The Hidden Impact of Chronic Conditions in the Workplace

Chronic health conditions are a growing problem for workers, damaging their well-being, productivity and job satisfaction, according to a new study.

The  “U.S. Employee Perspectives on Managing Chronic Conditions in the Workplace” poll by the Harvard T.H. Chan School of Public Health and the de Beaumont Foundation found that 58% of U.S. employees report having a physical chronic health condition such as hypertension, heart disease, diabetes or asthma. Among them, 76% need to manage their condition during work hours, yet 60% have never formally disclosed their health issues to their employer.

This lack of disclosure can create issues for both the employer and worker, affecting productivity, job satisfaction and overall workplace well-being.

Implications

Each year, chronic conditions account for $1.1 trillion in health care costs and $2.6 trillion in lost productivity, including $36.4 billion in employee absences, according to Kaiser Permanente.

Employees with chronic health conditions may be keeping mum for a variety of reasons, including:

  • Fear of stigma,
  • Concerns about missed work opportunities, and
  • Negative performance reviews.

As a result, employees are forced to make difficult choices:

  • 36% have skipped medical appointments or delayed care to avoid interfering with their job.
  • 49% felt unable to take time off or even a break despite needing one for their health.
  • 33% reported missing out on additional work hours or projects due to their condition.
  • 25% believe they have been passed over for a promotion because of their health issues.

Unaddressed chronic health conditions contribute to:

  • Absenteeism,
  • Decreased performance, and
  • Increased turnover.

Beyond managing their own health, many employees also care for family members with chronic conditions. One-third of workers have had to help a family member with a chronic illness in the past year, and 45% of those caregivers needed to do so during work hours.

The case for employer support

In a tight labor market, businesses that take proactive steps to support employees with chronic conditions can maintain a healthy workforce and gain a competitive advantage.

A minority of employees feel their workplaces are supportive of their needs:

  • 44% say their employer is very supportive of allowing breaks or paid leave.
  • 37% report strong employer support for flexible scheduling.
  • Only 27% say their employer is very supportive of remote work, even when the job allows for it.

How employers can help

According to the Centers for Disease Control and Prevention, many chronic conditions are linked to modifiable behaviors, including:

  • Tobacco use and secondhand smoke exposure,
  • Poor diet, including high sodium and saturated fat intake with low fruit and vegetable consumption,
  • Not being physically active, and
  • Excessive alcohol consumption.

Here are several ways for employers to support staff with chronic conditions:

Promote open dialogue—Create a culture where employees feel safe discussing their health needs confidentially. Help them access necessary accommodations without fear of judgment or career repercussions.

Encourage regular testing and doctor’s visits—Encourage your staff to take advantage of their health plans’ benefits, like annual blood work and health exams, and to follow physician-recommended regimens.

Offer flexible scheduling and remote work options—Allow employees to adjust their schedules or work from home when needed. This can help them manage medical appointments and symptoms more effectively.

Improve paid leave policies—Provide paid leave to help employees address their own or their family’s health needs.

Promote wellness programs—Offer resources such as health coaching, on-site screenings and wellness incentives that encourage employees to prioritize their health. Offer programs focused on tobacco- and alcohol-cessation programs.

Train managers to support employees with chronic conditions—Educate supervisors about chronic illnesses and workplace accommodations to help create a more inclusive and understanding environment.

If Medicare Starts Covering Wegovy, Will Private Insurers Follow Suit?

There is a general truth in the health insurance sector: If Medicare and Medicaid are given the green light to cover a certain drug, insurers in the group health and individual health insurance market usually follow suit.

The Centers for Medicare and Medicaid Services (CMS) typically allows Medicare drug plans and Medicaid to cover a drug once the Food and Drug Administration approves it for specific conditions. However, despite the FDA’s approval of popular yet pricey GLP-1 drugs like Ozempic and Zepbound for weight loss, these programs do not cover them due to a long-standing rule to not cover so-called “cosmetic” drugs.

