Managing Health Care Costs

Overview

The employee benefits landscape in the United States has been transformed by the escalating costs of health care and other benefits, by changes in employment and benefits laws, and by new initiatives and options in health care benefits, particularly those set forth in the Affordable Care Act (ACA). As a result, employers are exploring various ways to manage the costs of the health coverage portion of their overall benefits programs.

This toolkit provides a primer on varied approaches that employers can take to manage health coverage costs. The article examines the background, the business case and the role of human resources in health cost management. It discusses a number of cost-management methods—from shifting more costs and responsibilities to employees, to introducing high-deductible health plans, to implementing multifaceted wellness programs aimed at improving employees' health and thereby reducing health costs over the long term.

This toolkit also provides an overview of how the ACA affects employers' efforts to offer health coverage and manage its costs.

Background

In the United States, health care insurance has been handled mainly as a benefit of employment. Under the U.S. Internal Revenue Code, employers can generally deliver health benefits to employees as a tax-deductible cost of business, and employees can generally receive such benefits free of tax. The system has remained in place for decades, but the economics have changed. Health costs often rise at rates exceeding inflation and the pace of overall economic expansion, and the trend is expected to continue.

Because of the long-term trend of rising health care costs, employers are reassessing and redefining their roles as providers and subsidizers of their employees' health care benefits. Although most employers plan to continue sponsoring medical benefits for their employees, they are adjusting their ways of doing so. Many employers are integrating a pay-for-performance philosophy into their health benefits programs, and they are generally motivating employees to shoulder more responsibility for maintaining and improving their health and for contributing to the costs of their health coverage. See Planning 2021 Benefits Changes for the COVID-19 Era.

Business Case

Providing health benefits is an important tool for building a competitive workforce. For job seekers, the strength of an employer's benefits package may be nearly as valuable as salary. In fact, for a potential employee who has one or more dependents, benefits may be even more important than salary. Therefore, employers that want to hire the best, most productive employees must be prepared to pay the price in attractive, competitive health care benefits. See Benefits Are Often an Afterthought During Recruitment and Employees Are More Likely to Stay If They Like Their Health Plan.

For many employers, however, the price of benefits is becoming increasingly unaffordable. Health care coverage is the largest employee-related expense for U.S. employers. According to the Bureau of Labor Statistics (BLS), private industry employer costs for insurance benefits averaged $2.65 per hour worked or 7.3 percent of total compensation.¹

Health Coverage Cost Management Strategies

In recent years, employers have tried many ways to control the ever-rising costs of medical coverage for employees. Steps that can produce cost savings relatively quickly include offering new hires coverage that is less generous than that offered to current employees, requiring increased cost-sharing for all health plan participants, and consolidating third-party vendors or pooling insurance risks to achieve economies of scale. Approaches aimed at containing health costs over the long run include wellness programs and other methods of making employees more responsible for their own health and their health care decisions.

Specific cost-control approaches are discussed in more detail below and demonstrate the many effective tools employers can use singly or in combination to help control their health coverage outlays. See 15 Ways Employers Can Reduce Health Care Spending That Aren't Cost-Sharing.

Offering Consumer Directed Health Plans

Promoting health care consumerism

Increasingly, employers' efforts to manage their health care costs are focused on getting employees to become better health care consumers. Health care consumerism refers to efforts to persuade employees to make healthful choices in daily living and providing tools and education to help ensure that when employees use health care, they are aware of its costs and have an incentive to reduce those costs when possible. Health care consumerism is tied to health plan design, incentives, an effective communication strategy and enabling plan participants to engage in healthful behaviors.

In many ways, efforts to move employees toward greater health care consumerism are similar to the efforts employers have made to persuade employees to save for retirement by using 401(k) and other defined-contribution plans. In health care as in retirement planning, more responsibility has been shifted to employees, and employers are using incentives to reward desired behavior. Just as employers can offer matching contributions to motivate employees to contribute to their 401(k) plans, employers are using incentives, such as contributions to a health savings account (HSA) or a health reimbursement arrangement (HRA), to spur greater employee engagement in their health care decision-making. See Health Care Consumerism: HSAs and HRAs.

Adopting consumer-directed health plan designs

The use of consumer-directed health plans (CDHPs), particularly high-deductible health plans (HDHPs), is significant in promoting health care consumerism. Studies indicate that employees enrolled in CDHPs are more likely than others to make sustainable, positive behavior changes leading to significant reductions in health plan spending year over year. See Workers with High Deductibles Curb Health Care Spending.

