Why one of Alberta’s largest plans is rethinking its approach to benefits risk, plan design, and employee health and wellness
Advances in technology and information exchange have led to opportunities for collaboration that have transformed established industries. Recent examples include ride-sharing services such as Uber and Lyft, which bring together individuals with access to a car with those who need a safe, cost-efficient and reliable ride. Through a combination of background checks, inspections, safety training, technology, user ratings and instant communication, ride-sharing services have found a way to work with both partners and members to deliver value in new ways.
The results? Increased use of existing resources, decreased costs, increased speed of service delivery, enhanced quality and a growing legion of loyal members who illustrate how collaboration in any area is possible.
Just as collaboration has radically altered mature industries such as travel, education and finance, technology and information exchange are also bringing about innovation in employee health benefits.
An integrated approach
The seeds of this transformation in thinking—better use of existing resources in order to benefit members while also ensuring plan sustainability—are being planted in an office in south Edmonton. The Alberta School Employee Benefit Plan (ASEBP) is a health and welfare trust that serves more than 54,000 employees and their dependents across 58 school jurisdictions in Alberta.
ASEBP ramped up its health and wellness focus in 2006 by building healthy living partnerships with school jurisdictions, with the objective of improving individual and organizational health across Alberta’s public education system. One early success of the initial focus on health and wellness was awareness within the ASEBP Board of Trustees that benefit offerings, from an employee health perspective, needed to be expanded to better serve the needs of education sector employees.
This early work and results measurement led to support for and development of ASEBP-specific health state initiatives relating to diabetes and mental health. It also brought ASEBP to a very important discovery: there were initiatives already under way within the public health sector that ASEBP could embrace. The organization realized that it shared goals with many of these programs, so collaboration—not duplication—was a natural avenue to pursue.
As ASEBP’s CEO, Jennifer Carson, pointed out, “We discovered a number of quality health partners in Alberta with whom we can collaborate. The breadth of existing initiatives, which are often not connected, has caused us to modify our approach to partnerships in support of the health of our covered members. We believe that if all of our partners and suppliers can work closely together to improve the health outcomes of covered members, we will all be more successful.”
This broader view of collaboration is relatively new to the Canadian health benefits industry. Canadian plans have historically played a passive role in interactions with healthcare professionals and provincial healthcare initiatives. Discussions between non-government plan sponsors and provincial health ministries have largely focused on the delicate balance of maintaining both private and public investments in health—with an emphasis on cost containment, not health outcomes—and connections were rarely made to existing programs.
Governments establish healthcare funding models with healthcare professionals, while plan sponsors base coverage and funding decisions on public sector precedents.
Not surprisingly, this siloed approach has resulted in a fragmented system with programs that have low uptake, duplication, inefficiency and suboptimal health outcomes.
Knowing the risks
Over the last few years, ASEBP has done additional work to better understand the needs of the plan and to establish strategic priorities. Looking at its plan experience over the past seven years, which has helped ASEBP to prioritize where to focus its resources, the organization made several key findings:
• 42% of the ASEBP’s members being treated for diabetes are not adherent to their therapy, and 41% are not doing any testing of their blood sugars. With a growing diabetic population, this understanding has led to focusing on preventing diabetes risk factors, improving the health outcomes of diabetic plan members and measuring the impact on the plan over time. To this end, in 2013, ASEBP worked with leading researchers to develop a diabetes screening clinic (with followup support) tailored to the needs of school jurisdictions.
• 10.2% of members being treated for depression are experiencing a more difficult form of the disease, known as treatment-resistant depression. This discovery motivated the organization to find novel ways to assist this group of members. ASEBP has also begun to develop a comprehensive mental health strategy that will provide direction for prevention, treatment and management programs and services for covered members.
• 16% of members being treated for high blood pressure are using three different agents to control their blood pressure, suggesting that they are treating a more challenging form of the condition. This finding opened the door to making additional resources available to these members, including access to personal health coaching by in-house health advisors in the areas of physical activity, nutrition and stress management—interventions that have proven to be effective in preventing and managing high blood pressure.
• The top 10 pharmacy groups represented within the existing plan experience make up 70% of all claims. Yet no particular group stands out in terms of how they are driving better adherence to therapy and how efficiently they are providing medications to plan members.
Agents of change
The biggest challenge in moving toward a collaborative model is moving away from a transactional basis of providing services and administering plan designs. ASEBP has begun to engage provincial representatives of key health stakeholders on benefits plan cost and design challenges, with the message that the organization wants to work together in a new and more integrated fashion.
The response ASEBP has received to date has been positive, and opportunities for initiatives and collaboration in areas of mutual interest are apparent. However, more work is needed to outline required outcomes and determine individual stakeholder responsibilities in achieving these shared goals.
ASEBP has begun an extensive review of its health and dental plans to determine if the health, paramedical and dental benefits designs appropriately align with current best practices for the covered expenses. To assist in this review process, an ASEBP Health Benefits Advisory Panel has been established with physician, pharmacist, dental and dental hygienist representation to supplement the internal and external advisors serving ASEBP.
As Carson noted in response to initial discussions with pharmacy stakeholders on how best to approach drug plan design and funding, “This pharmacy dialogue is also an opportunity for ASEBP to more completely understand how we can encourage our covered members to have their comprehensive care plans completed at their respective pharmacy, with the funding now provided by Alberta Health.”
The recent Alberta Health strategy of expanding the scope of practice for pharmacists—and using pharmacists to supplement physician expertise to achieve better health—has resonated with ASEBP. This care planning approach is similar to ASEBP’s extended disability coverage: the organization’s biggest benefits risk.
Historically, ASEBP has managed cost in a traditional manner by download-proofing its health benefits contract wording—using dollar cap maximums and providing “reasonable and customary” coverage levels for practitioner charges for the average covered member.
This has led to a conceptual discussion at ASEBP about the potential for a more current health benefits plan design: tailoring benefits plans to address the needs of individuals rather than offering blanket coverage of a fixed amount of benefit at one level and hoping it will have the desired impact of promoting optimal member health.
ASEBP believes this process could be effectively managed by a third-party administrator through more integrated health navigation and support resources to covered members, as well as by working more closely with the healthcare professionals who serve ASEBP covered members.
Healthcare cost and effective reform are the biggest challenges facing the Canadian economy, and resources are being consumed at a voracious rate. Canadian businesses, health and welfare trust funds, and public sector employers need to move out of their silos and become champions of health and benefits plan collaboration and innovation. The future success and sustainability of our healthcare system and Canadian benefits plans is at stake.
ASEBP believes benefits plans can be the catalyst that supports reform in the healthcare sector. Their goal is to demonstrate how meaningful collaboration will achieve for its benefits plan what Uber and Lyft have achieved for transportation: increased use of existing resources, decreased costs, enhanced speed of delivery—and better outcomes.
Perry Dorgan (perry.dorgan1@aonhewitt.com) is senior vice-president with Aon Hewitt and Mike Sullivan (msullivan@cubic.ca) is president with Cubic Health.
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