However, the comment period for a proposed CMS regulation that would allow Medicare and Medicaid to cover GLP-1s and other drugs specifically for weight loss recently ended, and the industry is waiting to see if the Trump administration will finalize the rule.

If the CMS finalizes the rule, will group health and individual health insurers follow suit?

Current Medicare GLP-1 coverage

Medicare, through Part D drug plans, and Medicaid already cover GLP-1s for certain conditions, including:

  • Type 2 diabetes, and
  • Cardiovascular disease.

After the government programs began covering the medications for the above conditions, private insurers have largely done the same.

The drugs approved for these conditions include:

  • Ozempic,
  • Mounjaro,
  • Rybelsus, and
  • Wegovy.

The fine print

Experts say that if the CMS approves GLP-1s for weight loss, private health insurers would likely do the same. However, this does not mean they would cover them outright. Each plan’s copays, deductibles and coinsurance would still apply, as they do for all other drugs.

The list price of these drugs is around $1,000 a month or more. Since GLP-1s are expensive specialty drugs, insurers would likely put them in their pharmaceutical fee schedule’s most expensive tier, meaning that enrollees would pay higher copays and/or coinsurance for than for lower-tier drugs.

Additionally, health plans that decide to cover these drugs may require plan enrollees to first try less expensive treatments and/or lifestyle changes before approving a GLP-1 prescription.

Effect on costs

The rising cost of specialty drugs are contributing to overall premium inflation.

In 2023, health insurance outlays for prescription drugs increased by 10.8%, compared to 2.6% for all medical expenses, according to the U.S. Department of Health and Human Services. This increase was driven by brand name and specialty drugs, particularly those used to treat diabetes and weight loss, such as GLP-1 drugs. If more insurers start covering these popular drugs, it would likely affect premiums.

However, there could be offsetting cost benefits. Consider that:

  • These drugs often result in a significant drop in blood-sugar levels, reducing the risk of diabetes-related complications.
  • GLP-1s yield an average weight loss of 15 to 20%, and about one-third of users lose approximately 10% of their body weight, according to a study.
  • Multiple studies have shown that they can reduce the risk of cardiovascular events, including heart attack, stroke and death.
  • The drugs may help people cut back on drinking, according to a study published in JAMA.

A final word

It’s still unclear if the Trump administration will finalize this proposed rule. Much will depend on the new Robert F. Kennedy Jr., the new secretary of the HHS. He has stated his intention to “make America healthy again,” but he has also been critical of vaccines and other medications in in the past.

More Workers Miss Work Due to Depression, Anxiety; Employers Can Help

Each year, mental health issues such as depression and anxiety lead to a staggering 12 billion missed workdays globally, according to a new study by Resolute Psychiatry, an online platform that provides virtual counseling.

This absenteeism not only affects personal well-being but also results in significant financial losses. Employees who are struggling with their mental health can be less productive and may have lapses in concentration that can lead to poor performance and even workplace accidents.

Production and financial losses due to missed workdays, for any reason, cost the U.S. economy $1 trillion each year.

The compounding effects of these health challenges — fatigue, poor concentration, detachment, stress and physical symptoms — are obviously a serious challenge for businesses. Fortunately, there are steps that companies can take to provide mental health support in the workplace.

Access to mental health resources

One of the best ways to support staff dealing with depression and anxiety is to implement an employee assistance program. EAPs offer confidential services, including counseling, wellness workshops and access to mental health apps.

These programs can reduce barriers to seeking help and they address a range of issues such as substance abuse, occupational stress, relationship problems, emotional distress and major life events, providing employees and their families with essential support. 

One issue, though, is that EAPs are often limited in the amount of sessions that an employee can attend without out-of-pocket costs. A typical EAP limits counseling appointments to around three to six sessions per issue per year.

