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Data Analytics in Wellness & Controlling Prescription Costs

The use of data analytics in for managing wellness programs and the importance of controlling prescription costs were key discussion points at a recent wellness advisor practice group conference call.

Members have considered or have used Springbot, Benefitfocus and Zywave’s Decision Master Warehouse, although none received top recommendations. One challenge is that few clients have the ability to use such systems.

Data analytics are most critical for clients that self-insure some or all of their exposure. Analytic programs, for example, allow an employer to enter data on people who belong to a Weight Watchers group or a diabetes management program. It could violate HIPPA regulations to track them as individuals, but analytics can be used to see whether the group had fewer claims for medical expenses or took fewer sick days than others with similar health risks.

Quarterly reviews with clients are useful but are difficult to schedule. One agency sets a date for the next quarterly review at the end of each meeting, and this has been successful.

Controlling prescription drug prices

Services can help employees find out if there are possible alternatives for expensive medications, or whether there are significant price differences among local pharmacies.

GoodRX got positive remarks. The employer pays a month fee, and Good RX will help look for the least expensive place to fill the prescription. In the case of some very expensive drugs, GoodRX has found financial help.

RX Help Centers charge an administrative fee of $50 a month but the fee is waived if they are unable to save money for the member. Most participants save $500 to $600 a month. Not only does this help the employee, but it also creates a better claims experience for the employers.

Sometimes local pharmacies are willing to work with a large employer and can offer lower costs than chain pharmacies.

Higher Premiums for Tobacco Users

One client of a member agency is considering charging higher premiums for tobacco users. In order to do this legally, it is important to make resources available to help employees cease tobacco use. There is no requirement for a full-fledged program as long as employees receive information about the available programs. Although some companies will reimburse employees for the cost of tobacco-cessation programs, many programs also are free. The employer does not have to pay for a program.

Reference-based pricing is helping employers control costs, several members found. Comments included the following:

  • “We have been telling employees that they have to pay attention to prices.”
  • “Some TPAs negotiate up front before a procedure, while others wait to negotiate until afterward. People have more comfort in negotiating costs in advance.”
  • “We encourage members to be active in seeking preauthorization when something is planned.”
  • “We use a local third-party administrator that helps with pricing. “
  • “In some cases, doctors and hospitals outside the city are happy with reference-based pricing because the payment is higher than Medicare.”
  • “We had two clients where costs were running more than 200 percent over projections. With reference-based pricing, one is at 82 percent and the other, at 96 percent.”
  • “Working with providers is a challenge because some will look at an insurance card and say they don’t take it without looking any further. We have to tell them to type in the payer ID number.”
  • “It’s important to tell employees that they MUST open their mail. When bills pile up and no one says anything, it gets messy. Stress that employees must open their mail and send their bills in immediately.”

Advanced Medical Pricing Solutions (AMPS) in Peachtree Corners, Georgia, got good marks for helping control costs.


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