TAKING CONTROL OF YOUR HEALTHCARE. healthcare solutions. Specializing in Strategies for Cost Containment and Improved Employee Health

Transcription

1 TAKING CONTROL OF YOUR HEALTHCARE healthcare solutions Specializing in Strategies for Cost Containment and Improved Employee Health

2 How To Deliver Great Healthcare in a Cost-Effective Way EPI s Healthcare Experts Have the Formula We work with organizations to respond to their immediate needs and develop their Go-forward healthcare action plan. We provide organizations with a fresh perspective and action-steps that will reverse runaway healthcare cost and create greater focus on employee well being. EPI s experts probe the reasons for cost escalation and plan designs that are at odds with the desire to improve employee health. What Does EPI Do? EPI works with employers, employees and vendors to address current beliefs, contracts, systems and processes that can be improved or changed resulting in a lower healthcare spend, improved services and healthier employees. EPI is not a healthcare broker, payor or insurance provider. Rather, we are a team of independent healthcare experts and business advisors who understand the inside drivers and nuances for healthcare spending and unnecessary costs. We listen carefully to each organizations history and needs as we complete an analysis and provide an action-oriented roadmap to lower healthcare spending, simplified service and improved employee health. We will create a tailored plan to lower cost and improve employee well-being. Working with clients to maximize opportunities to reduce cost and improve employee health. At the heart of EPI s Healthcare Solutions is an understanding of the importance of healthcare to the employer and employee. We know that the ability to provide and receive great healthcare is being threatened by costs, demands, regulations and market complexity. The EPI team will guide organizations in regaining control of their healthcare issues by creating an immediate plan for: > Cost reduction that doesn t necessitate reduced benefits. > Greater transparency and accountability from vendors, brokers and health plans. > Improved employee engagement, trust and well-being. 2

3 It takes serious know-how to work through the maze. The Core of EPI s Healthcare Solutions We deliver an end-to-end analysis leading to the production of a detailed and actionable roadmap that addresses each healthcare tipping point. Depending on the organizations on-going needs, EPI can also provide oversight or execution of: > Performance based procurement standards for brokerage, medical management and health plan coverage including plan design, prescription drugs and sourcing of fully-insured and self-funded products. > A system for producing vendor reports and tracking quality measures. > Standards for creating the architecture between claims, wellness, prevention and case management. > Labor negotiations and workforce benefits planning. > Employee engagement around personal healthcare and well-being. We have worked with over 2000 employers and 1 million covered lives related to healthcare cost containment and medical management, EPI s experts know that the greatest opportunity to reduce costs, simplify service and improve employee health occurs when there is a conscious effort and serious know-how in linking medical claim review, payment, wellness, prevention, adherence, cost containment, disease management, plan design, vendor decisions and employee involvement. Let EPI show you how or let us do it for you. E X E C U T I V E PA RT N E R S.CO M 3

4 EPI s Healthcare Philosophy We focus on an end-to-end analysis of factors and conditions that are driving costs and blocking employee involvement. We will use this analysis and our expertise to create new opportunities for how employees, employers, brokers, payors, providers, health plans, wellness services and networks must work together to create and sustain a cost effective healthy-living partnership. As everyone knows, efforts to tweak components of a health plan almost never sustain a reversal of the upward trend in healthcare costs. And, tweaks seldom encourage real employee involvement. No employer or employee should just accept what they are typically told: > Your premiums are going up next year because your cost of claims is up. > The only option is to increase employee out-of-pocket costs or cut benefits. > No other company will bid your group. > Our network discounts are the best. > No one wants to change. > It s too hard to get employees to take wellness seriously. > We ve already tried all those ideas. > We have a contract, the union won t want to make any changes. EPI offers a new objective approach that embraces analysis and provides quality options for immediate action and long term planning. 4

