Two Sides of the Coin

How integrating dental, vision and medical improves health management

Health plan administrators, including insurance carriers, have always utilized medical and prescription claims information to better serve the member, and keep costs down. And they continue to ask: "How can we improve the member experience?"

By integrating medical claims information with dental and vision coverage, a health coverage provider can better spot potential problems - and future high-cost claims.

"It makes sense to do. It helps the individual. It helps the employer encourage the good health of their employees. It increases productivity. And it can have a favorable impact on their medical claims and their costs in the long run," says Lee Bowers, specialty sales executive at HealthLink, Inc., a WellPoint company.

"When you talk to employers about their goals for their employee population, you'll see them paying close attention to the wellness story and what can be done to impact costs," he says.

What's an example of integration?

Dentists look for receding gum lines, periodontal disease or anything to indicate your body is not 100 percent. If a dentist sees an expectant mother with periodontal disease that throws up a red flag because she is five to seven times more likely to have a low-birth weight baby. Health plan administrators understand how this impacts the medical side of the coin, so they temper that expense by incorporating dental provisions that can identify potential health risks.

With an integrated health care program, not only is this information shared via the health plan administrator, but proactive steps also can be taken. For example, most plans allow two diagnostic preventative cleanings per year. But if a woman becomes pregnant, she can be authorized additional cleanings as a preventative measure as part of the employer's group plan design.

Don't doctors already talk to each other?

Not as well as they could be. That's where health plan administrators are trying to fill the gap, providing information such as the fact that someone is asthmatic, diabetic or has hypertension. They want to vet the medical information through their legal process to ensure it maintains confidentiality and legal compliance but can best serve the individual.

How is the information used?

It can be used with health care management programs, nurse counselors, nutritionists and other facilitators who can move health plan members toward wellness.

The health plan administrators are experienced at designing incentives and building out contractual provisions to help influence the individual's behavior. They also can assist plan sponsors in engaging with members through communication and educational materials.

Who pays for integration programs?

The cost depends on whether the plan is fully insured or an administrative services only (ASO) contract. Self-funded or ASO contracts are unbundled, so there is a separate fee for each component plan sponsors add to the mix. With a fully insured plan, the cost is embedded because the insurance company's money is at risk.

How can employers figure ROI?

It's not easy to measure how you made a difference in someone's lifestyle. Employers hear promises about ROI, but there's little proof. The biggest indicator is the actions of companies administering member claim information. These companies are starting to put their money where their mouth is - developing and paying for these programs as a part of their cost of doing business. They know paying a little more upfront can have a much greater impact down the road.

A buzzword in health care is wellness. So, what are you doing about it and how can you make a difference in the lives of your employees?

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