Managing Benefits in the Medical Fastlane

Clinical protocol updates are issued daily. What should we be asking third-party administrators about contracting and ‘editing’ best practices to ensure our employees get the most relevant, quality care?

Medicine has entered a fast-lane era of change with rapidly evolving protocols that are introducing opportunity with unprecedented guideline modifications. The science of medicine is moving faster than benefits, and further complicating the environment is a new cast of tech players in the medical arena that are resourced by venture capital.

Wrap your head around this: In just one clinical specialty, more than 200 medical protocol changes were announced in one year. Out of 365 days, 200 of those came with “system updates.” But much like the pings we get from our devices alerting us of a new version or improved tool, how quickly are providers, medical institutions, insurers, and third-party administrators (TPA) “uploading” the daily latest-and-greatest?

Who could possibly keep up, and should we be so quick to adopt rapid-fire change? Is anyone putting on the brakes, and if so, how? Do employers need to ask more questions about TPA best practices for utilization review, case management, medical necessity criteria, and provider contracting? Most certainly. We all have a role to play, and the first order of business is gaining awareness—and then, taking actionable steps to learn more about how TPAs are managing the situation so you can educate your employees.

Scroll back 20 or more years, when clinical guidelines trickled down from provider led research, verification, and practical application to publication to practice. Much of medical advancement was driven by practicing providers who identified trends within their populations and were looking for solutions. Today, research has moved outside the provider practices to tech companies that are funded by venture capital.

Is information overload overburdening the healthcare ecosystem?

Remember the children’s book, “The Very Hungry Caterpillar” that teaches kids about pacing themselves? The caterpillar loads up on junk food in the beginning, gets sick from being a big consumer, and while it was fun at the time, the outcome was not so great.

How does our change-a-minute healthcare world compare? When providers are dealt beyond a full house of change orders to their clinical protocols, those who adopt in real time (if possible) could be delivering care that is not recommended the next day. Those who wait and see could be preventing employees from accessing needed care.

There is a balance.

Change is healthy. Evolution is essential. But maybe we need to pump the brakes on all the changes and let them marinate a bit. Perhaps we need to assign some accountability to TPAs and other traditional and non-traditional partners to help advance additional review and practical application of new medical advancements or simply help create a lag in the process to ensure the ‘new best practice’ can be verified as having a medical application.

As employers, we sit at the intersection of care delivery: understanding how social determinants of health impact our employees and containing cost while ensuring the financial means to access care when needed. We’re stewards in a very dynamic sea.

Let’s change for the better. What can we do now? We hope you’ll share your ideas with us. Here are some of ours.

A​​​​​sk the questions: Changes come down the pike at a fast pace, so how are TPAs keeping up while balancing thoughtful evaluation of new clinical protocols? Who are they turning to as the industry experts? How often do they review and update coverage protocols and do they use models that reflect the latest clinical guidelines based on science or practical application? Communication and purposeful progression are key.

Dig into the data: Identify high-cost claims and take a close look at the numbers to determine where your employee population’s benefits utilization is the greatest. Are there certain chronic conditions such as diabetes or hypertension that are driving a large number of claims? How is your TPA reviewing utilization, and what conversations are they having with your organization about medical criteria? Are your employees getting too much, too little, or just the right amount of care? ​

Inquire about contracting. If a provider in the network is known to be practicing based on antiquated clinical standards that are no longer considered best practices, what discussions or education is the TPA or network partner having with this provider? Find out what provider contracting and network development processes are in place to ensure your employees are getting relevant, quality care.

Stay engaged and steadfast. Awareness and change are essential. The more we understand how our benefits partners are reviewing and managing change, the better insight we can deliver to employees so they can make informed decisions when using the valuable benefits you provide to them.

About Health Action Council 
Health Action Council is a not-for-profit 501(c)(6) organization representing mid-and large-size employers that enhance human and economic health through thought leadership, innovative services, and collaboration. It provides value to its members by facilitating projects that improve the quality and moderate the cost of healthcare purchased by its members for their employees, dependents, and retirees. Health Action Council also collaborates with key stakeholders – health plans, physicians, hospitals, and the pharmaceutical industry – to improve the quality and efficiency of healthcare in the community.