AmeriHealth NJ to Offer Self-Funded Administrative Services to Employers with 51-99 Employees

CRANBURY, N.J.–()–AmeriHealth New Jersey today announced it will provide employers with 51-99 employees the option of obtaining self-funded administrative services. Continue reading

Blue Cross Blue Shield of Michigan to Provide Low-Cost Individual Health Plans

DETROIT – Blue Cross Blue Shield of Michigan, four southeast Michigan hospital systems, four independent community hospitals and more than 4,700 doctors will partner in 2015 to provide low-cost insurance coverage and health care services to local residents.

The localized network – called an Exclusive Provider Organization (EPO) – is coming together following responses to a comprehensive RFP issued by Blue Cross last year to hospitals asking for participation. Physicians – totaling 4,789 on Jan. 13 – are still coming aboard.

“In a region where hundreds of thousands of people are without health insurance coverage, the Affordable Care Act gives insurers and providers new opportunities to work together to provide people with affordable access to coverage and care,” said Susan Barkell, BCBSM senior vice president for Health Care Value. “Local hospitals and doctors are committed to providing quality care and keeping it affordable. Blue Cross is very pleased to join with local healthcare leaders to offer a quality, localized and low-cost insurance product to meet the needs of people not covered at work.”

For more news and information go to and

Narrow-Network Plans Spark Lawsuits and Renewed Debate

Carriers are increasingly turning to narrow-network plans help lower premiums to attract cost-conscious consumers to thier products offered through insurance exchanges .

This trend is getting pushback from some hospitals in the form of lawsuits and has renewed the debate over what is “reasonable access.”

AISHealth examines this issue in their featured Health Business Daily story found here.

Employers Are Dropping Spousal Coverage, Cite Affordable Care Act Costs for Decision

Pointing to costs of the Affordable Care Act (ACA), some employers are dropping spouses from their group health plans next year.

In Mercer’s 2012 National Survey of Employer Sponsored Health Plans, which represents data from nearly 2,810 employers of all sizes, 6% of employers reported excluding spouses from coverage, and another 6% reported charging a spousal surcharge. This represents a total of 12% of employers with some type of special provision for spousal coverage, says Tracy Watts, a senior partner in Mercer’s Washington, D.C., office.

See the full story at

More Employers To Offer Only CDH Plans in 2014

More than one in five, or 22%, large employers plan to offer their workers only consumer-driven health plans in 2014 as a cost-control strategy, according to a recent survey of 108 employers by the National Business Group on Health, Modern Healthcare reports. By comparison, 19% of employers offered only CDHPs this year, while about 7% did so in 2009.

According to Modern Healthcare, the appeal of CDHPs for employers is that high-deductible plans are less costly than more-traditional plans, like preferred provider organization plans. Data released last week from the Kaiser Family Foundation show that the average cost of family coverage through CDHPs is nearly $1,500 less per employee than PPOs.

Read the full story at


Express Scripts, Walgreens To Offer 90-Day Retail Solution

In an unexpected display of camaraderie, Express Scripts Holding Co. and Walgreen Co. have come up with a new offering presumably aimed at competing with CVS Caremark Corp.’s highly successful Maintenance Choice program. Industry observers say the launch of Smart90 Walgreens is a plus for both parties and reflects increased interest in custom retail networks.

In a joint press release issued on Aug. 1, the companies said Smart90 Walgreens is designed for Express Scripts clients that are “interested in 90-day prescription drug programs that drive lower costs and improve health outcomes for people with chronic diseases who require long-term treatment.” Not only will clients achieve savings from more aggressively discounted pricing on 90-day prescriptions, but the program has the potential to increase medication adherence by cutting down on the number of opportunities a member has to forget to fill a prescription, maintain the companies.

Read the full story at


Towers Watson: Health Care Reform Heightens Employers’ Strategic Plans for Health Care Benefits

Over the short term, employers plan to retain active medical plans amid projected cost increase and excise tax concerns; greater change expected to retiree medical plans.

The breadth of health care reform is prompting changes and ushering in emerging opportunities for employers, according to a survey of 420 midsize and large companies by global professional services company Towers Watson (NYSE, NASDAQ: TW). While employers remain concerned about a predicted 5.2% increase in 2014 health care costs and the risk of triggering the excise tax* in 2018, most (82%) continue to view subsidized health care benefits as an important part of their employee value proposition in 2014.

However, the 2013 Health Care Changes Ahead Survey found that a majority of employers do anticipate making moderate to significant changes in their health benefit programs for all employees and retirees by the beginning of 2016. It also revealed a clear disparity in how employers view public and private exchanges. Nearly 30% of employers have confidence in public health insurance exchanges as a viable alternative to employer-sponsored coverage in 2015. In contrast, private exchanges are more appealing, with 58% having confidence in them as a viable alternative. In short, employers are intrigued by the potential of private exchanges to control cost increases, reduce administrative burdens and provide greater value.

