The court acted after hearing a presentation from three members of HealthFirst, a Tyler-based third-party administrator which reviews and pays county workers’ and officials’ medical bills. Also attending were Roy Brown and Miriam Hill of The R. Brown Company, a Gilmer insurance agency which handles the county’s medical insurance.
HealthFirst Director of Underwriting Kevin Hall said the changes will lower the county’s overall health care costs “a little bit.”
Under changes approved Tuesday, employees must participate in a wellness program requiring certain medical tests and doctor visits.
The revised plan wouldn’t change the in-network deductible, but the deductible for using out-of-network providers rises to $1,500 for a worker, or $3,000 for his/her family. The out-of-pocket maximum increases from the current $2,000 to $4,000 for a worker, and jumps from the current $4,000 to $8,000 for a worker’s family.
(In a statement Wednesday, HealthFirst Marketing Communications Mgr. Trish Terrell, who was not among her firm’s representatives attending Tuesday’s meeting, clarified that “The definition of out-of-pocket costs has changed due to the Affordable Care Act, so changes were required to help keep the county compliant. Out-of-pocket now includes deductibles, co-pays and coinsurance. Previously, it did not.”)
In addition, county employees will pay nothing for 30-day supplies of generic prescription drugs, compared to $15 in the past. But they will pay 20 percent or $50—whichever is less—of the amount of name-brand drugs if no generic is available.
They also will pay 20 percent for name-brand drugs chosen over a generic. In the past, insurance made a flat rate co-payment on name brand drugs.
In-network co-insurance remains unchanged, but under the overall changes, pre-certification will now be required for certain procedures. In addition, “Out-of-network co-insurance was changed from 60 percent to 30 percent to limit county costs,” Ms. Terrell said.
The court also chose Optum to remain as its stop-loss carrier and transplant carrier.
HealthFirst Account Mgr. Rachel Robertson, who made most of the firm’s presentation during a 1-hour and 57-minute discussion of the issue, presented the changes which the court adopted as money-saving measures.
She said that while the county’s health-care costs are expected to come in well under the projected amount for this fiscal year, 69 percent of the pharmacy bill is due to 17 percent of the prescriptions since they are name-brand drugs.
She proposed pushing employees toward less-expensive generics, but Pct. 3 Comm. Frank Berka said some physicians get commissions from pharmacies for prescribing name-brand medications.
Ms. Robertson also proposed “step therapy,” under which workers wouldn’t take a name-brand drug until they tried a generic equivalent, but the court didn’t accept that change.
She said 26 employees’ use of Nexium or nasal steroids were the “biggest offenders” cost-wise.
When County Treasurer Myra Harris said generic drugs didn’t work for some persons under a step program, HealthFirst Director of Account Services Scott Nassimbeni said a physician can decline to accept prescribing a generic.
Berka complained that “we asked to have help” from county workers in containing costs, but they said no because the benefit costs them nothing.
He also said two other counties’ officials he spoke with were “amazed” that Upshur’s deductible was only $500 since theirs was $1,000. Ms. Robertson replied that not that many Upshur employees have met the $500 deductible.
And while June was a “rough” month cost-wise, she said, “We’re very, very well pleased” at how expenses have gone overall.
“You offer fabulous benefits,” Ms. Robertson told the court, adding “(you) can be conservative and still offer the benefits you’ve been offering your employees.”
Pct. 2 Comm. Cole Hefner expressed the desire to know “what can we do to sustain our current benefits as long as we can.”
Said Ms. Robertson, “I want to keep as close to what you’ve got as I possibly can.”
However, after she suggested reducing the benefit for out-of-network costs, Nassimbeni told the court, “I think your out-of-network (cost) is your biggest risk.”
Ms. Robertson also discussed a wellness program for employees, saying certain workers who aren’t going to a doctor or taking medication for a certain condition should be contacted within the parameters of the program.
Nassimbeni said that if those workers hung up the phone without acting, they will eventually cost the county a “significant amount in claims.”
“You’ve got to make behavioral changes is the point,” Nassimbeni said. “If I’m not willing to do the right things for my own health,” he asked, should all county residents “bear the burden?”
“This is for. . .your people to get healthy,” he added.
Berka said a wellness program “is not a negative,” but a “win-win for everybody.” Ms. Robertson added that those who don’t participate would pay for people who do, but “I don’t think we’re going to have that many people not want to do it.”
Said Berka, “The employees better jump on board (by participating in the wellness program to prevent more serious illness), or it’s going to cost a fortune” for them and the county for years to come.