HEALTHCARE ROUNDTABLE

What is open enrollment and how should I prepare for it?

Dr. Gene Ma, Tri-City Medical Center:

Open enrollment is a period of time when you can enroll in a new or different healthcare plan for the next calendar year.You can make any changes to your plan from Oct. 15 through Dec. 7. This change will take effect on Jan. 1 of the following year.You can also make one change during the Open Enrollment Period from Jan. 1 through March 31. This will take effect on the first day of the following month. It is important to know what kind of coverage you and your loved ones need and what options are available to you. Some questions to consider: How high of a copay do you feel comfortable paying? What about your deductible? Will you need a major surgery in the next year? Do your research so you don’t feel rushed and make the best decision for yourself and your family.

What are the changes — or the latest trends in healthcare coverage — to look for during 2022 open enrollment?

Keith J. Evans, Kaiser Permanente:

Latest in technology: Many healthcare providers offer an electronic health record (EHR). Kaiser Permanente was a pioneer in implementing an EHR. Among many other benefits, EHRs help avoid duplication and repeat medical tests if employees switch doctors or see a specialist. At Kaiser Permanente, all visits and care are recorded, allowing employees secure online access to their health record, so they can fully engage in their health journey.

Maternity care: Health plans should offer coverage for care at every stage of pregnancy, in support of a healthy pregnancy and baby. Providing health education and tours of the hospital where a mom will deliver her baby are added benefits.

Travel Coverage: Employees should be covered for emergency and urgent care anywhere around the world. Ensuring that students going to college have coverage is also important.

What is the difference between a PPO and an HMO plan?

Sasha Yamaguchi, Cigna:

A Health Maintenance Organization (HMO) is a type of health plan that offers a local network of doctors and hospitals for you to choose from. It usually has lower monthly premiums than a PPO or an EPO health plan. An HMO may be right for you if you’re comfortable choosing a Primary Care Provider (PCP) to coordinate your healthcare and are willing to pay a higher deductible to get a lower monthly health insurance premium. A Preferred Provider Organization (PPO) is a type of health plan that offers a larger network so you have more doctors and hospitals to choose from. Your out-of-pocket costs are usually higher with a PPO than with an HMO or EPO plan. If you’re willing to pay a higher monthly premium to get more choice and flexibility in choosing your physician and healthcare options, you may want to choose a PPO health plan.

[Other information provided by Yamaguchi: Those covered by an HMO must have a primary care provider make a referral to a specialist. Those using an HMO may generally not seek medical help outside their network, unless it is an emergency. Those using a PPO may go out of network; however, they may find the cost of doing so is higher.]

What is a primary care provider (PCP)? What are the benefits of having one?

Dr. Louis Maletz, Palomar Health (PHMG):

A primary care provider (PCP) is a physician who functions as the main contact for your healthcare. Most insurance plans, whether HMO or PPO, rely on the PCP to assist members with access to medical services covered under their insurance. A PCP is not what was called in the past a “GP” (General Practitioner). The training of a PCP includes three years of a residency after finishing medical school. This training allows a PCP the skill to assess, treat and make appropriate referrals for a wide range of medical conditions covering all ages. The PCP must also provide immediate access to medical attention when necessary and work in the area of illness prevention at all stages of life.

Sasha Yamaguchi, Cigna:

Some health benefit plans require the selection of an in-network primary care provider (PCP) for the member and their covered dependents. PCP designation can be changed at any time.

The PCP chosen will coordinate

Do your research so you don’t feel rushed and make the best decision for yourself and your family. Dr. Gene Ma

Chief Medical Officer Tri-City Medical Center

Your out-of-pocket costs are usually higher with a PPO than with an HMO or EPO plan. Sasha Yamaguchi

Market Growth Leader Southern California & Nevada Cigna

members’ healthcare needs and refer them to specialists as needed. The benefits plan carrier may need to pre-certify hospitalizations and other outpatient care referrals.

Dr. Gene Ma, Tri-City Medical Center:

A primary care provider is a healthcare professional who helps you manage your health.Your PCP is your partner and shares the responsibility for your mental and physical health, as well as your overall well-being. These include physical and wellness visits. When you are sick or not feeling well, a physical exam helps your PCP figure out what the problem is and what needs to be done. When you are healthy, you want to stay that way. A wellness visit helps your PCP understand what is working for you and how to support your continued health and well-being. It is important to have a wellness exam annually and have any of the recommended preventive services completed.

