What Employers Should Know About Covid-19 Testing When Bringing Employees Back To Work

What Employers Should Know About Covid-19 Testing When Bringing Employees Back To Work

The COVID-19 pandemic has played out with unexpected twists and turns. The truth is, with a novel infection such as this one, we have to learn as we go along. This has been apparent as we’ve watched public health agencies, state and federal governments and essential businesses respond to the pandemic every step of the way. This is also true for how we track the infection and its immunity.

Employers need guidance on COVID-19 testing. Companies are asking who should we test, when and how often should we test, what do we do with the results and, what kind of testing should we use?

Types of testing for COVID-19

It is important to understand how we test for COVID-19 infection and how we test for presumptive immunity to the infection. There are two different types of tests – diagnostic tests and antibody tests.

  1. A diagnostic test can show if you have an active coronavirus infection and should take steps to quarantine or isolate yourself from others. Currently there are two types of diagnostic tests – molecular (RT-PCR) tests that detect the virus’s genetic material, and antigen tests that detect specific proteins on the surface of the virus.
  2. An antibody test looks for antibodies that are made by the immune system in response to a threat, such as a specific virus. Antibodies can take several days or weeks to develop after you have an infection and may stay in your blood for several weeks after recovery. Because of this, antibody tests should not be used to diagnose an active coronavirus infection. At this time researchers do not know if the presence of antibodies means that you are immune to the coronavirus in the future.

What Employers Should Know About Covid-19 Testing When Bringing Employees Back To Work 1

The FDA is also tracking new diagnostic tests available with alternative methods and benefits.

  • Rapid, point-of-care diagnostic tests use a mucus sample from the nose or throat but can be analyzed at the doctor’s office or clinic where the sample is collected and results may be available in minutes. These may be molecular or antigen tests.
  • At-home collection tests are prescribed by a doctor but allow the patient to collect the sample at home and send it directly to the lab for analysis.
  • Saliva tests allow a patient to spit into a tube rather than get their nose or throat swabbed. Saliva tests may be more comfortable for some people and may be safer for health care workers who can be farther away during the sample collection.

Reliability of these tests have improved and whereas symptomatic testing is usually paid for by medical insurance carriers, there are significant gaps in coverage for other types of testing (see below). Testing for asymptomatic employees (and dependents) is usually not covered. Guidance on diagnostic testing has shifted over the past several months in the United States as more testing becomes available. Most of this guidance, notably, is intended for health care professionals. 

The guidance and use of antibody (immunity) testing is still evolving. There have been more questions around reliability of these tests and the dust has not settled on how or whether employers should leverage antibody (presumptive immunity) testing. 

What does the sensitivity of a Covid-19 test mean?

Sensitivity measures how often a test correctly generates a positive result for people who have the condition that’s being tested for also known as the “true positive” rate. 

A test that’s highly sensitive for current COVID-19 virus infection will flag almost everyone who currently has the virus and not generate many false-negative results. 

For example: a test with 90% sensitivity will correctly return a positive result for 90% of people who currently have the virus, but will return a negative result — a false-negative — for 10% of the people who currently have the virus and should have tested positive.

What does the specificity of a Covid-19 test mean?

Specificity measures a test’s ability to correctly generate a negative result for people who don’t have the condition that’s being tested for also known as the “true negative” rate. 

A high-specificity test for the COVID-19 virus will correctly rule out almost everyone who currently doesn’t have the virus and won’t generate many false-positive results. 

For example: a test with 90% specificity will correctly return a negative result for 90% of people who currently don’t have the virus, but will return a positive result — a false-positive — for 10% of the people who currently don’t have the virus and should have tested negative.

Testing for COVID-19 infection in the workplace

It should be noted that much of the return to work preparedness and business continuity planning involves making adjustments to workplaces, operating procedures, administrative protocols and the requirements for work-from-home versus onsite work. The Occupational Safety and Health Administration (OSHA) points out that employers should continue to implement the basic hygiene, social distancing, workplace controls and flexibilities, and employee training described in this guidance in ways that reduce the risk of workplace spread of COVID-19, including by asymptomatic and pre-symptomatic individuals.

