Reference-based pricing, also called metric-based pricing, is an alternative to the traditional PPO model that offers substantial cost saving and benefits for self-funded employers by leveraging fair and transparent practices.
If you aren’t familiar with reference-based pricing, it could seem disruptive to your operations to make a change. However, many self-funded employers are implementing this alternative and reaping the benefits.
How does reference-based pricing compare with the PPO employers are currently offering to their employees?
PPO: The most prevalent form of health insurance, where the annual cost for employers increases year-over-year and high deductibles are a challenge for patients.
Members use a network of hospitals and doctors under a discount to take advantage of pre-negotiated costs. Oftentimes, these discounts vary widely inside the network and result in fluctuating costs. An independent study conducted by Castlight Health, a San Francisco-based healthcare price transparency company, shows PPO allowable amounts for common procedures swing as much as 500% in some regions.
The variable discounts are calculated on variable billed charges from the hospitals’ chargemaster, prices that many times are inflated and fluctuate dramatically between hospitals for the same service. In one example, the California Public Employees’ Retirement System (CalPERS), which manages the largest public employee benefit fund in the U.S, found that facilities throughout the state charged vastly different rates — between $15,000 and $110,000 — for a hip or knee replacement.
Referenced-based pricing: A modern solution for self-funded employers to manage healthcare costs for their business and employees.
Under this model, reimbursements to providers are based on the actual cost to deliver service or Medicare reimbursements. This more level approach starts at the bottom and adds a fair profit margin. Working with a reputable solution provider, self-funded employers can save up to 30% in their first year after switching to reference-based pricing.
See also: Myths on Reference-Based Pricing
It’s not uncommon for employers to question making the switch from a PPO to a reference-based model. Is it worthwhile to make a change? Will employees understand the change? Does it require a lot of work? Let’s explore six tips for a smooth transition to reference-based pricing without disruption.
1. Do a little homework: Start by finding an experienced provider
Employers should only work with partners that are trusted and experienced with providing successful reference-based pricing solutions.
Look for a provider that has more than five years of experience auditing claims in all 50 states, welcomes reference calls, shares case studies from successful partnerships and retains clients long-term.
2. Schedule face time: Vet your potential provider
Request to see a provider’s operations in person to assess if the provider is financially secure, is equipped with resources and demonstrates a commitment to the success of their clients.
Look for a partner that welcomes site visits and pay particular attention to the size of the customer service team.
3. Commitment counts: Co-fiduciaries are an important consideration
Your reference-based pricing solution provider should be a partner that is 100% invested in your success.
Look for a partner that is willing to sign on as a co-fiduciary because it may be asked to assist in managing the financial assets of your plan.
4. Knowledge is power: Employee education is paramount
When you make a change to a benefits package, clear communication is important to ensure employees understand the new plan.
Look for a partner that will educate, answer questions and serve as a continuing resource to your office for the duration of the partnership.
5. Relationships count: Employers and medical providers must work together
Reference-based pricing is not a one-size-fits-all solution.
Look for a partner that collaborates with health systems (especially solution providers with established partnerships), and demonstrates dedication toward fair provider reimbursement.
See also: Innovation: ‘Where Do We Start?’
6. Measure the impact: Assess how your plan is working
The partnership doesn’t stop after a plan is in place!
Look for a partner that is results-driven and reports on your cost savings. A provider should also provide a dedicated support specialist and be a continuing, committed resource.