Train managers on mental health support

Equipping managers with the skills to recognize and address mental health challenges is vital for fostering a supportive workplace culture. Training should focus on:

  • Recognizing signs of mental health challenges: Managers should be trained to identify indicators such as changes in behavior, decreased productivity, increased absenteeism, and signs of stress or withdrawal.
  • Initiating supportive conversations: Managers need guidance on how to approach employees sensitively and confidentially, expressing concern and offering support without judgment.
  • Providing resources and referrals: Training should include information on available mental health resources, both within the organization (like EAPs) and externally, enabling managers to guide employees toward appropriate help.

Encourage staff to use their health plan

All Affordable Care Act-compliant health plans cover nearly all mental disorders, as well as substance use disorders and treatment for alcohol and chemical dependency.

In addition, federal law requires that mental health and substance use disorder benefits are covered in the same way as most medical and surgical services. This means that things like deductibles, copays and insurance must be the same for mental health and substance use as for other medical benefits.

Offer flexible work options

Developing flexible work arrangements, such as remote work opportunities, adjustable hours and designated mental health days, can significantly aid employees in managing their mental health. These arrangements can allow workers to take time off to take care of errands and other matters, or to attend counseling sessions.

These options help reduce stress, improve work-life balance and enhance overall job satisfaction. If you have an employee who is struggling with depression or anxiety, you may want to consider:

  • Adjusting roles and responsibilities, or
  • Moving to a different role or department if the current job negatively impacts their mental health.

The takeaway

Since the COVID pandemic, mental health issues have risen to the fore and employers have experienced the effects on their workers. Many Americans are dealing with growing stresses in their lives, particularly with the cost of living having skyrocketed during the last few years, the tenor of national discourse and global problems.

By integrating the above strategies, organizations can create a more supportive environment that addresses mental health proactively, benefiting both employees and the company’s bottom line.

Specialty Drugs, Expensive Surgeries Driving Stop-Loss Insurance Costs

Companies that self-insure their group health benefits, or are in partial self-insured plans called level-funding, are likely to see higher stop-loss insurance renewal rates due to the rapidly increasing costs of specialty drugs and cancer surgery claims.

Stop-loss insurance steps in to pay claims when they reach “catastrophic levels,” or if the aggregate amount of claims exceeds a set dollar amount. The increases in stop-loss insurance rates are also likely to affect group health plan providers, which typically pass on their higher costs to employers.

Executives of Cigna Corp., which provides medical stop-loss coverage to employers, warned of the coming wave of stop-loss increases during the company’s Q4 2024 earnings call with analysts in late January. Brian Evanko, the company’s chief financial officer, said that Cigna’s stop-loss insurance costs had spiked in the fourth quarter.

The main drivers of the cost increase were:

  • Spending on costly injectable specialty drugs, like Keytruda, an anti-cancer drug, and
  • Higher spending on inpatient surgeries for serious conditions such as cancer and heart problems.

Cigna’s experience mirrors what’s been happening in the overall stop-loss insurance market.

From 2022 through 2024, the overall individual coverage stop-loss insurance premium rates grew at an annualized rate of between 10.4% to 13%, depending on the deductible size, according to the 2024 “Aegis Risk Medical Stop Loss Premium Survey.”

Deductibles are usually in increments of $100,000 per claim. The average monthly premium per employee for a $100,000 individual deductible was $210.80 per month last year, while for a $500,000 deductible the cost was $46.30 a head.

Sun Life, another stop-loss insurer, has noted equally rising costs. In its 2024 “Sun Life Stop-Loss Research Report,” it said that:

  • Million-dollar claims rose 8% on a claims-per-million-covered-employees basis
    between 2023 and 2024, and were up 50% over the past four years.
  • Average cost of cardiovascular disease treatment was up 33%, higher than expected given medical inflation, and significantly higher than average cost for all claims, which was 5.9% over the same period.
  • Five new drugs entered the 20 high-cost injectable drugs list in 2023; two are used
    primarily in the treatment of cancer, and one each for immunodeficiency disorders, gout and blood disorders.

