Large employers are on board with social determinants of health and virtual care strategies

My Take

Large employers are on board with social determinants of health and virtual care strategies

By Sarah Thomas, managing director, Deloitte Center for Health Solutions, Deloitte Services LP

Keeping employees healthy, happy, and active is essential for a productive workforce. One of my favorite perks at Deloitte is our well-being subsidy. Each year, eligible employees receive $500, which can be used for everything from gym memberships, to bike tune-ups, to 5K registrations. There are other health-focused features, too. If I don’t pack a lunch, our local cafeteria offers a wide range of healthy options—and a lovely view of the Potomac River. As a regular bike commuter, I really like having a secure room for storing my bike and a locker room where I can shower and change after a summer-morning ride. Although I haven’t used it yet, there is a new onsite fitness center on the ground floor of our building—and steps from my office is a space dedicated to meditation and yoga.

According to new report from the National Business Group on Health (NBGH),¹ a growing number of large employers are doing more to address the physical, mental, and financial well-being of their workers (see the August 20, 2019 Health Care Current). This lines up well with our research and vision for the future of health.

Employers are focusing on drivers of health/social determinants

I am well aware that many hospitals, health plans, and states are implementing or developing strategies to improve people’s health by connecting them to services that address the underlying drivers of health (e.g., housing, food, transportation). What I hadn’t realized is that large employers also are making a significant push in this direction. Many of the large employers surveyed for the NBGH’s report are interested in insurance coverage that goes beyond the traditional definition of health care. For the 2020 plan year:

• 90 percent of respondents say they are considering financial/economic issues to be part of their health and well-being strategy.
• 84 percent are considering health care access/literacy as a part of that strategy.
• 34 percent of employers are including food quality and access in their well-being strategy for next year, and an additional 60 percent expect to include it over the next year or two.
• 10 percent of employers are including housing as a part of their well-being strategy for 2020, and 84 percent intend to include it over the next year or two.

As health plans begin to expand from funding community projects to designing benefit packages that take on the drivers of health and well-being, it makes sense to me that they might team up with their employer clients to address this issue. If health plans, employers, and hospitals (along with state and local governments) could work together on this issue—and leverage technology that can help identify services and track whether people’s needs are met—the impact could be powerful! One of the key takeaways from our smart health communities research is that a multi-stakeholder approach can help ensure a sustained impact.

Employers see value in virtual care

Deloitte’s Center for Health Solutions has been closely tracking the rise of virtual care, which is an important component in the future of health. One of our recent surveys found that consumers have a strong interest in receiving care virtually. This technology could help reduce care costs, expand access, and extend the reach of clinicians.

It appears that employers are more aligned with this vision than I would have thought based on some discussions I’d had with employers a couple of years ago. Back then, employers were skeptical that employees would really take advantage of these options. Fast forward to now: in the NBGH report, 63 percent of large employers expect virtual care to have a “significant” or “very significant” effect on health care in the future.

Some strategies seem familiar

When I wrote about employer strategies last fall, I noted that many employers are considering ways to enhance primary care—mostly through onsite clinics. As a supporter of primary care, I was heartened to see that employers have a strong interest in advanced primary care models and accountable-care organizations (ACOs).

According to the NBGH report, more than one-third of large employers plan to offer on-site or nearby primary care in 2020, and another 18 percent said they intend to offer it within the next year or two. Nearly 25 percent of employers said they plan to offer products that steer patients toward physician-led accountable care organizations, with another 34 percent planning to do so within the next year or two. Both of these investments are backed by evidence. Other research has found that physician-led ACOs have been more effective than peer groups at controlling costs and generating better patient outcomes.²

At the state level, recent research indicates that spending on primary care is associated with better patient outcomes.³ Minnesota, which spends more on primary care than any other state, has both lower rates of emergency-department use and fewer hospitalizations compared to other states, according to a July report from the Patient-Centered Primary Care Collaborative. The report also notes that seven states have introduced or enacted legislation—or issued executive orders—to measure and eventually increase their investment in primary care without increasing overall health spending. In California, three organizations launched a primary-care improvement program using a grant from the US Centers for Medicare and Medicaid Services (CMS)—and saved $346 million ($6 for every $1 invested) over a four-year period (see news item below).

