Transcript

Hello, this is doctor Eric Bricker and thank you for watching a healthcare see today's topic is nationwide employer healthcare strategy. So here we are in the middle of 2025 and employers in America have a big problem. I hear many stories of employers who are frankly over budget and having to add more money to their employee health plan because their health care costs have become so expensive this year. They're they're and it's because of their high cost claimants anytime an employee benefit plan is running hot. And over budget, you immediately need to look at your high cost claimants because that's the source of it, right? The the 550 role, 50% of your costs are coming from 5% of your claimants. So it's those 5% of the claimants that are driving this, OK. And everybody knows that healthcare cost equation, right, Where cost is equal to the price of the service times the quantity of the service. So if we're really going to get down to brass tacks here, OK, if we're going to get serious, I mean, because these employers are like 10s of millions of dollars over budget. And so like, if you really want to get serious and down to brass tacks. Like what would you do? So here's what I would do. The end of the day for your network, there's really only one network out of the four major carriers that's really worth anything, OK. The other three, like they're allowed amounts, they're contracted rates. At the end of the day, they're like really not good compared to Medicare and compared to that one other carrier. And I'm not going to name what that one other carrier is, but like you can you can beat around the Bush, but at the end of the day. Unless you're switching over to that one network, then like you. You're avoiding the obvious thing that you need to do, which is you need to get on that one. And if you're already on that one and you're running hot, there's other things you can do too. But if you're not on that one, that's the first thing you can do. And I have no affiliation with them whatsoever. OK, next, OK, and oh, by the reason why the other three are bad is because they have these horrible provider stop loss provisions where they and I'll leave a link in the show notes to the to the video that I made about it. But for their high cost claimants, once they flip past like 50 grand to build charges. Then it just reduces to like a 70% of build charges reimbursement, only 30% discount. And so certain carrier, I mean you talk to the broker consultant, they'll tell you they're like known for having these balloon high cost claimants. Whereas if you just had it through this other carrier, like they don't have that type of clause because I mean they have it sometimes, but not nearly to the extent because they are just bigger. And so therefore they don't have to go, I mean because the hospital that wants that. And so these other three carriers basically aren't able to. Negotiate out of that like this other one can. OK, Now this one carrier is notoriously inflexible. OK, So it's not ideal to work with and we're going to talk about strategies related to that coming up. OK, so the next thing you need to do is you need to get your claims data. This is for large nationwide self funded employers. They got employees all over the place. You have to get your claims data. There's no other way, OK? Why? Because you're going to do analytics to identify. And assist the high cost claimants and then you're going to predict and prevent the people who are going to become high cost claimants and many other employers that get their claims data. They do that successfully. This is not something like random pie in the sky theory. Other employers do this. OK, now the the actual fields that you need to get that the carrier is going to push back on it's again, I'll leave a link in the show. It's through a video that I did about this, OK. You're gonna, you're gonna want to get the bill charges the allowed amount after it's been repriced. You want the NPI numbers for the physicians and you want the tax ID numbers for the facilities. Now this is where the carriers really don't like this because they don't want to give you the allowed amount plus the identifying provider information because they feel that that's quote UN quote proprietary, that they have like a, a rate for an anterior an A CDF, an interior server discectomy and fusion as at. You know at Baylor, Scott and White for $7500, they don't want to tell you that. They don't tell you that an A CDF at New York Presbyterian is $15,000. Like they don't want to literally tell you that. So like if they really push back, then be like fine, like give us the allowed amount. Give us the 75 hundreds, give us the 15,000. Don't tell us that it's at Baylor or New York Presbyterian. But I need to know like with all the other information on the claim like that, like all the pH I like it's Joe, it's Jane, this is their. Date of birth, blah, blah, blah. So that I know that Joe and Jane had their a CDF blah, blah, blah. OK, man, when the carrier says no, you're like, fine, we're gonna RFP it. OK, we're going to RFP the carrier. All right. And I have seen a large nationwide employer in Florida that absolutely did this and they got their claims data and they RFP did and they got exactly what they wanted. And so again, you're, you're kind of delaying the inevitable. If you don't RFP your carrier because that's what you need to do, OK, then once you get the claims data like you need to, you need to trust, but verify. You need to verify that they're actually sending you real aloud amounts. And I'll that's, I'll save that for another video for another day. But you can't just like take it at face value that they're actually sending you the allowed amounts. You need to like verify that they really are giving you a lot of money and you need to put contractual language with penalties in the RFP that if they say they're going to give you the claims data. And then they don't give you the accurate claims data. OK, so Next up, what are you then going to do with these analytics? You're going to engage the high cost claimants. Note, I did not say engage the entire employee population. I didn't even say engage the people that are using their benefits and generating claims. I specifically said you're going to engage the high cost claimants. Again, 5% of the claimants driving 50% of the cost. You need to engage those 5%. You can leave the other 95% largely alone, but you've got to engage those 5. Sense now create another video where there's a matrix of what those high cost claimants are made of they are made of 50% that have previously generated high cost claims and then 50% that are new and then the other and then there's a two by two matrix and then the other way to identify it is folks that have like ongoing claims in other words dialysis year after year after year. Most of the folks that have episodic claims they had a heart attack it was super expensive they had stents put in and now they're great it's episodic like you can't do