The takeaway

If you are a self-insured employer or have a level-funded plan, you’ll want to budget for these higher stop-loss rates as you will likely see your premium rise.

You can always tinker with your deductible as well to lower your costs, but that could mean holding more of the bag for any high-dollar claims. But you can also take steps to address your health plan’s cost drivers. For example, you can:

  • Consider encouraging your employees to engage in programs that focus on general health management, such as monitoring of blood pressure and blood sugar, weight management and exercise to improve their overall health.
  • Ensure that your employees have access to mental health services, particularly those who are dealing with a chronic or acute high-cost condition.
  • Ensure plans offer coverage for preventive care during pregnancy.
  • Provide assistance to employees who are having trouble navigating the health care and health insurance system.

Finally, to get a good understanding of your potential costs and for planning purposes, you should know the average cost of various high-cost claim conditions. Sun Life’s report has extensive lists of how much these types of claims are costing. You can find it here.

Most Workers Uncomfortable with Cash-for-Coverage Plans

A recent survey found that the majority of employees prefer traditional employer-sponsored health insurance over receiving cash through an individual coverage health reimbursement arrangement (ICHRA) to buy their own coverage on the Affordable Care Act marketplace.

The survey, conducted by Softheon, a health coverage distribution technology firm, and its subsidiary W3LL, found that 80% of respondents would rather have their employer provide health insurance, while only 20% preferred receiving employer funds to purchase their own plan.

The findings also showed that 54% of workers favored their firm offering multiple health plan options, while 26% preferred a single plan.

The findings reflect the importance of educating workers about ICHRAs if an employer is planning to start offering these vehicles.

How  ICHRAs work

ICHRAs allow employers to provide tax-free funds that employees can use to purchase their own health insurance on the marketplace or through private insurers.

With an ICHRA, employers set a fixed allowance for employees to use toward their health insurance premiums and qualifying medical expenses. Employees then select their own coverage and pay premiums upfront, submitting receipts for reimbursement up to their firm’s contribution limit.

The employer’s funding is tax-deductible, and reimbursements are tax-free for employees as long as they purchase a plan that meets the ACA’s qualifying criteria.

These plans have grown in popularity as companies look for cost-effective alternatives to group health insurance, especially small and mid-sized businesses that may struggle with the rising costs of traditional plans.

While ICHRAs provide greater customization, they also require employees to take a more active role in selecting and managing their own health coverage, which can be a barrier for those unfamiliar with navigating the insurance marketplace.

Employee comfort levels with ICHRAs

Workers’ attitudes toward ICHRAs varied depending on how the questions were framed. When asked directly about receiving a cash stipend for health coverage:

  • 29% said they were very comfortable with the idea.
  • 40% said they were somewhat comfortable.
  • 31% expressed discomfort with the concept.

Concerns about selecting their own coverage were also significant:

  • 30% of respondents worried about choosing the wrong plan and either getting too much or too little coverage.
  • 29% were primarily concerned about paying too much for a plan.
  • 63% believed that employer assistance in navigating the ACA marketplace would improve their experience.

ICHRA awareness and adoption

Four out of five respondents admitted to knowing little or nothing about ICHRAs, while 20% said they were somewhat or very familiar with the concept, even though they didn’t have ICHRA coverage themselves.

In light of this lack of awareness, if you plan to offer an ICHRA, you’ll want to educate your staff about the arrangements and ensure employees understand that they are responsible for selecting their own individual health insurance plan under an ICHRA. 

Key points to cover when educating staff:

Basic definition: Explain what an ICHRA is, highlighting that it’s a reimbursement account where the employer contributes a set amount towards the employee’s individual health insurance premiums. 

Eligibility: Clearly state who is eligible for the ICHRA within the company, including any criteria based on job role or location. 

Allowance amount: Specify the monthly or annual ICHRA allowance each eligible employee will receive. 

