Agentes de seguros médicos

Most employee health benefit plans start with medical benefits, which, at their most basic, cover the health care and services that are critical to maintaining one’s physical health and treating illnesses and injuries when they arise.

Medical benefits generally include coverage for certain services and procedures from primary care providers, specialty providers (like an endocrinologist for diabetes) and other medical professionals, as well as virtual visits and trips to urgent care facilities and emergency rooms. These benefits subsidize employee cost-share based on several factors including plan design, premiums, copays and deductibles.

Most medical plans allow employees to choose where they get their care and from whom — based on their plan’s provider network and other factors. And employers often have a choice of several health plan designs, such as a high or low deductible plan or a newer plan design with a copay-only structure — like the Surest® health plan from UnitedHealthcare.

Medical plans like Surest are designed to help make care more accessible and affordable by offering preventive care at no additional cost, low- or no-cost virtual visits and other programs that can help with cost-sharing before employees meet their deductible.

Since chronic diseases are the leading cause of illness, disability and death in America, accounting for $4.5T of the nation’s annual health care spend,⁵ it’s also becoming increasingly important that medical plans have a clinical care management component to help employees impacted by a chronic or complex condition.

Addressing costly conditions, like heart disease, cancer and diabetes requires looking at the whole person — from one’s lifestyle and behaviors to the financial or behavioral health concerns an employee may be experiencing. Health plans that incorporate clinical and care management programs can provide a data-driven, collaborative approach to helping employees manage their conditions and get healthier.

These care management and clinical programs often use advanced analytics to proactively identify and reach out to employees who may be at risk for chronic conditions, and who are eligible for programs that can help. These programs may also include access to 1-to-1 advocacy support for employees who need help managing their condition and adhering to prescribed medications. Advocates also offer support on everything from site-of-care decisions to case management for closing gaps in care.

As Dr. Rhonda Randall, chief medical officer for UnitedHealthcare Employer & Individual, explains: “Clinical and care management programs are all about providing employees with end-to-end support across the entire health care continuum, which can result in better health outcomes and reduced costs.”

Pharmacy benefits often play a key role in just about any care plan, whether employees are facing a medical, behavioral, chronic or complex condition.

Since pharmacy costs continue to rise, these benefits are becoming even more critical to both employers and employees.

When these benefits are integrated and managed by one carrier, the path to reducing costs and improving health outcomes often becomes clearer through advantages such as more immediate access to patient data and clinical program information, which can enable more informed decision-making.

Consider specialty drugs: 60% of specialty drug spending tends to be covered under the pharmacy benefit, while the remaining 40% tends to be covered under the medical benefit.⁶ Cross-benefit drug management works to help determine whether it’s most appropriate and cost-effective to cover a medication or treatment under a member’s medical or pharmacy benefit.

But if benefits aren’t integrated, employers and members may miss out on the potential savings opportunities that cross-benefit drug management can provide, in addition to the other advantages that come with taking a whole-person approach.

Having a view into data and insights across a member’s benefits can help provide a simplified experience and help enable more informed decisions regarding a member’s care. For instance, 99% of employees started on the right specialty medication at the start of treatment, and up to 60% of care was redirected from higher- to lower-cost settings.⁷

Streamlined sharing of pharmacy data can also lead to earlier identification of chronic or complex disease, potentially enabling employees to enroll in relevant clinical programs sooner. In fact, referrals to clinical programs occurred up to 44 days sooner with integrated benefits.⁸

Increased efficiencies are also apparent during prior authorization. Although intended to ensure a medication is safe, medically necessary and effective from a quality and cost perspective, prior authorizations can sometimes cause frustration by adding another administrative step to the prescription process. When benefits are integrated, this process can be shortened, allowing employees to access necessary medications quicker.

“The power of UnitedHealthcare is the data-driven, embedded decision-making that can occur when pharmacy and medical benefits are integrated,” explains Vesledahl.

Many employer-sponsored benefits also include dental, vision and hearing plans. Together, they’re known as specialty benefits and are another way of encouraging employees to attend to all aspects of their physical health.

It’s important for employees to have access to these types of benefits since oral, eye and ear health can be an indicator of overall health and well-being.

For instance, good oral health practices are linked to reduced cost and complications of diabetes, heart disease and pregnancy.⁹ And at least 20 diseases can be detected from a regular eye exam alone.¹⁰ Vision impairment can also affect mental health, with vision loss linked to loneliness, social isolation and anxiety.¹¹

When employers bundle these and other supplemental and financial protection benefits—like short-term disability and absence management solutions—with their medical and other core benefits, they can enable more holistic management of their employees’ health and well-being, leading to better outcomes and lower costs.