In the OSHA Guidance to Returning to Work [4045-06 2020] employers may consider implementing strategies to reduce risks to the safety and health of workers and workplaces from COVID-19 that include conducting diagnostic testing. “Neither the OSH Act nor OSHA standards prohibit employer testing for diagnostic testing, if applied in a transparent manner applicable to all employees (i.e., non-retaliatory)” the guidance affirms. 

Because of the limitations of current testing capabilities, employers should act cautiously on negative test results. OSHA is quick to point out that employers should not presume that individuals who test negative for COVID-19 infection present no hazard to others in the workplace. 

OSHA also provides guidance and resources for employers and employees  on the control and prevention of COVID-19 by industry. This guidance applies to all workers and employers, while other sections focus on those at lower risk of exposure and those with increased risk of exposure, including workers involved in:

  • Airline operations
  • Border protection and transportation security
  • Business travelers
  • Construction
  • Correctional facility operations
  • Dentistry
  • Emergency response and public safety
  • Environmental (i.e., janitorial) services
  • Farmworkers (developed in partnership with CDC)
  • Healthcare
  • In-home repair services
  • Laboratories
  • Manufacturing (developed in partnership with CDC)
  • Meat and poultry processing (developed in partnership with CDC)
  • Postmortem care
  • Retail operations
  • Solid waste and wastewater management 

Testing asymptomatic employees for infection

According to the May 2020 CDC Activities and Initiatives Supporting the COVID-19 Response and the President’s Plan for Opening America Up Again, testing of asymptomatic individuals is a growing consideration as the role of asymptomatic and subclinical infections in transmission becomes more apparent. 

Emerging evidence suggests that asymptomatic infections may play an important role in the epidemiology of the disease. Nevertheless, it is important to define the circumstances where testing asymptomatic persons is likely to be helpful in controlling the COVID-19 pandemic. 

The CDC provides further clarification that effective testing programs will focus on (1) persons with an increased likelihood of infection and (2) settings with particularly vulnerable populations, including but not limited to the following: 

  • Contacts of known (symptomatic or asymptomatic) cases. This may include testing of contacts going back one to two weeks before the onset of symptoms, particularly contacts who work with vulnerable populations.
  • Staff of long-term care facilities. Periodic testing and sentinel surveillance in these settings may serve to detect outbreaks early in this setting, where devastating outbreaks are known to occur and to be associated with high rates of asymptomatic infection. 
  • Other healthcare facility workers and first responders. Healthcare facilities may consider testing staff periodically, starting with staff in high traffic, high risk areas such as emergency departments.

Workforce: CDC guidance on “vulnerable individuals”

As workplaces consider re-opening it is particularly important to keep in mind that some employees are at higher risk for severe illness from COVID-19. These vulnerable workers include individuals over age 65 and those with underlying medical conditions (regardless of age). Such underlying conditions include, but are not limited to, chronic lung disease, moderate to severe asthma, hypertension, severe heart conditions, weakened immunity, severe obesity, diabetes, liver disease, and chronic kidney disease that requires dialysis. Vulnerable workers should be encouraged to self-identify, and employers should avoid making unnecessary medical inquiries. Employers should take particular care to reduce vulnerable workers’ risk of exposure to COVID-19, while making sure to be compliant with relevant ADA regulations.

OSHA recommends that employers should identify workers who may be at increased susceptibility for COVID-19 infection or complications and consider adjusting their work responsibilities or locations to minimize exposure. Other flexibilities, if feasible, can help prevent potential exposures among workers who have diabetes, heart or lung issues, or other immunocompromising health conditions. 

Serology testing for immunity to COVID-19

The CDC recently acknowledged that serologic testing may play a role in a back-to-work strategy provided it can be shown that serologic testing can reliably infer immunity. This immunity may not need to be absolute: protection against severe infection may be enough even if immunity against reinfection isn’t reliable or durable. Some employers, and some industries in particular are counting on serologic testing for immunity.

While there appears to be considerable public optimism that serologic testing will allow return to work without the need for PPE or other precautions, there are many unknowns at this early date that limit implementation of serology for this purpose. 