Plan selection process: Guide employees on how to shop for an individual health insurance plan on the marketplace or through other providers, emphasizing the importance of comparing coverage options to find the best fit for their needs. 

Reimbursement process: Explain how to submit claims for reimbursement, including required documentation and deadlines. 

Impact on premium tax credits: Inform employees how the ICHRA may affect their eligibility for premium tax credits, and how to navigate this aspect when selecting a plan.

Employers Wrestling with Fiduciary Benefits Compliance Issues, Leave Laws

A new report has found that employers are increasingly wrestling with two challenges in their human resources departments: growing employee benefits fiduciary liability issues, and administrative difficulties in managing employee leaves.

Employers are facing lawsuits by employees who allege they mismanaged their health and wellness benefits, and recently enacted legislation has increased their fiduciary responsibilities, the 2025 “NFP U.S. Benefits Trend Report” found.

Additionally, firms are spending more time ensuring that employee leave requests comply with federal laws, their own state’s laws and their company policies.

The report highlights the importance of employers putting in place processes for vetting vendors and taking steps to comply with federal and local laws to avoid penalties and lawsuits.

Growing fiduciary risk

A new class of lawsuit has emerged in the last year: Employees suing their employers over how they handle their health plans or for choosing vendors they allege do not have patients’ best financial interest in mind.

Any party with discretionary decision-making authority over the plan or plan assets must adhere to ERISA fiduciary standards and responsibilities, including acting solely in the best interest of plan participants and beneficiaries.

Recent legislative developments have expanded employers’ fiduciary obligations. The Consolidated Appropriations Act of 2021 introduced comprehensive reforms, requiring group health plans and insurers to enhance fee disclosures and pricing transparency.

These laws mandate that employers ensure their health plans are cost-effective, provide quality care, and comply with mental health parity and pharmacy benefit requirements. 

The rules apply to all employer-sponsored plans regardless of the funding methodology selected, whether fully insured or self-insured.

As well, employers are facing legal challenges over allegations of that they or their health plans failed to properly vet pharmacy benefit managers, leading to inflated prescription drug costs for employees.

In parallel, there has been a surge in litigation where employees allege that employers have breached their fiduciary duties under ERISA.

Notably, class-action lawsuits have been filed challenging the imposition of tobacco surcharges in employer-sponsored health plans, asserting that such surcharges violate ERISA, the Affordable Care Act and the Health Insurance Portability and Accountability Act.

The NFP report recommends that level-funded or self-insured plans regularly review vendor contracts to ensure compliance with contract terms. This improves cost-containment provisions of the plan and is essential to proper plan oversight.

Leave administration headaches

Employers are increasingly struggling to manage the complexities of leave requirements thanks to a tapestry of federal and state laws, as well as company policies.

More than 70% of employers spend more than four hours on administration for each leave request they receive from employees to ensure they comply with the Federal Family Medical Leave Act.

Here’s why the administrative burden is so challenging:

Unpaid leave laws — The FMLA requires that employees can take job-protected leave for up to 12 work weeks for health reasons or to care for a family member with health issues. In addition to this federal law, states have their own laws that may expand the acceptable reasons for taking leave and providing additional time off.

Paid leave laws — These are typically at the state level, but there are a few cities or municipalities that require that certain time off should be compensated to some degree. Paid leave laws provide benefits that are typically for shorter-term absences, while mandated state disability or paid family leave benefits cover leaves for longer-term absences (serious health conditions).

More states are enacting laws that require employers to provide a certain amount of paid sick leave as well.

Employer leave policies— Many employers will also have their own in-house rules for leave. The most common, according to the report, are:

  • Medical — 68% of firms
  • Family care — 65%
  • Personal — 53%
  • Bereavement — 53%
  • Parental (bonding) — 34%
  • FML-like — 23%

The takeaway

With employers facing a significantly higher fiduciary compliance burden and with the threat of lawsuits, ensure that your human resources team conducts comprehensive evaluations, while also emphasizing cost management and optimizing plan performance.