What factors should employers consider when they select healthcare coverage for their employees?

Laura Josh, Gallagher on behalf of California Schools VEBA:

One of healthcare’s greatest shortcomings is its one-size-fits-all approach. No two people are the same, and the care they receive should reflect their differences. At VEBA, we recognize this and are developing solutions to personalize healthcare for the members so everyone has access to the care they need, when they need it, in the modality they prefer. For example, we offer a plan for employees who may need surgery that includes access to the country’s top surgeons, plus a team who handles planning and paperwork at no cost to the member. We also offer a plan aimed at millennial employees to help save for healthcare in retirement using a Health Reimbursement Arrangement (HRA).

Preventative care should also be considered when selecting coverage, which is why in 2019 we launched the VEBA Resource Center (VRC). Through the VRC, we provide well-being and education resources designed to work in conjunction with traditional medical treatments. By creating an integrated healthcare system that treats the whole person, we have been able to improve member health outcomes and reduce employer costs.

Keith J. Evans, Kaiser Permanente:

When selecting a plan, look at the following:

• Cost – Be mindful of the tradeoffs between cost and coverage

• Network Size – Larger networks offer employees more choice for care

• Plan Offerings – Align the right combination of plan offerings to meet all your employees’ needs

• Quality – Look for a plan with highly qualified, skilled healthcare professionals with demonstrated quality of care

• Convenience – Care should be hassle-free, with seamless access to primary and specialty care, lab and pharmacy services, as well as digital and virtual formats for care

• Flexibility – The ability to select from a wide group of physicians, and change physicians easily

• Technology – The use of the latest evidence-based technology in care

• Cultural Competency – Select a plan that meets the cultural and demographic needs of your entire employee community

What healthcare benefits are the most popular among employees?

Keith J. Evans, Kaiser Permanente:

Since the outbreak of the pandemic, and the ensuing “social distancing” and isolation, digital mental health apps have become very popular. One example: as of March of this year an app that Kaiser Permanente offers its members — the myStrength app — saw a 140% increase in utilization. Apps like these are helpful because they can be accessed remotely, are contact-free and available on demand 24/7. Apps are also anonymous, so employees can access mental health resources without fearing the stigma around asking for help. Four out of five workers with a mental health condition say shame and stigma have prevented them from seeking traditional mental health care — and these tools can be an important first step toward receiving the care they need.

One of healthcare’s greatest shortcomings is its one-sizefits-all approach. No two people are the same, and the care they receive should reflect their differences. Laura Josh

Area President Gallagher on behalf of California Schools VEBA Since the outbreak of the pandemic, and the ensuing 'social distancing' and isolation, digital mental health apps have become very popular. Keith J. Evans

Vice President, Second Sale & Retail Kaiser Permanente

To what degree should quality influence an employer when making benefit decisions?

Dr. Louis Maletz, Palomar Health (PHMG):

Quality cannot be compromised because the goal in medicine is to seek the best outcomes using the most modern methods available.

It is an obvious consideration and, unfortunately, many times the cost of care becomes the higher priority — although sometimes not putting patients through needless procedures and medications is quality care. Consider the fact that medical care is in constant change and advancement. Choosing a medical system should be based on the culture of that system that supports and encourages physicians to pursue and maintain the highest quality. Physicianled medical groups integrated within a hospital system have an advantage in ensuring quality through the constant support and oversight of providers.

Michael Byrd, Sharp Health Plan:

Employers should consider quality when evaluating health plans. Highquality clinical care leads to the best possible outcomes: improved employee health and well-being, improved satisfaction and retention, and improved cost effectiveness, to name a few. The National Committee for Quality Assurance, or NCQA, conducts annual health insurance plan ratings based on clinical quality, member satisfaction and accreditation survey results. Reviewing NCQA’s ratings is a good starting point to assess the quality of a health plan. Additionally, the Consumer Assessment of Healthcare Providers and Systems, or CAHPS®, is another measure of quality in terms of member satisfaction. Based on CAHPS results among reporting California plans, Sharp Health Plan is the highest member-rated health plan in California for the eighth year in a row.

