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Click here to download a PDF of the Private Exchanges Special Report.

Private health insurance exchanges are expected to grow substantially and dramatically change the way employers provide health care, including vision, to employees.

While the public health insurance exchanges have gotten much of the attention, both good and bad, resulting from the passage of the Affordable Care Act (ACA), the insurance executives that Vision Monday interviewed predict that their counterpart, private exchanges, are destined to have an even greater impact on managed care once they become established and group buyers become aware of the benefits of using them to provide health care to their employees.

As a result, the promise of more managed vision care plans sold via private exchanges is destined to increase the number of patients seeking access to eyecare. (See “How Will Private Exchanges Impact Optometrists?”).

In 2013, major companies such as Walgreens, Sears, and Darden Restaurants made headlines when they moved their employee coverage to private exchanges, and the transition has gained momentum since then.

With fewer than one million enrollees in 2012, enrollment through private health insurance exchanges tripled to three million in 2014 and then doubled again to an estimated six million in 2015, according to a new report by Accenture. With predictions of 100 percent growth year-over-year, private exchanges have the potential to reshape employer-sponsored health insurance, which covers 149 million people, according to the Kaiser Foundation.

While still in their infancy, having been established only in the past couple of years, studies predict that private and public exchanges will each reach matching enrollments of 30 million by 2017, and private exchanges will surpass public exchanges by 2018, enrolling a predicted 40 million lives compared to the 31 million expected to enroll through public exchanges that year. (See chart on “Public vs. Private Exchange Annual Enrollment,” below).

“Private exchanges are becoming more mainstream, as employers recognize more of the vendors offering exchanges than in the past,” according to a survey of 446 employees from 34 different industries released by the Private Exchange Evaluation Collaborative in December 2014.

The change is happening not only as a result of the Affordable Care Act, which established public exchanges as a format upon which private exchanges could be modeled, but also as part of the trend toward consumers having much more say in their health care and insurance coverage choices while simultaneously working toward reducing costs.

“Around the time that the Affordable Care Act was passed, many of us had conversations with our clients, and what they told us was they had increasing health care costs, increasing administrative burden, and at the same time employees didn’t really have a lot of choice, so Mercer Marketplace was created in response to many of our clients’ needs,” said Sharon Cunninghis, business leader for Mercer Marketplace.

Providing options from which employees select their health insurance coverage allows employers to switch from a defined benefit model, in which employers are the ones who choose the health coverage for their employees, to a defined contribution model, in which employers provide a fixed amount of money for employees to spend shopping from among a selection of available plans online.

Health insurance executives compare this major transition from a payor-driven to a consumer-driven model to the transition that occurred when companies began switching from pensions to 401(k) plans. Rather than employers making the choices, instead they provide options from which their employers can select investments, in the case of 401(k) plans, and health coverage, in the case of private health insurance exchanges.

While private exchanges enable employers to change to a defined contribution model, they also allow the company to remain involved in their employees’ health care.


Why Private Exchanges?
There are a number of reasons employers have switched or are considering the switch to private health insurance exchanges. Among the most influential is the unprecedented change occurring in health care as a result of the Affordable Care Act. Specifically, the public exchanges established to sell health insurance to individuals created a format on which private exchanges were modeled.

“The influence of public exchanges got more employers thinking about it,” Andrew Alcorn, president of Superior Vision Benefit Management, told Vision Monday about the launch of private exchanges. “Providers like us have the opportunity to participate as standalone plans, which is not permitted on public exchanges.”

In addition to the influence of the Affordable Care Act, other reasons include rising health care costs, the desire for more options while reducing administrative burdens, a trend toward consumer choice, and new technologies. Also, in some cases, benefits consultants have established exchanges as a means to remain relevant in an era of unprecedented change in health care.

“Employers are trying to figure out how to control their overall health care spend, and they can’t continue down the path of cutting benefits,” Rob Malley, VP of Aon Exchange Solutions, told Vision Monday. He explained that Aon Hewitt developed its Aon Active Health Exchange after spending a lot of time in Washington, D.C., during the formation of the ACA. They realized that creating a competitive market in which the consumer decides would lower prices. “Make it like a retail shopping experience, and competition lowers prices every time,” he said.