The focus should be on insulating your employees against more costs than necessary. As your broker, we can help with this.

Meanwhile, administration of leave requests must be approached with care to ensure compliance with local and federal law, which takes time. If you have a large workforce, the report recommends implementing tools like technology-supported or outsourced leave management.

Another option is a third party administrator that is skilled at handling leave requests under local and federal law.

Employee Surveillance Doesn’t Boost Productivity, but Breeds Resentment: Study

As more people have been working remotely over the last few years, some employers have turned to employee-tracking software to ensure that these staff are working while on the clock, and to boost productivity.

Tools like activity monitors and locations trackers, however, do not actually increase productivity and they can instead cause a backlash among workers, affecting job satisfaction and stress levels, according to a new poll.

Additionally, 26% of tracked employees said they distrust their employer and half of them feel pressured to work more hours, the survey by review website Software Finder found.

These findings cast doubt on the effectiveness of remote-employee monitoring and tracking, in light of the fact that one in four remote or hybrid workers are tracked.

What employers are tracking

Companies are mostly tracking workers to ensure they are staying productive and working their schedules. They employ a myriad of methods, including:

  • Time-tracking software — Helps monitor when employees log in and out of work systems, and how they distribute their time across tasks.
  • Screen monitoring — Offers real-time insights into employees’ screen activities, providing a glimpse into their work habits and efficiency.
  • Keystroke logging — Tracks every keypress, offering data on productivity and potential security risks.
  • Communication monitoring— Analyzes team messaging platforms to understand communication patterns, collaboration and information sharing.

Some employers also track a worker’s company-issued phone and computer locations.

Employee resentment

The survey found that:

  • 53% of employees believe it’s a privacy violation for employers to track their activity.
  • Three in four employees believe it’s a privacy violation for employers to track their location.
  • 64% of untracked employees would recommend their company to others, while 58% of tracked staff would do the same.
  • 36% of employees whose activity is tracked are currently looking for a new job, compared to just 18% of those who are not tracked.

Some employees have gotten wise and try to thwart software that tracks mouse movements by using “mouse jiggling,” a device or software that mimics mouse movement, or other software.

This prevents tracking software from detecting inactivity and makes employees appear active when they aren’t. The survey found that 17% of workers use mouse jiggling and that 12% don’t, but want to.

What you can do

All of the above said, remote-worker tracking can be a good thing if it’s implemented with care.

Insightful.com has this advice for companies that aim to track their employees’ work:

  • Don’t track remote workers’ time outside work hours.
  • Don’t install monitoring software on their personal devices.
  • Don’t track remote workers without consent.
  • Don’t use data to micromanage your employees.
  • Don’t ignore signs of burnout in your staff.

If you do plan to implement tracking, it is important that you are transparent about the process. The review website recommends the following:

Set standards for remote staff. Make sure they are treated equally and entitled to the same break schedules and hours as their peers. Also, if you allow your office workers to chat with one another around the water cooler, you should allow the same deference to your remote workers who log into a social media account for a few minutes.

Encourage staff to raise questions/concerns. If you are implementing remote-employee monitoring, your staff will have many questions and concerns. It’s important that you keep an open line of communication with those who may feel that their privacy is being invaded.

Be transparent about the implementation of monitoring software, and cover the program in meetings with your staff and address their concerns.

After you’ve started using tracking software, you should hold a few meetings a year to check in with your workers about issues they may have. This will give you the chance to also adjust your tracking metrics.

Train remote employees. Your workers, supervisors and managers should know how to use the software properly and be familiar with its features and understand why it’s being used.

The Top Five Health Conditions Driving Insurance Costs

A new study has identified the top five health conditions that are driving the overall cost of group health plan outlays, and without which spending would actually be falling.

