HBCH Connect, News Houston Employers Can Use - 2017 Print

Message from the Executive Director

HBCH continues to grow and impact health benefits design and delivery in the Houston market.   We have become the recognized voice of health benefits design and delivery for employers in the Houston market.    I want to take this opportunity to provide to you a State of HBCH message as we are now halfway into our third year.

Our mission is clear; “To be the leading resource for Houston employers dedicated to providing health benefits at a sustainable cost while improving the quality and experience in their delivery.”  We started out with 20 legacy members from the old Houston Wellness Association and Houston Business Group on Health.  We now have 82 organizational members of which 65% are employers vs. associate health services provider members.  We represent ~553,000 local employer-sponsored lives and ~ 2,000,000 lives nationally. 

Our Board remains diverse and employer-centric.  It consists of 12 employer members from different sizes and industries and 4 associate members (providers of health services to employers).  Our 2017 Board includes several new members as a few have rotated off the Board.  HBCH is thankful for the service of outgoing Chair, Karl Dalal, who will remain on the Board in 2017; Ann Hollingsworth, Memorial Hermann; and Tom Stewart, BCBSTX.    New members are Sandy Clark (King Ranch), Richard Easley (ABM), John Fosdick (DHS Group), Dennis Fox (CB&I), Sue Prochazka (Rice University) and Michael Tucker (Willis Towers Watson).  Returning Board members are Mark Christensen (MetroNational) who is our new Chair, Dr. Faiyaz Bhojani (Shell Oil), Becky Brosche (Pfizer), Sheri Gutzmer (The Friedkin Group), Valerie Hulse (KBR), Sheri Lytle (Silver Eagle Distributors), Jason Mahler (Aon), Bethany Spurrier (Stewart & Stevenson), Jerry Turner (Sysco) and Jocelyn Wright (City of Houston).

Our strategy in the beginning was to provide a variety of actionable general membership programs that allowed for networking and actionable education.  Our programs continue to address a variety of employer challenges.   It was and remains important that HBCH programs be presented from the employers’ perspective with actual case studies.   Employers want to learn from their peers and do not want to be sold to; they get enough of that through other means.   Our average program attendance is 100 with a majority of employer attendees.   We have had two general programs so far this year, January 18: Evidence-Based Navigation of Musculoskeletal Conditions (An Integrated Approach for Better Outcomes); and February 28- Local Non-Profit Resources for Employers to Achieve Improved Workforce Health.  Remaining programs are April 18-Legislative & Regulatory Update; June (TBD)-Alternative Delivery & Payment Models; October (TBD)- Improving Health through Integrated Data Platforms; and December (TBD)- Improving Health through Integrated Wellness Programming. 

Our strategy now includes providing employers and their associate partners with opportunities to collaborate to improve cost, quality and experience.  HBCH has four initiatives that are currently underway.    HBCH received a grant from the State to support the National Diabetes Prevention Program in our market.  HBCH has also initiated an Employer Specialty Pharmacy Data Collaborative.  More information is available on these initiatives in this newsletter.    HBCH is also exploring two other initiatives in 2017.  The first is a project focused on a maternity bundled care offering for employers.    The second is a musculoskeletal navigation system for the Houston market.    The evolution of all of these initiatives will be determined by our members that choose to participate.

Finally, I am pleased to announce that HBCH will host its inaugural conference in late February of 2018.  The HBCH Board of Directors is committed to making this best conference its local and national members can attend in 2018.  We will have the Best in the U.S. in HoUSton to share the best strategies, best tactics and best results related to improved cost, quality and experience outcomes in health benefits design and delivery.

I hope you remain or get involved in HBCH and best wishes for a great 2017.

Chris Skisak, PhD
Executive Director, HBCH


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Your Opportunity to Contribute to HBCH Connect

HBCH encourages its members to submit articles, case studies or other information they believe is newsworthy and worth sharing to other HBCH Connect readers.  Please submit or forward your items for consideration to info@houstonbch.org.  We will select several pieces each publication and recognize our contributors for assisting in our mission to improve the cost, quality and experience in health benefits design and delivery in the Houston.     HBCH is published on a quarterly basis. 

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HBCH Publishes first Houston Cost & Benefits Trends Survey

HBCH Survey Results 2016 - Houston Healthcare Cost & Benefit Trends

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HBCH Publishes 2017 Interest Survey Results

The survey was completed was between December 15, 2016 – February 15, 2017.  It was included along with 2017 member invoices and was used an incentive to reduce the annual fee by 15%.  It was also sent to HBCH member prospects.  The survey was sent to each organization’s primary contacts to HBCH.  The survey was administered via Survey Monkey.  

I. Organizational Demographics, Challenges & Opportunities

The survey was completed by 41 organizations of which 98% were HBCH members.  Employers represented 60% of responders, reflective of employer HBCH membership.  The energy & support services sector was the leading industry completing by survey.  Respondents represented 319,281 local employer-sponsored lives and 616,017 national lives.

Survey participants were asked to describe their top three 2017 health benefits challenges. Several themes were identified.   The list below is a summary of top issues listed in order of response prevalence with listed comments, recognizing there is overlap between categories. Read more...

