2013 Segal Health Plan Cost Trend Survey

Transcription

1 2013 Segal Health Plan Cost Trend Survey Projected Rate of Increase in Health Plan Cost Trends Slows for 2013 to Lowest Level in More than a Decade Health benefit plan cost trend rates are forecast to decline for 2013 to the lowest projected level in 11 years of trend forecasts, with most medical and all prescription drug projected trends dipping into single digits, according to data compiled in the 2013 Segal Health Plan Cost Trend Survey, The Segal Company s sixteenth annual survey of managed care organizations (MCOs), health insurers, pharmacy benefit managers (PBMs) and third-party administrators (TPAs) 1. (For a definition of trend, see the text box on page 2.) While the slowdown in projected trends is positive news, it is worth noting that trends are still more than three times greater than the consumer price index for all urban consumers (CPI-U) 2. It is also important for plan sponsors to keep in mind when negotiating renewals with their insurers that the data in this survey report should only be used as a general guideline. Plan-specific trends will take into account each group s demographics and experience. 1 The survey was conducted in May and June of Most responses were received before June 28 when the U.S. Supreme Court handed down its decision in cases challenging the legality of the Affordable Care Act, which upheld the part of the law requiring that nearly all individuals have health coverage or pay a penalty when they file their federal income tax return. (The Affordable Care Act is the shorthand name for the Patient Protection and Affordable Care Act.) For information about the survey participants, see the text box on the last page of this report. 2 As of August 2012, the annual change in the CPI-U was 1.7 percent. This statistic, which was released on September 14, 2012, was the most recent available at the time this survey report went to press. Trend Projections for 2013 Table 1 summarizes the key findings on trend projections for 2013 and compares them to projections for Notes about the projected cost trends for 2013 that are shown in Table 1 follow: Almost all medical plan types are forecast to experience trend increases under 10 percent. The exception is fee-for-service/indemnity plans. All managed care cost trends are expected to be in the single digits. Trends for health maintenance organizations (HMOs), preferred provider organizations (PPOs)/ point-of-service (POS) plans, which require referrals by primary care Table 1: Projected Medical, Prescription Drug, Dental and Vision Trends: 2012 and Projected 2013 Projected Medical (Actives & Retirees < Age 65) (with Rx) 1 (with Rx) 1 Fee-for-Service (FFS)/Indemnity Plans 11.7% 10.9% 10.8% 10.0% High-Deductible Health Plans (HDHPs) % 9.8% 9.1% 8.6% Open-Access Preferred Provider Organizations (PPOs)/Point-of-Service (POS) Plans % 9.5% 8.8% 8.3% PPOs/POS Plans (with PCP Gatekeepers) 10.4% 9.8% 9.3% 8.8% Health Maintenance Organizations (HMOs) 9.6% 9.2% 8.2% 7.9% Medical (Retirees Age 65+) Medicare Advantage (MA) 4 HMOs 6.6% 6.6% 5.8% 5.6% Medicare Supplement (Medigap) 6.4% 6.4% 5.3% 5.3% Prescription Drug (Rx) Carve-Out 5 Actives & Retirees < Age % 6.4% Retirees Age % 5.3% Dental Schedule of Allowance Plans 6 4.1% 4.0% FFS/Indemnity Plans 4.2% 4.0% Dental Provider Organizations (DPOs) 3.8% 3.5% Dental Maintenance Organizations (DMOs) 4.4% 4.1% Vision Schedule of Allowance Plans 3.8% 2.8% Reasonable & Customary (R&C) Plans 3.9% 3.7% 1 Trend projections were derived by proportionally blending medical trends and freestanding prescription drug trends. 2 HDHPs with an employee-directed, tax-advantaged health account a health savings account (HSA) or a health reimbursement account (HRA) are referred to as account-based health plans and are designed to encourage consumer engagement, resulting in more efficient use of health care services. HDHPs are defined as those plans where the deductible is at least the minimum health savings account (HSA) level required by the Internal Revenue Service ($1,250 single, $2,500 family in 2013). 3 Open-access PPO/POS plans are those that do not require a primary care physician (PCP) gatekeeper referral for specialty services. 4 MA plans, part of the Medicare program, can be private HMOs, FFS plans, PPOs or special-needs plans. This table captures medical plan cost trends for MA HMOs because enrollment in these plans is much higher than in MA FFS or MA PPOs. The survey collected information about projected trends for MA PPO plans, which are projected to be 5.5 percent for Prescription drug carve-out data was captured for retail and mail-order delivery channels combined. 6 A schedule of allowance plan is a plan with a list of covered services with a fixed-dollar amount that represents the total obligation of the plan with respect to payment for services, but does not necessarily represent the provider s entire fee for the service.

