Redesigning Your Wellness Benefits

Redesigning your wellness benefits: 5 questions you must ask your broker, TPA or PBM

By Daniel G. Garrett, RPh, MS
Vice President, Health Care Programs, American Health Care

It seems that everyone says they have a wellness program. If you Google "employee wellness program benefits," you get 1,690,000 hits. The challenge is to sort through all of the choices and rhetoric to find a program that actually works...one that results in documented improvement in health outcomes and real dollar savings.

Our current health care system focuses on "sick" care. Current medical and pharmacy benefit programs only pay when someone is diagnosed with an acute illness or chronic disease. Fifteen percent of the population accounts for 85% of the "sick" care costs. A significant amount of sick care costs are for people with chronic conditions like diabetes, high blood pressure, high cholesterol and asthma.

In order to make the transition from sick care to health care (wellness), there needs to be a focus on individual behaviors that help people with chronic conditions better manage their health and prevent those at risk from developing chronic conditions. There are only a few programs in the country that have peer-reviewed, published outcomes data looking at this approach. Fortunately, two of the best known programs are from Western North Carolina: The Asheville Project® and the Hickory Project.

Here are the principles of these models and the questions to ask your broker/TPA/PBM about any program they may suggest:

1. You need detailed data on the conditions that are driving your "sick" care costs. Two years of combined medical and pharmacy claims data gives a clear picture of areas that could be impacted by a disease management program.
   
Does the program integrate all claims data and provide a detailed analysis of what conditions are driving "sick" care costs?



2. Once the data has been analyzed and cost drivers are identified, a care model should be implemented that provides ongoing patient-specific strategies that help patients better manage their care. This is best done face-to-face with incentives for participation and improvement.
   
What is the care model that is used and what is the program's track record of getting patients to participate? How has the program demonstrated improvements in patient behavior?

 
3. Use of evidence-based guidelines and medication therapy is the cornerstone for management of chronic conditions. Fewer than 50% of people are prescribed medications based on national guidelines.
   
How does the program promote the use of cost-effective, evidence-based medicine and how is this documented?



4. Feedback is the "breakfast of champions." Data is needed at the patient level, the care manager level, the physician level, the employer level and the program level.
   
What are the data collection and monitoring systems used in the program and how are the outcomes reported? Is your TPA going to charge you more to get YOUR data?



5. Your CFO wants to know program savings in real dollars for the institution or company, not numbers based on trends and national averages.
   
How are the program savings calculated? Are they based on comparison to the plan's historic costs? Are comparisons made between employees enrolled in programs and those who are eligible and do not participate? Did total "sick" care costs decline?

These simple questions can really help you get the most for your healthcare dollars. Programs such as the Asheville Project and the Hickory Project work because they remove barriers to getting care (copay expense) and because the participants have a "coaching" relationship with their care manager. Designing better benefits is not about bigger discounts, higher deductibles/copays, rebates, postcards, telephone calls or glossy flyers. It's about making changes that are meaningful to your employees and generate proven savings to your plan.