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Texas Business Group on Health publishes Depression in the Workplace Survey

Depression in the Workplace - Executive Summary of TBGH's 2016 Survey of Texas Employers

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National Alliance to Host Employer Mental Health & Well-Being Summit, April 24-25

Click on this link to learn more, National Alliance April Summit

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2017 Employer Compliance Priority Issues

2017 Employer Compliance Priority Issues

(Source: Employee Benefits News, Contributor: Mercer staff, Aug. 2016)


  •          Wellness.  If your wellness program includes a health risk assessment or biometric screening or seeks spousal information, evaluate whether the program meets the new Equal Employment Opportunity Commission rules.  Work with vendors on wellness issues to ensure compliance with EEOC’s final Americans with Disabilities Act and Genetic Information Nondiscrimination Act rules. 


  •          Essential health benefits and ACA nondiscrimination rules.  Federal agencies, especially the Department of Health and Human Services, continue to issue regulations that will have direct and indirect effects on how large employers design benefits.  For 2017, employers should determine whether updated state benchmark plans for essential health benefits and final ACA nondiscrimination affect plan designs contemplated for the next year’s plan. 


  •          Mental Health Parity.  Confirm you plan meets recent parity guidance on coverage of mental health and substance us disorders (MH/SUDs) and prepare for possible Department of Labor audits of health plans’ compliance.  Also consider the Mental Health Parity and Addiction Equity Act when selecting vendors.  Assign responsibility for parity compliance in service agreements with vendors that handle both medical and MH/SUD benefits, and monitor vendor performance on parity issues. 


  •          Employer shared-responsibility strategy and reporting.  Assess 2017 health plan design and eligibility terms against employer shared-responsibility strategy, check whether medical options meet minimum value, minimum essential coverage, and affordability standards. 


  •          Preventive care.  Confirm non-grandfathered group health plans comply with final ACA rules on cost-free preventive coverage.  Modify benefit terms for 2017 plan year to reflect latest recommendations and guidance on preventive care, including FAQ’s on colonoscopy-preparation prescriptions and requests for contraceptives not on a plan’s approved list.


  •          SBC model documents.  Ensure delivery practices and procedures for your health plan’s summary of benefits and coverage align with final rule snow in effect.  Prepare to use updated SBC model materials on or after April 1, 2017.


  •          FLSA final overtime rules’ impact on employee benefit plans.  Account for any benefit impact stemming from the Final Labor Standards Act regulations redefining employees entitled to overtime compensation.  If desired, consider amending benefit plans to keep overall staffing costs as neutral as possible.


  •          Expatriate group health plans.  Position group health plans covering globally mobile employees to take advantage of ACA relief under Expatriate Health Coverage Clarification Act or other ACA and ERISA exemptions.


  •          HIPAA privacy, security, and electronic transactions.  Revisit health plan’ privacy and security obligations under the Health Insurance Portability and Accountability Act.  Consider whether evolving security threats merit strengthening risk-assessment or risk management activities.  Watch for revived federal requirements for self-insured group and other health plans to obtain national health plan identifiers and certify HIPAA compliance in specific electronic transactions.


  •          DOL fiduciary rule.  Assess the potential impact starting in April 2017 that DOL’s final conflict-of-interest rule for investment advice fiduciaries could have on health savings accounts and ERISA health and welfare plans with an investment component, such as a universal or whole life insurance policies.  

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HBCH Receives State Grant for National Diabetes Prevention Program

HBCH has received a grant from the Texas Department of State Health Services to promote of the NDPP in the Houston market.   HBCH’s primary role will be to promote adoption of this program by employers, inclusion as a funded option by health plans, and recommendation to employers by brokers and consultants.  Other coordinated activities by other stakeholders will include screening/testing/referral to NDPP providers by health care networks and building capacity in our market for providers of the NDPP program.

HBCH, Cities Changing Diabetes, and Texas AHEC East - Greater Houston Region, in collaboration with the Texas Department of State Health Services/Texas Diabetes Council and the National Association of Chronic Disease Directors hosted a 2-day kickoff forum February 7 and 8.  More than 100 stakeholders attended the first day overview.

On February 8, small action planning sessions with select participants were held.   These sessions helped outline strategies to increase coverage of the NDPP recognized lifestyle change program; increase clinical screening, testing and referral to the NDPP; and increase the availability of the NDPP in the Houston market.  Several HBCH member and broker/consultants and health plans participated in the Day 2 session devoted to employer adoption and coverage.  This will be one of HBCH’s major activities in 2017 and 2018.  Contact Chris Skisak at director@houstonbch.org  to learn more or get involved.

The Centers for Disease Control infographic on the next page describes the growing threat of prediabetes, its impact on employers, and value of the NDPP.  The infographic following that is provided by Curies Changing Diabetes.    Houston is one of only a handful of cities around the world selected as an incubator to develop best practices for the prevention, diagnosis and treatment of diabetes.  The infographic describes the face of diabetes in the Houston market.  Contact Chris Skisak at director@houstonbch.org  to learn more or get involved.

