Employer Benefits Management: Finding High-ROI Solutions for Complex Care Events

Self-insured employers, benefits managers, and brokers find themselves in an increasingly complex world when it comes to managing the needs of their employees’ healthcare. The COVID-19 pandemic exacerbated pain points across both healthcare management and care delivery, leading employers to reexamine key cost drivers, as well as understand the changing employee preferences for specific solutions and delivery methods. At an individual level, employees are often confused and overwhelmed by the breadth of offerings available to them, leading to underutilized benefits and improper, higher cost of care. In response to these trends, employee benefits companies, and the solutions they provide, continue to evolve with a focus on effective engagement, benefit transparency, and seamless integration across an employer’s full suite of employee benefits offerings.

Clinical / Surgical Decision Support
The time following a new diagnosis, or the onset of a chronic condition can be the most difficult time in an individual’s healthcare journey, and a key inflection point on the total cost of care for a self-insured employer. Surgical procedures alone can account for over half of a company’s healthcare spend. Often, the individual employee must navigate through numerous complexities surrounding these medical procedures including initial diagnosis, second opinions, determining coverage, choosing a location and provider, understanding costs, and enrolling in post-care therapy or recovery. Decision support platforms can play a crucial role in educating individuals as they make key healthcare decisions following a diagnosis, helping them to make informed choices about their treatment and care options. By utilizing objective, data-driven models, clinical decision support tools can help minimize unnecessary procedures, reduce readmission rates, and ultimately improve outcomes and lower healthcare costs. As we’ve monitored the market, we’ve noted several companies offering differentiated clinical and surgical decision support services:

Centers of Excellence / Bundled Payments
  • Carrum Health’s platform directly connects self-insured employers to regional healthcare providers through a comprehensive bundled payment arrangement, enabling patients to have greater visibility into their treatment options and reduce their out-of-pocket healthcare costs.
  • Through its two core solutions SurgeryPlus and CareCentral, Employer Direct focuses on those specialty care categories with high degrees of variability in cost and quality including surgical procedures and oncology treatments, providing solutions that align outcomes for providers, patients, and plan sponsors.
Healthcare Shared Decision Making
  • Welvie’s decision, outreach, and analytics programs guide members through the surgery decision-making process, from understanding treatment options to preparing for and recovering from surgery.
Clinical Decision Support and Second Opinion
  • Consumer Medical (Alight) offers clinical advocacy and expert medical opinion services intended to help individuals make informed medical decisions at every point of their healthcare journey. The company offers medical information, research, and clinical guidance services for all medical conditions of the patients, enabling them to navigate the complex healthcare system and access care that leads to better health outcomes at lower costs.
  • 2nd MD (Accolade) Provider of a video consultation platform intended to facilitate users in receiving medical opinions from board-certified professionals. The company focuses on providing expert medical opinions and connecting users to personalized local support and medical navigation services.
Fertility Benefits
The majority of women considering pregnancy get their healthcare coverage from employer-sponsored plans. The average age at which women give birth has been shifting upwards over the last three decades in the United States, with the median age currently above 30; which is correlated with an increased risk of infertility. This trend has driven a growing demand for fertility treatment, alongside potential increased risk-level and cost associated with pregnancies. More broadly, employers have been looking to better support wholistic women’s healthcare, an area that has been historically underfunded. Employers and benefit brokers have been paying attention and are actively looking for solutions to help manage the various stages of preventative care, family planning, and pregnancy including contain costs across fertility cycles. New solutions in this space are focusing on strategies to lower risk across members, by providing proactive (and often digital) preventative screenings, paired with care navigation and concierge services during episodic events. Strategic investors are also forming outpatient facility networks that offer enhanced care coordination with women’s health and fertility benefit providers. Companies are beginning to view fertility benefits as a must-have offering, with nearly 60% reporting family friendly benefits have helped them attract top talent in the last three years. Fertility solutions and women’s health companies expect that number to continue to climb and are actively working to expand their network of facilities, consultants, and care management specialists to respond to the anticipated demand. Relevant companies in this sector include:
  • Progyny (NAS: PGNY) is a leading provider of employer sponsored fertility management programs consisting of treatment services (Smart Cycles), a solution that provides access to Progyny’s network of high-quality fertility specialists while limiting the total cost to the company and employee.
  • Carrot offers a global provider network of fertility specialists as well as financial and administrative support to help alleviate key pain points for employers while offering a wholistic fertility solution.
  • Stork Club is a provider of enterprise-ready fertility and parental benefits including in-house claims processing and flexible coverage packages for self-insured employers.
  • Maven developed a digital health platform for the employer and health plan market designed to improve care for women and families by providing personal care plans, on-demand guidance, and extensions programs such as Maven Wallet and MavenRx to support families throughout the fertility process.
  • Wildflower offers a modular suite of software, support, and services, that offer comprehensive coverage of the entire women’s health ecosystem - the provider, the payer, the family - with a clinically integrated solution that covers both preventative and episodic care.
Employer Chronic Care Management
In the United States, six out of ten people suffer from a chronic illness or disease. The aggregate impact of these conditions costs U.S. employers over $36 billion annually. If left untreated, chronic illnesses can lead to expensive acute care emergency visits and increase the risk of serious medical events such as heart attack, stroke, and organ failure. Employers looking to better control healthcare costs have focused on this category; on average the sickest 6% of the employer insured population accounts for nearly 40% of the overall medical and pharmacy spend. Implementing a strategy to help employees manage chronic conditions can decrease both out of pocket expenses for members as well as overall health insurance costs incurred by the company. Early digital solutions in this space focused on specific chronic conditions such as diabetes management. As the industry began to appreciate the connectivity across multiples chronic conditions (behavioral health, MSK, hypertension, etc.) these companies have started to expand horizontally across point solutions and develop into chronic care platforms. These platforms are now working to demonstrate that they can deliver broad based ROI from a more comprehensive approach to preventative and chronic care management. When used effectively, employers can proactively manage their chronic population, and reap the benefits of healthier, more productive employees alongside decreased overall healthcare consumption. Companies offering chronic care platforms include:
  • Transcarent developed a consumer-directed care platform intended to facilitate improved outcomes and cost-effective decisions. The company leverages a combination of software and data science to empower consumers with information and access, enabling the customers to exercise choice and transparency when addressing chronic conditions in areas such as behavioral health, MSK, and oncology.
  • Vida Health offers a modular platform to employers, health plans, and individuals that combines mental and physical health treatments to support chronic condition management including weight loss, diabetes, sleep health, and stress management.
  • Wondr Health’s solution drives behavioral changes to deliver long-lasting results and improvements for its clients including sustained weight loss and reversal of Metabolic Syndrome, risk factors that can lead to serious health conditions such as type 2 diabetes or heart disease. The company’s programs promote the creation of other health habits leading to increased physical activity, better sleep, and less stress. In 2021 Wondr acquired eMindful, a provider of evidence-based mindfulness programs for everyday life and chronic conditions, to broaden its platform across mental health and provide a more wholistic offering to employers.
  • Renalogic provides dialysis cost containment and renal risk management services intended to reduce kidney-related treatment costs. The company offers dialysis cost control, data analysis and risk prediction, kidney dialysis avoidance program and kidney disease prevention program, thereby helping clients save on their overall medical spending.
As healthcare costs continue to rise, employers are trying to balance containing spend alongside offering attractive benefits that are responsive to the demands of their employees and the broader market. Within an increasingly competitive digital health landscape, solutions that can easily integrate into the employer’s benefit structure, demonstrate tangible ROI, and generate strong utilization rates across employees will find better traction from customers and seek greater attention from the investor community.
Aaron Stets
Calvin Dalton
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