In our knowledge segment, we talk a little bit about a big expense – pharmaceuticals. Many employers don’t know that prescription drugs make up 25-30% of their total healthcare spend. In fact, these numbers are projected to get more dramatic, reaching 50% in the next few years. 

Then we talk with Jake Frenz of SmithRx about the ways that we can continue creating value in the pharmaceutical space, his history of serving in the Marines, and a short digression into… classical music? In between Andrew Clayton’s prospects as a classical pianist, ski trips, and some shots taken at golf, we discussed the specific levers that can fix the problems of outsized pharmaceutical prices. 

Finally, in the “you know they’re a knucklehead when…” section, we discussed the role of people skills versus strategic vision in relationship-based businesses. It turns out – who knew? – that if you’re giving advice to someone, you need more than a good golf swing and a box of donuts.

One of the most significant hurdles faced by self-insured employers – especially those new to self-funding – is how to interpret the information and feedback you receive now that they have access to plan data. Even “blinded” data offers a tremendous opportunity to reveal claims trends and identify actionable strategies.

For those of us who have been immersed in the sphere for more years than we care to admit, gleaning insight and shaping strategies can seem obvious. But the things that are intuitive and obvious to us are often the result of our experience, and if you don’t have that same degree of experience, these things can be opaque, confusing, or seem contrary to common sense.

As stewards of self-insured benefits plans, how can we bridge this knowledge gap? How can we lend our expertise to improve the experience of employers using our funding methods? And how can we carry the burden of maintaining these strategies, so employers don’t have to?

One of the ways that we get this done involves our use of data, our flexible cost-containment measures, and good old-fashioned industry expertise to guide the owners of our captives – the Members.

We deliver this guidance through ParetoHealth Playbooks.

To explain what these do and their role in our benefits strategies, we have to go right back to the beginning.

We started ParetoHealth in 2011 and cost containment was central to our mission from day one. The approach was simple. Members implemented health risk assessments, conducted biometric screenings, and encouraged tobacco cessation. These basic strategies helped employers support the health and well-being of their employees.

These remain good foundational measures, but things have evolved dramatically. Today, a variety of strategically significant cost-saving measures are united under a single umbrella, ParetoHealth’s Integrated Cost Management (“ICM”) program. The ICM program is an optional solution for ParetoHealth Members, who are also welcome to opt out if they decide it’s not right for their group.

Launched in January of 2020, ICM analyzes employer-specific data and produces a customized, actionable plan for that group based on their unique data. Too often, “strategies” are based on the data of an entire industry or captive. Landing on an effective strategy is much like swinging away at a pinata while blindfolded – sure, there’s a chance you hit it, but there’s a better chance that you miss the mark completely. ICM is based on more than hope and luck – the strategies succeed because they respond to the specific needs of the group. Through a careful analysis of the data, we identify the most effective cost-management options for that group and eliminate programs that aren’t likely to offer much impact.

When it comes to programs, ICM expands the measures of earlier days to include a variety of fully integrated services, emergency interventions, and retrospective data analysis that helps our Members chart a course into the future. These things work in tandem to deliver a long-term solution to control costs while safeguarding the well-being of the people who work for them.

So, in other words, these playbooks are deep analyses of existing health plan data, which we deliver to everyone on our ICM platform. We eliminate the guesswork and maximize the ROI. After identifying the right strategies, we provide straightforward – often turnkey – advice on how to implement these strategies and optimize them for the future. We continually reanalyze the data and propose adjustments based on the latest data and trends.

Gone are the days when employers could only reduce healthcare spending by cutting their benefits. By implementing a data-driven, actionable plan, ICM allows ParetoHealth Members to embrace a true cost-management strategy that will serve them well into the future.

In this episode, we go over the phenomenon of medical inflation and what parts of the COVID-19 pandemic have contributed to rising medical costs – as well as what self-insured employers can do about it.

Then we chat with Brian Olsen of Sterling Seacrest Pritchard (SSP) to talk about his deep, committed relationship with self-funding and why that means we need a dating site for SIIA members. He shares one great insight about the often-misunderstood relationship between high claims and self-funded plans that you won’t want to miss.