A CDHP typically combines an HDHP with a tax-advantaged HSA or HRA to help enrollees pay for out-of-pocket medical expenses.

An HSA is a tax-exempt account set up to pay or reimburse employees for eligible out-of-pocket medical expenses. HSAs must be linked to a high-deductible health plan, and the plan's deductibles and contributions are federally set and adjusted each year. HSAs can be funded by employees, employers or both. An HSA is owned by the employee, and unspent funds are carried over from year to year and are portable if the employee leaves the organization. Employer contributions to HSAs are not taxable for the employee. Employees may make contributions with pretax dollars through a Section 125 salary-reduction cafeteria plan. See Employees Still Perplexed by HSA Plans During Open Enrollment.

An HRA is an employer-owned account funded solely by employer contributions to assist employees in paying for or reimbursing eligible out-of-pocket medical expenses. HRAs are often linked to an HDHP but are not required to be. There are no government-mandated minimum deductibles or out-of-pocket maximums for plans linked to HRAs. The employer may, but is not required to, let funds accumulate from year to year. Contributions are not taxable for the employee. See Employers' Interest in Individual Coverage HRAs Is Rising.

These tax-advantaged accounts allow employees to access funds to cover higher cost-sharing provisions in exchange for lower monthly premiums. Because employees are more involved in the cost of health care services, they may be more inclined to consider the necessity of high-cost health care in certain circumstances, for example, an urgent care visit versus a visit to the emergency room.

Developing a robust employee wellness program

As much as 70 percent of health care spending can be attributed to behavioral and lifestyle choices;² thus, employers are increasingly offering employees health improvement programs. Numerous studies have indicated that employers can contain or even reduce health care costs by implementing wellness programs. According to a SHRM survey of employer wellness initiatives, more than half of employers said their organizations offered some type of wellness program in 2019.

Wellness benefits can take many forms, and they can be as simple or as complex as an organization desires. Some wellness benefits help employees deal with preventable and chronic conditions such as obesity, high glucose and elevated cholesterol. Other wellness benefits are incentive programs designed to motivate employees to complete certain health and wellness activities such as annual health risk assessments, smoking-cessation programs or weight-reduction programs. According to the 2019 SHRM Employee Benefits Survey, the most common wellness benefits provided by more than one-half of organizations were wellness tips and information sent to employees (64 percent), onsite seasonal flu vaccinations (60 percent) and a wellness program (58 percent).

Before implementing a particular wellness program or initiative, an organization should carefully consider the potential costs, advantages, levels of employee participation and legal concerns. For wellness programs to be effective, employees must know about and participate in the offerings. According to recent research, employers view low engagement as the greatest obstacle to their wellness initiatives. Fine-tuning an organization's benefits communication efforts can pay big dividends in getting employees involved in wellness initiatives.

Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), employers' group health plans are not permitted to discriminate against employees on the basis of health factors by varying premiums, but the law does allow employers to offer wellness programs and wellness incentives.

The law's nondiscrimination rules generally prohibit group health plans from charging similarly situated individuals different premiums or contributions or from imposing different deductibles, co-payments or other cost-sharing requirements based on a health factor. There is an exception, however, that allows plans to offer wellness programs. If none of the conditions for obtaining a reward under a wellness program are based on an individual satisfying a standard related to a health factor, or if no reward is offered, the program complies with the nondiscrimination requirements—as long as all similarly situated individuals can participate.

Examples of programs that would be in compliance are as follows:

• A program that reimburses all or part of the cost of membership in a fitness center.
• A diagnostic testing program that provides a reward for participation rather than for outcomes.
• A program that reimburses employees for the cost of a smoking-cessation program without regard to whether the employee quits smoking.
• A program that provides a reward to employees for attending a monthly health education seminar.

For details on HIPAA's rules regarding wellness plans, see The HIPAA Nondiscrimination Requirements.

See also:

• Employers' Dream of Controlling Health Costs Turns to Workers' Sleep
• EEOC Issues Final Rules on Employer Wellness Programs
• Designing and Managing Wellness Programs
• How to Establish and Design a Wellness Program
• EEOC's Final Rule on Employer Wellness Programs and Title I of the Americans with Disabilities Act

Shifting health care benefit costs to employees

A major trend in managing employers' health care costs is having plan participants take on increasingly larger portions of the costs of their health care. Methods of doing this include raising the deductibles and co-payments for medical services, having participants pay larger shares of premiums, and increasing the costs of using out-of-network health providers rather than in-network providers. Employers must balance this approach with affordability requirements under the ACA.

