Good morning. I am president and ceo of the National Business group on health. I welcome you to the briefing on the 2018, the results of the 2018 Large Employer healthcare strategy and plan design survey. The Business Group is a membership based Nonprofit Organization of about 450 Large Employers. These are large, multi states global employers, most all are selffunded. They provide Health Benefits for over 50 million americans in the u. S. This group is more of a convener. We bring employers together, and stakeholders together to advance improvements in Healthcare Delivery system and payment reform. To advance and accelerates and share best practices amongst each other on how to control healthcare costs, to manage conditions and pharmacy benefits, valuablys plan design and engagement and improvement in Employee Health and wellbeing and that impact on welfare strategy. We play a role in washington to represent Public Policy issues related to healthcare. You have with you which can follow along with the highlights i will walk through as well as detailed report available. I will spend 20 minutes on comments and then open for q a at the end. I would like to start with three highlevel observations about what i took out of the survey this year. The first is in a relation to the employerbased system. As you know, employers provide Health Insurance for most of americans in this country. The result of the survey reinforce the fact that employerbased system is the most efficient and effective way to provide americans with access to Affordable HealthCare Coverage and quality coverage in this country. Now, it is more stable than what was in the public exchanges. It cost less, typically. The rates are less volatile from year to year. We see less health plan disruption in employersponsored health care then we see in individual market today. That is not to say that we do not appreciate the individual market. We need a robust and stable individual market. Its important to note what is going on with repeal and replace of obama care and the instability that exists within the public exchanges today is not reflective of what is going on in the employerbased system. Employers are still concerned about the inefficiencies of the Healthcare System and rising healthcare costs. Healthcare cost is a top priority for employers. It is a drain on the bottom line and they are concerned about the number of employees who are struggling with affordability. It is still a major concern. The second observation has to do with the shift or seen among Large Employer community to focus more on Delivery System or supplyside opportunities. Employers have been using healthcare Cost Management and Consumer Directed Health plans for years to help offset costs and manage healthcare services. The, we are seeing employers point toward the Delivery System and opportunities to purchase healthcare differently. Usually an alternative payment delivery models looking and experimenting with organizations, more bundled and trying to weigh from feeforservice. Were getting some of that data going through. The third observation is the increase focused on the Consumer Experience within the Healthcare Delivery system. Employers have concluded that as much as we would like employees to be sophisticated, consumers of healthcare, the system is too complex and fragmented and they do not touch the system enough with enough frequency to be sophisticated consumers. Racine a big surge in 2018 for support services. To help employees understand their benefits, understand Treatment Options and where to go for care. Those are three things i pulled out of the survey that i felt were important from a high level. We will get into some of the specifics. The survey we typically field in june of every year because thats when most companies finalize their decisions for the upcoming year. Survey results are about what companies will do in 2018 not about what theyre considering doing. The survey asked employers to provide information on healthcare strategy, medical trend, on plan design and costsharing, cost drivers, and also on benefit management and some issues related to policy. 148 Large Employers participated in the survey. Covers over 15 million americans. Think about it as 10 of all the americans covered through the healthcare. To put that in perspective, look at the individual market that market covers 11 million americans today. That survey is covering more people than what we have covered in the individual market today. Participants cover a wide range of industries from retail and hospitality and technology to banking, financial and manufacturing these are large, multistate employers 80 have 10000 employees or more, 30 have 50000 employers or more. Just about all are selfinsured. Moving through some highlights related to the survey, we talk about stability for the fifth Consecutive Year employers project the cost of providing health and pharmacy benefits to rising 5 2018. It will go up to over 14000 annually per employee. Employers typically pay 70 and employees pay roughly 30 . It varies a bit by industry. Overall healthcare inflation or topline healthcare inflation is projected to be 6. 