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 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 | Jan 14, 2020 | Uncategorized
The U.S. Fifth Circuit Court of Appeals has upheld a lower court’s decision that the individual mandate portion of the Affordable Care Act is unconstitutional because the penalty was set to zero in 2017.
However, the fate of the entire law is still in play after the court remanded the question of whether that
means the entire ACA should be declared void back down to the district court.
Proponents of abolishing the ACA say that its lack of a “severability provision” means that if any element of the ACA is found unconstitutional, the entire law must go. However, that would likely create chaos for the health insurance marketplace.
Two of the three judges on the court on December 18 upheld a lower court’s decision that the individual mandate is not constitutional because it cannot be construed as a tax.
The judges wrote: “The individual mandate is unconstitutional because it can no longer be read as a tax, and there is no other constitutional provision that justifies this exercise of congressional power. On the severability question, we remand to the district court to provide additional analysis of the provisions of the ACA as they currently exist.”
The decision prolongs the court process and ensures that the future of the landmark health care law remains uncertain.
There is much at stake in this case. If the entire law is thrown out by courts, it would reverberate through the health care industry, including insurance providers and hospitals, and put the coverage of millions of Americans at stake.
The decision would affect people who buy coverage in the individual market and those with coverage through Medicaid expansion, Medicare and from their employers.
The ruling that the individual mandate is unconstitutional will be appealed to the U.S. Supreme Court by the 20 Democratic states that are now defending the ACA in this court fight against republican states that filed the suit to abolish the law on the grounds that it is unconstitutional.
Some background
The ACA individual mandate provision ― or “individual shared responsibility” provision ― initially
required many people to own what the government classifies as solid major medical coverage, or else pay a penalty. Congress passed a tax bill in 2017 that included a provision setting the penalty at zero.
ACA critics challenged the mandate through a case that reached the Supreme Court in 2012.
In a ruling on that case, the Supreme Court held that a federal law that blocks challenges to new taxes
protected the individual mandate provision, because the penalty was a tax.
Critics of the provision say that, now the new tax law has set the individual mandate penalty at zero, the
individual mandate is no longer a tax and can no longer benefit from the legal protection accorded to federal taxes.
The takeaway
Because of this ruling, the lower court will likely start hearings on whether the entire law should be thrown out based on the elimination of the penalties for not securing coverage.
The other part of the ruling, that the individual mandate is unconstitutional, is destined for appeal to the Supreme Court. It’s unlikely that it would be heard in 2020 and that the issue about the fate of the rest of the law will take years to wind its way through the courts.
by US Rx Care | Jan 3, 2020 | Uncategorized
A new study published in the Journal of the American Medical Association estimates that about 25% of all health care spending in the U.S. is attributable to waste in the system.
The study, conducted by health insurer Humana and the University of Pittsburgh School of Medicine, estimated that between $760 billion to $935 billion of health care spending in the country is wasteful.
The study is eye-opening and reflects the need for new approaches in the health care system and how medical care and pharmaceuticals are paid for. It also reflects the tremendous waste caused by complex administrative procedures, which again cries out for changes in the health insurance and care delivery models.
The researchers identified wasteful spending in the following six areas:
Failure of care delivery: $102.4 billion to $165.7 billion
Failure of care coordination: $27.2 billion to $78.2 billion
Overtreatment or low-value care: $75.7 billion to $101.2 billion
Pricing failure: $230.7 billion to $240.5 billion
Fraud and abuse: $58.5 billion to $83.9 billion
Administrative complexity: $265.6 billion
“This study highlights the opportunity to reduce waste in our current health care system,” William Shrank, MD, lead author and Humana’s chief medical and corporate affairs officer, said in a prepared statement. “By focusing on these opportunities, we could make health care substantially more affordable.”
With that much waste in the system, the industry is crying out for more efficiency in hospitals, medical services delivery, health insurance and administration across the spectrum.
The researchers said that if the industry worked on concrete solutions, it could reduce waste by up to $282 billion a year.
They identified the most promising areas for reducing waste, and said that value-based care and reimbursement models represent a major opportunity to reduce the greatest source of waste: administrative complexity.
Value-based care
They said that value-based care models could improve administrative coordination in the system, which is currently severely lacking. The researchers wrote:
“In value-based models, in particular, those in which clinicians take on financial risk for the total cost of care of the populations they serve, many of the administrative tools used by payers to reduce waste (such as prior authorization) can be discontinued or delegated to the clinicians.”
That, they said, would reduce complexity for physicians and give them incentives to reduce waste and improve value in their treatment decision-making.
Using value-based care in which all parties share some in the financial risk would benefit insurers, employers who sponsor health insurance for their workers, hospitals, doctors and patients.
More and more insurers are experimenting with value-based care, which is primarily a payment model that offers financial incentives to physicians, hospitals, medical groups and other health care providers for meeting certain performance measures. Essentially, they are paid based on patient health outcomes.
Value-based care differs from a fee-for-service or capitated approach, in which providers are paid based on the amount of health care services they deliver. The “value” in value-based health care is derived from measuring health outcomes against the cost of delivering those outcomes.
Other waste
To further reduce waste, the researchers also recommended:
- Addressing the high cost of pharmaceuticals (especially for high-cost specialty drugs).
- Implementing hospital price transparency.
- Implementing market competition policies.
- Improving payer-provider collaboration to reform care coordination, safety and value.
- Implementing new measures aimed at reducing fraud and abuse.
by US Rx Care | Dec 31, 2019 | Uncategorized
May this year bring new goals, new achievements, and a lot of new inspirations for life. Wishing you a year fully loaded with happiness. Happy New Year!
