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Episode 2029 Transcript:

00;00;01;14 - 00;00;05;15

Announcer

And now America's Healthcare Advocate, Cary Hall.

00;00;05;20 - 00;00;21;00

Cary Hall

Hello, America. Welcome to America's Healthcare Advocate. I'm Cary Hall. I'm your host here on America's Healthcare Advocate today. Thank you for joining us. For all of you out there listening on the 238 affiliates. We appreciate all of you in our audience. For those of you that are listening on the podcast platform, there are 15 of them.

00;00;21;03 - 00;00;39;04

Cary Hall

We're on almost every one you can think of, from Spotify to Rumble to Audacy to iHeartRadio. We're out there. So when you hear one of these shows, you want to tell somebody about it, that's a great place to go. We're also on our own YouTube channel at America's Healthcare Advocate. We've had about a half a million views up there on the YouTube channel, so we're feeling pretty good about that.

00;00;39;04 - 00;00;58;21

Cary Hall

And that's thanks to all of you in our listening audience. I want to give a shout out to WLEA 1480 AM and 106.9 FM in Elmira-Corning, New York. Been on the air with them for some time and had some calls from their last week and want to thank the folks up in New York for reaching out to us and being part of the America's Healthcare Advocate family.

00;00;58;21 - 00;01;22;10

Cary Hall

If you want to learn more about us, go to the website AmericasHealthcareAdvocate.com. Joining me in studio today, Todd Houston from Bravewind Benefits. And we're going to do a show today that I've been wanting to do for some time. And that show is going to focus on small group as employers are being squeezed across the country on these ACA plans and solutions that are different than what are being offered typically in the marketplace.

00;01;22;10 - 00;01;30;06

Cary Hall

So brokers out there, this show is targeting you, and we're going to show you solutions that, you probably haven't seen before, right, Todd.

00;01;30;09 - 00;01;30;28

Todd Houston

Absolutely.

00;01;31;02 - 00;01;40;03

Cary Hall

Yeah. I think folks are going to be a little surprised that some of the things we have to say today and some of the things that, we're going to be able to talk about, really will make a difference in this marketplace.

00;01;40;10 - 00;01;40;18

Todd Houston

Yeah.

00;01;40;18 - 00;02;00;04

Cary Hall

They really well, a little bit about Todd Houston. He's the CEO and founder of Performance Health. He's also responsible for business development, broker relations, brand management, marketing and current development plans. He's also a partner in Bravewind. Prior to joining Performance Health, he worked for Commerce Benefits Group and Health Smart, which acquired Commerce benefits groups in 2014.

00;02;00;10 - 00;02;26;07

Cary Hall

During his tenure at Commerce Benefits Group and Health Smart, he pioneered the level funding plan. So a lot of those level funding plans you see out there were the result of the work of Todd Houston. Houston has been involved in various aspects of consulting services and solutions relating to health care for the past 24 years, he's been a benefits consultant and his ideas itineraries to develop is to deliver meaningful, self-funded solutions to their clients across the country.

00;02;26;09 - 00;02;40;26

Cary Hall

He graduated with a double major in economics and sociology from Oberlin College in 1992, and earned his NBA in 1984 from Cleveland State University. So welcome to the show. Thank you. Welcome to Kansas City from Cleveland. Absolutely. That was a bit of a trek coming in from Cleveland.

00;02;40;27 - 00;02;41;29

Todd Houston

It wasn't so bad. Yeah, yeah.

00;02;41;29 - 00;03;05;01

Cary Hall

But but you got here. That's good news. So let's just kind of dive into this. You know there's a huge gap in this small group market right now. Because what's happening is the ACA plans are constricting Todd. Employers who are looking for ways to get the hell off of those plans, because the costs keep going up. Brokers don't have a lot of opportunities that are different than the ACA model.

00;03;05;03 - 00;03;23;03

Cary Hall

The level premium plans, you know, they work for a while, but you go into that, you know, you got a level premium plan, you have two good years. You go into that third year and you walk away with a, you know, huge claims number, and you're going to get one of those beautiful, letters in the mail from your carrier saying you're going to get a 1000 present.

00;03;23;03 - 00;03;34;24

Cary Hall

You can stay on the plan, but we're going to raise you 100% over where you were last year. So talk a little bit about how that whole marketplace is working now and why there's this tremendous need for some different solutions out there.

