Five key questions for state and municipal purchasers

General

1. In what areas is our plan design or spend an outlier compared to other state employee health plans or the employer-sponsored insurance market more broadly?

• What’s the average actuarial value of our plan?  (Benchmark = ~86%)¹
• How many active plans do we have? How are the options communicated to employees? (Benchmark = ~3)²
• What’s the average cost per employee?
• How much have premium costs increased year-over-year?  (Benchmark = 8.2% for ESI)³

High-Value Network

2. Where do we see the greatest variation in price across specialty areas or procedures? (Benchmark = varies by market but often includes hospital-based outpatient procedures, imaging, maternity/delivery care, and higher-cost surgeries such as joint replacements and other orthopedic procedures)

• Have we evaluated or implemented innovative purchasing strategies to address this area? (e.g., network of excellence program, narrow network plan option, direct contracting)

Drug Spend Management

3. What percentage of our overall health care costs is driven by pharmacy spend, including specialty drugs and GLP-1s? (Benchmark = 25% for ESI)⁴

4. Who has access to coverage for GLP-1s on our health plan? (Benchmark = BMI of 35+)⁵

• Have we evaluated or implemented innovative purchasing strategies to address this area? (e.g., utilization management and prescribing controls, integrated obesity care models, financing and cost-share approaches)

Quality and Cost Steerage

5. How do we measure and communicate provider quality, appropriateness and cost efficiency to employees? (e.g., CT Health Care Options Planner Example | NY State Health Insurance Program Website)

• Have we evaluated or implemented innovative purchasing strategies to address this area? (e.g., provider quality directories, variable copays)