By Kelsey Waddill
Employers are stuck between a rock and a hard place in 2024, with unsustainable healthcare spending in their employer-sponsored health plans and a reticence to shift any more of the cost to their workers.
Some experts are calling the new year “2023 2.0” because companies faced the same dilemma in 2023. The year before that in 2022, employers tried to shift costs from premiums to out-of-pocket spending. In 2024, however, this approach is not as attractive because it may drive away potential job candidates and drive out current employees.
As a result, 2024 is the year that employers must be creative to reduce healthcare costs.
Chief executive officer of the North East Business Group on Health (NEBGH), Candice Sherman and Drew Hodgson, actuary and national practice leader of health care delivery at Willis Towers Watson, Drew Hodgson shared with HealthPayerIntelligence some of the strategies successful employers may implement to overcome cost barriers in the new year.
Cost Is The Biggest Concern
The resounding theme across the healthcare system at the start of 2024 is: healthcare spending is astronomical, it is only getting higher, and it will be a major factor for all healthcare leaders.
Employers are no exception. In fact, they are in a strategic but challenging position to influence the final cost for patients by bearing the brunt of the expense. As a result, they have a vested interest in healthcare spending and will be responsive to fluctuations.
Employers anticipate the total health benefit cost per employee to increase 5.4 per cent in 2024 on average, according to Mercer. If they leave their plans as-is, employers indicated the cost growth would be even higher, around 6.6 per cent on average. Other sources project even higher costs, with Aon anticipating an 8.5 per cent growth in employer healthcare spending.
“Most of the employers that we speak with are not eager to impose those extra costs on employees because of concerns about attracting and retaining employees,” Sherman explained. “And so I think employers are looking for other levers to pull that will enable them to continue to offer a robust benefits equation for employees without battling them with additional costs.”
Mercer experts noted a couple of key drivers to this trend, including healthcare consolidation and high costs for popular prescriptions.
Consolidation can have its benefits, but it also tends to increase premiums.
“We’ve seen a lot of health systems and providers having financial strains—especially ones that were still fee-for-service rather than being based on value-based care—[and] consolidation within the hospital space,” said Hodgson. “And whenever you consolidate, prices start to go up, and we’re already seeing a ton of difficult negotiations between insurance companies and healthcare providers and health systems.”
In addition to the factors that the Mercer study underscored, Hodgson noted that data transparency had increased costs, instead of leading to spending cuts. Once providers had the ability to see what their peers were making on certain services, they began to demand greater reimbursement from payers.
A third factor that Hodgson highlighted was utilization. After a couple of wild years of oscillation due to the coronavirus pandemic, when healthcare utilization dropped to a 7.0 per cent decline in growth and then shot up to an 8.6 per cent increase in growth, utilization rates seem to have stabilized. In 2022, the average quantity index of healthcare services grew 3.1 per cent, which represented typical growth trends pre-pandemic.
However, even stabilized growth is still growth. From 2006 through 2013, the average quantity index of healthcare services never exceeded a 2.5 per cent increase. The 2022 quantity index may be stabilizing but it remains on the higher end of the trend.
In 2024, Hodgson expected utilization to increase. He found that some of the growth was profit-driven and reflected the need for a broader uptake of value-based care. GLP-1 use would drive utilization trends higher.
Employers’ cost-cutting efforts for the past year may have been working. The spending increase should have been higher in 2024, given the massive inflation rates of the past two years.
Drug Coverage Will Extend Beyond Medications
The previous year was momentous for the pharmaceutical industry. In 2023, these companies introduced a number of drugs targeting widespread and debilitating conditions, such as the first over-the-counter contraceptive, an antidepressant for postpartum depression, and a controversial treatment for Alzheimer’s.
The drug category that sparked the most buzz, however, was the glucagon-like peptide 1 (GLP-1). Most GLP-1 drugs were created to control diabetes with the potential for weight loss. But some, like Mounjaro, Wegovy, and Zepbound, have an additional objective: to treat chronic weight management.
GLP-1s gained greater popularity in 2023 as weight loss treatments. And employers are starting to follow employees’ lead, with the number of employers planning to cover GLP-1 drugs in 2024 expected to double, according to a survey from Accolade. Most of those who already cover the drug say the decision led to higher employee satisfaction and well-being (75 per cent).
However, this drug type, with its many uses, poses a significant challenge for employers. According to PwC, GLP-1 drug prices cost US$10,000 a year or more. Wegovy’s price tag, for example, is around US$17,000 per year.
The impact of GLP-1 coverage on overall healthcare spending extends beyond price. Even if it was not so expensive, the overwhelming demand for these drugs would likely impact spending.
Hodgson attributed GLP-1s with driving up utilization which, in turn, will drive up costs for 2024. He compared the drug’s arrival to that of Xanax and opioids. Both became popular quickly and developed ulterior uses, which, along with other downstream impacts including employment outcomes, contributed to higher spending.
Controlling overprescription is possible, as evidenced by the declining prescription rates for both Xanax and opioids. But it took decades of excessive spending to achieve those lower rates.