A 2020 Kaiser Family Foundation health benefits survey found paid employees paid 17 percent of the premiums for single coverage, on average, and 27 percent of the cost for family coverage. The survey also showed that employers are shifting costs to employees through increased deductibles and out-of-network co-pays.

Attaching a surcharge to spousal coverage

Some employers have added "working-spouse" provisions to their health coverage plans. These provisions limit an employee's spouse's access to a plan when the spouse works for another employer that offers health insurance. Working-spouse provisions—also called "spousal carve-out" or "spousal exclusion" policies—generally take one of three forms:

• A requirement that an employee's working spouse pay a premium surcharge for coverage through the employee's enrollment if the spouse's employer offers health insurance and the spouse has declined it.
• A requirement that an employee's working spouse purchase health insurance through the spouse's employer's plan before also purchasing it through the employee's enrollment.
• An outright exclusion of an employee's working spouse from coverage through the employee's enrollment if similar coverage is available from the spouse's employer. This approach is not commonly used.

Before adopting such rules, employers should determine if the savings from the requirements would at least offset the administrative costs and predict possible adverse employee reactions that the rules might entail. Employers must also be aware of the nuances of spousal exclusions, which can determine whether they are effective—and legal.

See What is a spousal carve out and a spousal surcharge program, and how do they differ?

Changing prescription drug benefits

Prescription drug benefits are fast becoming a larger, more complex and integral component of an employer's total approach to managing health care costs. Over the past several years, prescription drug cost-increase trends have outpaced medical cost trends. In addition, more expensive specialty drugs are entering the market, and trends for these drugs are forecasted to have twice the cost-increase trends of retail drugs. Specialty drugs accounted for less than 1 percent of prescriptions yet totaled 40 percent of total drug costs, according to data from Willis Towers Watson's Rx Collaborative.

The most popular mechanism to control prescription drug costs among employers has been to use a multitiered formulary, an approach devised by pharmacy benefit managers to shift some pharmaceutical costs to employees. This tactic also involves the use of techniques such as requiring prior authorization for some medications and step therapy—seeing if less-expensive drugs work before allowing payment for more-expensive drugs.

A new approach some employers are considering are co-pay accumulator programs that don't count the value of co-pay assistance cards from manufacturers toward patient deductibles. The goal is to discourage the use of expensive medicines when cheaper or generic (and equally effective) options or treatments are available. See New Tactic Emerges to Control Rx Spending and HHS Issues Final Rule on Drug Company Rebates.

Other tactics to manage prescription drug costs include the following:

• Prior authorization required before filling a prescription.
• Quantity limits.
• Step therapy, requiring less expensive drugs to be tried first.
• Having the member pay the difference between generic and brand prices.
• Closed formulary excluding certain brand name drugs.
• Integrated medical and pharmacy data for more effective cost management.
• Mandatory mail order for maintenance medications.
• Four-tier or higher pharmacy plan design.
• No co-pay for select generic medications.

Techniques focusing on specialty drugs include:

• More aggressive use of management protocols for specialty medications.
• Requiring specialty medications to be obtained through a specialty pharmacy.
• Pharmacy plan designed with a specialty tier with greater cost sharing.

Although managing pharmacy benefits costs serves a worthwhile and necessary goal, employers should keep the larger picture in mind when developing strategies. Cost-cutting that denies individuals access to necessary medications or that makes purchasing prescription drugs a financial hardship may have negative effects on an employer's long-term health care costs and workers' health and productivity.

Additional Options

The following are additional options that have potential for significant savings in employers' health care costs.

Auditing family-member eligibility and other aspects of the plan

Plan sponsors have a fiduciary duty to administer their health plan in the interest of eligible participants and their eligible dependents. If an employer is providing health plan coverage for nonqualified participants, the employer not only is wasting money but also is at risk of violating federal requirements and the Internal Revenue Code. Organizations can avoid such negative outcomes by carefully managing dependent eligibility. Providers of dependent-eligibility audit services have reported in past years that more than 12 percent of covered dependents have been found during audits to be ineligible.3 Removing ineligible persons from the plan can ultimately save the employer substantial sums. See Health Insurance Dependent Audit Checklist.