6 next year. Its creeping up. That is before companies implement plan design changes or other initiatives to try to manage. This is a challenge because healthcare trend continues to increase at twice the rate of wage increases. Its unsustainable in the long term. From an employee perspective they can expect a typical annual enrollment this year. Contributions will increase about 5 , consistent with the last several years. About 25 of companies are moving to wage base contributions. Thats an increase over this year. 37 of employers will have wage base contributions of those that make more will pay more for healthcare. Employees should expect minimal changes to deductibles and copays. Although some will look at Consumer Directed Health plans. In 2018, 90 of Large Employers will be offering Consumer Directed Health plans to their employees. Of from 84 this year. Just about 40 of Large Employers will offer high deductible plans is the only option. Thats up from 35 in 2017. The Consumer Directed Health plans in the Employer Market are very different from what you find in the individual market. They typically have lower deductibles, lower premiums, and that not factoring in employers contributions to Health Savings accounts, which roughly about 650 per employee, 1000 per family. Thats consistent for the last several years. Has returned to crossed drivers at 6. 6 per year. For the second year in a row pharmacy is the top driver. If its not number one, its the top three. Even the Specialty Pharmaceuticals touch only about two or 3 of an employers population these are typically expensive drugs. They cost thousands or tens of thousand dollars per year for treatment. I might require special handling and patient monitoring to ensure proper dosing. Managing highcost drugs is a top priority. In particular, managing where they are administered. Theres about a 50 increase in the number of employers decency to Care Management for certain specialty drugs, either through health plan through so instead of having a drug administered in the hospital is administered in a fusion center. Instead of having it administered in an outpatient facility its administered in a physicians office. The reason why its important, their already expensive but the variation in price between sites of care is significant. We seen it as much as 7x between various sites of care. Other tactics employers are expanding around pharmacy is were seen close formularies on the rise and that includes certain brand drugs from coverage. 43 of coverage had a close in 16 and then that increase to 55 . Were beginning to see employers experience with value purchasing and pharmacy. About 9 of employers are exploring the possibility of outcomes based or indication base pricing for certain medications. For next year. An area of concern for general pharmacy is the growing availability of manufacture of coupons to offset copays, deductibles, coinsurance for consumers. Thats having an impact on consumer behavior. Coupons are difficult to track and difficult to administer or integrate with a plan design. While some, especially those that are expensive to be very beneficial and helpful, they can also be offered to encourage a patient to pursue a higher construct versus a generic medication which increases overall healthcare costs other top drivers include highcost claims which is up every year as well as specific disease conditions such as musculoskeletal, diabetes, cancer, and that can differ by industry and demographics. To address these cost employers implementing a number of solutions to manage specific chronic conditions and centers of excellence for treatment of these. I like to spend a few minutes to talk about Behavioral Health. Behavioral health has grown as an area of focus for most employers. Making an attempt to improve access and reduce stigma with that. 56 of Companies Offer tele behavior health, more than a 50 increase this year. 20 will offer selfdirected online cognitive therapy in 2018. Thats up from 8 . Many Large Employers will offer manager and employee training to help bring sensitivity to help recognize Behavioral Health issues and provide tips to reach out to their peers and colleagues and direct them to appropriate resources. In addition, 18 will hold anti stigmas campaigns for Behavioral Health conditions at their worksite. The vast majority are concerned about abuse of prescription opiates. And while it was not in the survey, it is information we have pulled from other sources, employers are working directly with their healthcares to address this in a number of ways. First through approving a limited supply of opiate medication. Theyre limiting these to select network of pharmacies or providers. Theyre ensuring coverage of alternatives for Pain Management such as physical therapy. There providing training in the workplace as we talked about to increase awareness and recognition of symptoms. Theyre working through the health plans to encourage physicians drink kurt talk about the dangers of opiates and target physicians who are prescribing more frequently th than expected to consider alternatives for Pain Management. Turning to the Delivery System efforts by employers. Were seeing more activity around alternative payment models with employers. Virtually all employers are making telehealth available to their employees. Its universal these days. Is becoming a more accepted practice. Were seen 20 of employers having at least 8 utilization with telehealth. Sourcing it become more accepted among employees as a more convenient way to supplement their healthcare access. Care organizations are showing promise as a way to address rising cost and improve outcomes. For those of you who dont know when providers come together to take on responsibility for the total cost of care and the outcomes and quality of care in that particular market. Nearly half of employers will implement acos as part of their strategy in 2018 or by 2020. These are not broadbased implementations. There are more location specific. Pilots if you will, where employers are trying it out in markets and the test capability and effectiveness before they go broader. Healthcare is a local phenomenon, its important to look at