Finally, we discuss one knucklehead move that too many brokers use in a feeble attempt to contain costs. It’s the epitome of short-term thinking. Is your broker guilty of this particular howler?

Employers must have a sound strategy to combat rising costs

You’ve heard the grim statistic – Americans pay more for healthcare than any other nation but receive less treatment and poorer outcomes. Spending on drugs and medication makes up a large portion of these costs. According to The Peter G. Peterson Foundation, U.S. healthcare spending averages $12,500 per person. By comparison, countries such as Canada, Austria, and France only pay about one-third as much1.

The Congressional Budget Office has calculated that the share of US healthcare spending on prescription drugs has risen from 5% of the total in 1980 to almost 10% in 2018. Both the number of prescriptions written and their overall costs have increased.

But why do drugs cost so much? Among the reasons:

1. The cost of drug research and development (R&D) is massive

This factor is the primary driver of the high cost of drugs. The process of turning raw materials – whether natural or synthetic – into drugs safe for consumption is extremely costly. The National Academy of Sciences revealed that it costs anywhere between hundreds of millions of dollars to $2 billion to bring a drug to the market2. Also, consider that nearly 9 out of every 10 drugs developed never make it past clinical trials3. The price of a prescription drug includes all the research and development costs of failed drugs, plus the cost to manufacture your prescription drug, plus a layer of profit for the drug company. Add all of these things together and you face a whopping price tag.

2. A lack of market competition and drug-specific monopolies

In the prescription drug industry, a single company often has a monopoly on the rights to a drug. Thanks to patent exclusivity, they get to produce, distribute, and sell it without any competition.

Also, since drugs are necessities and not luxury goods (despite some drugs being priced as high as luxury goods), drugmakers can set prices that they know people – and insurers – will have no choice but to pay.

3. “Pay for delay” agreements

Generic alternatives help to decrease the costs of drugs. When the patent exclusivity of a drug expires, other companies can develop generic drugs – ones that function the same but aren’t branded.

To stall this, pharmaceutical companies who own the patents to the drug may engage their competitors in “pay for delay” agreements, whereby they pay their competitors to delay producing and launching generic versions.

As a result, a single drug company may continue to hold a significant market share of a drug well after expiration of patent exclusivity.

4. Patent evergreening

Going back to patent exclusivity, drugmakers sometimes engage in “evergreening” to extend their exclusive rights to a drug. There are a few ways they can do this, such as repurposing or altering the drug.

For example, if the medication was formerly distributed in pill form, pharmaceutical companies may revamp the drug by turning it into a powder. They rename the drug and apply for new patents, giving them extended rights to expiring patents.

5. Lobbying from Big Pharma

The power of pharmaceutical companies is massive, with the lobbying group for the pharmaceutical industry spending about $27.5 million on lobbying activities in 2018 alone4. They’ve managed to achieve this through a vicious cycle of leveraging money to secure power to continuously grow financially. It’s a loop that leads to more profits for drugmakers and the intermediaries involved.

As prescription drug costs rise at a rate of 2 to 3 times that of inflation, Congress has responded with bills to curtail costs2. But given the mammoth lobbying machine of big pharma, the likelihood of successful legislative reform is dubious, at best.

6. Drugs don’t have price regulations

The U.S. Food and Drug Administration (FDA) regulates how new drugs are tested, marketed, and released on the market. What they don’t regulate (and control) are prescription drug prices and enforceable mechanisms for value-based pricing5. That role goes to drug companies who very clearly have an interest to price drugs as high as possible.

7. There is no price ceiling on drugs

According to a report by Healthline, the U.S. government does not set ceiling prices like in other countries6. Because of this, the price for an annual supply of certain drugs can cost as much as a single-family home.

8. The cost of marketing and advertising drugs

Did you know that in many pharmaceutical companies, the cost of marketing and advertising can go as high as – if not even higher than – a drug’s R&D costs8? Marketing and advertising drugs is a hot business, especially between drug companies and healthcare professionals, to influence the medical choices of patients.

9. A lack of transparency in the chain, with intermediaries that complicate the whole process

Intermediaries such as insurance companies and Pharmacy Benefit Managers (PBMs) play a key role in getting drugs from the makers to the payers – but they can also contribute to the expense of drugs. It’s a complicated multi-player system where many entities are each taking a margin, and the employers and individuals who pay for healthcare plans suffer the brunt of the cost.

