The Artemis Platform is ever evolving to meet the needs of our clients. We’ve learned over the years which features make benefits teams and advisers jump for joy. The Actionable Overspending App is always a favorite for seasoned analysts and data newbies alike.
Let’s walk through how this app works and how self-insured employers and consultants are using it to make an impact on their benefits.
First, some background. Benefits teams struggle with two opposing missions:
These missions are tough to balance, and they’re what inspired us to build the Actionable Overspending App. Built on a series of proprietary data models, this app can help Artemis customers understand where their spending is inefficient. Instead of cutting programs or pushing costs to members, we allow benefits teams to make their spending count without sacrificing great benefits.
Benefit advisers are key in helping employers balance these missions, too. They’re all about finding ways to make benefits more efficient, more attractive to potential employees, and more focused on overall population wellness.
Now, let’s look at the Actionable Overspending App.
Actionable Overspending calculates the benefits dollars that are wasted, and it focuses on problems that benefit managers can do something about. It highlights five common areas of overspending.
This helps you understand what various providers for your network are charging for various procedures and treatments, and how those costs are inefficient. For example, if one of your members sees an in-network orthopedist for a shoulder surgery and pays $23,000 of the episode, but another member pays $16,000 for the same procedure with another in-network doctor, your in-network variance is $7,000.
Benefits teams and advisers can take this information to the negotiating table. They can work with their carrier to adjust their network, and also work alongside health systems and doctors to set fair prices for common procedures. Another trend among innovative self-insured employers? Transparency tools. They can let members look up prices for doctors and procedures ahead of time to save money for both the employer and the employee.
Artemis’ Avoidable ER model calculates the spending wasted when members visit the ER for injuries and illnesses that could have been treated elsewhere. For example, a first-time parent might bring an infant with a fever to the ER instead of seeking treatment at an urgent care center, onsite clinic or primary care office.
This is where member education can have a big impact. Employers can help members understand the best avenue for care and redirect them to less expensive, more convenient options. To learn more, check out our recent blog post on Avoidable ER spending.
We count prescription claims as “inefficient” based on models created by Artemis’ Chief Clinical Officer Rance Hutchings, Pharm.D. His work identifies prescriptions that could have been less expensive for the employer due to generic substitutions, prior authorizations, step therapy, and other formulary management techniques.
Benefits managers can incentivize lower-cost drugs for patients by working with their Pharmacy Benefit Managers (PBMs). They can choose to cover equally effective, cheaper drugs at a lower copay, but require a higher copay for name-brand, higher-cost drugs. They can require a prior authorization for certain medications, or require members to try identical generics before covering an expensive drug.
When members go out of network for care, the employer’s costs skyrocket. Large employers and health plans broker deals with hospital groups to drive patients to effective, efficient care. Some members are willing to pay out of pocket for a certain doctor, and most out of network costs are driven by mental health visits.
Member education is the key to controlling out of network spending. Make sure members know where to seek care, how to find out if a doctor is in network, and help them plan ahead for where to go in an emergency. Employers can also mine de-identified data to find out which services are most likely to be out of network. In the data above, it’s largely behavioral health services. This employer may need to expand their network, contract with an EAP, and help members find the care they need.
Like most of us, you probably have a half-empty prescription bottle in your medicine cabinet. Maybe it was a drug that didn’t work for you, or a short-term pain medication following a surgery that you stopped taking when you switched to OTC pain relief. This is a great example of Inappropriate Rx Quantity. It’s wasted spending.
Benefits teams often work with their PBMs to solve this problem, too. You can put limits in place on pricey drugs that drive these costs. It might require more frequent refills, but it also results in less benefits spending (and capsules) down the drain. One Artemis customer used the Inappropriate Rx Quantity model to find and eliminate wasted spending on diabetes test strips.