GLP-1s could follow a similar trajectory if healthcare leaders and employers are not careful. The patient outcomes of overprescribing or off-label prescribing of GLP-1s might not be as severe as for addictive, potentially deadly drugs like Xanax and opioids, but it could still have lasting effects on employers’ and employees’ financial strain.
“Employers really have to have a GLP-1 strategy about how they’re going to cover these drugs, when they’re going to cover these drugs, what authorizations need to be in place now before it starts to escalate and get out of control,” Hodgson said.
Sherman emphasized that employers need to provide wraparound support for employees who receive the medication. Such services include dietary coaching, nutritional education, exercise benefits, and behavioral health support.
These wraparound supports are not intended to replace the medication, Sherman clarified. Rather, they ensure that employees and their families have ways to manage their costs and can pursue holistic care.
Data Will Be Central To Strong Decisionmaking
Beneath the pressures of looming costs and vendors’ proposals, overwhelmed employers can start the year by securing sufficient data.
“A lot of times, plan sponsors have basically gone out to bid every three years, gone to the major carriers, looked at discounts and said, ‘Okay, they’re cheaper. I’m going with that.’ Those days have got to end. Those days are over,” Hodgson asserted.
Companies can no longer let discounts alone determine their benefits and plan options. Instead, Hodgson encouraged employers to use their workforce data to drive what solutions are best suited to their employees. Depending on the data, traditional solutions like virtual care, centers of excellence, and accountable care organizations may still be worth the investment.
“Without data, you’re nowhere. You have to have that bedrock of data to understand what’s happening and ‘where do I expect everything to go in the next year or two,’ and then have a strategy from the opportunity side to really look through a lot of these types of solutions in the market,” Hodgson explained.
Employers Will Reassess Benefits For Equity
Data will also help employers determine if every employee population has equal access to healthcare. After a Deloitte report revealed strong disparities in the costs of healthcare benefits for female employees compared to their male counterparts, employers will be refining their women’s health benefits.
In addition to evaluating benefits based on gender and sexual orientation, employers will assess benefits by generation.
“The other thing that we’re hearing from our members is just the fact that many of them have as many as five different generations in their workforce now. So how do you develop an array of benefits that give people what they need at those different stages of life?” Sherman summarized.
Assessing benefit equity based on race and ethnicity is also crucial. People of color are more likely to miss work for health-related reasons than their White colleagues, according to McKinsey. Plus, among employees with household incomes of under US$100,000, seven in ten employees of color lacked two or more basic needs such as housing or transportation (69 per cent), compared to five in ten White employees (49 per cent).
Employers should also stratify their benefits analyses based on income, Sherman suggested.
“Something that works for someone at a very high income may not work for someone at a lower income level. So you want to make sure that you’re offering not equal benefits, but benefits that provide equity,” advised Sherman.
Point Solutions Will Require Reevaluation
Once employers have gathered all the right data and conferred with their consultants or brokers, they will start reassessing their benefits and point solutions.
Employers are offering a smorgasbord of point solutions, Hodgson indicated. Half of employers offer four to nine point solutions, but large companies can have over 20 or 30 solutions. Hodgson has encountered employers offering more than 45 point solutions to their workforces.
This issue did not occur by happenstance. The coronavirus pandemic led to a surge in telehealth adoption, particularly in the mental and behavioral healthcare space. Growth in access to digital health resources and other types of vendor point solutions can be a good thing, but only if these tools are producing better outcomes.
In 2024, vendors will experience a reckoning. Employers will assess the solutions that they selected in recent years and determine whether the return on investment is satisfactory. Any solutions that are not producing outcomes will be slashed as employers reduce wasteful spending.
Nearly a third of employers (32 per cent) are putting vendors or health plans out to bid in 2024 and 47 per cent are considering doing the same, according to a WTW survey. In 2022, only a quarter of employer respondents in a separate WTW survey said they made changes to their clinical point solutions and a quarter planned to do so over the next couple years.
The key metric will be integration. Employers will reassess their vendor solutions based on how the tools and offerings integrate into their existing ecosystem of benefits and digital health options, Hodgson shared. Without easy navigability, employees will not use the point solutions and the investment will be meaningless.
“Make sure that this is something that is going to fit well into your overall benefits, so that you can get the utilization,” Hodgson urged. “We see it all the time where someone will put a vendor in place and we think it’s great, it’s going to save money, and nobody uses it. It’s a huge problem. So when you have 20, 30 different vendors, that happens all the time.”
Sherman specifically highlighted the necessity for better organization of mental and behavioral health support tools.
Most self-insured companies have established a mental health continuum, Sherman observed. For these large organizations, the question is less about whether they will offer mental health support and more about how to make it accessible.
“How do you create something so that employees know how to navigate: ‘I’m having this kind of mental health issue, so what’s available to me?’ So, I think really trying to organize that into a continuum that makes sense, that’s easy to navigate, and it’s clear where to go for what is going to be key,” Sherman said.
Sherman also noted that this challenge for employers presents an opportunity for health plans.
“There’s an opportunity there for health plans who have increasingly become adept at using digital partners that make sense. They’ll be offering employers some tools and some ways of integrating into a digital menu that might make sense,” Sherman shared.
As employers start the new year, their strategies will center on lowering costs and making wise partnership decisions.