The maddening reality for employer-sponsored health plans (and consumers) is these particular factors are largely beyond their control, and absent widespread reform within the industry, costs will continue to climb. However, there are strategies and resources for employers that very effectively help employers to manage the costs. Contact ParetoHealth to learn more.

References

How is anyone able to buy specialty pharmaceuticals without going broke? What are some of the economic pressures on doctors to prescribe expensive meds? Where is Andrew Clayton hiding, and will he be back next time?

Join us with special guest host Ashley Hull and guest Rashaun Reid of ParetoHealth as they team up with Andrew Cavenagh to tackle these questions in an updated format.

Along the way, they go into why taking the convenient route when you should be helping people is a classic knucklehead move, the strange phenomenon of giving up transparency for a few dollars off your PEPM costs, and how to educate physicians on best pharmaceutical practices.

How do you provide first-class healthcare benefits while also containing costs?

That’s the main question of this live episode, recorded with Suzanne Lutz, Laura Williams, and Santina Daily, three captive Members from very different industries and backgrounds. What they all have in common is a complete dedication to the well-being of their employees and a desire to change that relationship.

This is only a small part of the value that you can get from a ParetoHealth Members’ Meeting. If the advice here resonates with you, visit https://paretohealth.com to learn more.

Did you ever wonder why cost containment is one of our core differentiators at ParetoHealth? Do you want to know what ideas and beliefs fuel our passion for this important part of our mission?

In this ongoing series, I’m going to break down a few fundamental concepts related to the U.S. healthcare delivery system and the associated impact to how we consume and pay for care. Since it’s such a relevant and intricate topic, it’s going to take more than one article.

By the way, if you’re interested in the historical context – how we came to be a nation that spends more per capita on healthcare than any other industrialized country while ranking poorly in quality, access, and outcomes – I recommend this article from the Kaiser Family Foundation, as well as this CNBC treatment. They aren’t strictly necessary to understand the ideas I am going to put forward here, but they do provide a nice amount of context.

One of the most important aspects of the healthcare market is that it doesn’t function the way other markets do. Notably, it lacks price transparency.

What is price transparency? You may have heard about it on the news or during a Presidential debate in the last few years, but it is just a fancy way of talking about something that we do everywhere else for goods or services we consume — shopping around, or “consumer choice.” I’m going to use a simplified series of examples to demonstrate why such a simple idea is so powerful.

To put this into some perspective: let’s say you want to get an oil change for your car. At one place it costs $185, and at another one just down the street the same oil change costs $30.

Not exactly a difficult choice, right? But it’s a choice that most traditional health plans actively discourage people from making.

Think about it: you go to the pharmacy, provide your last name and date of birth, pay your $10 co-pay, and walk out with a tiny bottle of pills in a giant paper sack. What nobody has told you is that not only does the actual cost of the drug exceed the $10 you’ve paid, but it also costs $185 to fill the script at this pharmacy while down the street the exact same drug costs $30. Without actively seeking out this information (which by the way, is no small feat either), you would never know this variance exists.

Now, I can already hear the cynics reading this asking: why should I care if someone soaks my insurance for an extra $155? Isn’t that why I have insurance? Don’t they already make enough money?

A fair question. Also, one with varying answers based on who is footing the bill for that $155 difference. Let me explain.

Let’s assume you are covered by a plan that is financed through a traditional “fully insured” arrangement.  This means that your employer has entered into a contract with an insurance carrier whereby they pay a specific amount in premium each month (some of that premium is passed along to employees) and in exchange, that insurer will pick up the costs for all covered services, even if they exceed the amount of premium received. Now let’s go back to the prescription example. Do you think the insurance carrier won’t find a way to make that $155 back? Do you think they won’t find a way to pass those costs along to you, or to someone else?

Do you think they aren’t already passing on someone else’s costs to you?

As most of you probably know, insurance is risk-sharing. Everyone who takes out a policy from a particular insurer shares risks with every other person who has a policy. With most commercial health plans, policyholders don’t know the names, risk profiles, or buying behaviors of the other policyholders with whom they are sharing risk.