Offering and encouraging the use of telemedicine

Virtual doctor visits are a trending health care savings strategy and the COVID-19 pandemic accelerated employer's implementation of this offering. According to a Kaiser Family Foundation health benefits survey, telemedicine coverage increased to 85 percent in 2020 by employers with 50 or more employees.

Telehealth visits are often less expensive than a traditional office visit and more convenient to individuals who are seeking care after hours or who cannot easily go to a doctor's office. Major health insurance carriers are more frequently offering telemedicine options as are health care providers.

Employee education and communication are necessary for making effective use of telemedicine benefits with employers often promoting the convenience factor to working parents or traveling employees. See During the Pandemic, Telehealth Steps Up and Virtual Physical Therapy Could Be Telehealth's Sweet Spot.

Establishing tiered health insurance plans

Given that the ACA requires employers to expand their health benefits programs to employees' adult children, some employers are looking for ways to share the increased costs of this requirement. Under the law, health plans that offer dependent coverage—as employer-sponsored plans routinely do—must allow participating employees' unmarried adult children to remain on their parents' plan until age 26. One way for employers to share this cost is to charge health insurance premiums on a per-participant basis.

Employers have always differentiated premiums based on types of coverage. What has changed is the detail involved in structuring premiums. Instead of offering family coverage with one premium no matter how many children are covered, employers are creating tiers of premium rates. A common four-tier strategy is:

• Employee only, generally called individual coverage.
• Employee plus one, which can mean employee plus a spouse, a partner or a child.
• Employee plus child or children without a spouse or a partner.
• Employee plus spouse or partner and child or children—often called family coverage.

Other options for employers include expanding tiers to require higher premiums for three or more children or having uncapped tiers under which the employee's premium is based on the number of individuals the employee enrolls in the employer's plan. Some employers limit the number of tiers to avoid making coverage too expensive for larger families.

Alternatively, to deal with the affordability of employees' premiums, employers are showing interest in basing premiums on employees' salaries by charging lower-wage earners less for health insurance. See Income-Based Premiums Help Make Health Care Affordable.

Offering health risk assessments

As wellness programs become more prevalent in efforts to keep health care costs under control, more employers are having health risk assessments conducted in their workforces to gain better understanding of their employees' health risks so that they can choose the health issues on which to focus their wellness programs. Employers are increasingly becoming convinced that employees will be more informed and engaged in health-improvement efforts if they learn their health risks through confidential personalized health risk assessments and if they are given tools to improve their risk behaviors.

A health assessment can provide a wealth of data cost-effectively, and the data can be used to tailor the wellness experience for each individual. Research has shown that when wellness programs are well designed and offer a health assessment with relevant follow-up and options customized to meet individuals' needs, the programs have a positive impact on population health and financial outcomes.

However, employers that conduct risk assessments need to be aware of limits established for such assessments by the Americans with Disabilities Act (ADA) and the Genetic Information Nondiscrimination Act (GINA). The ADA requires that health- and disability-related inquiries and employee medical examinations be completely voluntary unless they are specifically job-related and consistent with business necessity. Similarly, under GINA, risk assessments that request genetic information must be completely voluntary. GINA also stipulates that no rewards can be provided for the completion of risk assessments that solicit genetic information. Accordingly, employers cannot impose any penalties on an employee who declines to complete an assessment that solicits such information.

Nonetheless, employers can offer bonuses or reduced health insurance premiums to employees who voluntarily take health-risk assessments or enroll in recommended disease management or behavior risk management programs.

Negotiating better benefits contracts with vendors

Many employers, particularly smaller businesses, could be more aggressive in negotiating contracts with health insurance vendors. Benefits experts indicate that health insurance providers have a generally accurate sense of an organization's "pain" threshold—the level of premium increase an organization will tolerate. A current carrier will likely keep raising rates year after year because it knows most organizations do not want to take on the difficulties of re-enrolling an entire employee group with a new provider.

Insurance providers often bundle costs for administration, network access, wellness programs and reinsurance into one total cost figure. When services are bundled, however, employers may have difficulty comparing the costs of individual services from provider to provider. But employers can achieve comparisons and thereby stimulate competition by requesting that services be unbundled and then by negotiating each piece. This approach can lead to better control of health insurance costs.