There is a need for high-level consensus on the role of serologic testing in a back-to-work policy. Consensus is also needed on a plan for how to provide documentation of that immunity, be it through federal- or state-based immunity registries, digital proof-of-immunity, or physical documentation such as “immunity certificates”. Despite these limitations, continued interest in the use of serologic testing in a back-to-work policy is likely.

In its most recent guidance, however, CDC Interim Guidance said that antibody test results “should not be used to make decisions about returning persons to the workplace.” 

In light of this CDC guidance, under the ADA (Americans With Disabilities Act) an employer may not require antibody testing before permitting employees to re-enter the workplace. An antibody test constitutes a medical examination under the ADA. An antibody test at this time does not meet the ADA’s “job related and consistent with business necessity” standard for medical examinations or inquiries for current employees. Therefore, requiring antibody testing before allowing employees to re-enter the workplace is not allowed under the ADA.  

Of note the EEOC acknowledges that an antibody test is different from a test to determine if someone has an active case of COVID-19 (i.e., a viral test).  The EEOC has already stated that diagnostic COVID-19 viral tests are permissible under the ADA. The EEOC will continue to closely monitor CDC’s recommendations, and could update this discussion in response to changes in CDC’s recommendations.

What’s covered?

As of this writing, most insurance carriers will cover COVID-19 testing under certain circumstances and employers should factor costs into their plans to include these tests in business continuity planning and execution. Employers should be sure to contact their insurance carrier(s) and understand exactly what is and what is not covered under each of their health plans. Insurance testing for coverage will almost certainly be a moving target, so employers should plan to monitor insurance carrier communications and postings on a regular basis.

Medical insurers typically don’t cover medical services that aren’t ordered by a health care professional, or that aren’t considered medically necessary in fully insured, or through medical insurance administered self-funded plans. As an example, pre-employment testing for job requirements are usually paid by the employer themselves. Some insurers and health plan administrators explicitly exclude surveillance testing for their members.

According to a recent AXIOS article, UnitedHealthcare, for example, says that “we will cover medically necessary COVID-19 testing at no cost-share…when ordered by a physician or health care professional.”

  • BlueCross BlueShield of South Carolina will cover diagnostic tests “when ordered by an attending health care provider and provided at the point-of-care for individuals who are symptomatic and are concerned about infection.”
  • Blue Cross and Blue Shield of Kansas City will cover both diagnostic and antibody tests “with no cost share if you have symptoms consistent with COVID-19 and your physician orders the test.” 
  • BlueCross BlueShield of Mississippi  says it won’t cover tests that are “not medically necessary,” which includes tests for asymptomatic people as part of public health monitoring efforts or screenings for returning to work. 

Not every insurer has added coverage limitations. Aetna, which is owned by CVS, has waived cost-sharing for all diagnostic tests, which “can be done by any approved testing facility.”  

Partnering with employers on COVID-19 testing

Employers are interested in partners who can help them deploy, manage and track testing. If new testing technology enables that, it must have the proper regulatory approvals solidly in place. FDA approval is paramount. Healthtech companies or test provider must remember that there are tremendous liabilities attached to all aspects of this testing- companies are looking for demonstrable reliability and sufficient specificity and sensitivity.

Employers need to follow CDC’s and the Occupational Safety and Health Administration (OSHA) guidance for reducing workplace exposure for all employees. All decisions about following these recommendations should be made in collaboration with local health officials and other State and local authorities who can help assess the current level of mitigation needed based on levels of COVID-19 community transmission and the capacities of the local public health and healthcare systems. In addition, specific industries may require more stringent safety precautions. Finally, there may be essential workplaces in which the recommended mitigation strategies are not feasible.

It is important for any test provider   to fully appreciate the regulatory landscape that employers face. This is the time to be a true partner.

What Employers Should Know About Covid-19 Testing When Bringing Employees Back To Work 2

Ronald S. Leopold, MD, MBA, MPH, Physician Consultant

MDisrupt Advisor and Senior Consultant Specializing in Employee Benefits, Medical Cost Solutions, New Medical Technology

As a credentialed and experienced professional, Dr. Leopold brings credibility and a breadth of knowledge as a consultant, client advocate, and marketplace spokesperson. He is an industry thought leader in employee benefits and health and productivity.