The report is enlightening, and employers can use the findings to offer programs aimed at education and prevention to help control their employees’ health care costs and cut into health insurance premiums paid by both employers and workers.

Inspecting its study data for trends, the Health Action Council (HAC) determined that 63% of its covered lives had at least one of five conditions that were driving health care costs. Most of these top five conditions are preventable or treatable with lifestyle modifications that employers can encourage. 

Here’s a look at the five conditions and the burden they put on your employees and your company:

Asthma

Average costs paid per member of the HAC for asthma treatment are increasing on average 6.4% a year. This is one of the most prevalent health conditions in the country. Three important stats:

  • The incidence of asthma was 31% higher among women than men.
  • The incidence of asthma among African American covered lives was 20% more prevalent than among other races.
  • The average age of HAC members with asthma was 31.9, two years younger than the overall membership average age of 33.9.

Diabetes

Average costs paid per member of the HAC for diabetic treatment are also increasing 6.4% a year. Three important stats:

  • Diabetes was 20% more common in men than women among the HAC’s enrollees.
  • The average age of HAC plan enrollees with diabetes was 52.
  • Although Asian covered lives amounted to only 3% of the HAC enrollees, they had the highest incidence of diabetes of all racial groups.

Hypertension

Average costs paid per member of the HAC for hypertension treatment are increasing 6.3% a year. Three important stats:

  • Hypertension was 23% more common in men than women.
  • The average age among HAC enrollees with hypertension was 53.1.
  • The risk of African Americans developing hypertension was 63% more than for other races.

Back disorders

Average costs paid per member of the HAC for back treatment are increasing 3.4% a year. Three important stats:

  • Back disorders were 27% more common in women than men.
  • The average age among HAC enrollees with back disorders was 43.3.
  • Caucasian HAC members had 14% higher back disorder prevalence than other races.

Mental health, substance abuse

Average costs paid per member of the HAC for mental health and substance abuse treatment are increasing 2.7% a year. Three important stats:

  • Mental health and substance abuse problems were 39% more common in women than men.
  • The average age among HAC enrollees with mental health and substance abuse issues was 32.8.
  • Caucasian HAC members had 20% higher mental health and substance abuse issues than other races.

The takeaway

To help workers with these conditions, the report recommends:

  • Creating and implementing simple education and targeted wellness programs to address common conditions among your employees.
  • Instituting an exercise, stretch or meditation program at the beginning of a work shift to improve safety and decrease injuries. These types of practices are preventative and may decrease the severity of an injury if one occurs.
  • Evaluating benefit plan design for opportunities to implement continuum-of-care protocols. For example, employers can make chiropractic care or physical therapy mandatory for back disorders before moving to more aggressive treatments.
  • Covering medications for specific common chronic conditions as preventative care. Another option is to promote the use of patient assistance programs for medicines that may be excluded in your plan’s drug formulary.
  • Promoting virtual care for specific conditions; for example, mental health support if you have staff in rural areas.
  • Working with your health insurer or medical expert(s) to identify opportunities for provider outreach and education to your workers.

Hidden Costs in Healthcare

Hidden costs in healthcare are a pervasive issue that significantly impacts patients, providers, and the overall healthcare system. These unexpected expenses often catch patients off guard and can lead to financial strain, delayed care, and reduced trust in the healthcare system.

One of the most common hidden costs is facility fees, which are charges imposed simply for using a medical building or facility. These fees can add hundreds or even thousands of dollars to a patient’s bill, often without any prior notification. For example, a patient visiting an ENT specialist might be charged $348 for the consultation and an additional $645 just for using the medical office building.

Another source of hidden costs is the lack of price transparency in healthcare services. Many patients are unaware of the full cost of their treatment until they receive a bill weeks or months later. This opacity in pricing makes it difficult for consumers to make informed decisions about their care and can lead to unexpected financial burdens.