But you share risk anyway. It doesn’t matter how responsible you are individually – whether as a single employer offering a benefit plan to their employees or an individual covered under a group or individual policy – you are swimming in a risk pool with a bunch of unknowns compounded by a perverse incentive system for providers that rewards the wrong behavior.

Let’s go back to our example of the $155 dollar difference. Multiply it over millions of people sharing risk with you – meaning the anonymous sea of other policyholders – and you’ll begin to understand why this lack of transparency in pricing is such a massive problem.

Price transparency leads to market competition which ultimately leads to lower prices. If one provider is selling a product for $185 and the other is selling an identical product for $30, the first provider has a choice between lowering it and going out of business.

But that only works if the consumer knows this difference exists and they are compelled to care.

Now, from the perspective of pure risk management, wouldn’t it be great if you knew something about the pool of other people whose risk you’re sharing? Wouldn’t it be great to know that they’re doing something to stop spending $185 when they had the opportunity to pay only $30?

That’s another one of those easy questions.

I mentioned that there were varying answers to the “why should I care” question posed earlier. Well, let’s consider an employer who has chosen to self-insure their benefits.  In this model, the $155 overspend would be at the cost of the employer, not the insurance carrier.  It’s human nature to care a lot more when we have more skin in the game, right? Let’s also consider that said employer is an equity owner of their own insurance company, where they are sharing risk with hundreds of other employers who have also elected to take on the risk of their health plan. Like-mindedness just got a bit more important, right?

Employers who choose to self-fund their benefits with ParetoHealth have access to a suite of tools and solutions, including those in the area of price transparency and patient advocacy, to ensure that their health care dollars are being spent wisely and effectively by informed consumers. They are joined by a group of peers who have the same approach to managing costs. And all of this is protected by a risk financing vehicle that makes it all possible.

Stay tuned for upcoming articles in our series on cost containment where we share additional strategies and solutions that members of our community are using to preserve and improve benefits while also controlling costs.

If you haven’t yet, please use the form below to subscribe to new issues of The Contrarian so you never miss an update.

Guest host: Jack Longstreth, SVP, ParetoHealth

In our second live episode from our San Diego Members’ Meetings Andrew Clayton and guest host Jack Longstreth chat with two VP’s of Human Resources: Kim Bauer of Altra Federal Credit Union and Lisa Levanger of Wasatch Property Management Inc. This episode delivers great conversation about how a high-quality self-insured solution can help develop better relationships with employees, drive an employee-centric culture, and improve retention.

Hi. I’m Maureen Becker, Chief People Officer at ParetoHealth.

This series will discuss ways to attract, assess, and retain talented people.

In fact, these are the same strategies that make companies 5.1 times more likely to engage and retain employees.

Let’s get right down to it, starting with employee experience.

Employee Experience

It would be nice if there were an easy way to fix large organizational problems. The good news is the best way to approach this is simple. The bad news is that “simple” doesn’t mean easy – it just means not overly complicated.

It isn’t easy to cultivate an environment where people grow, thrive, and contribute their best work. But it IS incredibly rewarding – both personally and professionally and a holistic approach to human resources management will give you a talent advantage.

You can do a few things today that will bring positive impacts, ranging from engagement at work to innovation for the future.

What Makes up the Employee Experience?

Employee experience is often defined as the interactions an employee has with the people, systems, policies, and the physical and virtual workplace starting from the application process through termination.

Consider the way the employee:

And then think about the overall effect of those feelings and perceptions on their well-being.

Let’s make this a little bit more concrete:

Geraldine works in your IT department. She comes into work every morning with a good attitude, she’s patient when your computer just needs to be turned off and on again, she set up that one system that everybody uses, and she’s the only one who can talk to the big, blinking server box in the corner.

In other words, she’s an exemplary employee. But she could be having a poor employee experience and feeling disengaged from the company.

Ask some questions, and don’t be afraid of hearing the answers:

Does Geraldine know what role she plays in your company’s mission? If her friends and family ask her what she does, can she explain how she fits into your general efforts? What story does she tell herself about her job and her company?