Specialties: Medical Costs, High Cost Claimants, New Medical Technologies, Employee Benefits, Heath and Productivity, Population Health Data Analytics, Global Workforce, Generations in the Workforce, Financial Wellness, Thought Leadership, Public Speaking.

At MDisrupt we can help, If you are an employer wanting to deploy back to work protocols and would like expert guidance – please contact us.   

If you are a test developer wanting to access the Employer market we can help you understand the strategies and protocols necessary to be successful.

Talk to us—we can help.

Understanding Medical Necessity: Guidance for Healthtech Companies to Address Medical Insurance Coverage Limitations

Understanding Medical Necessity: Guidance for Healthtech Companies to Address Medical Insurance Coverage Limitations

Many healthtech companies want to access the self-insured employer market.  In my previous blog, How Healthtech Companies Can Successfully Access the Self-Insured Employer Market I highlighted the important factors that healthtech companies need to consider when accessing this channel.  Many companies focus on this channel as a way to commercialize and drive adoption before their product is reimbursed by a health insurance plan.

The goal of this blog is to help you understand some of the key definitions that are important to understand in this channel and the process by which decisions are made.

Let’s get familiar with the important definitions: 

  • Self-Insured Employers: While the risk falls on the insurance company in a fully insured plan, in a self-insured plan the employer or company assumes most of the risk. Businesses that have self-insured plans must pay for employee medical claims and associated fees from their own general assets. Larger employers tend to be self-insured. The percentage of medium and smaller companies that self-insure is growing significantly.
  • Insurance Company: A company that offers health plans to customers. These can also be known as medical insurance companies or health insurance carriers.
  • Health Plan: A health insurance policy with defined benefits coverage. An employer can offer several health plans, from one or several health insurance companies.
  • Benefits Coverage: Defines both the dollar amounts of coverage (i.e., contributions, deductibles and copays) and the medical services covered.
  • Medical Necessity: A determination as to whether and when a medical service should be covered (paid for) by the insurance company.
  • Clinical Policy: A written document containing the clinical rationale for medical necessity determinations for a particular medical treatment or diagnostic.

Now that we understand the terms, let’s get back to the central conundrum that new healthtech companies face: 

“Why should I pay for this if it isn’t covered by the insurance company?”

In other words, If an employer’s medical insurance company doesn’t cover a diagnostic or therapeutic service, why should the employer consider buying it separately?

The answer is found in the corridor between “medical necessity” and what can be argued is genuinely “medically necessary.”  In order to prove that your product/service is medically necessary, you first need to understand the medical insurance company’s medical necessity policies for your technology.

Medical Necessity: Health Plan Clinical Policies

As defined above, medical necessity is the process for determining benefits coverage and/or provider payment for services, tests or procedures that are medically appropriate and cost-effective. 

Some policies may be developed internally, some externally. Most medical insurance companies maintain a clinical policy unit of internal and external clinical advisors that apply their own process of medical diligence which includes: 

  • Regularly monitoring new treatment, technologies and indications

  • Reviewing new treatments submitted for coverage

  • Searching the National Library of Medicine’s PubMed database of peer-reviewed medical literature

  • Assessing regulatory statutes of new technologies (e.g., FDA)

  • Reviewing evidence-based clinical practice guidelines, such as the Agency for Healthcare Research and Quality’s (AHRQ) National Guideline Clearinghouse database

  • Reviewing recommendations of national medical societies and their guidelines.

  • Considering the indications accepted by the USP DI (United States Pharmacopeia-Drug Information) and ASHP (American Society of Health-System Pharmacists) for drug treatments

  • Assessing the opinions of relevant experts where necessary.

As described in my previous blog, most employers have insurance companies, or some other plan administrator, process medical claims. These insurance companies and administrators abide by a set of clinical policies around medical necessity established by the clinical policy unit(s). These policies apply these criteria for assessing a service, test or procedure:

  • Is it in accordance with generally accepted standards of medical practice?

  • Is it clinically appropriate and effective?

  • Is it not primarily for convenience?

  • Is it not more costly than an equivalent alternative service?

  • Is it endorsed or recommended by national medical societies and associations?

