Thursday, September 27, 2012

Healthcare Consumerism

By:  Tonya Williams, Employee Relations Specialist
School District of Janesville

Every decade seems to have produced a transformation in how healthcare is administered in the United States.  In the late 1940s and ‘50s it was the expansion of employer-sponsored healthcare.  In the ‘60s it was the creation of Medicare and Medicaid and their impact of employer-based fee-for-service plans.  In the ‘70s it was the passage of ERISA and the movement of large employers toward self-insured arrangements.  In the ‘80s it was the expansion of managed care and the birth of the HMO.  And in the 1990s it was the shift of risk to providers.  The new millennium has seen another new transformation-healthcare consumerism.

Healthcare consumerism can be defined as transforming employer-based health benefits into a model that puts economic purchasing power and decision making in the hands of participants.  Employers supply the information and decision support tools employees need to make informed choices, along with financial incentives, rewards, and other benefits that encourage participants to positively alter their health and healthcare purchasing behaviors.

Why is this important?  According to the centers for Disease Control and Prevention 50 percent of Americans’ health status can be attributed directly to their behavior or lifestyle.  Only ten percent of overall health status is influenced by the healthcare system, yet that’s where most of the efforts are focused.

Today’s consumerism model is not limited to plan design changes.  Instead, it encompasses the broad spectrum of tools, incentives and plan design that have the potential to positively impact health, healthcare purchasing and treatment decisions.  In fact, the School District of Janesville’s healthcare plan has moved toward healthcare consumerism in a number of ways.

In September 2008, the District introduced a Wellness Plan that rewards employees a decreased insurance premium share by participating. The Wellness Plan promotes healthy lifestyles by encouraging staff to participate in wellness activities throughout the year.  Employees also have the ability to compare their own health profile from year to year with the online tools offered by the provider that administers the District’s Health Risk Assessments.  Currently the District’s participation rate is 98 percent.

In January 2008, the District implemented Navitus, our prescription benefit manager.  Navitus has some drug programs that save you and the District money in drug costs.  For example, tablet splitting is a program that allows a member to extend drug supplies by splitting certain tablets.  Another program in place is the generic prescription program.  If a member is on a more expensive drug, and he/she tries a generic drug versus the more expensive drug under this program, the first co-pay for the generic drug will be waived.  Mail order through Welldyne is the most cost-effective and proactive consumer choice you can make regarding your prescriptions.  If you currently take a maintenance drug, mail order will provide you a 90-day (3 months) supply for the amount of two co-pays versus paying three co-pays at the pharmacy.

In November 2011, the District implemented Coordinated Health Care to help employees navigate through a complex medical system.  Coordinated Health Care is also used to have specific tests and services pre-certified such as outpatient surgeries, MRIs, MRAs, PET scans, oncology care, home health care, Hospice care, organ and bone marrow transplants, speech therapy, physical and occupational therapies, and dialysis.  This eliminates redundant testing and services that cost you, the consumer, and the District more money in claims.

The idea of making informed and cost-effective healthcare decisions is a new concept for most consumers.  District employees, however, have some tools in place to save out-of-pocket costs.  Co-pays for office visits can be lower by using the referral service from Coordinated Health Care and drug costs can be decreased by using mail order or some drug programs mentioned earlier by Navitus.  Participation in the District’s wellness plan helps employees maintain good health, reduces health risks, and enhances productivity.  In order to contain healthcare costs, the District will continue to educate employees on healthcare and how their decisions can promote positive healthcare consumerism.

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