2 Prescription drug trend for active participants and early retirees is projected to be 6.4 percent, which represents a significant drop of more than 13 percentage points from 10 years ago. Graph 1: Cost Impact on 2012 Plan Trend to Implement Preventive Care Coverage for Plans That Lost Their Grandfathered Status 1 physicians for specialty services (gatekeeper feature), and openaccess PPOs, are projected to be approximately 1 percentage point or more lower for 2013 than were projected for The prescription drug trend (retail and mail order combined) for active participants and early retirees is projected to be 6.4 percent, which represents a significant drop of more than 13 percentage points from 10 years ago. For 2013, Medicare-eligible retirees can expect similar trend rate increases for both medical and prescription drug coverage: 5.8 percent for Medicare Advantage (MA) HMOs, 5.5 percent for MA PPOs and 5.3 percent for prescription drug trends (retail and mail order combined). What is Trend? Trend is a forecast of per capita claims cost increases that takes into account various factors, such as price inflation, utilization, government-mandated benefits, and new treatments, therapies and technology. Although there is usually a high correlation between a trend rate and the actual cost increase assessed by a carrier, trend and the net annual change in plan costs are not the same. Changes in the costs to plan sponsors can be significantly different from projected claims cost trends, reflecting such diverse factors as group demographics, changes in plan design, administrative fees, reinsurance premiums and changes in participant contributions. In 2013, trend rates for all dental and vision plan types surveyed are projected to decline. Trend rates for dental provider organizations (DPOs) are projected to trend at 3.5 percent, a slight drop over the 2012 DPO projections. Vision plans on a fixed schedule of allowance are projected to decline to 2.8 percent. The survey also looked for regional variations in trend rates. Projected trend rates for PPOs and POS plans combined exhibit regional variation. For 2013, trend rates for PPOs and POS plans combined are forecast to be 7.5 percent, down from 8.9 percent in 2012, in the Midwest and 10.5 percent, down from 10.8 percent in 2012, in the West. Impact of the Affordable Care Act on Costs Segal asked the survey respondents about some of the experienced and expected impact on costs of the Affordable Care Act, which introduced new rules and requirements for group health plans. Responses reveal that in the short term the law is expected to add to plan sponsors costs by only a minimal amount. The vast majority of survey respondents (86 percent) indicated that the cost impact on 2012 plan trend of implementing the law s preventive care coverage requirements for plans that lost grandfathered status 3 was 2 percent or less. As shown in Graph 1, for almost half (43 percent) of survey respondents, the increase ranged between 0.1 to 3 Plans in existence as of March 23, 2010 and that remain largely unchanged from that date are grandfathered. 33% 5% 10% 10% 43% Actual Cost Impact: Cost Neutral +0.1% to 1.0% +1.1% to 2.0% +2.1% to 3.0% + > 3.0% 2 Other 3 1 This data reflects responses from 21 of the health insurers, MCOs and TPAs that participated in the survey. 2 No respondents selected this option. 3 Other includes decreased that are greater than zero, but less than 0.1%. 1 percent. More than one-third (33 percent) of survey respondents indicated they experienced a cost increase of 1.1 to 2 percent. In addition, almost half (48 percent) of survey participants projected a total overall cost increase of 1.1 to 2 percent higher for nongrandfathered plans compared to grandfathered plans. More than 80 percent of respondents are not currently providing medical loss ratio (MLR) rebates to large group insured plans under the Affordable Care Act s MLR requirement. 4 Forty-five percent of survey respondents anticipate placing other limits on essential benefits, such as medical management, visit limits and frequency and network limitations in lieu of removal of plan dollar limits, in light of the inability to place lifetime or certain annual dollar limits on essential health benefits under the Affordable Care Act. 4 Under the MLR requirement, an insurer must spend 85 percent of premiums on claims or quality improvements for health plans in the large group market. Those that fail to do so must provide a rebate. 2