Does she have everything she needs to do her job? Is success in her role clearly defined? Do the people she works with know what her success looks like, and does everyone help each other achieve it? Does she feel like the leadership understands this the same way she does?

These are just some of the questions you need to be asking.

This brings me to the cornerstone of an effective approach: communication.

Communication

When most of us think of communication, we think of the things we send out: our internal value proposition, our employer brand, and our important messages.

That’s human nature: we focus on what we do. But it’s less than half of the whole issue.

Communication goes two ways. You need to ask questions, but far more importantly, you need to make it okay for employees to answer and you must truly listen to the responses.

Why is that?

Because a strong employee value proposition must be aligned with what people value, and you may not fully understand what your people value unless you listen to them when they share their perspectives.

Start now. Ask people if everything is working well for them. Make the responses anonymous if possible, and act on those responses.

In the next part of this series, I’m going to review the existing research on what people want from the employee experience.

I’ll be talking about 24 factors that influence the employee experience, with particular attention to the four things that people quoted as the most important to them.

If you aren’t already subscribed to The Contrarian, you won’t want to miss this.

Guest host: Jack Longstreth, SVP, ParetoHealth

We took the bold step of recording this episode before a “live audience” at our recent Paradigm and StructuRe Members’ Meetings. Andrew Clayton and guest host Jack Longstreth have a lively conversation with two great CFOs: Jill Kindell of Miami Valley Steel and Chris Bissinger of Essential Ingredients.

This episode is chock-full of advice from ParetoHealth Members who have seen phenomenal success in controlling their benefits, delivering tangible value to their employees, and forging a stronger company culture through their health plans.

The advice they share is specific, actionable, and a quick sampling of the value that our Members’ Meetings offer.

Most people think of volatility as a bad thing. Prices go up, the stock market goes down, and your pockets feel distinctly lighter at the end of the day than they did at the beginning.

But what if I told you this was only one of the aspects of volatility?

…In other words, what if there was an advantage to volatile prices that you could tap into, if you only had the proper structure to do it in?

Well, you’re in luck. That’s exactly what I’m about to tell you.

You see, your costs can swing both ways – up or down.

The goal for any risk-management solution is to give you as much positive exposure as possible, while sheltering you from the downsides. What you want to do is get as much as you can from good years, while stopping the bad years from taking you out of the game completely.

Let’s look at an example to make it clearer.

Big insurance companies like it when people use old-fashioned insurance products – when you pay large, fixed costs every year. They call it fully insured, but that’s just a marketing term.

If you pay $1,000,000 dollars to insure your employees, but their costs come to only $400,000, what happens?

Well, you’re rewarded with next year’s renewal quote: $1,100,000. “They” pat you on the back and tell you this is a great deal for you.

In other words, you don’t get the benefits of positive volatility.

On the other hand, if your employee claims are $1,600,000, then your carrier makes a serious face and tells you that with claims like those, you ought to be grateful that your renewal is “only” $1,800,000…

…Even if the vast majority of these are one-time claims. You know – not likely to arise again.

With your new-found knowledge of positive and negative volatility, you should see what’s going on here:

You aren’t exposed to positive volatility, but you’ll pay dearly for negative volatility. The system is literally rigged against you. There’s no winning.

Now, let’s say you are self-insured. Here’s the situation:

In a good year, you pay only for the $400,000 of claims actually incurred. You gained some positive exposure to volatility. In the bad year, you pay the full $1,600,000, because you also have full exposure to negative volatility.

If you have the cash on hand to absorb the costs of a bad claims year, then you have a shot at reaping the benefits of this type of insurance. But it’s not as simple as that.

We’ve talked on The Contrarian before about the biggest risks for self-insured employers in 2022. These have one big thing in common:

The claims are mostly low-incidence and high-cost. This means that most of your years will be good – the problem is that the bad years can be so costly that they take you out of the game.

This brings us to the five ways that our captives shield you from negative volatility while also allowing you the benefits of positive volatility:

1. Risk-sharing

When you join a benefits captive, you share risk with the other members. This means that you accept a small portion of their risk and they accept a small portion of yours.

This means that in a good claims year, you might pay a small amount more than you would otherwise – continuing our example from above, this might be around $410,000. However, it also means that in a bad year, you’ll only pay $900,000 – you aren’t socked with the extra $700,000 that you saw above.

