Employers should consider the following design characteristics when evaluating their healthcare benefits and recommendations presented in this toolkit.
The severity and complexity of a member’s disease can affect the characteristics of their needed services. Due to the chronic nature of substance use disorders and pain, coverage limitations on lengths of stay, number of visits, or associated spend can become barriers to treatment. Furthermore, member access to high quality and appropriately located services can be impacted by in-network vs. out-of-network providers.
Costs associated with prevention and treatment for OUD and pain can be a significant barrier for members to access the services that they require. A review of the health plan’s prior cost-sharing requirements, such as copayments, coinsurance, and deductibles, around these services can help assess the possible magnitude of this barrier. These requirements should be considered in the context of employee income and cost of living.
Utilization management assesses the appropriateness of a service before it is provided using evidence-based criteria or guidelines to approve or deny services. The appropriate application of utilization management is an important consideration for benefits related to OUD and pain. Prospective, concurrent, and retrospective reviews of services and claims can influence a health plan member’s access to treatment as well as protect against health care fraud, waste, and abuse. Employers should examine the structure of these reviews, the frequency and justification of denials and approvals, and align prior authorization requirements to ensure that individuals get timely access to quality care.
Network adequacy refers to whether a health plan covers providers that sufficiently allow members to receive timely, quality, and convenient care. Inadequate provider coverage can impede care, leading members to absorb significant financial costs in order to get care specific to their needs. When evaluating network adequacy for care related to prevention, treatment, and recovery services and a biopsychosocial model of pain treatment, employers should consider standards based on physician availability, geographic accessibility, and clinical appropriateness.
How are health plans performing?
The Health Effectiveness Data and Information Set, or HEDIS, created by the National Committee for Quality Assurance (NCQA), is used by more than 90 percent of America’s health plans to measure physician quality. Because many plans collect HEDIS data and because the measures are specifically defined, HEDIS makes it possible to compare the performance of health plans on an “apples-to-apples” basis and provides valuable information to employers on health plan opioid prescribing patterns compared to national benchmarks. Employers can request this information from their health plans and use it to evaluate their health plan’s performance on benefits focused on substance use.