Self-Insured Plan Reporting: Key Elements for Insight into Plan Spend, Utilization, and Performance

By Team PCM | Oct 31, 2024 | Blog post, Plan Management, Contract Management

Self-insured employers face the ongoing challenge of managing healthcare costs while ensuring their plans deliver optimal value to employees. Reporting is critical in this process, providing plan sponsors with the data needed to understand plan spend, track utilization, and assess performance. By focusing on the correct elements, self-funded employers and their broker partners can use reporting to effectively validate their pharmacy programs and supplemental solutions.  

Report on Plan Spend 

One of the most critical aspects of self-funded plan reporting is understanding where and how plan dollars are spent. Detailed spend analysis allows plan sponsors to: 

• Break Down Costs by Service Type: This includes pharmacy versus medical spend, helping plan sponsors identify high-cost areas and opportunities for cost containment. 

• Track Spend by Member Population: Employers can segment their data by member groups, such as employees, dependents, or retirees, to understand how utilization patterns impact total spend. 

• Monitor Trends Over Time: Analyzing spend over months or years provides insight into emerging trends and helps employers predict future costs. This is especially important when managing chronic conditions or high-cost specialty medications.
  

Accurate spend analysis is essential for validating the effectiveness of a PBM program. Employers can track if the PBM delivers on cost-saving initiatives, such as formulary management, rebates, or network discounts. By examining detailed spend reports, employers can confirm that negotiated rates are being applied correctly and that their PBM is adhering to contractual obligations. 

Report on Utilization Management 

Utilization reporting goes hand in hand with spend analysis, giving employers insight into how their members are using healthcare services. Key utilization metrics include: 

• Pharmacy Utilization Patterns: Tracking prescription fills, adherence rates, and specialty medication usage helps employers assess the effectiveness of pharmacy management programs and pinpoint areas for improvement. 

• Medical Utilization Trends: Employers can evaluate how often members are accessing primary care, urgent care, emergency rooms, and specialty care services. This data is crucial for identifying over- or under-utilization, which can indicate potential gaps in care. 

• Preventive Care Utilization: Monitoring preventive services, such as screenings and wellness visits, helps employers understand whether employees engage with programs designed to promote overall health and reduce long-term costs.
  

Utilization data is invaluable for validating supplemental solutions offered by PBMs, such as medication adherence programs, clinical interventions, and utilization management tools. Employers can assess whether these programs are driving positive outcomes and making a measurable impact on plan performance. 

Report on Program Performance 

Reporting also plays a vital role in evaluating the performance of the overall health plan and comparing it to industry benchmarks. Performance reporting should focus on the following: 

• Clinical Outcomes: Employers should measure outcomes such as blood pressure control, cholesterol levels, or diabetes management within their population. These metrics provide insight into how well the plan is managing chronic conditions. 

• Cost Efficiency Benchmarks: Employers can compare their plan’s spend per member per month (PMPM) against industry standards to determine if they are effectively controlling costs. 

• PBM Program Effectiveness: Employers should assess whether the PBM is meeting key performance indicators (KPIs) such as generic fill rates, specialty drug cost containment, and member engagement in clinical programs.
  

When employers access robust benchmarking data, they can determine if their pharmacy and medical programs and supplemental solutions are performing as expected. If gaps are identified, employers can take proactive steps to adjust their strategy or renegotiate terms with their PBM. 

Best Practices for Leveraging Reporting Tools 

To make the most of their reporting capabilities, self-insured employers should adopt the following best practices: 

• Use a Centralized Platform: A robust reporting system that integrates pharmacy and medical data allows employers to view the complete picture of their plan’s performance and make data-driven decisions. 

• Customize Reports Based on Business Needs: Employers should choose tools that offer flexibility in report creation, whether through custom-built reports or pre-created templates. This ensures they can easily access the specific data to manage their plan effectively. 

• Review Reports Regularly: Employers should establish a routine for reviewing reports, whether monthly, quarterly, or annually, to stay proactive in managing plan costs and utilization.
  

Self-insured employers need comprehensive and accurate reporting to gain insight into plan spend, utilization, and performance. By focusing on critical elements, spend analysis, utilization management, and performance benchmarking, employers can validate the effectiveness of their PBM programs and supplemental solutions, ensuring they deliver value and meet their plan objectives. With the right tools and reporting capabilities, employers can manage costs and drive better health outcomes for their employees. 

For more information on PCM’s new Report Builder Tool and how it can support your self-funded plan reporting needs, contact us today or visit pcmsavings.com. 