intensive like case management afterwards because like. They're pretty good. They're fine. OK. So you're going to want to intervene on the folks that were previous high claimants and they're ongoing and you're going to use the claims data for that. But then for all the new people that pop up, you're going to use a combination of claims data because you're going to see people who are diabetics and see people that have multiple sclerosis and might not be high cost claimants etcetera. And you're going to use demographic information as well and the a #1 demographic piece of information that you're going to want to use. Is plan member age greater than 50? Because what's the number one predictor of high health care costs? It's age. OK, it's your folks between the ages of 50 and 65 that are driving the vast majority of your claims cost for most employers, unless like, unless you're like Facebook and your average employee age is 28, well then you're going to have a whole bunch of moms and babies, right? For the vast majority of other employers, the average employee age in America is 48, and it's all those 50 to 65 year olds on the plan that are driving it. So again, like be like, we're not engaging our men in their 20s and 30s. Who cares? Like you can completely ignore them from a brass tax claim cost, state claim cost frame of mind. You've got to engage with your folks over the age of 50. It's not rocket science. OK, Now how are you going to engage them? Different employers use different strategies. There's a hugely successful trucking company in Arkansas that employs their own nurse case managers. OK, this is not a carrier solution the the trucking company. Themselves has nurse case managers at work with these employees and planned members, their high cost claimants. There's another large manufacturer in Tennessee that uses a navigation service that's not the carrier. There's another employer in Illinois that is a nationwide retailer. Again, these are folks that are spread out all over the country and they're using virtual primary care, OK. All of these are non carrier solutions. Do not use the carrier solution to do this. People don't want to talk to the carrier, OK so. You're, there's a, there are multiple ways to engage these folks, but you've got to engage them. Now this is for nationwide employers. I always promote on site and your site direct primary care, but that's for concentrated employers, for this retailer that has people in 50 States and there, there are 20 people at this store here and 30 people at this store there. You can't do on site near side primary care because people are too spread out in small pockets. OK, Next up, fraud, waste and abuse. You're going to use the claims data if you get all the claim fields, including the revenue. Codes, then you're going to look for fraud, waste and abuse. And I'm just going to specifically say, look, it's fraud. And I'm just going to specifically say, look, we're going to give the billers at the hospital the benefit of the doubt and we're going to say that it is accidental fraud. We're not going to say that it's intentional fraud. And what you're going to do is, is that you either yourself or you're going to hire a vendor to then get the medical record and reconstruct hour by hour what happened during their hospital stay and then compare that to the itemized bill and the revenue. Codes and when you do that you'll be shocked at what you find you will find billing for things that did not happen again, I won't say that that was intentional fraud, but it's fraud nonetheless. OK and so you need to catch that. Now here's the problem is that that bills already paid OK it's called pay and chase if they've already that bill is you know by the time you deal is fraud, waste and abuse. That claim has already been paid by the carrier. So how do you get your money back? You're going to ask the hospital for the money back. The hospital is not going to give you the money back. So what do you do? You withhold future payment from your plan to that hospital equivalent to the amount of the fraud. For example, I talked to a gentleman who was the head of benefits, large nationwide employer. They had a cabbage that was $800,000. That cabbage was not actually $800,000. There were hundreds of thousands of charges in there that were completely inappropriate. And so were they gonna get the 800 grand back from that hospital? Of course not. But they withheld future payments from their plan to that hospital to the equivalent of that amount. So you have to have super cooperation from your carrier in order to do that. Most carriers are not interested in doing that. So again, you have to put that in the RFP, OK. And then finally, because about 30% of your spend is going to be on the pharmacy and 70% is going to be on the medical, you're gonna carve out your PBM and of which 30% I said of your plan now is probably RX, right? It used to be 2025%. It's gone up to like 30% because 80% of your total drug spend is on your specialty medications. Who cares about your generics? Who cares about like 90% of your prescriptions? You don't care. All you care about is your specialty pharmacy could has 80% of your spend. So you take 80% of 30%, in other words, 24% of your overall plan spend is specialty pharmacy. And what are you going to do? You are going to not use one of the big three PBM's because those big three PMS require their own specialty pharmacy to fill mail order on the specialty medications. And what that allows them to do is to then bake a lot of the cost into the pharmacy and not into the PBM. So in other words, the BMW. And have all these rebate dollars to give back to you because they've paid themselves, they've paid their own specialty pharmacy a lot of money to pay for the drug. So in other words, in that case, the PBM itself is actually not keeping a ton of money because it's the specialty pharmacy that's keeping all the money. And you don't see those rebate dollars. So if you have a carved out pass through PBM, then you can use whatever specialty pharmacy you want. So you have to free yourself from that yoke between the PBM. And the specialty pharmacy that they own that they require you to use. So that separation is key when you go and when you carve out your PBM. OK. And oh, by the way, those PMS also own group purchasing organizations, NGO's that are headquartered in Europe where that G PO is keeping money. You have no access. You have no insight into how much that G PO is keeping, keeping from the PBM. So the PBM might say, oh, we don't have that much rebates. It's because the GPO, which they also own. In Europe is keeping the money so if you want to get down to brass tax because your plan spent is millions or 10s of millions of dollars over then here is what you need to do. I am not trying to sell consulting services. If you contact me I will say no I'm not interested in consulting for employers but talk to your own consultant because this is a solvable problem. Thank you for watching a Healthcare Z.