Appendix H

9/17/19

SENATE COMMITTEE ON FACULTY BENEFITS

Report on Survey of Employee Satisfaction with Aetna/CVS Caremark Results

(Informational)

Overview

In the fall of 2018, Penn State’s Committee on Faculty Benefits expressed interest in soliciting feedback from employees regarding the University’s health care plan third party administrators: Aetna and CVS Caremark. The Committee, in collaboration with the Joint Committee on Insurance and Benefits, Human Resources, and the Office of Planning and Assessment, sponsored and developed a brief survey to be administered during the 2018-2019 academic year. The survey assessed employee satisfaction with the current vendors, awareness and use of resources, and interest in voluntary benefits.

Methodology

The Penn State Health Benefits survey was administered by email in January 2019 to all employees who were enrolled in the University’s health care plan.  Of the 18,005 employees who were emailed a link to the survey, 29 percent or 5,272 employees, responded to the survey.  Of the employees enrolled in the PPO Savings Plan, 30 percent responded, and 28 percent of those enrolled in the PPO Plan responded.  In total, 70% of the respondents were enrolled in the PPO Plan and 28% in the PPO Savings Plan.  Two percent were not sure which plan they were enrolled in.  Thus, the composition of the respondents is very comparable to the distribution of employees in each plan.

In addition to multiple choice type questions which asked respondents to choose one answer from the choices given, there were also several open-ended questions in which survey takers could write comments.  Part I of this report will discuss the results to the multiple-choice questions and Part II will discuss the most common responses to the open-ended questions.

PART I: RESPONSES TO MULTIPLE-CHOICE QUESTIONS

Aetna

The first set of questions deal with Aetna, the university’s administrator for medical services other than prescription medicines.

Results

The first set of questions were to be answered only by those enrolled in the PPO Savings Plan.

  • Are you aware that the University contributes money to your Health Savings Account (HSA)?
    • Yes 98%.
    • No 2%.
  • To what extent was the University’s monetary contribution to the Health Savings Account a factor in choosing the PPO Savings Plan?
    • extremely large factor 24%
    • large factor 34%
    • moderate factor 26%
    • small or extremely small factor 16%

The next question was to be answered only by those who were enrolled in the PPO plan since only those in the PPO plan are eligible for Value-Based Benefits (VBB).

  • Are you aware employees can enroll in the Value Based Benefit (VBB) through Aetna? (The VBB eliminates member cost sharing for visits/tests related to diabetes, high blood pressure, or high cholesterol.)
    • Yes 44%
    • No 56%

Comment: Clearly, this indicates one benefit that the university has not been successful at informing employees about.


The next set of questions were to be answered by all survey takers regardless of which plan they were enrolled in.

  • Please indicate your level of satisfaction with Aetna (medical benefits).
    • Very Satisfied 9%
    • Satisfied 40%
    • Neutral 30%
    • Dissatisfied 15%
    • Very Dissatisfied 7%
  • Please indicate your level of satisfaction with being able to see the same provider or other healthcare practitioner you did prior to the move to
    • Very Satisfied 38%
    • Satisfied 41%
    • Neutral 15%
    • Dissatisfied 4%
    • Very dissatisfied 3%

Comment: One of the factors that influenced the university’s decision to not renew their contract with Highmark was the concern that many employees in Western PA would have to switch to new medical providers because of the contract dispute between Highmark and UPMC.  That 94% of employees were either very satisfied, satisfied, or neutral about being able to see the same provider has to be gratifying to those who were involved in choosing to leave Highmark over the concern about losing UPMC providers.