5 Providing Superior Information and Options EPI s Work Style Makes a Difference! Since we are also organizational experts, we understand the presence of cultural issues and other dynamics that may have a significant affect on healthcare decisions. The following are challenges we all face and will help describe EPI s work: Example 1: What drives healthcare costs? An employer has been told by a broker or plan that next years premiums will increase 8%. Th e Reason: Your employees have additional claims and the cost of healthcare went up. The broker may add: We worked hard to keep the increase at 8%. It could have been much worse. This answer shifts the blame to hospitals, medical practices and employees. While this answer may be partially true, it is insufficient and closes the door on medical claim analysis and best practices that must be explored. EPI will work with you and your broker to do a deeper analysis to discover key reasons why costs have risen and what you can do to bend the curve back in your favor. Example 2: How to control unnecessary healthcare spend? Employers are spending money on medical services and prescription drugs at an alarming rate. Some of those claims should not be paid. Indeed, surveys from numerous sources state that billions of dollars in employee and employer money is paying for mistakes, fraud, up-coding and medical services that are not necessary or evidence-based. This is common and it s happening in your plan. Most health plans DO NOT perform a thorough enough review of medical claims to find and stop these errors before the claim is paid. EPI will identify the cost drivers and sources of these errors and provide action steps to improve vendor performance. Example 3: How to involve ourselves in our health? Based on national trends and a review of actual claims, many people with chronic diseases including diabetes and heart disease are not adhering to common disease management steps including recommendations from their personal physician. Many people do not properly monitor or control their known disease or diseases. Others in the work force are not following recommended guidelines from the Center for Disease Control for testing and prevention. These employees are likely the primary reason for most of the increase in healthcare spend and the occurrence of terminal illness. These employees are likely to have greater absenteeism. Moreover, these employees may not be engaged in their own well-being. Based on what the employer does today, EPI will demonstrate options to engage employees in their health. Our emphasis is on building a supportive environment, education, positive incentives and participation. 5

6 How EPI s Work Process Produces Real Results EPI s Deep Dive into Your Healthcare System As the employer s trusted advisor, EPI will explore goals, contracts, employee concerns, vendor performance, and work processes that address cost and employee health. EPI s focus includes the following: Step 1: Broker and Procurement Best Practices Engagement We believe a transparent, fact based relationship between the broker and the employer is essential. The broker is often the employer s only window into the health insurance market. Using EPI s Best Practices Checklist, EPI works to make sure everyone is getting the most out of this crucial relationship. EPI will examine procurement practices used to secure competitive terms and pricing. Our review includes: > How is your broker working with the insurer in your best interest? > What does your broker do to bring options and competition to your attention? > When premiums increase, what do you do to explore the rational for the explanation? > How do you analyze PPO networks, administrative costs and containment efforts? > How is price actually compared? How will net savings achieved through networks and cost containment strategies be credited back to the best benefit of the employer? > What contractual obligations and processes exist to ensure your partners meet performance standards? Step 2: Plan Coverage and Insurance Origination / Sourcing EPI will review your plan design (e.g., high deductibles, prevention based) and origination/sourcing options (e.g., fully insured and self-funded plans). Contracts and other key aspects of the employer s healthcare plans will be analyzed including: > What best practice plan design options are offered? How are these options communicated to employees? > How well does your health plan track costly diseases and accidents to ensure positive intervention (with the use of predictive modeling) that supports savings and employee health through case management and chronic disease coaching? > To what degree has a true self-funding option with stop-loss coverage been explored? > How does plan language reflect state-of-the-art options and encourage healthy living? 6