Keith J. Evans, Kaiser Permanente:

Quality of care is extremely important and should play a key role when selecting a health plan provider. So much so, that the State of California’s Office of the Patient Advocate provides an annual ratings report on providers’ quality of care. This report card shows the quality of healthcare for millions of Californians who get their care through HMOs and PPOs. For 2021-22, the report notes Kaiser Permanente as the only Southern California Health Plan provider to receive an overall five out of five-star rating for their quality of medical care. Ratings were scored in the following areas:

• Appropriate use of Test, Treatments and Procedures

• Asthma and Lung Disease Care

• Diabetes Care

• Heart Care

• Maternity Care

• Behavioral and Mental Health Care

• Preventive Screenings

• Treating Adults

• Treating Children

Reference: State of California, Office of the Patient Advocate Report Card (2021-22 Edition) reportcard.opa.ca.gov

Physician-led medical groups integrated within a hospital system have an advantage in ensuring quality through the constant support and oversight of providers. Dr. Louis Maletz

Chief Medical Officer of PHMG ACO and Population Health and Family Physician Palomar Health (PHMG) Sharp Health Plan has been a proponent of population health for a long time, and it plays a major role in our ability to deliver high-quality and affordable coverage. Michael Byrd

Vice President and Chief Business Development Officer Sharp Health Plan

Laura Josh, Gallagher on behalf of California Schools VEBA:

You should not have to sacrifice high quality benefits for reasonable costs. In fact, in our experience, providing our members with the highest quality care has been good for our bottom line. For nearly 30 years, VEBA has been a leader in purchasing healthcare based on value. We even incentivize members to enroll in quality care programs by offering plans with the highest quality providers at the lowest cost to the member. Fast forward to today, 90% of VEBA members are enrolled in high-performance networks and VEBA has saved members and employers millions of dollars. By directing our members to high quality providers who know what’s best for their patients’ overall well-being, our members are healthier and utilization is lower.

How do you ensure that you are offering high quality benefits packages, while making them affordable to your employees or the populations that you serve?

Michael Byrd, Sharp Health Plan:

Sharp Health Plan has been a proponent of population health for a long time, and it plays a major role in our ability to deliver high-quality and affordable coverage. Population health uses “big data” to tell us what’s happening in our populations. Integrated delivery systems like Sharp have a unique ability to share actionable

population health management data to deliver personalized health interventions to members at the right time, which helps reduce overall healthcare costs by preventing unnecessary acute care events and hospitalizations. For example, at the start of the COVID-19 pandemic, Sharp Health Plan was able to prioritize outreach to our highest-risk members — people with chronic conditions and people with disabilities — to share trusted resources and tips for staying safe.

Laura Josh, Gallagher on behalf of California Schools VEBA:

VEBA is unique in that we were formed nearly 30 years ago as joint labormanagement trust and a new way to purchase healthcare in Southern California. Through this collaboration, labor and management work together to provide quality health benefits at the lowest possible cost. By leveraging the power of collective bargaining, all of our employer groups benefit from the size of the VEBA pool.

We have also long understood the relationship between quality, outcomes and long-term cost control. Over the years, we have implemented strategies to ensure that members are getting the right care at the right time, which in turn has reduced costs. We believe that an integrated model that focuses on each member’s personalized needs improves health outcomes and lowers unnecessary spending.

Physical and mental health are inextricably linked. What role does behavioral health play in keeping employees healthy?

Sasha Yamaguchi, Cigna:

At Cigna, we recognize the close connection between mental and physical health. That’s why we encourage everyone to get their annual checkup and speak to their doctor openly and honestly about how they’re feeling, body and mind. We know that a healthy workforce is critical to business growth. In fact, our recent Healthy Workforce survey found executives and their employees agree that worker well-being is essential to business success. The survey emphasized the importance of mental health, finding that the combination of fatigue, burnout and stress is a top barrier to business growth.

What is your organization doing to provide mental health resources to your employees or the populations that you serve?

Laura Josh, Gallagher on behalf of California Schools VEBA:

VEBA has long been a proponent of holistic approaches to healthcare, including mental health. Like many organizations, VEBA’s employee assistance program (EAP) supports members with a variety of challenges, from establishing healthy work-life balance to addressing anxiety or depression. In the new year we will be bolstering that program by bringing on additional EAP consultants to work exclusively with VEBA members. As dedicated consultants, these licensed professionals will have a comprehensive understanding of our membership and available resources.

The VEBA Resource Center—which has offered holistic wellness services like meditation and yoga since its inception—will also soon provide free, one-on-one and group counseling to VEBA members. Our hope is that these counselors can be a safety net for members in need of immediate mental health services, and also support members awaiting long-term care with an outside behavioral health clinician.