3 Price inflation continues to be the biggest element of cost increases. Trend Components The survey also examined 2013 projected medical trends by service type. Table 2 presents that data. Consistent with prior year projections, price inflation continues to be the biggest element of cost increases and remains high for hospital services and brand-name medications. Utilization of prescription drugs in 2013 is expected to be 1.8 percentage points lower than 2012 projections. The 2013 trend rate for specialty drugs is projected at 17.2 percent, which is almost 2 percentage points greater than 2012 projections. This projection is also more than two and one-half times greater than the projected retail trend for actives and retirees under age 65. Additionally, the portion of total prescription drug trend for 2013 attributable to specialty drugs is forecast at 22.7 percent. This jump of 7.5 percentage points over 2012 projections signals the increasing impact of the specialty drug market. Accuracy of 2011 Projections To assess the accuracy of the reported projections, Segal compared the average 2011 trend forecasts by national and regional insurers, MCOs, PBMs and TPAs for group medical, prescription drug benefit and dental plans to the actual average trend rates experienced by the health plans covered by those organizations for the same 12-month period, as reported by survey respondents. Similar to previous survey findings, comparing past projections to actual increases Table 2: Components of 2013 Projected Trends for Hospital Services, Physician Services and Rx Trend Component Price Inflation 6.4% 3.9% 6.8% Utilization 2.2% 2.8% 0.7% Total Trend 2 8.7% 6.8% 6.4% 1 Hospital and physician trends are for open-access PPOs. 2 The components do not add up to the totals because there are other components of trend not illustrated, reflecting such factors as impact of cost-shifting, technology changes and drug mix. Also, not all participants provided a breakdown of trend by component. The portion of total prescription drug trend for 2013 attributable to specialty drugs is forecast at 22.7 percent. reveals that insurers and PBMs tend to make conservative projections for cost increases. Historically, forecasts have been generally higher than actual experience. The following are the most notable findings about the accuracy of trend projections based on the data shown in Table 3: In 2011 (the most recent full year for which actual data is available), actual medical and prescription drug trend rates were significantly lower than 2011 projections. For example, the actual trend rate for PPOs for actives and retirees under 65 was 7.5 percent while the projected PPO trend rate for that year was 11 percent. That represents a 46 percent differential between projected trend and actual trend. The greatest differential between trend forecasts versus actual trends experienced in 2011 can be found in the rate for combined retail and mail order prescription drugs for actives and retirees under 65. For Similar to previous survey findings, comparing past projections to actual increases reveals that insurers and PBMs tend to make conservative projections for cost increases. 3 Hospitals 1 Physicians 1 Rx 2011, the actual trend rate was 5.0 percent, while the projection for that year was 9.2 percent. Actual trend rates for MA HMOs in 2011 were 4.5 percent, while trend rates were projected to be 7 percent. Table 3: Comparison of 2011 Projected Trends to 2011 Actual Trends Projected Actual Medical (Actives & Retirees < Age 65) FFS/Indemnity Plans 12.7% 9.7% HDHPs 11.7% 8.1% Open-Access PPOs/ POS Plans 11.0% 7.5% PPOs/POS Plans (with PCP Gatekeepers) 11.2% 7.8% HMOs 10.2% 8.0% Medical (Retirees Age 65+) MA PPO 6.4% 3.8% MA HMOs 7.0% 4.5% Rx Carve-Out* (Actives & Retirees < Age 65) 9.2% 5.0% Rx Carve-Out* (Retirees Age 65+) 8.2% 7.2% Dental Scheduled Plans 4.8% 3.2% FFS/Indemnity Plans 6.6% 3.1% DPOs 5.5% 3.1% DMOs 4.2% 4.1% Vision Scheduled Plans 3.2% 3.2% R&C Plans 3.5% 4.2% * The 2011 survey captured prescription drug carve-out data for retail and mail-order delivery channels combined.

