Health directed plan which most employers offer today, where do you go from there . The plan is already high dedistrictable. You need to turn your sights on the Delivery System if you want to control the health care costs. Theyre looking at alternative models for delivering health care. And one of the alternative models that has really grown is telehealth. About 7 of employers offered it five years ago. By 2017, 90 of ploirs will offer telehealth and by 2019 its pretty much universally offered by companies to their employees. So whats the value of telehealth . Telehealth is a much more convenient access point than a number of different venues. Emergency room cost 700 on average per visit. Urgent care costs 150 on average per visit. Physician office 100. Telehealth 40. Telehealth is not meant to be a replacement for primary care. Its meant to supplement primary care and give people access when they cant get afterhour coverage, twhen they have a long time to get an appointment or they didnt get off work to see a fen for a select group of services. Telehealth is one vehicle to Access Health care. One of the things about telehealth is the mobile application. Today if your strategy doesnt include mobile, then your strategy is not complete. 80 of the workforce has a smartphone and most of the information, both from a Decision Support perspective as well as access for telehealth and other services is being pushed to mobile. When you look at alternative delivery models, were seeing growth in the use of Accountable Care organizations and the use of select High Performance networks. Accountable Health Locations are between the providers come on to ultimately take on responsibility for the cost and quality for a defined population. And i say ultimately because these are works in progress. Acos when they first come together are not really going to take on risk or not be accountable to that extent. Theres a lot they have to do to gear up, to drive care coordination, primary care at a high level, have the analytics to manage their population. And this takes, this takes time. And so theres a developmental period for Accountable Care organizations. But 25 of employers now have acos as part of their strategy, mostly through their health plan, some going direct. High Performance Networks fit in the same category. Theyre a leveraging aco. And in about a quarter are of employers are also using those. But a number of employers are still unsure. Most employers are still unsure, what do you get from these new delivery models, how do they differentiate from the market . How do i know that they are providing or delivering a Better Service or even a better cost than the market . One of the questions we ask employers look another the next slide is trying to get a sense of their their expectations were for aco performance versus the market. Both from a trend per spec ty, how much can an ac objection affect trend or bend the cost curve and then an aco thats highly efficient, how much better than the market should they be for a total cost care perspective. For three levels of an aco, look at this as a journey map or as levels of maturity, an aco launching within the first couple of years, what do employers think the impact will be on trend, on lowering trend. Most respondents said no impact, that there wouldnt be much of an impact first couple of years out of the gate, wont be much impact on trend. For a developing aco, an aco that has established the care model, the patients in a medical home, better data analytics, better data sharing, the expectation is that they will bend tleen 1 to 3 . If send is 6, take it down to 5 or 3 . Most respondents believe that was probably a realistic expectation of acos. But for a mature aco, an aco driving on all competency levels, whether its network, whether its the care model, whether its technology, the financial model, that they should be able to beat trend by 2 to 5 . Which means if its 5 , then its getting it in line with cpi o general inflation. But even 2 is taking it down to 4 without making any plan changes or the like. The other question we asked was about the maturity of mature aco, how much more efficient than the market should they be . In other words you have a well functioning aco in the market, whats their total cost of care versus that market . Most employers said that it would be between 3 to 5 or 6 to 10 better than the market in total cost to care perspective. Were trying to get a sense of alignment, what do employers think and what do providers and health plans think and how do we align that thinking around expectations when it comes to the delivery of care with these more models. There will be more to come on this as more employers begin to move into this space. If we shift out of the Delivery System and look at plan design and cost sharing, as i said, theres not a lot of change for 2017. As you can see, Consumer Directed Health plans are pretty much universally offered if not by today, 84 of Companies Offer them. Certainly over the next couple of years it will be universally offered. Weve only seen a small incremental increase for Companies Offering them for 2017. So we know that the focus is shifting away from plan design to the Delivery System. If you look at the median cost sharing