Partnering with employees to save healthcare costs

There’s an enormous amount of waste & inefficiency in musculoskeletal benefits. The primitive benefit designs prevalent in most companies keep employees away from discovering the actual cost of care. The existing system is constantly shifting costs to employees, often without informing people of those costs in advance. This creates no incentive whatsoever for employees to explore conservative treatment options or shop for higher quality care. Until people are able to connect the cost of care to their out-of-pocket spend, they should not be expected to change.

Steering employees away from overpriced healthcare providers through benefit design incentives and helping them make better care decisions can drive down costs for everyone. However, doing so requires disciplined execution of efforts that obtain employee buy-in and commitment to necessary decisions and behavior changes.

Positive messaging

Communication of any cost-cutting initiative needs to be handled carefully. Start by helping employees understand why savings matter in the first place. Share with them the effect of making better decisions to their financial well-being and enrichment of their benefits.

Make it simple

Employees should be empowered with the right tools and support that helps them make better decisions. Create an easy shopping experience that provides clarity on best treatment solutions for their current needs and suggests high-quality, low-cost providers. Remove barriers such as ‘deductibles’ that cloud people’s judgement in making a better decision.

Timely Education

Including cost-saving suggestions during open enrollment is not enough. It won’t sink in the first time. Repetition is essential. The cost-saving targeted messages should be delivered at health fairs and when people are looking for care, via multiple channels.

Share the savings

Allowing employees to personally share in the savings they generate can go a long way. Tying incentives directly to cost-sensitive behavior encourages people to seek out ways to save.

Measure the ROI

Evaluate your investments against overall cost savings, tweak it regularly to gain the maximum impact.

At Sprite Health, we work hard every day to help self-funded employers design simpler, lower-cost, higher-value musculoskeletal benefits. Sprite empowers your people with simple, transparent, upfront pricing for services and treatments that address their specific needs. With hands-on support by our concierge, your people get a seamless, personalized experience that makes accessing, understanding, navigating and paying for care effortless.

Meeting the Changing Demands of Health Benefits

Working in employee health benefits is a very rewarding experience. There are only a few opportunities in corporate life that offer the ability to positively impact the lives of so many people. However being a benefit leader is a hard job. The complexity and ever-changing landscape can be quite challenging.

The latest challenge is the explosion of new point solutions in the health benefits market. Besides medical, dental, vision and pharmacy, benefit leaders are constantly sifting through voluntary, supplemental, indemnity and many other types of benefits. On top of all this, hundreds of new and innovative digital health benefits are available in the market – each claiming to impact health outcomes and reduce costs. While a thriving ecosystem of health benefits can be a great thing, for many companies it has become a source of aggravation, with growing administrative and technology burden of implementation and engagement.

The expectations of employees from their health benefits are also changing faster than ever before. For several years now, companies have been steadily shifting the cost burden (premiums, deductible and copay) to employees, who have now started to expect personalization and suitability of offered benefits to their unique needs.

How can companies meet the fast changing demands of health benefits, and provide a delightful experience to employees?

They can start by bring all benefits together in a single platform. This is much more than providing links on your intranet. This is about truly integrating benefits – on one website and mobile app. One login to access all benefits, integrated appointment scheduling across providers, integrated health records, claims and a seamless, unified interface for employees.

With such a platform, you can start to monitor what programs are working and fix which ones are not. You can start to personalize programs to meet the specific needs of each employee. You can start to engage employees by presenting them the right care, from the right provider, using the right benefit, at the right time.

There is no doubt that benefit leaders are working very hard to make a difference in employee’s health and well-being. Having a command-and-control system to manage and optimize all benefits will make their life easier and provide them the ability to deliver personalized and complex solutions, regardless of their size.

At Sprite Health, we work hard every day to help self-funded employers design simpler, lower-cost, higher-value musculoskeletal benefits. Sprite empowers your people with simple, transparent, upfront pricing for services and treatments that address their specific needs. With hands-on support by our concierge, your people get a seamless, personalized experience that makes accessing, understanding, navigating and paying for care effortless.

Outcomes-based benefit design for primary care


Primary care remains underutilized in most self-funded plans. Employees and dependents continue to go to specialists and ER for services which can be more cost effectively treated under primary care setting. Meanwhile due to lack of “significant” demand, primary care physicians are seeing more patients, spending less time with each one and increase their income by frequently using lab testing and imaging. These unnecessary ER visits and tests end up eating a big bite of the plan budget.


This challenge provides an opportunity to the employer to re-define primary care benefit based on predictable costs and specific outcomes.  A design where easily accessible, low-intensity  longitudinal care is provided by primary physicians in a lower cost, high-value primary care setting.


This benefit can be delivered in a “carve out” model by direct partnership between employer & PCMH (patient-centered medical home) or “included” in the broader plan contracted with an ACO or an integrated health system.


Most most employees, the primary care can make up 80-90% of healthcare. The primary care must include preventive care as well as routine visits. Depending upon the capabilities of the partner network, you may choose to include chronic care as well.

For any service that lands outside of that should be closely overseen by the designated primary care physician.

Plan Goals

Besides keeping workforce healthy, the plan goals should specifically include:

  • Reduction in total claim costs for employees and dependents.
  • Significant reduction in ER and outpatient claims.
  • Metrics to measure improvement in chronic care management.

Plan Design

For primary care, VBID (value-based insurance design) can be an innovative solution to maximizing health outcomes with available health care budget.  The basic premise of VBID is to align consumer incentives and payment strategies with value by reducing barriers to high-value health services.

For example, you can choose to reward members for selecting PCP at enrollment and reduce or eliminate copays for office visits, annual physical exam, physical examinations, gyn visits, mammograms, cancer screening, smoking cessation, weight management etc.  This will redirect care to the primary care setting to help you eliminate inefficient and unhealthy healthcare system access downstream.

Any additional costs for such incentives can be balanced by raising co-pays and/or co-insurance for using “unnecessary” ER visits.

Payment Model

Services in this model should be paid for through subscriptions. Employees should enroll in the medical home, and physicians should be paid a risk-adjusted amount per enrolled member per month. The risk adjusted score can be based on a mutually agreed methodology for determine low, moderate and high risk members.

Low Risk: Healthy members with very limited need of care.

Moderate Risk: Members with one or more chronic condition.

High Risk: Members with multiple chronic illnesses, and who are accessing healthcare regularly.

Provider Incentives

To better align physicians, you may choose to add incentives (based on health outcomes and other metrics) on top of the subscription costs.

Plan Metrics

Since the goals of the new model is to improve general health, redirect care to primary care setting, manage chronic conditions and manage referrals, metrics should include-

  • Reduction in PMPM costs for specialist, ER and Outpatient care.
  • Reduction in overall claim costs.
  • Improvement in health outcomes based on conditions managed in care plans. For example, how average drop in HbA1C levels for all members enrolled in diabetes intervention programs.
  • Number of referrals managed.
  • Member engagement in their care plans.
  • # of same day/next day appointments.
  • HEDIS metrics for primary care

Talk to us about how our health insurance solution can reduce costs, improve health outcomes and provide you better visibility &  control over your health benefits.

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