2020 vision: Top health care issues for employers

With a presidential election looming on the horizon, few key policy issues are generating more debate on the campaign trail than health care. But beyond the candidate sound bites and headline-grabbing policy proposals, emerging industry trends continue to capture the attention of payers, consultants, brokers and employers–with many directly impacting the care experience for American workers and their families.

So, what are the key issues shaping health care in 2020? And how can employers continue to manage costs while providing access to quality care? Three UnitedHealthcare experts sat down recently to discuss what they have their eye on this year and what it means for employers and their employees:

• Dr. Joel Feigin, Senior Vice President, Chief Medical Officer, UnitedHealthcare National Markets
• Paul Kiser, Senior Vice President, Client Relationships, Optum Commercial Markets
• Craig Kurtzweil, Vice President, Healthcare Economics, UnitedHealthcare National Accounts

Q: Cost control, advocacy and member experience, and whole-person health are priorities for employers this year. Related to those topics or beyond, what should employers be thinking about in 2020?

Feigin: The first thing that comes to mind is how employers can focus on being proactive and getting ahead of their medical cost drivers and impact on cost trend. Some of the areas would be making sure that their employees are aware of how to access the highest quality, most cost-efficient resources. I think a strategic configuration of their network and how the benefits support that configuration is a good starting point. Some examples would be seeking a quality physician and thinking about where they access care–seeking care in a more cost-effective ambulatory setting versus the more expensive hospital outpatient setting.

Kurtzweil: First, the trend in specialty pharmacy costs is extreme; over a quarter of our cost trend is driven by specialty medication.¹ Second, one area that really gets impacted by specialty medications is cancer. For our book of business, cancer accounts for about half of our overall cost trend, with almost all of that being driven by specialty medication. The other area that doesn’t get as much press is behavioral health. We're going to see behavioral health become a major chronic condition because the next generation of employees are more willing to be treated and be seen for those types of issues.

Kiser: As a pharmacy benefit manager (PBM) focused on lowest net-cost strategy for medications, the first thing we look at for our clients is making sure that drugs overall–specialty and non-specialty–are affordable for employees and their families. The second area focuses on specialty medications specifically. While 1% to 2% of the population take specialty medications,² this category of drugs soon will be driving 50% of the total pharmacy spend.³ Last, the third item for employers to pay close attention to is whole-person health as more of the population experiences multiple chronic conditions that need to be effectively managed.

Q: With costs under the microscope, what are your biggest cost-related themes ahead of 2020?

Feigin: If employers and employees focus on seeing a quality provider first, then they're likely going to get the best outcome, and they’re likely going to get the most cost efficiencies out of the system. They’re also likely going to avoid unnecessary care, which is a huge waste of cost in the system. Focusing on quality first should lower the total cost of care because you’ll likely get to the right diagnosis earlier and have fewer complications–a better short- and long-term outcome.

We’re working with employers to focus on long-term goals, not exclusively focusing on short-term goals, such as next year’s budget and cost drivers for the next 6 months. We’re asking questions about making sure they have the right long-term insurer and the right resources to help employees and their families with complex health care needs.

Kurtzweil: We do have compelling analytics packages that tell the total cost of care story–looking beyond network discounts and cost only, thinking about member experience and outcomes, as well. We're talking more about the impact of quality, the impact of using UnitedHealth Premium® physicians, the impact of Centers of Excellence and Accountable Care Organizations more than we ever have before. We’re sharing the idea that “quality is a stronger story than network discounts” at a rapid pace.

Kiser: We are actively engaging with drug manufacturers to lower costs for employers, their employees and their families. There are multiple ways that we approach that, which can include outcomes-based contracting arrangements, as well as strategies focused on genetic testing–using a proven test to determine if a person will respond to a particular drug or to avoid a potential adverse event or reaction from a specific drug. We are also focused on lower-cost site of care for patients that need their drug administered by a health care professional. This could be in a physician’s office or home infusion setting versus a hospital outpatient setting. This can result in material savings for employers and high satisfaction from patients.

Q: What areas of advocacy and member experience do you have your eye on?

Kurtzweil: We’re really thinking about how to help members in a concierge sort of way to navigate the health system and make better choices, versus just expecting them to do that on their own. A big part of delivering strong advocacy and support is data and using it proactively. Rather than waiting for the claims to come in to suggest ways that employers can save money and improve their employees’ experience, we're mining the data and finding the issues proactively, engaging employers in the solutions earlier than ever. We’re operating more in a real-time way.