them on the markets market basis. While half of employers are pursuing this strategy the other half are not. At this point. And, i think some reason for that is that theres a proliferation of acos in the market, there are hundreds of acos out there today. A Large Employer can offer them a 150 or 200 that they can deploy across the country. For a lot of employers they dont know what to make of that. They dont know how these acos differ from the market that there and from what theyre in today. Theyre struggling with trying to understand how to make a decision around acos. Couple years ago the Business Group put together a multi Stakeholder Task force of employers, health plans and providers to see if we could address the issue and agree on what the Market Expectations of acos are. And help employers identify while performing acos and then prioritize which markets to go after to help accelerate adoption. Its hard to do this on a broad base. Its going market by market. Your largest markets see whats available and then drill down. Thats what we are beginning to see thats why you see the activity around acos to be market specific and targeted. Like acos theres considerable interest in highperformance networks. Those are little different but they typically are networks of providers that are deemed tie performing on efficiency and quality measures. About 20 have highperforming networks. Like acos letter target are specific, they probably been in ten locations or more for the companies that have done that. Most employers have implemented centers for excellent strategies. Theres a growing spectrum of procedures that are being covered through centers of excellence today, ranging from transplants to cardiovascular to infertility. Whats interesting is as we look at 2018, the number of contracts that will be based on bundled payments, meaning package payments for episodes of care. As opposed to feeforservice. Twentyone to 48 offered by employers will be tied to bundle payments or alternative models as opposed to feeforservice. Twentyone to 48 depending on the type of condition. Some conditions are more defined around what bundles will be, orthopedics for example. Thats promising to see them move away from feeforservice i would say the other area were seeing growth is an Onsite Health and Wellness Centers within the community. These centers are covering a wide range of services from not only acute and primary care and Occupational Health which is where they started, but health improvement, condition management, Behavioral Health are all being integrated into these health centers. Their growing in locations around the country. This could be incentives to use an onsite clinic or incentives to use a center of excellence or Care Organization to manage a chronic condition. Your see not only value based purchasing opportunities through centers of excellence in acos, but are seeing value based design to encourage people and align incentives to make sense. The last area focus is one of the more interesting ones but i thought was the focus on the Employee Experience in the Consumer Experience within the healthcare. We saw huge increase, 60 of Companies Offer support and Second Opinion services in 2018. An increase of 47 the share. This is employers trying to help employees navigate the system. By helping make decisions around best Treatment Options. How to my benefits apply, where do i go for care, even setting up appointments in some cases and helping manage people through those experiences. The number of Companies Offering high touch Concierge Services will jump to 36 . That could be really more focused on Specialty Care issues that are very complex. They need someone to really walk them through all of the mechanics and challenges with managing that condition and bringing the resources that Health System can provide to manage that. The other thing were seen as these solutions around condition management. Around medical Decision Support. Employers are looking to integrate them into engagement platforms so that they can reach employees more in the moment and provide them with resources in one place, onestop, and driveup engagement and utilization. I was in closing, we are seeing, for decades employers focus in using strategies that affect consumer demand for Health Services to control costs. Now we are seeing more of a shift with most companies and high deductible plans. A shift focus on the Delivery System, focus on the supply side and pursuing value based alternatives to improve healthcare cost and outcomes. Ill be happy to take questions. When obama care was being discussed, were told that hospitals another medical services were increasing the cost to the insured to cover their uncompensated care and that added up to 1000 to the cost of individual insurance. So they were talking about if obama care implodes, what is said to to these numbers they have been giving us. And if i could add another to the list, consumer directed care. Ive heard a lot about their in recent years but im not sure what it means. If i killed over and six people here called 911, as a consumer of healthcare, what can i be doing so i think if obama care implodes or they continue to destabilize and you have more on his shirts, more insured means more constituted care which means more Cost Shifting to the employerbased system which will driveup medical trends. Thats one thing were concerned about. We very much want the stable individual market to complement employerbased care. So that those who cannot get access to their employer have a robust market to actually purchase healthcare. Were concerned about the we want to ensure we dont increase the number of uninsured because that will driveup the cost to employers. I think right now we are ready see numbers about 36 higher cost than medicare pays. So, will that increase . Most likely. I dont think we saw come down much when obama care came into play. I dont think we saw a reduction in the amount of Cost Shifting that we saw when more people got Health Insurance. It may have helped minimize rate increases over time as we have been seeing roughly 5 , 6 increases as opposed to eight or 12 . But, i do think if you have more uninsured it will drive more cost to the employer. I can estimate how much that will be. The 14000 figures cited, is this a combination of people that are employee only or employee plus spouse, employee family, and if so is this an average of 1. 