Better than that, your renewals won’t be ruinously expensive.

After good claims years, they can even be negative. As in, you pay less for next year.

Wild, right?

Another important aspect of how this can work is the following:

2. Vetting of new members

We don’t just let anyone become a captive member.

It requires a process of vetting and education. Let’s break that down:

The vetting process makes sure that an employer is financially viable. You don’t want to share risks with someone whose house isn’t in order, and chasing short-term gains risks weakening the captives.

Second, we need people who understand the nature of our solutions. Unlike old-fashioned insurance products, these require engagement and initiative. The last thing we want is to let people in before they’re ready.

By the way, this is a perfect time to shout out to our benefits Consultants. Without their expert guidance, that education effort would be much more difficult.

So that means we’re exclusive – not by industry or the flashiness of your sports car, but instead by whether you share the proper mindset. It’s part of our responsibility to ensure that our community of like-minded employers stays that way.

Our next way that the benefits captive manages volatility is related to this one:

3. Cost Management Efforts

During the vetting process, we make sure that every employer is serious about implementing cost management efforts (stay tuned for more articles on our approach regarding this: it’s too big a topic to cover fully here).

This means one thing: every Member gets the benefits of all of these cost-management efforts.

Want to hear a secret?

When you use other insurance products, you’re also sharing risks…

…But it’s with an anonymous mass of strangers. You don’t know if they’re pursuing the best care at the lowest cost, whether they have a wellness program, if they pay for gym memberships for their employees…

You don’t know anything about them. Knowing the people that you share risk with should be the rule, not the exception. But it almost never is.

This transparency is a key reason that our benefits captives are the largest in the country. People like to know that their risk-sharing is in good hands.

Our growth has led us to another key part of our strategy:

4. Size and buying power

Our captives manage almost three billion dollars in healthcare spending.

Let that sink in.

To put it in context, in terms of pure healthcare spend, these captives are bigger than a couple of well-known companies:

…Well, you get the idea.

And with that size, we can negotiate terms from our stop-loss providers that are among the best anywhere.

That’s a major part of our mission: delivering enterprise-level healthcare solutions to small and medium businesses. When we act together, we can do things that were impossible when we all acted separately.

Look, if you want to take on the big insurance companies, you need to be big as well. And if you’re not big, you need to belong to a big club.

By acting together, you can work for yourself much better. You can understand what you’re doing, share ideas with everyone else, and learn from everyone’s mistakes and victories.

That brings us to my last point:

5. Transparency

If you have access to your own healthcare data, you can make the right interventions.

Think about it:

If you know that a lot of your claims are coming from people with end-stage renal disease or diabetes, you can tailor your wellness program to answer those needs specifically.

If you don’t know what’s going on, then you’re forced to fly blind and address problems that your people may not even have.

By making things transparent, by introducing skin in the game, and by respecting local knowledge and expertise, we can take a long-term approach to healthcare.

Isn’t that the entire point of strategic leadership? I think so.

That’s something that you’re not going to get with the dinosaurs who are still pushing old-fashioned, one-size-fits-nobody policies. If you have no healthcare data, you can’t apply the Pareto Principle – focusing on the 20% of problems that are causing 80% of your expenses.

No, it’s not named after us. But people always ask.

Check out our resources if you’re ready to learn about captive insurance and what it can do for your healthcare spend.

And, as always, don’t forget to subscribe to future posts from The Contrarian using the form below.

Why does stop-loss premium increase at a different rate than medical trend?

We broke down why on this episode. It turned out there was some math involved.

Hilarity ensued, but we got to the bottom of “leveraged trend” when it was all over. And with only a small number of… all the insurance terms you can possibly imagine.

Then we sat down with Seth Denson, our friend and partner to talk about staying focused on what’s really important in a world full of shiny distractions, the supply chain crisis in healthcare, and the differences in economics when you’re talking about care versus insurance.

After that, we launched into the… curious practice that some knucklehead brokers have of comparing a best-case scenario for fully-insured plans to a worst-case scenario for self-insured ones.

Hmm. I wonder what their motivation could possibly be. Really gets the old noggin joggin’.