Feigin: With advocacy, we look at it much more broadly than how the industry looks at it, which primarily is focused on customer service. For us, everything that we do as an enterprise is built around advocating on behalf of employers and their employees. The foundation of that advocacy is helping members make better health care decisions and supporting the doctor-patient relationship.

Kiser: There are several key areas to highlight related to how we’re supporting members taking specialty medications. In an effort to increase adherence and help members become more knowledgeable about their condition from the start, we provide live video consultations with specialty pharmacists to demonstrate what’s required to take their medications as prescribed, as many of these specialty drugs require the member to self-inject the medication. Members also can access on-demand videos of real patients with the same condition to hear from others on how they are managing their condition, offering encouragement. And, as one approach to support adherence, we have introduced a Smart Pill Bottle for certain medications. The bottle reminds an individual when it’s time to take their medication, and it monitors if a member is taking their medication as required. If members miss their prescribed dose, our pharmacist team will know and will reach out to determine if there is an issue, offering help based on what they learn from the member. While these are examples focusing on specialty medications, our approach is to look at the person holistically and assess all medications and treatments for that individual.

Q: How do you see the conversation on whole-person health evolving, where there’s an increased focus on the integration of medical, Rx and behavioral care?

Feigin: We know that 40% of the population with chronic illnesses has underlying depression, but it's often unrecognized in clinical practice. That could be because the patient doesn't want to talk about the symptoms, or it could be that the primary care physician doesn't have the time, isn’t trained or just doesn't have the resources to deal with members’ psychosocial needs. When there’s untreated depression, staying on chronic medications is a big challenge. The literature also demonstrates that people with chronic illnesses see their diseases progress at a faster rate when they have an untreated, underlying depression. When we provide medical, behavioral and pharmacy resources holistically, this becomes a great example of the value of integration.

Kurtzweil: When employers traditionally think about whole-person health, they think about opioids, substance abuse, alcoholism, etc.–and those things are important. But discussions of whole-person health go beyond that. The discussion will shift to conditions employers are less familiar dealing with, such as anxiety and depression. These issues impact diabetes and back pain too–chronic conditions that employers manage closely as they address how to best build a framework of care around their employees.

Kiser: The integration discussion is as important as ever in the context of specialty drugs. From a cost perspective, about 45% of the spend for specialty medications is under the medical benefit since they must be administered by a health care professional. That leaves 55% of the spend under the pharmacy benefit, and we see that ratio continuing into the future as we look at the pharmaceutical pipeline.⁴ So in order to manage the overall specialty drug category, you have to have a full view across the benefit spectrum. Then it’s important to have both clinical and cost strategies that are consistent across the medical and pharmacy benefit. There are many conditions in which there are specialty therapy options under both the medical and pharmacy benefit.

Q: Will social factors impacting employee health continue to rise as an employer priority?

Kurtzweil: I would break the social factors into two components: one being a community’s social determinants of health, and the second being what I’ll call social disparities. We’re going to put a spotlight on social disparities in 2020. We know there are dramatic differences in the way different ethnic and cultural groups access care, how they receive care, the quality of care they receive, and their compliance of care. There are remarkable variances that we see across the country and within individual markets. There are ways that we can help educate and train providers across the country around those differences, what they need to do to be culturally sensitive and how to best deliver care. Employers also can be more culturally sensitive in how they’re communicating messages to their employees and dependents. We can help employers tailor a more generic message and customize it for a more specific population within open enrollment and engagement collateral.

Regarding social determinants of health, the adage that if I know your ZIP code, I can tell you a lot about your health holds remarkably true from a data perspective. The structure of the communities and how they’re set up–education system, poverty levels, and household income–do matter a lot in what we see in actual employer cost and claims data.

Feigin: One of the things we like to make sure employers understand is the headwinds around social determinants in the community in which their populations live. When Craig (Kurtzweil) shows customers their community health measures, they all are fascinated by that, and they start asking questions about their employees’ communities. Employers become focused on getting involved in their local communities and overall community health. Working together with the health system partners in the community and people like us cooperatively to address some of those social determinants is probably going to be the thing that is going to have the biggest change in the local health care system.