00;03;34;24 - 00;03;43;01

Todd Houston

Todd Yeah, I mean, I think you you were very diplomatic when you said small employers were getting squeezed. I've used different words, but,

00;03;43;03 - 00;03;44;10

Cary Hall

We are on the radio .

00;03;44;13 - 00;04;06;14

Todd Houston

I’m aware. There's a huge need. So if you look at it, you know, what's happened historically is the small group, you know, they're out there, the employer groups out there, they have a broker. The broker shops it to the BUCA’s, Blue Cross United, Cigna, Aetna, Humana. There's no information, right? They have nothing to go on.

00;04;06;16 - 00;04;29;07

Todd Houston

And then they just, they get a number back, and that's what they're stuck with. So what we're trying to develop are programs that are meaningful, for employers, things that, give them actual data, like actual actionable information that they can utilize, that they can use to help control cost. And that's what we're creating. So the small group is getting squeezed.

00;04;29;10 - 00;04;32;10

Todd Houston

And it's a, it's, it's a, it's a bad spot to be in right now.

00;04;32;14 - 00;04;50;18

Cary Hall

So, you know, there's a friend of mine who I worked with for a number of years on the on the self-funded side. I used to say, you can't manage what you can't measure. And and the problem is you don't have the data yet, especially on the small group side. So talk a little bit about that and why. You know, why.

00;04;50;18 - 00;04;58;24

Cary Hall

You some of the models that are that we're going to talk about today are going to make a difference, and how the cost containment portion of that would work.

00;04;58;25 - 00;05;17;21

Todd Houston

Yeah. So it's that old adage of the, the definition of insanity is doing the same thing over and over and expecting a different result. So, if you have no idea what's driving your health care spend, there's nothing you can do about it. But just, you know, just hope it disappears it. Right? I mean, but but you don't even know.

00;05;17;24 - 00;05;40;22

Todd Houston

All too often we go to employers. We use, different, mechanisms, mechanisms to try to underwrite groups. And we'll take data back to the employer, and they have no clue what's happening inside of their group. You know, whether it's an employee or a we're a, you know, one of the members, like the spouse or a child, they they just don't have any idea, and they have no idea how that's impacting their, their cost.

00;05;40;24 - 00;05;53;17

Todd Houston

And ultimately, you're going to pay for your claims, you know, whether you're a self-funded plan or, or a fully insured plan. And so what we're trying to do is give people that data so that they can hone in on ways to control cost.

00;05;53;19 - 00;06;21;16

Cary Hall

And that's that's critical. You know, it's funny, I but I was looking at a group the other day, there were about 140, 748 lives and four people on that plan for people made up half $1 million of the claims on that plan. That was half of the total claims for the year made it by four people. You pull those four people out, you would have had a much more manageable plan from the standpoint of cost control and, and, and how you're managing that plan.

00;06;21;18 - 00;06;45;02

Todd Houston

Yeah. I mean, so you think about health care. It's the Pareto theory. The 80/20 rule turned completely on its head. It's not 20% of the people generating 80% of the cost. It's more like 1% of the population generating 90% of the cost. So and we looked at, a plan recently, I did myself that less than 1% of the population was driving about 40% of the spend, less than 1%.

00;06;45;02 - 00;06;56;13

Todd Houston

And, the numbers are staggering. So, you know, being able to wrap your hands around that and see what's coming and also see how to how to react to that will really help a health plan, long term control cost.

00;06;56;17 - 00;07;14;24

Cary Hall

And so which brings us to, you know what what happens every year. And you know, as a recovering 27 year broker, I certainly can speak to it is, you know, you sit down with your client and you when you're looking at the plans that come across the the carriers, the carriers are governed now by the federal government.

00;07;14;24 - 00;07;30;06

Cary Hall

You've turned health insurance basically into what, you know, is like a utility. Now they're told how much they can make and they're told how much they can keep, and they're told what they have to cover. So you get it. The carrier gets a census. They have no idea what they're getting in terms of the health of people on the census.