7 people covered or whats the figured . Is a combination of everyone, with the per capita cost on the employee and family. Is it 2. 2 the average family size is 2. 1 Consumer Directed Healthcare will not help you much in urgent care situation. Youre going to go where you need to go to get healthcare. Consumer directed healthcare is more about the resources you have to either find out what pricing is, whats the best place for care. You dont have that in an urgent situation. But you can leverage the resources or have navigation tools if youre in a situation where you can plan for a healthcare episode. What to know about how often the companies are changing the companies they contract with . Has that been stable or we seem companies shift more often . I think it is stable for the most part. I think companies bid this every three years. Thats a common practice to go out to bid for a procurement perspective. Unless theres a compelling reason to move, companies will use that to keep everyone honest. So, you see more stability with employers. Most employers offer one or two health plans. And they offer more plan design offices but theyre doing it through one or two carriers primarily. To have a sense of how much time employer navigators are spending on helping employees avoid outofnetwork surprise . Outofnetwork bills . I dont have a sense but thats something they will work with in terms of where to go to care. They will try to keep people in the network and try to steer them to senators of excellence are in Network Providers to help understand the benefit impact of in network forces outofnetwork. I dont have numbers. To ever hear stories about ambush outofnetwork bills for the anesthesiologist or radiologist is in the hospital but hes not in the network . We hear those and its surprising that you still have those situations when youre staring someone to an in network facility. I think these Concierge Services and decisionsupport systems can help resolve these things. Were seen the concierge take on that abacus zero in addition to helping people navigate through the system and where to go for care. Is the focus on cost and price a big part of their job in terms of helping employees with the shop the pricer compare what different people are charging her figure out was something even costs which seems impossible. It is part of their job to extent the data is available. Employers offer Price Transparency is a part of services they provide two different transparency vendors or through the health plan. They are more Physician Office and lab and maybe even pharmacy to some degree. Sometimes elicits a bundled payment is hard to know all of the cost associated with it. But they will know for certain providers who are the more higherquality fission providers. And typically the steer them to the provider more so than the hospital. It always starts with the provider. Do you have data and whats more effective . Were hearing some of the same strategies but what seems to be working the best . Was the most effective is the high deductibles. Thats the most on the demand side for healthcare services. I think everybody is looking to focus on the delivery side now. I think there lies the opportunity. The date is not rich yet on what they can provide because he wanted to be more value based not price space. This is an about going about deeper discounts on certain networks. This is about, can a Network Rather an ac or highperformance network deliver Better Outcomes than the market . How do we get that data . Thats where the focus is now. Kennys entities perform better than the market and can they demonstrate that to the employer communities . Thats receive this experimentation in certain markets to see if we can prove that out. If they can deliver better care coordination, Better Outcomes and integrated care. This is what theyre experimenting with the models. I have a followup. I guess medicare has found that the internet cost drivers so still a question of whether they can actually reduce funding. I would say youll see date is in here about employers thoughts on the confidence of the acos ability to improve quality and reduce costs. They feel more strongly about improving quality and costs. But again, the jury is out. Value based model, there are different examples, their physician based and theres combinations of the two. Physician based on more noble in the market because they dont have the baggage of a hostile bed to fill and how to transition out of a feeforservice tomorrow value based system. Both models are necessary and hostile base models take longer to get there. We are seeing some promise that they are getting there faster. The key is that you need to be sharing savings back into the Delivery System. It providers can perform better on total cost of care they should be able to win on that. That would be part of the equation. You talk about disease management. What are the challenges for employers for seen that as a way