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HBCH Kicks Off Specialty Pharmacy Data & Action Collaborative

HBCH has launched a specialty pharmacy data and action collaborative.  This follows last year’s HBCH program, summer workshops and recent meeting of interested employers.  Specialty pharmacy remains one of the highest employer concerns and provides one of the best opportunities to impact cost, quality and experience.  It is not too late to join 13 other local employers committed this initiative.  The information below describes the need for the collaborative, process and expected outcomes.   Participating employers should expect to decrease their specialty pharmacy spend by 25%.    The cost to conduct this assessment is reduced the more employers participate.  Contact Chris Skisak at director@houstonbch.org for more information. 

The Issue

For most employers today, managing the specialty drug benefit has become a frustrating and often overwhelming challenge. Expenditures have grown at a rate of about 12%-20% annually in recent years and are projected to exceed $1,000 per member per year (PMPY) beginning in approximately 2019. Yet, these high costs have not always represented good value—clinical benefit for the money spent. Specifically, many specialty drug claims are more costly than necessary, meaning that the price paid was too high for the clinical circumstance, and/or clinically inappropriate, meaning that the drug was used in a patient for whom it is likely to be ineffective or even harmful.

To improve the value of specialty drug expense, any program must address the following key challenges, most of which are unique to specialty medications:

-Missing information. About 40% of specialty drug cost is paid through the medical benefit using a variety of methods, such as percentage of billed charges that often lead to payment inefficiencies.  Medical claims for specialty drugs commonly lack key information, even about what drug was dispensed, making it difficult for employers to “manage what they can’t measure.”  As a result, traditional drug benefit management tools, such as prior authorization and step therapy, are underutilized in the medical benefit.  A better way: Give employers comprehensive, holistic information about specialty drug use in both the medical and pharmacy benefits.

-Misaligned incentives. Pharmacy benefit managers (PBMs) and other vendors make decisions on behalf of employers, and those decisions may or may not promote high-value utilization. PBMs obtain revenue by processing prescription claims through their own fulfillment pharmacies and, in some cases, making formulary decisions based on “rebate chasing,” rather than on clinical value.  As such, PBMs have little incentive to promote cost-effective drug use, enforce prior authorization requirements, or report the outcomes of their management interventions to employers. A better way: Give employers specific, objective, quantitative information about areas of waste and inappropriate use, let them make the choices that are right for them and their employees, and provide them with specific, actionable data about the outcomes of those choices.

-Clinical complexity. Making value-based coverage decisions—right drug, patient, dose, and duration—is particularly challenging for specialty medications because appropriate use depends on a large and complicated list of clinical factors about which most employers have limited or no knowledge. As a result, inappropriate use of specialty drugs is common. For example, at least one-quarter of uses of Aloxi, an expensive antiemetic drug, are unnecessary according to labeled indications, based on the “emetogenicity” (likelihood of vomiting) potential for the specific chemotherapy regimen being used.  Unsupported and off-label use of chemotherapy is also common.  Excessive quantities of medication billed to the payer often go undetected because weight-based dosing requirements are complex and vary by diagnosis for some drugs (e.g., Remicade). Patients may also receive “pharmacogenomic” drugs (i.e., targeted to a particular gene) without first getting the necessary genetic test to show if the drug will be safe and effective for them. A better way: Give employers information about the extent and cost of clinically inappropriate use in their plan population, based on evidence that is continually monitored and updated by a team with expertise in specialty medication use.

-Excessive price. Specialty drug pricing is highly variable, especially in the medical benefit across various sites of care. The charge for a specialty drug administration performed by one provider may be double or triple that for exactly the same drug and clinical circumstance (e.g., patient diagnosis and condition) at another provider, even though the more expensive provider is no safer and is often less convenient for the patient. As a result, many employers are simply paying too much for specialty drugs. A better way: Measure the extent of wasteful pricing and, if necessary, redirect utilization to the most cost-effective, clinically appropriate site of care (same quality, lower price, therefore higher value).


The Answer

Summary of Project Goal: Improve specialty drug management through a comprehensive specialty drug program that spans the pharmacy and medical benefit, focuses on value-based drug coverage decisions, and removes the embedded conflicts of interests inherent with the PBM model. 

Action Steps:  The proposed project will provide the following services to employers to promote value-based use of specialty medications by measuring, reporting, and rewarding appropriate uses of specialty drugs, and discouraging inappropriate use and wasteful spending:

1. Performance assessment. Identify controllable measures of waste by assessing medical sites of care, pharmacy and medical payment rates, clinical uses, and benefit design. These assessments routinely find savings opportunities that exceed 20% of specialty spend across the pharmacy and medical benefits.

2. Targeted program implementation. Assist in the implementation of a comprehensive specialty drug management program to reduce low-value spending by taking advantage of these savings opportunities.

3. Performance measurement. Measure the performance of the program based on metrics of value and quality that are evidence-based, specific to specialty medications, and objective rather than targeted to the financial interests of a PBM or vendor.

4. Roadmap for the future. Develop a roadmap/checklist that can be used by other employers.

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Employer Perspective of the Future of the ACA

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