7 Step 3: Cost Containment EPI will examine your health plans actual pre-payment processes for detecting and acting on claims that may involve fraud, abuse, coding errors and inappropriate invoicing. An essential part of this review is your plans process for detecting large medical claims that are not medically necessary. EPI s experts have cracked the code on cost containment and will work with your team to determine how they are using best practices in this regard. > How effectively does your payor review medical claims to ensure proper coding? > How effectively does your plan detect excessive billing regardless of network discounts? > What does the payor do to ensure that all large claims are medically necessary and are paid according to reasonable and customary rates? > How are promised network discounts compared to the costs of actual claims? Step 4: Healthy Employees A great health plan must build trust and demonstrate how to engage employees in taking responsibility for their own health. Employers and employees can collaborate to ensure that the focus is on avoiding unnecessary and costly medical claims. High performing organizations know how to create a culture that includes an authentic commitment to healthy choices. Creating a culture of healthiness is a platform for employer and employee engagement. > What positive practices are in place that help employees with chronic disease and comorbidities stay within their treatment plan thus avoiding costly claims and improving their productivity? > How are employees and their employer engaged in practices that help all employees and their dependents live healthy lives? > How is the employer using the incentive opportunities in federal law (and best practice) to promote healthy decisions? > What are the advantages of increasing employee understanding and responsibility in the healthcare challenges faced by the employer? The link between wellness, prevention, disease management and claims management is the ultimate formula for reducing healthcare cost and creating productivity. 7

8 Signs That You re Ready For EPI Are You Ready To: > Have your entire healthcare team aligned to maximize your healthcare investment? > Know what it means to have independent industry experts on your side? > Hold your broker and health plan accountable for cost increases and service failures? > Have a more positive workplace where employees are invested in their health? > Implement a plan that addresses your goals for many years to come? > Know that your practices are best practices? > Ensure your money isn t wasted on procedures that are medically unnecessary? If so, contact Executive Partners today to arrange for a no-obligation meeting. Act now to get ahead of your next renewal process. This EPI Healthcare Solution Process will pay for itself many times over. Can you afford not to do this? Contact Us Today Robert Oberwise CEO & Managing Partner 14 Hidden Brook Drive North Barrington, IL Office (847) Mobile (847) Fax (847) roberwise@executivepartners.com Web Peter Burchard Healthcare Team Lead Office (847) Mobile (706) Fax (847) pburchard@executivepartners.com Web 8

9 Your Partners at Executive Partners Peter T. Burchard Peter, our Executive Partners Healthcare Team Lead, has over thirty years of executive level experience as a chief operating officer in the healthcare industry and as a city manager. Peter is a former board member and chairman/moderator for a Chicago suburban hospital where he also served on various healthcare committees. Peter has extensive experience working with industry brokers, fully insured plans, self insured plans, employee unions, cost containment experts, wellness providers and employers. While representing self-funded plans in Washington D.C., Peter has discussed the impact of healthcare reform on employers with numerous members of the U.S. House of Representatives and Senate staffs. Luke Burchard, MD Luke is a board certified family practice and medical management expert with over 28 years of experience. He has been instrumental in instituting cost-containment and wellness practices, which have saved organizations millions and provided appropriate care for their employees. Luke is an expert in the medical market and methods to manage it effectively. Loral Blinde Loral brings over 25 years of experience as a top Human Resources executive responsible for negotiating benefit agreements with providers, controlling costs and delivering outstanding benefit services to employees. He has a track record of building productive partnerships with both brokers and benefit providers. An active, hands-on leader, Blinde created a unique process of quarterly business reviews to ensure cost effective and high quality service delivery of all benefits, including workers compensation. His experience includes working with both union and non-union employee groups, public and private sector employers and 12 years of Board level executive compensation and benefit administration. In the aviation industry, Loral achieved industry leading low OJI rates and WC costs. Rob Oberwise Rob is the Founder and Managing Partner of Executive Partners, a consulting firm focused on strategy development, execution, and alignment. Over 23 years, EPI has worked with large and mid-size corporations, governments, and healthcare providers. The healthcare work has been primarily focused on transformational strategies and business operational effectiveness. Rob is an expert at systemic change. 9

10 TAKING CONTROL OF YOUR HEALTHCARE GO BEYOND Serving the needs of business, government and not-for-profit organizations for over 20 years. 14 Hidden Brook Drive North Barrington, IL Office (847) Fax (847)