of containing costs, given the tenure of their employees may not be long enough . Youll probably see a much older population. In those environments you will see more robust public condition management and focus on those things. The wellbeing and Wellness Programs are not just about improving your healthcare cost and reducing healthcare costs. It is about improving your workforce capability and competitiveness of the workforce and production of your workforce. Even i would say in retail and hospitality and other industries. It is that i want to improve the health of my employees and it might increase healthcare costs but it is about putting out the most Efficient Health care. It is not just about the cost is about the workforce. Could you provide more color about these Concierge Services and what exactly you mean. Is this a website that in hr manager might post about in the lunch room . And someone can look this up . Can we talk a little bit about what you mean and how or what services or what resources actually win engagement from employees . As a concierge falls into a couple of categories. There is broadbased which will be an intersection for all of the resources you provide and you can call this and probably to assess digitally but also calling and talking to a live person. They will navigate you through all of the resources and employer means available but also navigate you through the Healthcare System. So there will be benefit questions as well as claims as well as what resources and employer may have to help you in a particular situation. And actually even play coordination role with health plans. That is more broadbased. But there are also im saying we talk about high end concierge. It is more around these specialty conditions. Sometimes rare conditions where it is hard to know where to go for treatment, for the best providers, how do i get the appointments he, had read get into see these people . And how do i navigate through and the rest of the Delivery System. Both of the models exist. In terms of how concierge is being provided. Was there another part to the question . [inaudible question] i think the challenge historically employers have had with all of these resources is that you start with Broadbased Communications and you sweep certain people in the need the services of the time. And then, if i do not need healthcare, i forget this exists and six months from now, i do not realize that the Company Offers all of these resources and i missed that. So it has been frustrating you know one of the major issues for employers as to how to engage people in the resources . Was developing is the intersection of data and technology. And integrating them into these engagement platforms that can do Predictive Analytics based on claim data, pharmacy data, consumer data and push information to you at the time that you need it. To engage you in the moment. So to drive up engagement to call the concierge or overage from the concierge based on data they know about you that you may be contemplating back surgery and we have the information for you. You may be using your emergency room and we know that trying to line you up with primary care will go to urgent care or try to educate you on the different time he can save and the money you can save by using different resources. The predictive analytic capability is going. There is a lot of promise there. These services are really entering the market over the last couple of years and will continue to expand and play a major integration role for all of these Point Solutions and employer offers. To bring them together and Fresh Information you know to smart phones about what is available. Yes . One of the improved obamacare rather than repeal it idea is that in discussions in the house to change employer mandate so that employees who work 30 to 39 hours would no longer be in that mandate. Given the labor force situation that we are in or the labor market we are in right now, do you think your members would change who they offer insurance to if that mandate went to only 40 hour employees . And related to employer support for healthcare, the 70 percent cost share. Has that been around that level for five years . Was last time im not sure when it stepped down last time. Because we have to go back and look at that. I think that if you go back five years ago it was to present suit has incrementally been shifting but i think relatively speaking it is still in the ballpark of where it has been. The question about employer mandate. If you go back before and obamacare we did have it. Employees, many provided coverage for people must much less than 40 hours a week. When the mandate came in requiring 40 hours, we did not see much change among the Employer Community. Of course there were some companies that change but we did not see much change in the Employer Community in terms of what they were offering. I went into super that if it went away completely we would not see a lot of change again you know because of the Employer Market and it is a great recruitment tool to get people to join the company. And retain people in the company. So steve, i do not know if you have seen anything different. Steven wojcik with the Business Group, Public Policy. We have seen you know i think is a small employer or maybe Certain Industries where there had to adjust coverage and they had to do an adjustment if the hour requirement changes. But by and large i think it is mixed because we have had some employers offer coverage all the way down to 20 hours a week. Through when the aca passed, a change that so that those employees who work parttime could take advantage of this. So it is a mixed picture. I dont think we can