Dr. Gene Ma, Tri-City Medical Center:

Our employees have access to an array of mental health and wellness services through their benefits. Our local community can also receive behavioral health services at our longstanding outpatient treatment program in Vista. The program includes group and personal therapy and a team of mental health professionals. We are also excited to expand our services by building a modern, state-of-the-art inpatient psychiatric health facility on the Tri-City campus in Oceanside to provide acute mental health care for our North County friends and neighbors.

What coverage options are available to non-benefit eligible employees, and can they get financial assistance?

Michael Byrd, Sharp Health Plan:

Employees who are not currently eligible for medical coverage under an employee benefit plan or changing to a non-benefit status are encouraged to become familiar with health coverage options offered through Covered California. As the state’s health insurance marketplace, Covered

Employees who are not currently eligible for medical coverage under an employee benefit plan or changing to a non-benefit status are encouraged to become familiar with health coverage options offered through Covered California. Michael Byrd

Vice President and Chief Business Development Officer Sharp Health Plan At Cigna, we recognize the close connection between mental and physical health. That’s why we encourage everyone to get their annual checkup and speak to their doctor openly and honestly about how they’re feeling, body and mind. Sasha Yamaguchi

Market Growth Leader Southern California & Nevada Cigna

California makes it simple and more affordable for millions of Californians to get quality health insurance. They offer a variety of plans for consumers to choose one that best meets their health needs and financial situation. Financial assistance is available for those who qualify, based on estimated household income and taxable household size, and can take the form of reduced monthly premiums or costsharing amounts. With the recent passage of the Inflation Reduction Act, increased financial help has been extended through the end of 2025.

What can employers do to educate retiring or 65+ employees about transitioning to Medicare?

Keith J. Evans, Kaiser Permanente:

Preparing employees well in advance of retirement or their 65th birthday provides them with peace of mind when making Medicare decisions. A best practice is to provide “Medicare 101” seminars – well in advance of employees turning 65. Medicare can be very complex, and new laws and rules can change Medicare from year to year. Medicare 101 seminars provide the education of how Medicare works, and the timeline employees need to be aware of as they choose a Medicare plan that is right for them. Working with a health plan carrier who can offer Medicare 101 seminars to employees will equip the employees with the knowledge they need to make informed choices as they approach 65.

Sasha Yamaguchi, Cigna:

We do our best to communicate with clear messaging to help inform, encourage and educate employees as they approach eligibility for Medicare benefits.You can enroll in Medicare in the three months before your 65th birthday, during your birthday month, and for the three months after your birthday. If you enroll outside that initial enrollment period, you could face penalties.

It gets a little more complicated if you are still working with insurance through your employer. If you are still in the workforce, it’s a good idea to research whether you should opt-out initially and enroll later. Medicare’s Annual Election Period is the one time each year that most Medicare beneficiaries can choose a new plan. It begins on Oct. 15 and continues through Dec. 7.

Dr. Louis Maletz, Palomar Health Medical Group (PHMG):

It is very important for employers to provide information to employees transitioning to retirement and Medicare. There is a timetable for making the appropriate connection into Medicare, three months before and three months after the employee turns 65. At that time the employee MUST submit a choice of Medicare coverage. Missing this important stage could cost the employee a significant amount of money. Employers should consider making the education of this process mandatory for the employees approaching this stage.

What is a Medicare Advantage Plan? What are the advantages to having a Medicare Advantage Plan versus Original Medicare?

Sasha Yamaguchi, Cigna:

Nearly 50% of Medicare beneficiaries are now choosing a private Medicare Advantage plan and 93% report satisfaction with their plan, according to America’s Health Insurance Plans. Medicare Advantage (MA) plans cover everything covered by Original Medicare, and most also include dental, vision and hearing benefits. They often include prescription drug coverage, and other extras like over-the-counter drugs, transportation to doctor’s visits and pharmacies, and fitness plans. MA plans are often available at no extra cost.

Dr. Gene Ma, Tri-City Medical Center:

Medicare Advantage Plans are another way to get your Medicare Part A and Part B coverage. They are sometimes called Part C or MA Plans and offered by Medicare-approved private companies that must follow rules set by Medicare. Most MA plans include drug coverage (Part D). For HMO plans, you will need to use health care providers who participate in the plan’s network. With a Medicare Advantage Plan, you may have coverage for things Original Medicare does not [provide]. These things may include fitness programs, vision, hearing, dental, transportation to doctor visits and over-the-counter drugs. MA Plans have a yearly limit on your out-of-pocket costs. Once you reach this limit, you won’t pay anything for services Part A and Part B cover.