4 In addition, actual trends for 2011 were the lowest reported in 11 years for all managed care plans (with the exception of MA HMOs and DPOs). Table 4 shows selected trends (actual trends for and projected trends for 2012 and 2013). It should be noted that the accuracy of projections is subject both to underwriters conservatism in predicting future events and a natural lag in the underwriting cycle. In periods where costs are decelerating, forecasters will tend to overestimate trends. Similarly, when costs are accelerating, trend projections will generally be underestimated. Consequently, accuracy of trend assumptions is best measured by comparing projected trend to actual trend over multiple years. Graphs 2 and 3 illustrate the significant but declining variances between trend forecasts versus actual trends experienced in 2007 through Variance in 2010 rates illustrates a reversal of that pattern, with actual trend coming in well below prior forecasts. This is further supported by 2011 rates in which the split between actual trend and projections are even more pronounced. Table 4: Selected Medical, Rx Carve-Out and Dental Trends: Actual and 2012 and 2013 Projected* PPOs POS Plans 2001 Actual 13.9% 11.9% 11.1% 11.9% 17.8% 5.7% 2002 Actual 13.9% 12.2% 12.8% 12.9% 18.4% 6.4% 2003 Actual 12.0% 11.5% 11.5% 10.0% 14.3% 6.5% 2004 Actual 10.9% 11.6% 11.5% 11.4% 13.3% 6.2% 2005 Actual 10.4% 11.1% 10.6% 8.4% 10.5% 5.0% 2006 Actual 9.6% 10.0% 10.2% 7.2% 9.5% 5.1% 2007 Actual 8.9% 9.5% 9.8% 7.0% 7.9% 5.0% 2008 Actual 9.7% 9.4% 9.7% 7.7% 7.4% 5.5% 2009 Actual 9.5% 9.7% 10.2% 4.0% 7.9% 4.7% 2010 Actual 7.6% 8.3% 8.7% 3.6% 6.4% 3.0% 2011 Actual 7.5% 7.8% 8.0% 4.5% 5.0% 3.1% 2012 Projected 10.0% 10.4% 9.6% 6.6% 7.2% 3.8% 2013 Projected 8.8% 9.3% 8.2% 5.8% 6.4% 3.5% * All trends are illustrated for actives and retirees under age 65, except for the MA Plans. (A graph comparing 13 years of survey data 2012 and 2013 projected trends to actual trends for 2001 through 2011 is available on the following page of Segal s website: Segal also asked the survey participants to indicate the top five major diagnostic categories that had the highest actual cost trends in The five, from highest to lowest, by rank were: (1) musculoskeletal; (2) digestive and heart disease (tied for HMOs MA HMOs Rx DPOs second place); and (3) cancer and complications of pregnancy and childbirth disease (tied for third place). Four of the top five categories for 2011 were also in the top five for 2010 (although the order varied). The exception was complications Graph 2: Comparison of Projected to Actual Trends for PPOs for Actives and Retirees under Age 65: Graph 3: Comparison of Projected to Actual Trends for Retail Rx Carve-Out Coverage for Actives and Retirees under Age 65: % 12% Key: PPOs Projected PPOs Actual * 2009* 2010* 2011* Key: Rx Retail Projected Rx Retail Actual * Actual trend for and projected trend for 2010 and 2011reflects retail and mail-order delivery channels combined. 4

5 from pregnancy and childbirth, which overtook mental health conditions, one of the top five major diagnostic categories in Commentary & Outlook While it is welcome news for plan sponsors that medical and prescription drug trends are projected to decelerate in 2013, it is important to note that the trend projections are more than three times greater than the annual change in the consumer price index for all urban consumers, which was 1.7 percent as of August 2012, and more than three times greater than the annual increase in average weekly earnings, which was 2.0 percent as of August Nonetheless, the deceleration in medical plan costs trends is likely the product of several forces including plan designs that encourage use of lower cost providers, greater shift to generic drugs and less intensive treatments and improved medical management efforts, such as greater investment in hospital-discharge coaching. Although plan sponsors continue to grapple with high health plan