Out-of-pocket costs, such as copayments, deductibles, and coinsurance, can also accumulate quickly and unexpectedly. These expenses may not be clearly communicated to patients beforehand, leading to surprise bills and financial stress.

The healthcare industry’s complex billing practices and varying insurance coverage levels contribute to the problem. Patients may unknowingly receive care from out-of-network providers, resulting in higher out-of-pocket costs through surprise medical billing or balance billing.

To address these issues, there’s a growing push for greater transparency in healthcare pricing. Some states have enacted laws requiring healthcare entities to publicly post their prices, and federal regulations like the Hospital Price Transparency Rule aim to make pricing information more accessible to patients.

Ultimately, hidden costs in healthcare not only burden individual patients but also contribute to the overall inefficiency and rising costs of the healthcare system. Addressing this issue requires a concerted effort from policymakers, healthcare providers, and insurers to improve transparency, simplify billing practices, and empower patients to make informed decisions about their care.

Many Group Health Plan Users Make Costly Mistakes

Employees who are unfamiliar with how to access care using their group health insurance can inflate your plan costs and how much they pay out of pocket.

Those who may not use their health plan much, or at all, may end up going to the emergency room for an issue that could have been handled by a general care physician in their plan network. While they may not think much about the added cost when they seek non-emergency care in the emergency room, they do when they get a bill in the mail later.

The average cost of an ER visit with insurance in 2024 was around $400-$650, with the typical copay after meeting the deductible being around $412 nationwide, based on US Department of Health information. But some visits can go into the thousands of dollars for serious cases.

With health plans absorbing a portion of ER costs, decisions like this can negatively affect your plan as well.

The key to helping your staff avoid this is educating them on the health insurance they have, how to use it and also the importance of keeping up on vaccinations and checkups, particularly if they have children covered under the plan. 

Everyday conditions

With common conditions like headaches, sore throats or flu-like symptoms, employees often have access to more affordable care options than the emergency room. Virtual visits, for example, typically cost between $40 and $80, while retail clinics range from $20 to $100.

These options provide fast and convenient care, often with shorter wait times. Urgent care clinics are another excellent alternative, offering treatment for non-life-threatening conditions at a fraction of the cost of an ER visit.

Also, appointments with their primary physician in person for other issues are significantly less costly than the emergency room, particularly for plans with low copays.

One way your employees can find the best care for their needs is to check out FindTheRightCare.org, a resource created by the non-profit Health Action Council that’s designed to help employees explore health care options that fit their symptoms and budget.

Shopping around for scheduled procedures

For planned medical procedures like knee replacements or imaging tests, you can encourage your employees to shop around within their insurance network. Costs for these services can vary widely depending on the provider, and selecting a facility with lower cost-sharing can lead to substantial savings.

One way to simplify this process is by directing employees to cost-comparison tools offered by their health insurer or external resources, like the Health Action Council’s website. Transparent pricing information allows employees to make well-informed choices while staying within their budget.

Preventive care and vaccinations

Encourage your staff to schedule regular checkups with their primary care physicians, who provide comprehensive care, monitor ongoing health concerns and offer guidance on vaccinations.

For families with children, well-child visits are essential for tracking growth, monitoring developmental milestones and staying current on vaccinations. These visits protect children from serious diseases like measles and whooping cough, which are highly contagious and can have severe consequences, particularly for young children.

Education is key

Provide training and resources from your health plans that explain how employees can use their health benefits effectively.

A 2024 poll by Employee Benefit News found that 89% of employers surveyed were taking steps to control health care costs, with a majority focusing on improving preventive care access. They were incentivizing preventive care in a few ways:

  • 39% hosted vaccination sessions at the office,
  • 32% hosted educational talks or webinars about preventive care, and
  • 31% hosted disease screenings.

By equipping employees with knowledge, tools and resources, you can help them save money on their health care outlays without compromising their care or health.

That helps your bottom line as well, particularly if your health plan is not paying for expensive care when it could be delivered at a lower cost.

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