, which had been expected to raise $197 billion over 10 years.
- Starting
in 2021, the health insurance tax, which had been projected to raise $150
billion over the next decade, and
- The
2.3% excise on the sale of medical devices,
which had been expected to generate $25.5 billion in the next 10 years.
by US Rx Care | Feb 5, 2020 | Health care costs
A new study
has found that high-deductible plans and increased use of coinsurance are
exposing health plan enrollees to higher and higher pharmaceutical costs.
One of the
big problems for many enrollees in high-deductible plans is that their outlays
for drugs may not count towards their health plan deductibles and, if they are
enrolled in separate pharmaceutical plans, they may have to pay the full list
price until they meet their drug deductible, according to the “2019 Kaiser
Family Foundation Employer Health Benefits Survey.”
The report
warns of a growing crisis for American workers, more and more of whom are
struggling with their health expenditures, be they premiums, deductibles,
copays and/or coinsurance.
Workers in
small firms face relatively high deductibles for single coverage and many also
are saddled with significant premiums if they choose family coverage, according
to the study.
The cost of
group health insurance is growing at about 4% to 5% a year, reaching $7,188 for
single coverage in 2019 and $20,576 for family coverage.
Workers in
small firms on average contribute 16% of the premium for single coverage,
compared with workers at large firms (19%), according to the report. But small-firm
employees contribute 40% on average for family coverage, compared to 26% for
staff at larger firms.
That said, 35%
of covered workers in small firms are in a plan where they must contribute more
than one-half of the premium for family coverage, compared to 6% of covered
workers in large firms.
But premium
contributions are only part of the story. Eighty-two percent of covered workers
have a general annual deductible for single coverage that must be met before
most services are paid for by the plan, and that average deductible amount is
$1,655. But, the average annual deductible among covered workers with a
deductible has increased 36% over the last five years, and by 100% over the
last 10 years.
The hidden cost-driver
With all this
as a backdrop, the cost of prescription drugs is one of the largest challenges
facing group health plan enrollees, especially those who are enrolled in
high-deductible health plans, whose out-of-pocket expenses for pharmaceuticals
can be especially burdensome. It is the hidden cost-driver in the system.
The Kaiser survey found that about 90% of covered workers are enrolled in plans where the health plan deductible must be met before prescription drugs are covered. But, this number has been shrinking as group coverage pricing increases and employers shift more of the cost burden to employees.
There are a few ways that employees are taking on a significant load with their drug expenditures:
- First, more workers are enrolled in plans that carve out prescription drugs, meaning that their expenditures on medication do not count towards satisfying their health plan deductibles. About 13% of employees are enrolled in a plan with a separate annual deductible that applies only to prescription drugs.
- Many people with workers face out-of-pocket costs linked to prescription list prices regardless of the actual net, post-rebate costs. That’s because coinsurance percentages are computed based on the price negotiated between the pharmacy and the plan or pharmacy benefit manager. These negotiated prices are typically close to list prices.
Even worse, patients pay the entire negotiated price when they are within a deductible and do not enjoy the benefits of rebates that the PBM may have negotiated with drug makers. Patients with these benefit designs do not benefit from rebates, though major brand-name drug makers sell their products at half of the list prices.
- In the past, health plans had two- or three-tier benefit designs for drugs, mostly for generics and brand-name drugs, with lower copays and coinsurance for the lowest-tier medicines. But as prices have started increasing, many plans have four tiers and sometimes five (the specialty tier).
The disappearance of two- and three-tier benefit designs have made out-of-pocket expenses especially high for specialty drugs. Plans place therapies for such chronic, complex illnesses as cancer, rheumatoid arthritis, multiple sclerosis and HIV on the fourth and specialty tiers of benefit plan, for which the enrollee has to pay a larger share.