I encourage readers to dig further into the results of the NBGH’s 2020 Large Employers' Health Care Strategy and Plan Design Survey. There are some interesting findings about expected health care cost increases and the use of high-deductible health plans tied to a health account (still offered, but employers are adding other options). The report also looks into how large employers view the idea of Medicare for All. A majority of participants said making Medicare available to everyone would likely lead to higher health care costs, more taxes, and lower quality. However, more than half of employers said Medicare should be expanded to people who are younger than 65, although they disagreed on how young beneficiaries should be.

It is also interesting to see waning interest in some of the strategies of the past, such as the more traditional wellness programs and tighter provider networks. We are in a relatively hot labor market, which might be pushing more employers to view health as an integral part of their workforce strategy.

I hope readers get out there and enjoy the last weeks of summer—hopefully with something that supports your good health!

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¹ Large Employers' 2020 Health Care Strategy and Plan Design Survey, National Business Group on Health, August 13, 2019
² Half a decade in, Medicare accountable care organizations are generating net savings, Health Affairs, September 20, 2018
³ Investing in primary care: a state-level analysis, Patient-Centered Primary Care Collaborative, July 2019

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In the News

Health providers urge CMS to streamline prior authorization processes in Medicare Advantage plans

Several physician groups are urging CMS to streamline prior-authorization procedures for Medicare Advantage (MA). In June, the agency sought strategies for reducing the administrative burden on providers. The trade association Medical Group Management Association (MGMA) recommended that CMS implement electronic transaction and operation rules to support claims submissions and to help physicians meet the clinical documentation requirements for prior authorization. The American Medical Association (AMA) urged CMS to require all MA and Part D plans to publicly disclose which services and medications require prior authorization and other coverage restrictions. According to the association, this information would help inform physicians and patients. Two national organizations representing neurosurgeons urged CMS to accelerate the use of electronic prior authorization (ePA), which physician practices could integrate into electronic health record (EHR) systems to streamline processes. Both MGMA and the neurosurgeon organizations also advocated for full transparency on health plan clinical templates regarding prior authorization requirements.

America’s Health Insurance Plans (AHIP) defended prior authorization, noting that it applies to fewer than 15 percent of all covered health services and treatments. In a statement, AHIP said it would work to improve the prior authorization process to reduce provider burden. The American Hospital Association (AHA) and AHIP also suggested that greater automation could help reduce burdens from prior-authorization requirements. AHA also called on CMS to implement a standardized method for physicians to submit prior-authorization requests.

In an August 15 statement, CMS Administrator Seema Verma noted that some areas in Medicare require further utilization oversight, which is why prior authorization can be necessary. Verma also said that prior-authorization requirements should not interfere with medical practice or delay health services.

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HHS releases proposal to revise data-sharing rule, improve opioid monitoring

On August 22, the US Department of Health and Human Services (HHS) proposed a set of revisions to 42 CFR Part 2, a regulation governing patent privacy for substance-use records. This proposal is the third attempt since 2017 to change the rule, which mandates explicit patient consent to share records but can contribute to provider burden—and make medication and other patient history difficult to share. The proposed changes would allow doctors—with the patient’s consent—to incorporate information about the patient’s substance-use treatment history directly into an EHR if this data can be separated from other records. Further, the proposed changes would allow disclosure of affected medication-dispensing records to prescription drug-monitoring programs.

