Over the last several years we have seen employers, especially those with self-funded health plans, evolve in their approach to wellness programs. Programs have grown from gathering data – e.g., steps on a pedometer, answers to a health risk assessment – to using the information gathered to take a data driven approach to plan design for health plans and their stand alone or integrated wellness programs. We have also seen employers roll out their wellness programs to spouses, which is a positive trend especially given the latest NIH study which suggests a link between parental obesity and developmental delays in children. Low hanging fruit, such as targeting more hands on care management for high risk, high cost participants, identifying and implementing mechanisms to promote step therapy and generic drug spend, and removing barriers to managing chronic conditions such as $0 copays for maintenance prescriptions and lower cost office visits, have all been part of our self-funded employers’ toolkits over these past few years as the health care world evolves from volume based to value based reimbursement. So what will become of these trends if the Affordable Care Act is repealed and replaced?
Several popular provisions of the Affordable Care Act, such as dependent coverage to age 26, first dollar coverage of preventive care, prohibitions on lifetime annual/limits, annual out of pocket limits, and a ban on preexisting condition exclusions, have all played a role in ensuring access to care, and many hope these provisions remain. Regardless of the fate of these provisions, self-funded employers are in a unique position as they enjoy flexibility in plan design as they can keep the foregoing benefits as part of their plan design should they wish to do so. With that said, employers have also been doing more to control costs during the last several years since the enactment of the Affordable Act: they have been moving more employees into high deductible health plans. On the one hand, we can take the position that this approach puts employees in the driver’s seat and encourages them to take charge of their healthcare spending and shop around for high quality and value, while on the other hand, we can say that this approach simply shifts the cost burden to employees, especially for those employees who choose a plan with high cost sharing with albeit lower premiums.
One major aspect of the Affordable Care Act has been the push for innovative ways to shift to value based reimbursement – from Medicare accountable care organizations (ACOs), to greater use of telemedicine, to data mining and data integration and the rise of big data in healthcare. Certainly, whatever the fate of the Affordable Care Act, providers and self-funded employers alike have made a major shift in their approach to healthcare delivery, from a journey to deliver patient-centered care across the continuum on the provider side, to understanding claims trends on the employer side, along with integration of data from electronic health records and health information exchanges to manage population health. With such a major shift in the healthcare delivery system over the past several years, and with self-funded employers being able to design their health plans to continue to support the popular provisions of the Affordable Care Act should they wish to do so, if providers and employers can continue to partner to develop innovative ways not only to bend the cost curve but to engage patients to be better consumers of health care and better stewards of their health, whether or not the Affordable Care Act is repealed or replaced, may not have the negative effect feared. Indeed, helping employees to understand the health plan options available to them and incentivizing them to better manage their health and health care while looking at improving ways to support employees and their families and impact socioeconomic determinants of health can make a positive difference in the evolution to value-based reimbursement.