In mid-December of 2023, we published an Emerging Trends & Patterns in Healthcare Market Segments white paper that touched on a host of issues and considerations. Contained within was a series of observations around regulatory, legislative, and emerging legal matters.
Since the publication of this paper, Risk Strategies Consulting has devoted substantial resources in researching the underlying issues facing the industry, in terms of the aforementioned regulatory, legislative, and legal matters. We have carefully tracked legislation at the state level, aimed at overturning the Employee Retirement Income Security Act of 1974 (ERISA) Preemption under which self-insured plan sponsors operate. We have also carefully considered the implications of the Consolidated Appropriations Act of 2021 (CAA), along with the status of court cases against both plan sponsors and payors. We are preparing to release a series of white papers designed to inform our clients and hopefully, drive the market towards the needed directional changes.
Our first white paper will examine disclosure, transparency and fiduciary responsibilities of plan sponsors, payors, and consultants. The goal of our publication is to assist plan sponsors in holding both payors and consultants to needed levels of transparency and disclosure, as well as avoidance of conflicts of interest.
The paper will take great care to outline suggested matters of consideration for plan sponsors when undertaking a Request for Proposal (RFP) for either a payor or consultant. Risk Strategies Consulting has also created a series of disclosure questionnaires that are designed to clarify and require disclosure of all direct and non-direct revenue streams realized by medical payors, pharmacy benefit managers (PBMs), consultants, and auditors. These questionnaires are currently utilized by Risk Strategies Consulting and are available to anyone requesting them. We welcome a review and any suggested improvements.
Our second white paper will examine the suggested resources, approaches and depths of audit functions that plan sponsors should consider when selecting third parties to audit and review the performance of selected vendor partners.
Our third white paper will address the widely discussed issue of PBM transparency. This publication will include strong and clear suggested contractual language for plan sponsors to mandate from their PBMs regarding true net acquisition costs. As part of the development of this paper, we reviewed the terms and conditions with three of the four major PBMs. Each agreed that the paper was thorough, fair, and accurate; and contained language they were willing to adopt. We recognize that some readers may think that any language the PBMs are willing to accept in this area may be flawed or limited. We are hopeful that the language will be used as an “open source” starting point, and that knowledgeable individuals will lend a hand in enhancing and/or improving the terms and conditions, so that we can come to a strong common ground within the market.
Our fourth white paper will address the status and significance of the payment integrity (PI) marketplace and vendors. Over the past few months, we have performed a study of the market and its vendors, given the foundational role PI plays in billing and payment practices. Risk Strategies Consulting’s work shows that when PI is properly undertaken, unnecessary care is avoided, and an enhanced opportunity for inclusion of value-based reimbursement evaluation exists.
In addition to the above publications, Risk Strategies Consulting has been researching a number of clinically related issues. We recently published white papers on both Women’s Health and Reproductive Health. In the coming weeks, you will see our work on proper sleep care and management, as well as the current landscape for managing musculoskeletal disease through a whole health lens.
Risk Strategies Consulting welcomes feedback on all of our publications, as well as issues and considerations you would like to see us address. Email us at riskstrategiesconsulting@risk-strategies.com.
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