costs, the downward trend in the overall demand for some medical services is encouraging. An additional force might be decreased medical and prescription drug utilization due to higher medical plan participant out-of-pocket cost and limited disposable income. It remains to be determined if deceleration in medical plan costs trends is a long-term trend or temporary result influenced by current economic forces. A lingering question is whether care that is being delayed or avoided could lead to higher rates of undetected or undertreated conditions in the future. Consequently, it is unclear whether the current medical utilization patterns will continue over the next several years. Looking forward to 2014 and beyond, plan sponsors must also consider the impact of the Affordable Care Act on their health care plans. Because the U.S. Supreme Looking forward to 2014 and beyond, plan sponsors must also consider the impact of the Affordable Care Act on their health care plans. Court upheld the constitutionality of the law, all provisions relevant to health plan sponsors are unchanged. Consequently, plan sponsors need to continue to implement the law, monitor regulatory guidance and focus on certain immediate compliance action items such as: Preparing the Summary of Benefits and Coverage (SBC), which must be distributed as early as this fall, Addressing the removal of annual limits in 2014 or, if the plan has a waiver of annual limits, comply with the waiver s notice and reporting rules, Including the value of employersponsored coverage on 2012 W-2 forms issued in January 2013, and Distributing rebates to participants if the plan received MLR rebates from its insurer. The deceleration in medical plan costs trends is likely the product of several forces including plan designs that encourage use of lower cost providers, greater shift to generic drugs and less intensive treatments and improved medical management efforts, such as greater investment in hospital-discharge coaching. It remains to be determined if deceleration in medical plan costs trends is a long-term trend or temporary result influenced by current economic forces. Given that the Affordable Care Act will not lower health care costs or inflation in the short term, plan sponsors need to remain vigilant on this front. Over the long term, programs like the following can play a pivotal role in reducing the cost of care and the prevalence and severity of disease: Contracting with network managers that demonstrate the ability to provide stable and cost-effective provider networks, Implementing plan designs that provide incentives for appropriate use of medical services and reward healthy behaviors, including the use of plan design to support tiered medical networks, Exploring ways to move providers from fee-for-service to outcomebased compensation, Using salaried on-site clinics and/ or walk-in clinics for provision of basic medical services, and Taking advantage of new and improved efforts related to early detection of disease, better control of chronic diseases and more effective wellness efforts reducing the complications and cost of disease. The health care industry is expected to undergo considerable changes in the delivery of integrated health care to improve the quality and efficiency of care while minimizing health care costs. An example of integrated health care is the Accountable Care Organization (ACO). ACOs, which have mainly been developed for the Medicare population, are networks of providers and suppliers that agree to 5