for employees for 2016 from a deductible and outofpocket perspective, for all plans, the average individual median deductible is 1425, 600 for ppos, 1600 for Consumer Directed Health plans. Employers pay, on average, 78 of the overall premium, employees picking up the difference. Thats been pretty consistent over the last four or five years, its a little higher for employees, a little lower for dependents, on average of 78 and that really hasnt changed. When you think of high deductible plans, though, employers contribute to Health Accounts. And 80 of employers who offer Consumer Directed Health plans and a Health Savings account, contribute to the Health Savings account. On average they contribute 60 per employee, 1100 for an employee for the Health Savings accounts. This is important because it helps offset the dedukctibldedu. How that compares to a fair exchange, the net deductibilile 1000. So the average employee deductible nets out to be about 1,000 for an individual. When you compare that to the Public Exchanges silver plan, that deductible is around 3,000. When you compare out of pocket maximums with an employer plan, its around 4,000. With the Public Exchange its around 6500. And when you look at the change were see in the volatility around premiums right now, on average we said employee contributions would go up around 5 5 . Were seeing a doubling of that. A lot of volatility in the Public Exchange and the employer based system is the best solution for providing Affordable Quality Health care to employeesmployees. A couple of other considerations. When we looked at employer actions to the availability of Public Exchanges. Were not seeing a lot. Were seeing more early retirees moving into exchanges and parttime employees who dont have access to coverage getting access through private exchanges but not a lot in between. Employers really havent done much to push employees to Public Exchanges. One of the one of the tactics thats emerged over the last several years as more companies have moved to high deductible plans is wagebased cost sharing, and one of the reasons for that is employers are sensitive to the affordability and challenges with the high deductible plan so about 45 of employers have implemented strategies to balance that out a little bit, either by adjusting premium contributions based on wages, or adjusting Health Account contributions based on wages, meaning low wage people get more into a Health Account than higher wage people, or adjusting out of pocket maximums or deductibles more tied to wages to try to make these plans more affordable for lower waged employees. The other area were seeing resurgence is in the area of Mental Health and most Companies Offer telehealth today and were seeing a growth in telehealth offered by employers on the Behavioral Health side. 30 of companies are offering telehealth Behavioral Services where allowed by states and were seeing a resurgence of onsite Mental Health counselors. All Companies Offer e. A. P. S today but a lot has become telephonic. Were seeing resources on site, possibly in Health Centers merging in with primary care or making them available on site. To give people access. Access in Mental Health is a big challenge right now to providers and by bringing them on site, its an enabler, but also it makes it more convenient for people to access, as well. Just a few other comments, one on private exchanges. Weve seen interest in private exchanges decline over the last several years. If you think in 2014 it peaked at around 35 of employers were considering them for the future. Its dropped over time to about 10 this year. And weve only seen about 4 of employers actually move to private exchanges, at least large employers move to private exchanges. Weve seen more activity on the retiree side, where 26 of employers are moved retirees to private exchanges and 28 are considering moving over the next several years, so its a strategy that seems to make sense for retirees, but hasnt been for active employees. If you look at the next slide, it will give you some sense as to why. So the question for we asked in the survey and weve asked for several years now is how confident are you in the ability of a private exchange tad the following better than you do today. If you look at the bottom of the slide, its really about your ability to control cost better than an employer can, your ability to advocate on behalf of my employees better than i can, and your ability to drive engagement into Health Programs better than what i as an employer can do today, and that confidence is pretty low on that front. The model is still evolving and most employers are not willing to take a leap of faith to jump into this until they can get a better sense of their ability to reduce costs and sustain that Cost Reduction over time. And, in effect, change the underlying Delivery System. Thats what they are waiting to see before they are more willing to move into private exchanges. Excise tax, most employers still believe that they are playing with the highest enrollment will trigger the excise tax in 2020, if the excise tax is implemented. Theres still a lot of question as to whether that will actually happen, as theres bipartisan support in both houses to repeal the excise tax. So but because