The answer to managing rapidly rising healthcare costs doesn’t have to be unsavory choices between cutting benefits or doling out more cash, but instead, may be right here, hidden in plain sight – and already contracted and included as a part of your plan’s network. But your employees are unaware. 

 There is a fundamental shift underway in the relationship between health plans and employers – a shift that will not only save employers millions of dollars, but also deliver meaningful improvements in employee health and wellbeing.

In the past, many employers pursued a carve-out strategy — purchasing certain benefits outside of the health plan network to offer more responsive and innovative benefit solutions. This path has largely failed to address year-over-year rising healthcare costs, and has left many employers with a sprawling point solution ecosystem to manage and maintain.  

But the healthcare landscape has undergone a quiet transformation over the past five years. The COVID-19 pandemic and the subsequent Telehealth Safe Harbor Provision pushed health plans to rethink how they build their networks.

Since this shift, health plans – especially national plans – have taken a serious look at how to make their provider networks exponentially more valuable to members and employers. They have evaluated all aspects of population health to identify the most significant access gaps, as well as the biggest cost drivers, and found that virtual care options address both while delivering high-quality experiences. 

 

Many employers haven’t realized until recently that the high-value, cost-efficient care they sought through buy-up solutions is now embedded in their health plan networks, removing the traditional barriers of contracting and implementation, as well as concerns about fragmented care. By offering technology-enabled virtual care in-network, plans have unlocked strategic and integrated opportunities to help patients find high-quality care in the right moments.

These changes are positive for all stakeholders– members and plan sponsors gain access to high-quality care that has superior outcomes without paying more.  In some cases, plan sponsors are encouraged to ‘buy up’ for services already covered—something that neither side may realize, leading to duplicate spend. Looking ahead, the opportunity is clear: plan sponsors must actively  re-evaluate where innovation already exists inside their networks and surface these options to employees—maximizing value without duplicating spend.

What Exactly Are In-Network Providers?

In-network providers are care delivery personnel who have a contract to provide medical services to the health plan members at an agreed upon rate, and in return, get placement in the plan’s provider directory. 

The evaluation structure for in-network providers is rigorous. To start, all in-network care options must meet all medical standards and providers must meet licensing and credentialing standards in their field. Additionally, in-network providers are held to a much higher clinical standard than most point solutions and must overcome an actuarial review to validate value and ensure high standards for outcomes.

Health plans have significantly expanded their networks to include innovative, tech-forward virtual providers. State-of-the-art value-based care models and virtual-first clinics increase access to all members regardless of geography or socio-economic status, giving patients expanded access to next-generation care, building trust with exceptional care experiences, and superior sustainable outcomes.

What Exactly is a Buy-Up Solution? 

The complexity of our healthcare system, along with a desire to avoid a one-doctor-fits-all approach, has led to the adoption of buy-up solutions–specialized healthcare services created to address gaps in care. These buy-up services have conventionally have not met the standard of a covered benefit, and have thus  been carved out of the traditional networks to provide additional support for certain conditions.

Buy-up services have a very different evaluation and incentive structure from traditional in-network coverage. The evaluation filter for buy-up services is based on two factors: first, health plans want to ensure that the buy-up service will not harm patients, and second, they want to know that employers will purchase it. If a buy-up solution meets these requirements, health plans will often add it as a buy-up for plan sponsors. This often creates a valuable revenue stream for health plans, and employers get an employee retention tool. 

Most buy-up solutions have avoided the use of clinical care, in exchange for lower cost more scalable solutions like apps or coaching. This allows them to provide services to large populations without increasing costs, but it eliminates essential clinical access that in-network providers offer.

How can Employers Evaluate and Optimize Benefits?

Striking the balance between employee needs, an organization’s budget, and an organization’s unique values and benefits philosophy can be both challenging and confusing.

So where do you start? Our initial recommendation is simple: Before selecting condition-specific buy-ups, find out what virtual providers are now available in-network with your health plan. Spend some time looking into what is covered as part of your insurance premiums. In-network services are billed through medical claims and don’t require additional contracting, budget, program, or vendor management. 

As you evaluate your plan, here are some questions to ask to guide your research:

  • What buy-up services are you paying for? Are any virtual providers already in-network? Knowing what’s already included in-network will help you cut unnecessary or duplicative costs while identifying care gaps. 
  • What are the essential value levers for your healthcare strategy? You want your partner in a specific condition area to provide comprehensive medical care – to be able to diagnose, prescribe medications, and determine the appropriate lifestyle changes, not just the latter. Plus, make it easily and readily accessible through virtual options.  
  • How do the solutions you have create value for your members? Your benefits should support members in meaningful ways, close gaps in care, and expand access, but the real value comes through improving patient outcomes more quickly. A credible track record of proven outcomes is crucial. 
  • How do you control utilization? Each employer should have built-in stopgaps to their solutions designed to control utilization and reduce unnecessary costs while ensuring access to care for all.
  • How do you evaluate the ROI of buy-up solutions? Work should be done to determine if a buy-up solution is worth your investment and that the promised ROI isn’t just a number.

How to Approach Buy-Ups vs. In-Network

Designing healthcare benefit strategies that deliver higher value, better employee experiences, and measurable outcomes without unnecessary added cost is a challenging yet necessary endeavor.  It’s what allows your employees access to the care they need, without incurring a significant cost to your company. 

By activating your network solutions– essentially packaging your network and buy-up services into clearly defined, standardized offerings– you can transform their benefits offerings, ensuring clarity and accessibility. By asking the questions above and determining what benefits are truly delivering value to your employees, you can strike a balance between offering excellent benefits and managing costs. 

We pursued the rigorous but appropriate path to give plan sponsors and their employees access to Oshi as an in-network provider. Our clinic meets the rigorous standards (clinical, actuarial, affordability) for in-network inclusion with major health plans, allowing us to provide high-quality and effective GI care as a medical benefit, paid for by medical claims, integrated into medical care networks – and significantly improving medical budgets.