Self-Insured Plan Reporting: Key Elements for Insight into Plan Spend, Utilization, and Performance

By Team PCM | Oct 31, 2024 | Blog post, Plan Management, Contract Management

Self-insured employers face the ongoing challenge of managing healthcare costs while ensuring their plans deliver optimal value to employees. Reporting is critical in this process, providing plan sponsors with the data needed to understand plan spend, track utilization, and assess performance. By focusing on the correct elements, self-funded employers and their broker partners can use reporting to effectively validate their pharmacy programs and supplemental solutions.   

Report on Plan Spend 

One of the most critical aspects of self-funded plan reporting is understanding where and how plan dollars are spent. Detailed spend analysis allows plan sponsors to: 

• Break Down Costs by Service Type: This includes pharmacy versus medical spend, helping plan sponsors identify high-cost areas and opportunities for cost containment. 

• Track Spend by Member Population: Employers can segment their data by member groups, such as employees, dependents, or retirees, to understand how utilization patterns impact total spend. 

• Monitor Trends Over Time: Analyzing spend over months or years provides insight into emerging trends and helps employers predict future costs. This is especially important when managing chronic conditions or high-cost specialty medications.
  

Accurate spend analysis is essential for validating the effectiveness of a PBM program. Employers can track if the PBM delivers on cost-saving initiatives, such as formulary management, rebates, or network discounts. By examining detailed spend reports, employers can confirm that negotiated rates are being applied correctly and that their PBM is adhering to contractual obligations. 

Report on Utilization Management 

Utilization reporting goes hand in hand with spend analysis, giving employers insight into how their members are using healthcare services. Key utilization metrics include: 

• Pharmacy Utilization Patterns: Tracking prescription fills, adherence rates, and specialty medication usage helps employers assess the effectiveness of pharmacy management programs and pinpoint areas for improvement. 

• Medical Utilization Trends: Employers can evaluate how often members are accessing primary care, urgent care, emergency rooms, and specialty care services. This data is crucial for identifying over- or under-utilization, which can indicate potential gaps in care. 

• Preventive Care Utilization: Monitoring preventive services, such as screenings and wellness visits, helps employers understand whether employees engage with programs designed to promote overall health and reduce long-term costs.
  

Utilization data is invaluable for validating supplemental solutions offered by PBMs, such as medication adherence programs, clinical interventions, and utilization management tools. Employers can assess whether these programs are driving positive outcomes and making a measurable impact on plan performance. 

Report on Program Performance 

Reporting also plays a vital role in evaluating the performance of the overall health plan and comparing it to industry benchmarks. Performance reporting should focus on the following: 

• Clinical Outcomes: Employers should measure outcomes such as blood pressure control, cholesterol levels, or diabetes management within their population. These metrics provide insight into how well the plan is managing chronic conditions. 

• Cost Efficiency Benchmarks: Employers can compare their plan’s spend per member per month (PMPM) against industry standards to determine if they are effectively controlling costs. 

• PBM Program Effectiveness: Employers should assess whether the PBM is meeting key performance indicators (KPIs) such as generic fill rates, specialty drug cost containment, and member engagement in clinical programs.
  

When employers access robust benchmarking data, they can determine if their pharmacy and medical programs and supplemental solutions are performing as expected. If gaps are identified, employers can take proactive steps to adjust their strategy or renegotiate terms with their PBM. 

Best Practices for Leveraging Reporting Tools 

To make the most of their reporting capabilities, self-insured employers should adopt the following best practices: 

• Use a Centralized Platform: A robust reporting system that integrates pharmacy and medical data allows employers to view the complete picture of their plan’s performance and make data-driven decisions. 

• Customize Reports Based on Business Needs: Employers should choose tools that offer flexibility in report creation, whether through custom-built reports or pre-created templates. This ensures they can easily access the specific data to manage their plan effectively. 

• Review Reports Regularly: Employers should establish a routine for reviewing reports, whether monthly, quarterly, or annually, to stay proactive in managing plan costs and utilization.
  

Self-insured employers need comprehensive and accurate reporting to gain insight into plan spend, utilization, and performance. By focusing on critical elements, spend analysis, utilization management, and performance benchmarking, employers can validate the effectiveness of their PBM programs and supplemental solutions, ensuring they deliver value and meet their plan objectives. With the right tools and reporting capabilities, employers can manage costs and drive better health outcomes for their employees. 

For more information on PCM’s new Report Builder Tool and how it can support your self-funded plan reporting needs, contact us today or visit pcmsavings.com.