of the way its structured and how its indexed to general inflation as opposed to medical inflation, regardless of what employers do to control costs, theyll all eventually trigger the tax if it goes into effect. So i wanted to close with what employees can expect in 2017. Again, i mentioned at the start its going to be more business as usual. They wont see on average a lot of change. About a 5 increase in premium contributions, which is consistent with what they saw last year. Minimum changes to deductibles a encopays. Some will have access to bare yat rik surgery, infertility, heart, cancer, orthopedics, and theyll see more tools to help them navigate the Delivery System and help support the management of their conditions. Thats pretty much what 2017 is looking to shape into. So happy to take questions at this time. Jack . Hi, jay hancock, Kaiser Health news. Consumer shopping tools, now that all these cdhps are in place, what is your sense of the tools that employees and their families have to shop for care . Those have been sort of widely panned in the past, are they getting any better . Are employees of your members able to make smarter choices and is Price Transparency actually going to some day maybe happen . I think that they will continue to get better. They can continue to be a vehicle to integrate other resources, so if youre searching for a provider for orthopedics, youre starting to leverage those tools to push other resources that an employer may be offering, so maybe theres a Decision Support program to help you identify best place to go for care, as well as treatment options, so getting a little more sophisticated in their ability to bring other information, in addition to just shopping on price. I think the challenge right now is engagement. The number one issue, and this is not out of this survey, its a Different Survey we did, number one issues for employers is engagement. How do i engage people in using all of these resources . How do i optimize these resources i make available, whether its transparency tools, whether its telehealth, whether its Decision Support, concierge services, employers are offering a lot of services, but its hard to get them in front of people just in time just when they need them. So i think where were seeing the Technology Going is the emergence of of engagement platforms that you can plug all these resources in that push information to people at the time that they need it, and to drive engagement up, so i think thats where its going to try to leverage the use an, so some of these tools are great, whether they are Decision Support or web based tools, but its getting people to use them, which is more of a challenge and i think were seeing an emergence of enterprisebased engagement tools that you can plug in these resources that are going to leverage claims data, pharmacy data, Consumer Information to push information to a mobile somebodys mobile phone to ping them at the time that they need information to help them make a decision. I think thats where its going to go. Question over here . Tina reid from the washington business journal. You mention some of the drugs expected to come down the pike, but what are some of the drugs driving major increases . If you think of the top drugs, humara, remicaid, two that come in mind that are top users in the inflammatory space. If i think of other areas where i can give you a sense of class as opposed to an actual drug, multiple sclerosis, oncology, hep c, hepatitis c, become the poster child for specialty pharmacy. Those are the current classes where youre seeing a lot of the cost in specialty pharmacy. The other ones i mentioned is where we see a lot of the new drugs coming out. Other questions . Yes . Whats your take on the election and whoever wins, both clinton and trump have said the excise tax is not something they support, so were probably looking at big changes. How do employers respond to that, that unknown . Well, i think that if Hillary Clintons elected its going to be business as usual with the aca and trying to improve and drive improvements in the aca. If trump is elected, im really not sure what that means at this point from a health care perspective. I think both, theres a lot of bipartisan support to repeal the excise tax. Will it be replaced with something . Theres been talk of do you look at the taxation of benefits, that could be on the agenda. As we look to next year, but its its anybodys guess at this point as to what it ultimately means. But thats my best crystal ball at this point. Other questions . All right, well, great. Thank you very much. American history tv airs on cspan every weekend. This month American History tv is in primetime to introduce you to programs you could see every weekend on cspan3. Our features include lectures in history, visits to College Classrooms across the country to hear lectures by top history professors. American artifacts takes a look at the treasures at u. S. Historic sites, museums, and archives. Real america, revealing the 20th century through ar kooifl films and newsreels. The civil war, where you learn about people who shaped the civil war and reconstruction. And the presidency focuses on u. S. President s and first ladies to learn about their politics, policies, and