Benefits and Compensation

Open Enrollment Brings New Opportunity: Insights into Today’s Complicated Health Insurance Landscape

For employees, open season brings an opportunity to select a new healthcare plan that meets their needs. Unless they have the right information to evaluate their choices, however, they could end up with a plan that offers more headaches than health care.

Many people make their decision based on the cost of premiums alone, but doing so can open the door to a host of unexpected out-of-pocket costs or, worse, an inability to access the health care they need when they need it. Lower premiums are great, but they often come at a steep cost in terms of high deductibles, restricted networks and formularies, and rigid utilization management rules that create roadblocks to care.

How Can Employers Help?

First and foremost, employers can ensure the plans they offer do not create expensive and unnecessary roadblocks to healthcare services. Plans should be evaluated not just by their organizational costs but also by how they encourage preventive services and adherence to treatment for chronic and serious conditions.

It’s a fact that when the cost of health care increases, the use of healthcare services decreases. And when people delay preventive services and annual screenings due to cost, any chronic conditions may worsen, and serious diseases like cancer may go undetected. Researchers at the Harvard Medical School recently released a study showing that people in plans with a deductible of at least $1,000 had an average 5-month delay in the diagnosis of metastatic cancer, as well as delays in diagnostic biopsies and imaging for breast cancer and the start of chemotherapy.

These kinds of delays are bad for employees and bad for their employers. Not only are later-stage cancers harder to treat, but the costs of treatment are also likely to be higher and the disruption to lives and workplaces more significant.

Solutions in Search of a Problem

Other benefit design problems occur when unnecessary roadblocks such as prior authorization (PA) or step therapy are required for treatments that meet the current standard of care for that condition. Such obstacles are not uncommon and serve as a deterrent to needed care. One company we spoke to recently discovered that its benefit plans required PA for chemotherapy, which was delaying employees’ access to cancer treatments. It recognized that no one decides to get chemo unless they really need it, which begged the question of why PA had been required in the first place.

PA has become a particularly common cost-saving tool for medical services and prescription drugs, which may be because so many treatments subject to PA are abandoned while the patient awaits approval. And more than a third of physicians surveyed by the American Medical Association in 2021 reported that PA has led to a serious adverse event for a patient in their care. PA should be reserved for treatments that have been proven to be low value and drugs that have been shown to be abused. It should not be required for first-line therapies, generics, drugs approved 90% of the time, and drugs for which there are no alternatives to treat a certain disease.

High-Deductible Health Plans

As previously mentioned, there’s increasing evidence that high-deductible health plans (HDHPs) decrease healthcare usage, which can be bad for people’s health. There are ways, however, to ensure those employees with HDHPs can access needed health care despite their high deductibles. First, ensure that any HDHPs you offer are health savings account (HSA)-compatible and paired with an HSA. Offer incentives such as matching funds to encourage employees to add pretax dollars to their HSAs to cover out-of-pocket expenses. And be sure that your HDHPs take advantage of all the predeductible services allowed by the Internal Revenue Service (IRS), including preventive services and treatments for chronic conditions such as diabetes, heart conditions, and depression. Finally, make sure the employees enrolled in such plans understand their coverage, and encourage them to use their annual predeductible services.

Today’s health insurance market is a complicated landscape where what you see is not always what you get. Trying to balance the high cost of health benefits with the needs of employees means asking tough questions: Are promised cost savings actually the result of employees not using healthcare services? Do savings in one benefit category (such as prescription drugs) lead to increased costs in another (such as medical services)?

Helping your employees stay healthy, get early diagnoses for health problems, and access and stick to treatment plans will not only save you healthcare dollars but also show your employees you care more about them than the bottom line.

Patricia J. Goldsmith is CEO of CancerCare. A frequent speaker at national meetings and symposia, Goldsmith was named in 2021 to Forbes’s 50 Over 50 Vision List, honoring women making an impact on society and culture. In 2022, CancerCare published a free Toolkit that helps inform the benefits package design and decision-making process and offers key considerations when plans include utilization management.

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