Self-funding the health plan

In a traditionally insured plan, an insurance company assumes the risk, controls the plan's administration, establishes reserve capital levels and manages other major decisions concerning the health care coverage provided to employees and dependents. Under a self-funded arrangement—also called self-insured—the employer assumes the liability and risks of providing health coverage in exchange for more control over the plan's administration and funding. Self-funded plans are most prevalent among organizations with 500 or more employees, although self-funding can work for smaller companies also.

With self-funding, an employer takes the money it would otherwise pay to an insurer and establishes a special bank account to pay for claims. A broker or benefits consultant is hired to develop a customized medical plan for the group. A third-party administrator (TPA) is hired to receive and manage claims, and the employer authorizes the TPA to draw money from the bank account to pay claims. Typically, the TPA arranges to have preferred PPO networks, wellness programs and other managed care elements in place. The TPA issues employee ID cards, too, and thus from the outside the employees appear to have traditional medical insurance.

Self-funded plans are governed by the Employee Retirement Income Security Act (ERISA) and are attractive to employers because of the greater level of flexibility that comes with being able to tailor the plan to their needs. Although employers take on additional financial risk, they are able to limit total risk through the purchase of a stop-loss policy, and they benefit from the increased cost savings typical of the self-funded model.

Scaling back or eliminating medical benefits for retirees

Similar to the reduction in traditional pension plans, a decline in retiree health benefits has taken place over the past decade, mainly to cut costs. Only 29 percent of employers continue to offer a retiree health plan, according to the 2020 Kaiser Family Foundation employer health benefits survey.

Legal Issues

Many of the approaches that employers can take in managing health coverage costs are subject to various requirements of major employment laws. Employers should be familiar with the general purposes of laws such as ERISA, HIPAA and COBRA, to name a few. Before implementing a new plan or making changes to an existing one, employers should consult with health coverage experts and legal counsel to avoid breaching the boundaries of laws and regulations regarding the equitable treatment of employees. Employers must avoid practices that could be discriminatory toward individual employees or groups of employees.

The ACA presents some of the most extensive challenges for employers in managing health care costs. The ACA has directly and indirectly increasing the cost of employer-provided health care through a number of its provisions. For a full overview of the impact of the ACA on employers, see Complying with the Affordable Care Act and Affordable Care Act Penalties.

Communications

Effective communication to employees is critical for success when rolling out health care cost-control measures. In communicating about health care benefits, employers should consider the following recommendations:

• Communicate early and repeat the message often. Even though open enrollment is an important time for employers to educate employees about cost-conscious health benefits choices, health care communications experts recommend that organizations provide ongoing communication activities rather than concentrate only on open enrollment season. More employers now believe they need to engage employees continually in health consumerism because the results it can produce derive from day-to-day decisions.
• Communicate in a variety of media. Use both traditional and electronic methods. Traditional methods include open enrollment, payroll-stuffers, posters, a table outside the cafeteria where people explain the program and one-on-one benefits counseling. Electronic methods include intranet communications, e-mail, and mobile-device and social-media access to health benefits information.
• Provide employees with tools to help them make cost-effective health care benefit choices. These choices include selecting appropriate health plan options, treatments and providers based on available cost and quality information. With cost information at their fingertips, employees are able to make more insightful decisions about their health care and the care for their families. They can learn to balance cost, convenience and quality in a manner that meets their budgets. That process can lower the overall cost of health care for both employees and employers.
• Encourage employees to evaluate how they and their family members used health care in the previous 12 months. Suggest that they consider how much they spent out-of-pocket on deductibles, flat-dollar co-payments, and percentage-of-cost co-insurance and review the number of doctor visits and the cost of ongoing medications. Employees who have an HSA or an HRA should determine what remaining balance they might be able to apply to the subsequent year's expenses.

See:

Spotlight Value of Benefits Package During Open Enrollment

Benefits Communications Require a Balancing Act

Communicating with Employees About Health Care Benefits Under the Affordable Care Act 

Metrics

As each fiscal year draws to a close, an organization's leaders look for ways to save money and control health care costs in the coming year. As part of this process, they should gather and analyze data that can give them a clear picture of health plan enrollees and total health plan costs. Some key metrics in these areas include:

• Enrollee information, such as the numbers of employees, spouses or partners, and dependents enrolled and using the health coverage.
• Direct costs such as paid claims and administrative costs.
• Indirect costs attributable to health issues, such as lost time because of disability.
• Use of benefits trends.
• Benchmark data on the cost of health care and employer cost-sharing trends.