  • Please indicate your level of satisfaction with the Aetna concierge (call center). {This question was to be answered only by those who used Aetna’s concierge service.  57% of respondents indicated they had not used this service.}
    • Very satisfied 13%
    • Satisfied 33%
    • Neutral 35%
    • Dissatisfied 12%
    • Very Dissatisfied 8%
  • Thinking about your 2018 expenses in the health plan, were your out-of-pocket costs (copays, deductibles, coinsurance) excluding premiums:
    • Higher than 2017 57%
    • Less than 2017 8%
    • About the same as 2017 35%
  • As compared to Highmark, how would you rate your overall experience with Aetna?
    • Better 9%
    • Worse 35%
    • About the Same 56%

The Office of Planning and Assessment performed some deeper analysis.  Of those who indicated that their 2018 out of pocket expenses would be higher than 2017, more than 80% of them indicated they are worse off with Aetna compared to Highmark.  Of those who expected less out of pocket expenses in 2018, more than 60% of them indicated they were better off under Aetna compared to Highmark.  For those who indicated their out of pocket were about the same, 56% indicated they were better off with Aetna.

Comment: What the above analysis indicates is that those who faced higher out of pocket expenses in 2018 compared to 2017 were much more likely to be dissatisfied with Aetna.  It would be interesting to know how many of those facing higher out of pocket expenses had higher costs because of differences in reimbursement for services under Aetna compared to Highmark and how many simply had higher out of pocket expenses because they consumed more, or more expensive, health services and would have faced higher out of pocket expenses even under Highmark.


CVS

The next set of questions relate to the university’s administrator of prescription medicines, CVS/Caremark.

  • Please indicate your level of satisfaction with CVS Caremark (prescription drug benefit).
    • Very satisfied 16%
    • Satisfied 42%
    • Neutral 26%
    • Dissatisfied 11%
    • Very dissatisfied 5%
  • How satisfied were you with being made aware of any required prior authorizations for prescription drugs? (Prior authorization is a requirement that your physician obtain approval from your health insurance plan to prescribe a specific medication to )
    • Very Satisfied 8%
    • Satisfied 27%
    • Neutral 41%
    • Dissatisfied 15%
    • Very Dissatisfied 9%

Note: 45% of respondents indicated they did not need any prior authorizations.  Response percentages are only of those who did need prior authorizations.

  • How satisfied were you with receiving formulary changes from CVS Caremark? (A formulary is a list of drugs covered under the prescription )
    • Very satisfied.8%
    • Satisfied 28%
    • Neutral 44%
    • Dissatisfied 12%
    • Very Dissatisfied 8%

Note: 44% of respondents did not recall receiving the formulary.  Response percentages are only of those who did receive the formulary changes.

  • Thinking about your 2018 expenses in the prescription plan, were your out-of-pocket costs (copays, deductibles, coinsurance) excluding premiums:
    • Higher than 2017 40%
    • Less than 2017 12%
    • About the same as 2017 47%
  • As compared to Highmark (Express Scripts), how would you rate your overall experience with CVS Caremark?
    • Better 15%
    • Worse 20%
    • About the same 65%

Again, the Office of Planning Assessment performed some deeper analysis on the question.  Of those that indicated that their spending on prescriptions in 2018 was less than 2017, almost 60% felt they were better off with CVS/Caremark and fewer than 5% indicated they were worse off.  Of those who indicated that their prescription costs were higher than 2017, 40% of those indicated that they were worse off with CVS/Caremark.


Resources for Decision-Making

The next set of questions related to the resources available to employees to make informed choices concerning their health care providers.

  • How important is it to you to have pricing information available?
    • Extremely important 22%
    • Very important 30%
    • Moderately important 31%
    • Slightly important 12%
    • Not important at all 5%
  • How important is it to you to have information about the quality of providers (doctors and other health care professionals) and facilities (hospitals, doctor’s offices, urgent care)?
    • Extremely important 36%
    • Very important 41%
    • Moderately important 18%
    • Slightly important 4%
    • Not at all important < 1%
  • Have you used the Aetna pricing tool available on their website?
    • Yes 17%
    • No 43%
    • Did not know they had a pricing tool 40%
  • Have you used the CVS Caremark pricing tool available on their website?
    • Yes 19%
    • No 44%
    • Did not know they had a pricing tool 40%

Comment: Another indicator that there is still room for improvement in disseminating information about health care benefits including the pricing tools provided by both Aetna and CVS Caremark.