  • The technology must have final approval from the appropriate governmental regulatory bodies, when required. FDA approval, where applicable, is necessary but not sufficient to meet coverage criteria.

  • Medical insurance companies are not obligated to follow Medicare policy for their commercial members. Medicare coverage policy is often considered, however, in formulating clinical policies for commercial plans.

Medical necessity determinations arise most commonly where the service requested is subject to pre-authorization procedures. Here are some of the most common categories for pre-authorization:

Frequently Required Pre-Authorizations

Understanding Medical Necessity: Guidance for Healthtech Companies to Address Medical Insurance Coverage Limitations 3

The challenge, then, is how a healthtech company justifies the cost of the new service in light of the medical insurance company’s clinical policy. In order to do that, a healthtech company needs to understand what the clinical policy language is for medical insurance companies,recognizing that they can often vary.  In some cases, levels or degrees of coverage (including frequency, duration, pre-authorization requirements) may vary based on group plan design. Examples include: number of allowed physical therapy visits, coverage for alternative treatments such as acupuncture, and length of stay for substance abuse rehab.

Each policy includes: 

  • Coverage rationale that includes the scope of the decisions rendered, as well as their context

  • Documentation requirements for treating providers

  • Definitions of terms used in the policy

  • Applicable codes including CPT (medical procedures) and ICD10 (medical diagnosis) codes 

  • Description of services, e.g. a more complete review of when and how the services addressed shall be treated

  • Clinical evidence including a discussion of major studies, guidelines and other research used to craft the decision. These are defined here in the blog The Formula for Widespread Adoption of health Products that Every Investor and Healthtech Entrepreneur Needs to Know.

  • US Food and Drug Administration status, including relevant approvals from the FDA

  • Centers For Medicare And Medicaid Services status, including relevant information about what Medicare and Medicaid typically cover in the area addressed

  • References e.g. a useful bibliography for healthtech companies

  • Policy history/revision information e.g. a review of previous iterations of the current policy

  • Instructions for use e.g. a description of how the medical insurance company administers the policy.

Depending on the type of service, some healthtech companies may directly pursue the insurance companies. In most cases, however, marketing healthtech services directly to the self-insured employer should include a rationale as to why the covering insurance company does not cover the product or service.

Clinical policies can also be leveraged to identify what sources are used to establish the relevant clinical policy. The sources include: individual academic studies, national medical society guidelines, federal agency criteria (such as the FDA), federal institute guidelines (such as the CDC and the NIH), specialty and subspecialty medical colleges and organizations, and a fair number of others. These materials may be useful to make the case for your product or service.

Examples of Medical Insurance Company Clinical Policies:

For purposes of illustration, the following is a small subset of some of the clinical policies published by United Healthcare in a single year period.

Understanding Medical Necessity: Guidance for Healthtech Companies to Address Medical Insurance Coverage Limitations 4

Key Points For HealthTech Founders

  • Healthtech companies need to understand how health insurance companies define medical necessity in order to make the case for the solution they are bringing to the self-insured employer.

  • Medical necessity defines what is covered by a health insurance plan in a general population. That definition is intended to protect the self-insured employer and its covered members from paying for medical services that are excessive, cost-inefficient, or not clinically warranted. 

  • The opportunities for healthtech companies looking to directly reach self-insured employers lie in making the case for the business value of the solutions offered. 

Medical Necessity: Finding the Leading Edge, Avoiding the Bleeding Edge

In my next blog post, we will examine how healthtech companies can make the case for medically necessity even when an employer’s health plan does not cover the service. 

This includes addressing the following questions: 

  • What are the major reasons that a new approach should be covered even when the medical insurance company doesn’t cover it?
  • What advantages does your approach have (i.e., selection of appropriate members, place of service, etc.) that are not currently in place that can help maximize the return of investment for the service?
  • Why should an employer proactively include this service and pay for it above and beyond what is covered by the medical insurance company?
  • Will the service bypass, reduce, pre-empt or help avoid other costs incurred by the employer’s health plan?
Understanding Medical Necessity: Guidance for Healthtech Companies to Address Medical Insurance Coverage Limitations 5

Ronald S. Leopold, MD, MBA, MPH, Physician Consultant

MDisrupt Guest Blogger Specializing in Employee Benefits, Medical Cost Solutions, New Medical Technology

As a credentialed and experienced professional, Dr. Leopold brings credibility and a breadth of knowledge as a consultant, client advocate, and marketplace spokesperson. He is an industry thought leader in employee benefits and health and productivity.