SeeAnalytical Tools to Help HR Manage Benefits, Reduce Costs and An Open Enrollment 'Look Back' Captures What You've Learned.

Technology

Employers can use technology to provide employees and their health plan dependents with information and tools to manage their health and health care costs. Technology can also help employers understand the vast amount of data in their health plans, which can enable them to pinpoint potential areas of escalating health costs and identify opportunities to control health costs. A health plan's data hold vast potential. Organizations can use aggregate data to help design plans, improve employees' health and drive down health care costs.

Among the various ways that organizations can help employees improve their health is a tactic that many plan sponsors still overlook: data mining, the process of identifying data patterns and turning them into useful information. Data mining uses analytical software to examine a health care plan's raw data. Plan sponsors can use data patterns to make plan design decisions. Key information in this context includes the health services being used, the services available but hardly or never used, and the benefits or services currently not incorporated in the plan but that the data suggest should be included.

Medical data management companies collect such information from health insurers, third-party administrators, HMOs and pharmacy benefits managers. The data companies organize the information into specific clinical use and financial data sets. Sophisticated software allows analysts to sort, combine and contrast key data elements to help decision-makers and clinical managers take effective corrective actions. Individuals' information is not disclosed; the data are aggregated, and thus the information does not violate the privacy protections mandated by HIPAA.

Another tool for helping employers control health costs is predictive modeling, which uses claims data and lifestyle analytics to identify potential catastrophic claims and illnesses. Predictive modeling can sort a population according to its risk of nearly any outcome. This means identifying subsets of employees who are likely to need high-cost health care of one type or another within six to 12 months. Organizations can then offer particular subsets services such as health coaching to better manage their health and reduce the likelihood that they will need avoidable, costly care.

See Data-Driven Benefit-Selection Tools Are Just Getting Started and Virtual Benefit Fairs Draw Interest for Fall Open Enrollment.

Global Issues

The cost of employer-provided health insurance continues to increase around the world. Given the variety of health systems and market practices globally and the significant differences in costs for employers to sponsor health plans, the need for a global workforce health strategy has never been greater. Multinational organizations that have a clear strategy can better coordinate local health activities to improve their overall workforce health and increase the efficiency of their total spending on health care.

Multinationals in various regions have different health plan needs and goals. Corporations in the Americas, for example, are much more focused on medical cost containment, whereas European corporations are concerned with disability, lost productivity and absenteeism. Most national governments, even in the developing world, are far more involved than the United States in providing or mandating health care services. In countries where government-provided benefits are extensive, employers may find little need to add to them. In many countries, however, governments provide only very basic health care services. In less developed parts of the world, quality of care is often a problem.

Notwithstanding these differences, some common issues and trends have emerged globally with respect to managing health care costs. Many of these mirror cost-control measures being adopted by employers in the United States. These global trends include:

• Reform of pension and health and welfare systems. Such reforms, prompted by an aging population and the increasing cost of providing adequate retirement income and health services, are gathering momentum in numerous countries, including France, the United Kingdom, Australia and Canada. Without action, as the reforms progress, multinationals risk being hit by unsupervised and escalating costs and might violate regulatory requirements.
• Use of incentives tied to wellness program participation and behavioral change.
• Discounts for using networks of high-quality medical care providers that do not charge above-market rates for their services—for example, requiring employees to share the cost burden if they select a provider charging $3,000 for a colonoscopy when in their locality the same procedure is available for under $1,000 from a provider with a demonstrated record of high-quality outcomes.

When managing benefits for a widespread international workforce, employers should first establish a global corporate benefits strategy. The most common strategy is to design a plan that complies with applicable local laws and matches the benefits of local competitors.

See Do we have to offer the same benefits to our employees who work in other countries as to the employees working in the United States? and Viewpoint: Implement Global Policies, Not a Global Handbook.

Endnotes

¹Bureau of Labor Statistics. (2020, December). Employer costs for employee compensation. Economic News Release. Retrieved from https://www.bls.gov/news.release/pdf/ecec.pdf

²National Association of Heath Underwriters. (2015, June). Healthcare cost drivers white paper. Retrieved from http://www.nahu.org/legislative/policydocuments/NAHUWhitePaperCost.pdf

³PSA. (2013, April 30). Dependent verification audits: potential savings for your health care plan. PSA Perspective [Blog]. Retrieved from https://www.psafinancial.com/2013/04/dependent-verification-audits-potential-savings-for-your-health-care-plan/