“The convergence of a number of critical factors—the unsustainable rise in benefit costs, health care reform, consumer-driven solutions, and improving technology—is transforming the provision of employee benefits,” added Eric Grossman, senior partner and exchange business leader in Mercer’s Health & Benefits business. “Private benefit exchanges give employers the ability to continue offering competitive benefits to employees, which is important for attraction and retention, while actively managing spending and reducing their administrative responsibilities.”


Slow Start Gains Momentum
“The pace at which we thought companies would move to private exchanges has been slower than expected,” said Jim McGrann, president of VSP Vision Care, which participates on a number of private health insurance exchanges. (See “Vision Care’s Place in the Realm of Private Exchanges.”) He estimates that VSP Vision Care’s strategic alliance/private exchange business unit accounts for about 10 percent of overall revenue. Of that, close to 5 percent is comprised of business derived from private exchanges. Still, he predicts that private exchanges will grow over the next three to five years. “Once they understand what private exchanges can do, they will start to move more quickly, and we will see the growth we were anticipating in 2013 and 2014 happening in 2016 and 2017.”

In some cases, companies are first testing out the private exchange concept with retirees. McGrann believes that companies’ tentative steps toward participation could be based on a desire to keep control. “Benefits are an important part of the relationship between a company and its employees, and a lot don’t want to give up control,” he said. “One thing that we are seeing is some organizations that are offering it are testing it out first with their retirees. For example, we cover 500,000 IBM retirees through a private exchange.”

In addition to IBM, other notable major companies using private exchanges for their retirees as of 2014 are Time Warner, General Electric, Whirlpool, Caterpillar and Kinder Morgan.

According to a survey of 446 employees from 34 different industries released by the Private Exchange Evaluation Collaborative in December 2014, “37 percent of respondents have implemented (14 percent) or are considering (23 percent) a private exchange for their post-65 retirees.”

“The employer market in reality hasn’t aggressively moved toward private exchanges yet,” said Davis Vision president Celina Burns, who added, “the operative word is yet. There’s no question that there’s going to be growth in the private exchange segment.”

While growth on private exchanges has been slow, it has also been steady since they started appearing around 2013. By October of 2014, Mercer Marketplace announced that 247 companies chose the exchange for their active and retired employees. That has since grown to over 260 employers. In total, across the full range of its active, retiree, voluntary benefits only and individual medical, Mercer Marketplace will provide access to benefits to approximately 2.5 million lives in 2015, according to the company.

“Further evidence of our momentum is the acquisition of 40 new clients not previously served by Mercer’s health business in addition to our continued growth with existing clients,” said Julio A. Portalatin, Mercer’s president and CEO.

The December 2014 Private Exchange Evaluation Collaborative study found that “47 percent of employers have implemented or plan to consider utilizing a private exchange for full-time active employees before 2018, up from 45 percent in 2013; 6 percent have already implemented and 41 percent plan to consider before 2018.”

Dave Bailey, senior vice president and national practice leader, United Healthcare Specialty Benefits, agreed that a slow start will make way for further growth. “It will take time, but private exchanges will eventually be a large portion of our business,” he told Vision Monday. “Based on the activity in the marketplace, there wasn’t much business at all in this just a couple of years ago. Now we are seeing significant groups participating.”

Eventually, enrollment through private exchanges is expected to surpass that of public exchanges. (See “Public vs. Private Exchange Annual Enrollment"). “The potential for private exchanges to grow in the medium to long term is strong,” according to Booz & Company, a global management consulting firm that produced a series of white papers on the topic.

“After a flurry of activity in 2013 and 2014 among large employers, many feel we have moved beyond the ‘early adopter’ stage and are poised for broader acceptance,” according to The Institute for Healthcare Consumerism’s private exchange blog dated Feb. 17, 2015. “Private exchanges are becoming more commonplace with more organizations than ever before implementing exchanges or actively considering them.”

jsailer@jobson.com