UnitedHealthcare has seen integrated clients realize better identification of chronic conditions, higher rates of member activation and up to $4–$7 in per member per month (PMPM) medical cost savings when specialty benefits were paired with medical plans.¹²

When an employee’s mental health is ignored or unaddressed, the initial issue may escalate into a more serious mental health condition, which could lead to physical problems requiring medical intervention. Depression, in particular, increases the risk for chronic conditions like diabetes and heart disease.¹³

All of this can have an impact on employers as well. In fact, it’s estimated that globally 12B working days are lost annually due to depression and anxiety, costing employers up to $1T in lost productivity.¹⁴

Unfortunately, many employees face barriers unique to behavioral health that make it difficult for them to seek treatment. For instance, although 74% of U.S. employees think it’s appropriate to discuss mental health concerns in the workplace, only 58% say they are comfortable doing so.¹⁵

And there are real repercussions to this. Employees who aren’t comfortable talking about mental health at work are more likely to experience burnout than those who are.¹⁵

Building behavioral health benefits into a health plan can help. It can start by selecting a behavioral health network that includes a mix of providers across a variety of specialties, in-person and virtual visit options and digital self-help tools for less severe, low-acuity behavioral health conditions. This can help ensure employees are receiving the right care for their situation and that employees living in more remote areas have access to care.

“Adding virtual health options into our network designs ignited the demand for members to access care when and where they wanted, which prompted us to start on a path towards revolutionizing our entire digital ecosystem of offerings,” says Trevor Porath, vice president of behavioral health solutions for UnitedHealthcare Employer & Individual.

And when behavioral health benefits are integrated with medical and pharmacy benefits, those systems and processes are even more interconnected and can help ensure mental health needs are addressed more thoroughly, from all angles.

As Stacie Grassmuck, director of behavioral health product and innovation for UnitedHealthcare Employer & Individual, explains, “It’s typically the medical spend that increases when behavioral health is not addressed. When we work directly with members to get them into appropriate behavioral health treatment, employees are likely to see better health outcomes and lower overall medical costs.”

Employers who provide financial support resources and benefits can help reduce stress and create better health outcomes for their employees, leading to greater productivity and a healthier workforce. Those benefits can span a wide range of resources, from tools that improve financial literacy to benefits that help cover unexpected medical bills.

For instance, employee hotlines or assistance programs can go beyond traditional offerings to connect employees to financial planning assistance like 1-on-1 financial wellness coaching, online educational programs and help with budgeting and tax return preparation.

Employers can also look for:

• Plans designed to reduce out-of-pocket expenses upfront and empower employees to make more informed decisions
• Digital tools designed to help members estimate costs for services and providers
• $0 copays for certain services like primary care, urgent care or virtual care visits
   

To help employees plan and save for health care costs, employers may also consider including financial savings account options as well, whether that’s a health savings account (HSA) that allows employees to put aside pre-tax contributions to pay for covered health care services and qualified medical expenses or a flexible spending account (FSA) that works similarly except the funds don’t earn interest and must be used by the end of the year.

Employers can go a step further with both types of accounts by contributing to or matching employee’s contributions or offering a health reimbursement account (HRA), which an employer opens and makes contributions that employees can use towards premiums and qualified medical expenses.

And when employees experience added costs that accompany a major illness or accidental injury, financial protection benefits such as accident protection, critical illness, hospital indemnity, disability plans and absence management solutions, as well as life insurance plans, can help provide additional financial security and relief.

To help ensure employees do not miss a potential benefit, UnitedHealthcare uses integrated data to proactively look for medical claims that may qualify for a supplemental health plan payment. The result is a personalized experience that lets employees focus on their health while UnitedHealthcare handles the rest.

Many chronic diseases have underlying causes linked to certain behaviors and habits. For instance, in the U.S., nearly 42% of adults over 20 years old are overweight.²⁰ By making healthier lifestyle choices, one can reduce the likelihood of developing a chronic illness while improving their overall quality of life. Establishing healthy eating habits, getting regular physical activity, quitting smoking, reducing alcohol intake and getting regular wellness check-ups and preventive screenings can all help reduce risk.²¹

Additionally, wellness coaching and self-help apps can help employees feel supported and accountable as they make healthier lifestyle changes, with personalized action plans and tools.

Rewards and incentives programs can also help employees build behaviors that benefit their health and well-being. Programs that reward members and their spouses for reaching goals through activities like tracking daily steps and completing one-time activities, such as a health survey or an annual appointment with a primary care provider, can encourage employees to establish healthier behaviors while generating cash awards or points.

Some of these programs also connect multiple aspects of an employee’s health plan and benefits together, which may lead employees to be more engaged in the overall health and well-being. For instance, a weight-management program may include behavioral, medical and pharmacy components to support employees on a coordinated journey to help them navigate the system and ultimately drive better results.

Employers who want to support employee wellness even further can look to invest in on-site health centers, which may include a clinic, a pharmacy or even a fitness center. For example, the Unified Government of Wyandotte County/ Kansas City, Kansas, built an employee health center to help make health and well-being more accessible to their staff. Employees who used the health center experienced a 5.5% drop in emergency room visits compared to those who didn’t.²³