Importance of Plan Performance Reviews

What are your Medical and Pharmacy claims telling you?   

Most public sector employers cover partial, if not the full, premium rate of one or more of the medical and pharmacy plans offered to employees. While it is a significant cost for employers to cover premium rates, subsiding your medicals plans is a critical tool to attract and retain quality employees. More importantly, it allows employers to ensure employees and their families that they have access to quality, well-tailored insurance to manage their health and wellbeing.

Whether you are fully insured, or self-funded, it is vital that the health and pharmaceutical carrier(s) provide you with annual plan review metrics. These metrics should include:

  • Top disease states of your population
  • The utilization habits of your group
  • Inpatient and outpatient care
  • Top ten emergency room conditions
  • Wellness visits
  • High-cost drivers
  • Pharmaceutical utilization
  • The costs associated with each metric

If you have care management programs in place, outcomes reporting should also be reviewed and discussed.

You may discover that members are doing things that are costing more than they should. Examples of this are utilizing emergency rooms for common conditions that are better suited for urgent care, or that multiple members are using an out-of-network provider or facility. There is any number of possibilities that may be costing the plan, the member, and the employer money unnecessarily. Not managing critical health conditions to achieve the best outcome can also be very costly. For instance, people that are high-risk for diabetes who require outreach and preventative measures.

It is only through reviewing these detailed components can employers accurately analyze the plan’s performance. A revision of the plan can identify gaps in care, and discuss recommendations to improve the plan’s performance. It is also a great time to strategize on employee messaging and education. Knowing the habits and health of your employees drives decisions, along with providing a snapshot of costs to help with budgetary considerations.

Valley Schools understands that reviewing your healthcare plans can seem overwhelming, and we are here to support your organization’s healthcare needs. Contact us today if you have questions about your current plans performance and healthcare options.

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