Specialties: Medical Costs, High Cost Claimants, New Medical Technologies, Employee Benefits, Heath and Productivity, Population Health Data Analytics, Global Workforce, Generations in the Workforce, Financial Wellness, Thought Leadership, Public Speaking.

Accessing the self-insured employer channel correctly takes special expertise. If this channel is key to your commercial strategy, talk to us—we can help.

How Healthtech Companies Can Successfully Access the Self-Insured Employer Market

How Healthtech Companies Can Successfully Access the Self-Insured Employer Market

So, you have a new health technology that you’ve packaged into a hot product offering. You’re excited about your product. As you think about going to market, you practice reciting all the great things about your offering. This product’s going to take the world by storm! Your largest potential market: self-insured employers.

You’re not alone. The self-insured employer (SIE) marketplace is enormous. And with each year, more medium-sized and smaller employers are joining the fray. According to the most recent EBRI (Employee Benefit Research Institute) findings research, 78.5% of employers with 500 or more employees offered a self-insured health plan. That’s translates into more than 56,000 plans covering more than 75 million participants, according to a recent Deloitte study prepared for the Department of Labor.

However, self-insured employers are barraged by “next best thing” solutions touting a new technology that will revolutionize the marketplace in a new or unique way. Some recent examples include:

  • A new diagnostic blood test to help fine tune the treatment for certain kinds of cancer

  • A new application of telecommunications technology to optimize patient/provider interaction

  • Targeted pharmacogenomic testing for psychiatric therapeutics

  • A new stem cell treatment for joint injuries

  • A condition-specific self-management app

  • A new imaging technology that can be offered onsite.

Key Strategies That Drive SIE’s Business Goals

So how can you break through the noise and get attention in this crowded market? First, you need to understand what  self-insured employers are trying to accomplish. The four key strategies that usually drive SIE business goals for benefits are:

  1. Medical cost reduction through plan design
  2. Medical cost reduction through marketplace innovation
  3. Improved member engagement in health and wellness
  4. Improved workplace engagement and performance 

Self-funded health insurance plans enable employers to better customize plan and coverage options, as well as to better target cost-saving strategies. Naturally, employers struggling with escalating medical costs are looking for the next big thing. SIEs, in particular are sensitive to medical costs since they are spending “their own” money. 

To do this, employers typically choose one of two options: an Administrative Service Only (ASO) plan from an insurance carrier, or a Third Party Administrator (TPA) plan. ASOs tend to be more turnkey, offering ease of administration and more limited plan options. TPAs tend to be more flexible and enable employers greater choice in plan design and offerings. The distinction is important, as the appetite and feasibility for new solutions increases with greater employer flexibility.

How to Convince SIE’s to Adopt Innovation 

Many SIEs are willing to consider leading edge solutions if they can be convinced that the return on investment is worth the risk and the hassle. 

Understanding not just what your new product offers but how it aligns with what a particular SIE wants to accomplish makes all the difference in the world. Understanding employer cost drivers and identifying specific ways that those costs might be avoided or reduced is key to making a smart, targeted pitch to your potential customers.

Many healthtech companies promise medical cost reduction through marketplace innovation. But they often underestimate the level of detailed understanding of medical spending that SIEs and their advisors have. Increasingly, employers can influence cost trends and clinical drivers to an impressive degree.  Some of the key factors many SIEs consider include

  • Cost per member

  • Utilization trends 

  • Acute and chronic conditions 

  • Gaps in care 

  • Risk scores pharmacy/medical ratios for their plans.

These metrics can be further analyzed by company location, member type (employee, spouse and dependent), and by plan.

It is vital to understand precisely what metrics your new health product will impact, and how it will change them in new ways.

What the Self-Insured Employer Needs to Know From You

Do commercial medical carriers pay for your service? If not, why not?