generalize. Other questions . One more quick followup. You are saying the last five years this is the primary tool for the cost. And they are switching from that but i mean the numbers basically max it out. The 90 percent. But i did notice in looking in a little bit closer to the numbers among the latest pump from 85 to 90 it looks like the trend among the struggling employees, their spending even less on those that they are pushing into the health plans. I mean some numbers are going down for hsas and hras. I do not so much know that theyre going down. I think we have looked at, i think when Companies Enter in, they feed hsas and i think that seed provide some type of funding into the hsa. In the six copy for an individual on the thousand dollars per family. We do not see them pulling back in with their contributing very much at all. They see that as an important vehicle to offset the deductible. But also to engage people in playing a role in their healthcare. Okay and just to follow up on that quick. With a, the prevalence of these plans almost the universal nature of them. If im understanding correctly is what has made this move towards providing some sort of concierge expertise, guidance. Has made that you know that is more important if we are going to i think moving to, the intent was that they would engage people and making more informed decisions about their healthcare and put transparency tools in and other resources to help them. I think what we have learned is that it is too hard to recognize what all of these resources are independently and when i dont frequently engage with this i think the growth and Decision Support and navigation concierge is to simplify everything. For the employers. Still bring all those resources forward to help them navigate our simplified process. Simplify how i engage. To help maximize their experience. I think that is whats happening now. It is not just about the Point Solutions and offering them. We are not using utilization in the Point Solutions because people forget they are available for it is out of sight out of mind. The, integrating them, providing loss concierge to pull people in in providing more concierge to pull people in. We push the availability of these resources to employers and is showing promise to drive engagement. Yes . What percentage of employees are using a navigator or whatnot in a company that offers them . I do not know the number off the top of my head. I do know that the fact that they are there with some Predictive Analytics that we are seeing jobs in the engagement level. With those tools. I just do not have the numbers off the top of my head. The survey you are talking about today, or any of the companies in the survey part of the Health Transformation alliance . And give insight into how quickly they are developing . Has it been a slower process than you all thought in february 2016 . There are some in the survey that are part of the healthcare alliance. Many members are also participating in that. They are taking on a tall task. From my perspective, anything that can disrupt healthcare in a positive way is a good thing. So it will be interesting to see what they can achieve as a collective group. Healthcare is local. And it is very hard to implement something on a broad scale. We talked about acls being experimental and we need to identify the right will take time to get to the point where they can do something within the Delivery System that is different and scale it. The effort is worth noting and worth monitoring because theyre trying to do something very different in the market. Yes . Where the focus Large Employers in offering it and what are they doing to actually get people to use it . Again, telehealth is something of that to be out of sight out of mind. To take that with a grain of salt. The percentages across all employees. Not all employees, the denominator, not all employees need teleHealth Services or access to the Healthcare System. Whats been a challenge is trying to get back to be narrowed down to what is the scope of services that telehealth can really support . And then what is a percentage of employees using it for that scope of services and you see the number much higher. I think that is one of the challenges. I think the fact that 20 percent of companies are at eight percent utilization are higher, they are doing Something Different to drive that type of utilization and one of the things about the Business Group is we will take those examples and present them to the members to show best practice in terms of what are they doing differently to drive engagement up as high as they have . And profile those companies to give employees other ideas in how to do it. Telehealth will also be integrated into the engagement platforms we are talking about. To drive up engagement across all of these sources. So the number has to be taken as a grain of salt because it is two percent of across the population as opposed to two percent of selected services that you would actually use telehealth for. [inaudible question] i do not off the top of my head. I know someone does but it is not me at this point. Other questions . Okay well great, thank you all for your time. You are watching booktv on cspan2 with top nonfiction books and authors every weekend. Booktv, television for serious readers. Tonight on cspan2, booktv and primetime looks at president ial history. Starting with form advisor to president clinton, Sidney Blumenthal talking about the second volume of his biography of abraham lincoln, wrestling with his angel the political life of abraham lincoln. Then Political Science professor tony smith on why wilson matters . Henry olson discusses his book