Read the full story here:



Highmark Blue Shield’s Tiered Benefit Design to Expand in Pennsylvania

Camp Hill, Pa. (Aug. 16, 2013) — After rolling out a tiered benefit in July in nine counties in north central Pennsylvania, Highmark Blue Shield is now expanding the benefit to 21 counties in central and eastern Pennsylvania beginning on January 1, 2014.

Called Community Blue Premier Flex, it will now be offered to group customers in the following 21 counties: Adams, Berks, Centre, Columbia, Cumberland, Dauphin, Franklin, Fulton, Juniata, Lancaster, Lebanon, Lehigh, Mifflin, Montour, Northampton, Northumberland, Perry, Schuylkill, Snyder, Union and York.

With Community Blue Premier Flex, all area providers that participate in Premier Blue Shield are in-network. Community Blue Premier Flex includes two levels of in-network benefits — Enhanced Value Benefits level and Standard Value Benefits level. At both benefits levels, members receive high quality care.

Community Blue Premier Flex members receive Enhanced Value Benefits, or pay less, if they choose an in-network hospital or doctor that provides care at a lower cost. When they receive care from other in-network providers, members are covered at the Standard Value Benefits level or have higher cost sharing. Hospitals in the region are listed on our member websites along with the level of benefit coverage.

“In the short time since we have introduced this benefit design in north central Pennsylvania, we are pleased with the customer response and are excited about the rollout for the entire region,” said Steven Nelson, Highmark Health Services senior vice president of product, marketing and strategy. “We estimate that employers can save up to 20 percent on their premium costs depending on the group’s current utilization.”

Highmark Blue Shield has a number of transparency tools on its member website where members can compare estimated costs among providers for many common procedures.


Consumer Driven Health Care Plans Can Help Reduce Health Care Spending and Make Positive Behavior Changes: HCSC

CHICAGO, June 13, 2012 /PRNewswire via COMTEX/ — Consumers enrolled in Consumer Driven Health Plans (CDHPs) are more likely to make sustainable, positive behavior change leading to significant health plan spend reductions year over year, according to data studied by Health Care Service Corporation (HCSC), operator of the Blue Cross and Blue Shield Plans in Illinois, Texas, Oklahoma and New Mexico. Members who migrated to CDHP plans – those that have a higher deductible, prompting consumers to be more directly involved with the selection and usage of health care services – reduced their health care spending significantly.

This study is unique because of its focus on tracking individual members who migrated from traditional health plan coverage to CDHP coverage in order to analyze their health care behavior and their health care spending habits both before and after the switch. The data also showed that changes in behavior, including increases in preventive care and use of generic prescriptions, helped contribute to a reduction in health care spending for both employers and members.

The CDHP program, BlueEdge(TM), is offered through the four Blue Cross and Blue Shield Plans, and includes Health Savings Account (HSA) and Health Reimbursement Account (HRA) options. BlueEdge enrollment surpassed 1.5 million members earlier this year, after experiencing double-digit percentage increases for six straight years.

Key results from the study indicate that, following migration from a traditional non-CDHP plan to a CDHP, on average, the CDHP members studied:

  • were four percent more likely to take advantage of preventive services.
  • reduced health care utilization by an aggregate of more than 12 percent.
  • were 10 percent more likely to fill their prescriptions with generics.
  • spent 24 percent less on inpatient hospital services and eight percent less on outpatient services.
  • had a 12 percent decrease in emergency room visits.
  • reduced combined medical and pharmacy spend by an aggregate of 11 percent

In addition, data showed that employers who offered only a CDHP saw even greater spend reductions – up to an aggregate of 14.4% over the three years following migration from a traditional plan to a CDHP.

“Our BlueEdge CDHP program gives consumers the flexibility and tools to help make positive decisions to reduce their healthcare spend, coupled with broad access to care, award-winning service, comprehensive incentives, wellness and care management programs, and a personalized, engaging health care experience,” said Thomas Meier, Vice President, product development, HCSC. “Our experience finds that CDHP members tend to be more engaged and informed in making better health care decisions.”

This is the second year that HCSC has done this analysis, this year studying more than five years of data for more than 265,000 members (with pharmacy data available on 121,000 of those members). HCSC continues to invest in more consumer focused approaches, adding more robust incentives and value-based insurance design products in 2013 to complement both traditional and CDHP plans.

“Our findings are significant because they indicate both real and potential health care spend reductions. Rather than comparing the utilization of different groups of consumers, we have focused on the utilization changes of members who migrated from traditional plans to CDHP. The fact that we are comparing the same members in both plans allows us to minimize inherent risk differentials,” said Guy McGinnis, Vice President, client analytics, HCSC.