Most SIEs have an insurance carrier, or some other plan administrator, process their medical claims. These carriers and administrators abide by a set of clinical policies that relate to medical necessity. Some policies may be developed internally, some externally. Some common examples include: 

  • Is your service  in accordance with generally accepted standards of medical practice?

  • Is it clinically appropriate and effective?

  • Is it not primarily for convenience?

  • Is it less expensive than an equivalent alternative service?

  • Is it endorsed or recommended by national medical societies and associations?

  • Does your technology have final approval from the appropriate governmental regulatory bodies, when required? (FDA approval, where applicable, is necessary but not sufficient to meet coverage criteria.)

  • Is your service covered by Medicare? While carriers are not obligated to follow Medicare policy for their commercial members, it is often considered in formulating clinical policies for commercial plans.

How will your health product disrupt the status quo? 

When considering a new diagnostic, therapeutic or behavioral change solution as part of an employee benefits plan, there are some basic questions you should be prepared to answer for a SIE:

  • What does the new capability offer?

  • What is the upside of offering the new technology?

  • What are some of the potential downsides?

  • Do the benefits outweigh the costs?

  • Is it medical necessary? Is it advisable?

  • What population is it intended for?

  • How will it be implemented and what are the costs associated with implementation? (I.e. does it require a blood draw or physician order, and if so are those baked into the solution and costs?)

  • What are the ethical and legal ramifications of including this in the benefits program? 

  • What’s the ROI or the VOI (Value on Investment)? Can you prove it?

  • Are any other employers doing this? Why or why not?

The Practicalities: What a Smart Self-Insured Employer Looks For

In addition to understanding the details of what you offer and believing that it will accomplish what you say it will, employers need some assurances about your own credibility. Here are a few additional questions they might have for you? 

  • Can you do what you say you will do, and do it well?

  • Do you have a proven track record?

  • What will the service experience for the employees? For their families?

  • What will we see from you?

  • What kind of reporting do you offer back to us?

Anticipating this piece of the conversation is vital for new healthtech disruptors: The more you can answer these questions truthfully and with confidence, the better your position to get to the next step.

Wherever possible, providing a predicted ROI is advisable (a range is acceptable). Assume that your SIE has a sophisticated understanding of ROI and be as specific as possible. Dollars spent on your product and program should be demonstrable by key indicators. Thinking through the “what ifs” shows you understand their world. An even stronger case can be made if you’re willing to put dollars at risk. 

How Healthtech Companies Can Successfully Access the Self-Insured Employer Market 6

Before you knock on the door, have proof of concept. Pilots or case studies are critical to your credibility. Upstart enterprises will inevitably face a “chicken and egg” conundrum for this.  You need to solve for that. Funding your own study in some way may be something to think about.

Key Considerations

  • Every employer is different. Be prepared to pivot your pitch to meet what the SIE is really after.
  • An employer’s appetite for change and innovation will vary widely based on the views of decision makers, and the realities of benefits delivery for that company. Most times, “new and shiny” just isn’t enough.
  • Claims of medical cost reduction need to be credible and data driven. Understand the actual drivers of medical costs for SIEs and, if possible, touch on key cost “hot spots.”
  • Make sure you have carefully thought through the member (user) experience, as well as the employer experience.
  • Be prepared to explain why carriers don’t cover your diagnostic or therapeutic services as part of their core plan offering.

How Healthtech Companies Can Successfully Access the Self-Insured Employer Market 7

Ronald S. Leopold, MD, MBA, MPH, Physician Consultant

MDisrupt Guest Blogger Specializing in Employee Benefits, Medical Cost Solutions, New Medical Technology

As a credentialed and experienced professional, Dr. Leopold brings credibility and a breadth of knowledge as a consultant, client advocate, and marketplace spokesperson. He is an industry thought leader in employee benefits and health and productivity.

Specialties: Medical Costs, High Cost Claimants, New Medical Technologies, Employee Benefits, Heath and Productivity, Population Health Data Analytics, Global Workforce, Generations in the Workforce, Financial Wellness, Thought Leadership, Public Speaking.

If you are interested in exploring the Self Insured Employer channel for your healthtech product, MDisrupt has a network of experts that can help. Talk to us—we can help.