In-network vs. out-of-network medical claims are like night and day. Thanks to horror stories of unexplained bills, sky-high costs, and bankruptcies, many healthcare consumers know to check their network before they see a doctor or schedule a procedure. The same procedure with the same doctor (at a different, out-of-network facility) might be $2,000 or $20,000, and it is sometimes difficult for patients to ensure they’re making the best choice.
That’s where self-insured employers and other healthcare payers come in. We’ve written about network steerage as a strategy for reducing benefits costs, and it’s a popular tactic for employee benefits teams when they’re trying to control healthcare spending. They employ several strategies for helping employees and their families choose in-network providers:
These strategies are all helpful in directing members to the right care in the right places. Steering patients to the right points of care is just the beginning, though. Employee benefits teams, benefits consultants, and brokers also need to keep track of member behaviors, key benefits data metrics, and how their network steerage strategies are working.
This is where healthcare analytics comes in. Benefits data can give self-insured employers, consultants, and brokers the insights they need to find out if their network steerage efforts are resulting in benefits cost savings. Let’s take a look at an example from Artemis Health’s Platform, which is available to all clients as part of our pre-built Standard Stories.
First, we get a sense for the financial impact of out-of-network care on this sample benefits plan. You can see that 3% of the self-insured employers paid medical was for out-of-network care, and 11% of members visited an out-of-network provider. Both of these numbers are going down, which is great news for the employer. We also see a breakdown of which plans have the highest out-of-network utilization for both the previous year and current year. For both analysis periods, our HRA 1 Plan sees the highest spending on out-of-network benefits claims.
Next, let’s look at the geographic trends for out-of-network healthcare and benefits spending.
This map is populated with sample data for a sample employer, and shows where members are using out-of-network hospitals and physicians. It’s clear that our Maryland employees and their families are the most likely to go out of network for medical care.
Finally, let’s look at what types of visits are most commonly occurring outside the employer’s medical network.
Our sample data shows a clear trend here: the top 5 procedures that are out-of-network include emergency department visits, related services like an ambulance ride, and dialysis. Additionally, our top 5 out-of-network service categories also include emergency services.
The next, obvious question for self-insured employers is, “What can I do about emergency room visits and ambulance rides? They’re for emergencies!” While many ER visits are, in fact, unavoidable, Artemis Health has used data from an NYU Wagner study to build a custom analysis around avoidable emergency room spending. Employers and benefits advisors can see significant benefits cost savings with these tips:
Dialysis also popped up in our analysis as a potential problem for our network. In fact, billing and network confusion over dialysis centers is so widespread of a problem that comedian John Oliver did a segment on it for his HBO show, Last Week Tonight. Artemis Health helped one client conduct a thorough analysis of their out-of-network dialysis spending. Read about how they addressed dialysis overspending and made this treatment less expensive for members and for their plan.
Getting insights into network utilization is just one key way employee benefits teams and their advisors can identify benefits cost savings.