Preparing employees well in advance of retirement or their 65th birthday provides them with peace of mind when making Medicare decisions. A best practice is to provide 'Medicare 101' seminars. Keith J. Evans

Vice President, Second Sale & Retail Kaiser Permanente

With a Medicare Advantage Plan, you may have coverage for things Original Medicare does not [provide]. These things may include fitness programs, vision, hearing, dental, transportation to doctor visits and over-the-counter drugs. Dr. Gene Ma

Chief Medical Officer Tri-City Medical Center

Benefits will expand coverage of illness prevention: for example, obesity, the core of many chronic medical conditions. Dr. Louis Maletz

Chief Medical Officer of PHMG ACO and Population Health and Family Physician Palomar Health (PHMG)

Greater cost transparency will help guide value-based [health] plan designs and could allow payers and patients to make more informed decisions about where they get care. Laura Josh

Area President Gallagher on behalf of California Schools VEBA

Dr. Louis Maletz, Palomar Health (PHMG):

Medicare Advantage is like an HMO of Medicare. The patient chooses a primary care physician who belongs to a network of physicians and hospitals. It is important to know which Medicare Advantage plan offers the network the patient desires. Original Medicare allows the patient to choose any physician or hospital who accepts Medicare. However, the patient pays more because Medicare only covers 80% of costs and there is more paperwork with medical bills. Medicare Advantage has a less complicated process eliminating bills except for co-payments. It allows extra services, like membership to gyms. More emphasis is on prevention of illness compared to Original Medicare. Finally, medications can be costly but with Medicare Advantage a formulary list of medicines can help keep costs lower than other Medicare options.

What innovations in health care benefits and care delivery will be the most meaningful or impactful in the next few years?

Dr. Gene Ma, Tri-City Medical Center:

We are constantly innovating to bring on new services and elevate the patient experience at Tri-City Medical Center. Right now, we are in the middle of construction for our brand new 3T MRI Suite in the Radiology Department. In addition, we will soon begin remodeling our emergency department and will shortly start construction of a brand new 16-bed psychiatric health facility on our campus.

Dr. Louis Maletz, Palomar Health (PHMG):

1. Benefits will expand coverage of illness prevention. For example, obesity, the core of many chronic medical conditions.

2. Benefits will encourage technology at the Primary Care level. For example, the use of point of care ultrasound.

3. The generalized implementation and refinement of the Electronic Medical Record (EMR) and artificial intelligence. There may eventually be an EMR consolidation of vendors which will allow patients to have the same EMR no matter what doctor or hospital they see.

4. The primary care team workflow which empowers support staff to assist patients and physicians more quickly and effectively through the EMR.

5. In the specialty areas, technology is changing how procedures are done. For example, robotic surgery and minimally invasive procedures will be more common and be offered anywhere, anytime from any institution.

Michael Byrd, Sharp Health Plan:

I think most would agree that healthcare is moving toward a more integrated, consumer-focused delivery of care. Technological advancements will likely continue to be discovered and implemented up and down the value chain of healthcare delivery. However, consumer expectations remain the driving force for the most meaningful innovations. Therefore, it’s imperative for health plans to partner with delivery systems to provide members with seamless, easy-to-access care when, where and how they want it. Innovation is one of Sharp’s core values, and we’re committed to providing a consumer experience founded upon our coordinated care model to support high quality, superior health outcomes and exceptional service.

Laura Josh, Gallagher on behalf of California Schools VEBA:

In September 2020, in conjunction with America’s Physician Groups (APG), VEBA was successful in passing a law change (AB 1124) that will allow us to further expand direct-to-provider payment models that will focus on getting every member the right care, with the right provider. Value-based care—in which providers are paid based on the quality of outcomes rather than the quantity of services—is not a new concept, but like VEBA, a growing number of payers and health plans are finding new ways to incorporate it into their benefits offerings. For VEBA members, this change could manifest as more incentives to seek primary, preventive and mental health care, or encouragement to see one specific provider over another in their network. Recent changes in federal policy and market trends are also making price information for hospitals, health plans, and pharmacy benefits managers more readily available to consumers. Greater cost transparency will help guide value-based plan designs and could allow payers and patients to make more informed decisions about where they get care.