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