  • Have you downloaded the Aetna app?
    • Yes 16%
    • No 58%
    • Did not know there was an app 26%
  • Have you downloaded the CVS Caremark app?
    • Yes 20%
    • No 58%
    • Did not know there was an app 23%
  • What is your preferred way to receive benefits information/updates from HR’s Benefits Office? (Select )
    • E-mail 79%
    • Home Mailing 17%
    • Website 2%
    • Text Message 2%
    • Social Media 0%

The final section of the survey asked about employees’ interest in obtaining other voluntary benefits paid by the employee.  Below are the totals that said very likely and in parentheses very likely plus likely.

  • Home insurance: 7% (20%)
  • Auto Insurance: 8% (23%)
  • Pet (Health) Insurance: 5% (16%)
  • Cell Phone Insurance: 5% (17%)
  • Critical Illness: 13% (38%)
  • Hospital Indemnity: 12% (38%)
  • Long-term Care: 17% (45%)
  • Financial/Legal Services: 8% (30%)
  • ID Theft Protection: 9% (32%)
  • Student Loan Consolidation: 8% (17%)
  • Student Loan Refinancing: 8% (17%)

PART II: RESPONSES TO OPEN-ENDED QUESTIONS

There were three open-ended questions survey respondents were asked to answer.  There were more than three thousand written responses for each question.  It would be very difficult to include all of the responses.  The responses listed below are only those that had at least thirty people give the same or roughly the same answer.  The responses are listed in order of frequency with the most frequent response first.

  1. The total cost of your health plan consists of premiums (what you pay out of your paycheck), deductibles (what you pay before the plan begins to pay), copayments (a flat dollar amount paid when services are used), and coinsurance (a percentage of the charges once your deductible is met). Based on this, what was your primary reason for choosing the plan you did?

Top responses by those who chose the PPO Savings Plan (from most frequent to least frequent answer).  There were 1,375 comments received by those choosing the PPO Savings Plan.

  • Low utilization of plan because of health and age
  • HSA and University contribution
  • Lower premium
  • All expenses go toward deductible
  • More cost-effective based on comparison
  • Like the idea of being responsible for health care spending

Top responses by those who choose the PPO plan.  There were 3,100 answers received.  Responses listed in order of frequency from most frequent to least frequent.

  • Deductible (lower than the Savings plan)
  • Cost (couldn’t afford savings plan)
  • Health (chronic condition)
  • “Best” coverage
  • Advancing Age
  • Risk averse to financial exposure
  • Coinsurance
  • Predictability of out-of-pocket expenses
  • Easier (to understand and pay as you go)
  • Copayments
  • Cheapest (month to month expenses)
  • Availability of Value Based Benefits
  • Size of family
  • Use a lot of health care
  • Maximum OOP on prescriptions
  • Medicare/other coverage prohibited moving to Savings Plan. {Note: Legislation has been proposed to ease the rules to allow Medicare recipients to be enrolled in an HSA but so far none has been passed by Congress.}
  • Convenience

What the answers reveal:

  • Now that employees have a choice between health care plans, results indicate that age is a significant factor in shaping plan choice. Low utilization of plan because of health and age is among the top response for faculty investing in the PPO Savings Plan, meanwhile, chronic health and advancing age are among the top responses for faculty investing in the PPO Plan. This is cause for concern because no employee can protect themselves from aging and related risks to health over time. Therefore, as Penn State moves toward an insurance spending model that results in a 75/25 university/employee costs sharing structure, the relationship between age, employee contribution (in real dollars and percentage of annual income), copayments, and out-of-pocket expenses should be closely analyzed. However, before any conclusions be drawn, a more detailed empirical analysis is needed.
  • Philosophical Comment: A system that pays a fixed percentage of health care costs is not insurance.  The concept of insurance is that a person is willing to pay some fixed amount to prevent having to pay a much larger and often catastrophic expense in case a disaster occurs.  For example, suppose there is a 1 in 1000 chance that your car will be totaled in accident.  You are willing to pay some small fixed amount in case you are the unlucky one in a thousand and not have to pay some very large amount to replace your car.  To be economically efficient, the insurer should charge a premium based on the likelihood of being in an accident.  If it is totally random and all vehicles cost the same, the premium should be the same for everyone.  However, it is not random.  For example, those who receive moving violation tickets are much more likely to be in an accident, so the insurance company charges them a higher premium.  Further, if someone buys a more expensive car, if they are in an accident, it will cost the insurance company more money, so they charge that person a higher premium.  This is fair because in both cases, driving recklessly and buying an expensive car are voluntary actions, actions that the insured can refrain from doing.  Thus, the higher premium serves as a deterrent to engaging in those behaviors.  However, for health insurance it is a different story.  Among the biggest risk factors for incurring high health care expenditures are advancing age and genetic disposition.  Neither of these are actions can be controlled by the insured person.  Thus, penalizing people with advancing age or with genetic disposition to have some chronic condition is merely punitive.  There is no economic efficiency gained by having this person pay higher out-of-pocket costs.  Again, it appears from the comments that this may be exactly what has happened.  Those of advanced age and/or chronic conditions are in the more expensive health plan and those who are young and without chronic conditions are in the less expensive plan.  Is this really insurance?  However, before any conclusions be drawn, a more detailed empirical analysis is needed.
  • There is still a lot of education needed about how the health plans work. For example, there appeared to be some perception that the PPO Savings Plan entailed more paperwork.
  • Those in the Savings Plan seem to understand the benefits of the HAS (such as tax advantages, the concept that the employee gets to keep the savings, etc..).
  • There is a misconception that there are different provider networks in each plan. That is not the case.
  • There is also a misconception that you need referrals in the PPO Savings Plan. This is also not the case.

    1. In 1250 characters or less, provide any feedback you have about Aetna. (Please refrain from including any self-identifying remarks.)

There were 2,843 comments received to this question. Top responses in order of frequency from highest to lowest:

  • Paying more out of pocket
  • Some providers not in-network any longer
  • Many comments about prescriptions and Aetna. Note: Aetna is not the Rx provider!
  • Aetna costs higher than Highmark
  • Feedback on Aetna’s website is mixed
  • Able to see UPMC providers
  • Aetna concierge – mixed opinions
  • Billing takes too long
  • Copays are too high
  • Mixed opinions on Quest for labs
  • Mental Health Providers lacking
  • Health Equity and Aetna systems not connected
  • Deductibles are higher
  • Frustrated that more cards aren’t sent
  • Value Based Benefits are not paid as it should

    1. In 1250 characters or less, provide any other feedback you have about CVS Caremark. (Please refrain from including any self-identifying remark.)

There were 1,516 comments received to this question.  Top responses in order of frequency from highest to lowest:

  • Costs are too high/have increased
  • Every time I fill a prescription, it’s a different price
  • Like the App
  • Drug needed was not on formulary
  • Like auto-refill feature
  • Dislike prior authorization process
  • Using University Health Services instead
  • Can’t get 90-day supply at CVS stores
  • Takes longer to get scripts sent to you
  • CVS and CVS branding is confusing. Note:  There is evidence that many employees are unaware that they can prescriptions filled at many different pharmacies, not just CVS

Next Steps

  • The University will share the results of the survey with both Aetna and CVS Caremark
  • Develop communications strategy for 2020 incorporating feedback
  • Schedule Town Halls with both vendors present
  • Education will be at the forefront for 2020
  • Exploring an on-line plan comparison tool using actual claims data

SENATE COMMITTEE ON FACULTY BENEFITS 2018-2019

  • Ingrid Blood
  • Denise Costanzo
  • Lorraine Goffe
  • Cassandra Kitko
  • Raymond Najjar
  • Kathleen Noce, Vice Chair
  • Xuwen Peng
  • Linda Rhen
  • Ira Saltz, Chair
  • Geoff Scott
  • Gregory Stoner