About Health Care Service CorporationHealth Care Service Corporation, a Mutual Legal Reserve Company, is the country’s largest customer-owned health insurer and fourth largest health insurer overall, with more than 13 million members in its Blue Cross and Blue Shield plans in Illinois, New Mexico, Oklahoma and Texas. HCSC is an independent licensee of the Blue Cross and Blue Shield Association. For more information, please visit , visit our Facebook page or follow us at .

SOURCE Health Care Service Corporation


TriZetto Expert: Population Health Management, Informed by Clinical Analytics, Can Bend Cost Trend and Improve Outcomes

DENVER, Oct 13, 2011 (BUSINESS WIRE) — The TriZetto Group noted with interest a Health Affairs article in July reporting that national healthcare spending was expected to increase from 17.6 percent in 2010 to 19.8 percent in 2020, as economic recovery spurs higher utilization and an estimated 30 million additional people receive health insurance coverage under the Affordable Care Act. It is also expected that this group of consumers will have a higher incidence of chronic disease and untreated conditions. Further, chronic disease rates continue to rise throughout the population, notwithstanding disease and care management programs administered by the healthcare industry.

With the influx of these high-risk participants, healthcare payer organizations are thinking about how they can positively influence the health of the larger population by improving the health of their own membership. Care management can help health plans improve population health and control medical costs, and clinical-analytics capabilities are necessary and core to managing costs in a meaningful way.

“Old” vs “New “

The ‘old’ model of care management — the way it’s traditionally been thought about — is defined by a single patient view. A health plan knows the condition of a member based on claim activity and begins disease or care management activities to mitigate future complications and the possibility of major expenses. While such individual interventions can be effective for both member and payer, they cannot improve the health of members on a larger scale, across one or multiple group cases. Typically, traditional, reactive care-management programs have been ineffective in managing medical costs for lack of early intervention and appropriate, clinical plans for improvement.

What is needed is a new, broader, more anticipatory approach to population health management. Under this approach, healthcare payers would stratify group populations by risk, identify prevalent or high-cost conditions, and approach members for participation in disease-management and care-management programs prior to clinically or financially adverse health events.

Recent advances in technology and modeling have helped vastly improve payers’ capabilities in population health management. New, proven technology — clinical analytics — can give health plans the proactive, stratified views of populations that is requisite for clinically beneficial care management and highly effective new models of care delivery, such as patient-centered medical home (PCMH), accountable care organizations (ACOs), value-based benefits and value-based reimbursement.

Raw Data is no “Field of Dreams”

The challenge has never been about insufficient data. The necessary data, and lots of it, is there. But raw data alone is no ‘Field of Dreams’; meaningful information for impactful population health management does not automatically spring from data. That’s where analytics comes in.

Payers recognize this. A TriZetto research study conducted by Gantry Group in late 2010 shows that within two years every health plan will be investing in and using some form of clinical analytics to inform population health management programs. The number one reason? To reduce incurred medical costs. The second and third reasons, respectively? “To improve clinical and financial outcomes for co-morbid conditions” and “to improve member compliance with evidence-based care protocols.”

Healthcare payers clearly understand business intelligence is the foundation for reversing the trend of medical spend. Having robust analytics capabilities can help health plans:

— Maximize their ability to identify and stratify members for incentives

— Interpret data to derive meaningful information for use in automating decision making for improved administrative efficiency (e.g., automatic enrollment into programmatic interventions)

— Demonstrate and evaluate outcomes through deep, extensive reporting capabilities

There’s the story of Henry Ford’s comment when a finished car rolled off the factory line. Ford said, “There are exactly 4,719 parts in that model.” While most on hand were impressed that the company president had this fact at his fingertips, an engineer nearby remarked, “I can’t think of a more useless piece of information.”

Useful, accurate information — in the right place and at the right time in the healthcare system — is required for effective population health management. The good news is that technology-enabled solutions, informed by meaningful clinical analytics and available today, can meet this requirement for healthcare payer organizations large and small.

A point-of-view paper by Jerry Osband, M.D., vice president of product management for The TriZetto Group, Inc., served as the basis for this issue brief.

About TriZetto

TriZetto provides world-class healthcare IT software and service solutions that drive administrative efficiency, improve the cost and quality of care, and increase payer and provider collaboration and connectivity. TriZetto solutions, many of which are patented or patent-pending, touch half the U.S. insured population and reach more than 21,000 physician practices. TriZetto’s payer offerings include enterprise and component software, application hosting and management, business process outsourcing services and consulting. Provider offerings, delivered through TriZetto’s Gateway EDI wholly owned subsidiary, include tools and services that monitor, catch and fix claims issues before they can impact a practice. TriZetto’s integrated payer-provider platform will enable deployment of promising new models of post-reform healthcare. For information, visit .

SOURCE: TriZetto