6 be jointly accountable for managing the health of participant populations across the care continuum. Another example is the Patient Centered Medical Home (PCMH), which focus more comprehensive health care resources on primary care and prevention for patients with chronic conditions. As ACOs and PCMHs expand, they will offer new options for group health plan sponsors. The Affordable Care Act, intended to expand coverage for most Americans, will have an impact on almost all payers of health coverage. It is The Survey Participants likely that the reach of the law will go beyond adding individuals and employees working for small groups and will gradually have an impact on even large group health plan sponsors. Beginning in 2014, the presence of Exchanges, new federal subsidies for lower income households and new underwriting regulations could influence not only how some workers obtain health insurance but also could influence employment and hiring practices. The new health care benefits marketplace may present new options for health plan sponsors. The 2013 Segal Health Plan Cost Trend Survey was conducted in May and June of Survey participants were asked to provide the trend factors they will be applying to historical claims to predict expected claims for Segal received 95 responses to the survey. The following participants (81) agreed to disclose their names: Aetna; Amalgamated Life; Amerihealth of New Jersey; Anthem Blue Cross of California; Arkansas Blue Cross and Blue Shield; Blue Cross and Blue Shield of Alabama; Benecard; BeneCare Dental Plans; Blue Cross and Blue Shield of Illinois; Blue Cross and Blue Shield of Kansas; Blue Cross and Blue Shield of Massachusetts; Blue Cross and Blue Shield of New Mexico; Blue Cross and Blue Shield of Oklahoma; Blue Cross and Blue Shield of Texas; BlueCross and BlueShield of Tennessee; Blue Cross Blue Shield of Delaware; Blue Cross Blue Shield of Michigan; Blue Shield of California; Capital District Physician s Health Plan; Catalyst Rx; CIGNA; ConnectiCare, Inc.; Coventry Health Care; CVS Caremark; Delta Dental of Alabama; Delta Dental of Arizona, Delta Dental of Arkansas; Delta Dental of California; Delta Dental of Colorado; Delta Dental of Delaware; Delta Dental of District of Columbia; Delta Dental of Florida; Delta Dental of Georgia; Delta Dental of Illinois; Delta Dental of Indiana; Delta Dental of Louisiana; Delta Dental of Maryland; Delta Dental of Massachusetts; Delta Dental of Michigan; Delta Dental of Minnesota; Delta Dental of Mississippi; Delta Dental of Montana; Delta Dental of Nebraska; Delta Dental of Nevada; Delta Dental of New Jersey; Delta Dental of New Mexico; Delta Dental of New York; Delta Dental of North Carolina; Delta Dental of North Dakota; Delta Dental of Ohio; Delta Dental of Pennsylvania; Delta Dental of Tennessee; Delta Dental of Texas; Delta Dental of Virginia; Delta Dental of West Virginia; Delta Dental of Wisconsin; Delta Dental of Utah; Employers Dental Services; Excellus Health Plan, Inc.; Express Scripts, Inc.; Health Net, Inc.; Horizon Blue Cross Blue Shield of New Jersey; Humana, Inc.; Independence Blue Cross; ING ReliaStar; Kaiser Foundation Health Plan; MagnaCare; Medica; Medical Mutual of Ohio; MetLife; MVP Health Care; National Vision Administrators, LLC.; Nippon Life Insurance Company of America; SXC Health Solutions, Inc.; The ODS Companies; Trustmark Group Insurance; Tufts Health Plan; UnitedHealthcare; United Concordia; US Script and WellPoint, Inc. (Anthem Blue Cross and Blue Shield). The law may prompt some sponsors to revisit many aspects of overall employee compensation and benefits strategies. Plan sponsors should begin to study the implications of the key features of the Affordable Care Act on their benefit offerings to learn how best to take advantage of the new landscape to maximize the value of benefits for their workforce. n n n For assistance with health care cost management strategies, contact your Segal consultant or the nearest Segal office. A list of Segal offices can be accessed from the second hyperlink in the blue box below. To receive survey reports and other Segal Company publications as soon as they are available online, register your address via Segal s website: For a list of Segal s 22 offices, visit com/about-us/contact-uslocations/ Copyright 2012 by The Segal Group, Inc., the parent of The Segal Company. All rights reserved.