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New report shows increasing health care costs for families who have employer coverage

Health costs for families with employer-sponsored coverage rose twice as fast as wages—and by three times the rate of inflation—from 2008 through 2018, according to a recent report from the Peterson-Kaiser Health System Tracker, a joint effort between the Kaiser Family Foundation (KFF) and the Peterson Center on Healthcare. Other findings in the report include:

• In 2018, an average family of four with employer-sponsored health coverage spent $4,706 on premiums and $3,020 on cost-sharing. Ten years earlier, a family of four spent $2,838 on premiums and $1,779 on cost-sharing.
• Though the cost for benefits and care increased by 67 percent from 2008 to 2018, employee wages increased by just 31 percent and the inflation rate rose by 21 percent.
• Employer contributions to worker health benefits increased 51 percent, from $10,008 in 2008 to $15,159 in 2018.
• In 2003, deductibles made up 20 percent of out-of-pocket spending, co-payments made up 54 percent, and coinsurance accounted for 26 percent. By 2017, deductibles were 51 percent of these costs, co-payments comprised 19 percent, and coinsurance made up 30 percent of out-of-pocket costs.
• In 2018 total health spending for a family of four, including the employer’s premium contribution, family premium contribution, and family out-of-pocket spending, exceeded $22,000, on average. Total health spending for a family of four was $10,359 in 2003.

(Source: Peterson-Kaiser Health System Tracker, Tracking the rise in premium contributions and cost-sharing for families with large employer coverage, August 14, 2019)

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Physician quality improvement effort saves $345M by investing in primary care

Three California-based organizations—the Pacific Business Group on Health (PBGH), L.A. Care Health Plan, and the Southwest Pediatric Practice Transformation Network—used a $52 million grant from CMS’s Transforming Clinical Practice Initiative (TCPI) to launch a primary-care improvement program, which has saved $6 for every $1 invested (a total of $346 million) over a four-year period. State leaders, health plans, and provider organizations announced results during the California Transformation Summit on August 21.

• L.A. Care Health Plan concentrated on diabetes and depression, including screening for suicide risk for Medicaid beneficiaries.
• PGBH, which had consumers enrolled in commercial-payer plans, focused on asthma, cervical cancer screenings, diabetes, hypertension, and lower-back pain imaging.
• The Southwest Pediatric Practice Transformation Network targeted 12 quality metrics for six conditions: acne, acute gastroenteritis, bronchiolitis, asthma, community-acquired pneumonia, and headache.

To help transform primary-care practices, the three organizations facilitated a peer-based learning initiative and provided technical support to 9,800 participating physicians who provided care to 5.9 million patients in California. Results from the initiative showed that the efforts prevented 67,000 unnecessary emergency-room (ER) visits and 57,000 unneeded hospital admissions over four years. Moreover, about 750,000 patients had improved clinical outcomes.

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Breaking Boundaries

This mini laboratory—the size of your smartphone—could save lives

Researchers at Purdue University are developing a miniature laboratory, about the size of a smartphone, that can analyze a single drop of water to detect the bacterium that causes cholera. A simple test like this could help prevent outbreaks of the disease. While cholera is not a problem in the US, it kills up to 143,000 people a year worldwide and causes as many as 4 million more to get sick. The Vibrio cholerae bacterium causes extreme diarrhea and vomiting, which can lead to severe dehydration in a matter of hours. The treatment is relatively simple—rehydration supplements can cure most cases.

Cleaning up contaminated water with chlorine tablets or filters is typically effective at preventing outbreaks. The device developed by Purdue engineers can rapidly detect cholera bacteria in water to help identify potential sources. Currently, most tests take three to five days and require a well-equipped laboratory. The new invention is a portable, miniature lab that contains heating units, lenses, and uses a phone to process images. The mini-lab has chemicals that make copies of the toxin gene in the bacterium, which creates a viscous solution. By putting a water sample into a single-use disposable kit and waiting about half an hour, researchers can see if the water sample becomes more viscous. If so, harmful bacteria are present.

The phone can send information about the water quality to researchers or charities that can intervene and possibly help communities contain potential outbreaks. To improve on the device, the team is working on a “concentrator” that can take larger amounts of water and concentrate it down so that more water can be tested at one time. The team has done some initial field tests in Bangladesh that have gone well and more tests are planned for later in the year.

Cholera has been around for thousands of years, and the team at Purdue hopes tools like this can help answer important questions about how it is transmitted and how it shows up in water sources.

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