00;07;30;14 - 00;07;55;10

Cary Hall

They turn around and send back out a series of quotes, and it's a crapshoot. If you've got a group that's relatively healthy, you've got a group that trends under 45. You probably should get a better rate than somebody that's got a group that’s trending between 50 to 64, but unfortunately, that's not the way it works. The way it works is everybody's piled into this consortium called ACA and off we go.

00;07;55;12 - 00;08;14;03

Todd Houston

Yeah, it's a huge pool. It's the law of large numbers. But, you know, like as an individual group, what you really want to do is find ways to reduce what you're spending. So I mean, right now, like you just said, I mean, you laid out the perfect problem. You just take a bunch of lives, you throw it into a pool.

00;08;14;05 - 00;08;29;03

Todd Houston

The carrier is going to manage that, to try to manage that to an 85% loss ratio, because that's what the ACA says. And so that's I mean, that's basically where you're going to end up and you have no, I mean, no control over what's going on with your health plan. I mean, zero, absolutely zero.

00;08;29;03 - 00;08;46;08

Cary Hall

And that's the problem. And it's frustrating for the small business owner because they have no control and there aren't a lot of other solutions out there. Like, you know, we we'll talk about level premium. When I come back after the break. But you know that's a temporary solution. That's not a five year plan. That's not a plan.

00;08;46;08 - 00;09;04;02

Cary Hall

Like you know, you you reference Pareto and Pareto is one of the largest self-funded captives in the country. I think they're over a million lives now. What Pareto did, and they did it very successfully, was they they put tools in place where employers could come back and they could manage their health care costs by using these various tools.

00;09;04;07 - 00;09;25;27

Cary Hall

And the other thing they did it was really smart was they rewarded the employer, okay, by giving him awarding him points that then reduced his reinsurance costs every year. So instead of costs going up, if you implemented their smoking cessation plans, their weight management plans, the other plans they had, you drove down your cost of health insurance. It was remarkable how it worked.

00;09;25;27 - 00;09;27;00

Cary Hall

Still is.

00;09;27;02 - 00;09;31;24

Todd Houston

Yeah, it is. I mean, and it's not it's not rock. It's not that difficult. No, it's not rocket science.

00;09;31;24 - 00;09;50;06

Cary Hall

And we come back from the break. We're going to talk more about this. And now we'll talk about why it's not rocket science and what it takes to turn a group around, and what kind of information you should have. And then we'll get into the third segment. We'll talk about actual solutions. So stay tuned. You're listening to America's Healthcare Advocate Broadcasting here on the HIA Radio Network.

00;09;50;11 - 00;09;53;24

Cary Hall

Coast to coast Cross, USA. Stay right there. We've got more coming.

00;09;53;28 - 00;10;23;29

Steve Kuker

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00;10;24;03 - 00;10;59;21

Steve Kuker

Serving them in their greatest time of need. If you're looking for someone who can provide you experienced and objective guidance when searching for a senior care community, reach out today and discover the services of Senior Care consulting at 913-945-2800. Know your options and choose with care at SeniorCareConsulting.com.

00;10;59;23 - 00;11;20;06

Cary Hall

Welcome back. You're listening to America's Healthcare Advocate show broadcasting coast to coast across USA. You can learn more about us at the website. AmericasHealthcareAdvocate.com. All the shows are posted up there. They're also on 15 podcast platforms and on our YouTube channel, America's Healthcare Advocate, my Producers Day Behind the Microphones, Mr. Darren Wilhite behind the cameras.

00;11;20;13 - 00;11;44;22

Cary Hall

Doing all the camera work is Mr. Dave Thiessen, the gentleman that put all this together so we can get it up on those podcast platforms and on the YouTube channels. So in studio with me, Todd Houston, we are talking about Bravewind Benefits and the plans that Bravewind Benefits is going to be offering to small employers. And that's really what Bravewind Benefits is about, is targeting the small employer in the marketplace where they are not finding relief today.

00;11;44;22 - 00;12;08;11

Cary Hall

So the website is BravewindBenefits.com. That's BravewindBenefits.com Todd let you know. We kind of segued out of that conversation a minute ago about level premium. And I look at level premium as short short term gain long term pain. Because you know you go into it and on a level premium plan all the carriers are offering these things.

00;12;08;11 - 00;12;27;21

Cary Hall

And it looks really good in the first year. But you know so let's say you have two good years. But then the third year, you know, somebody comes in that has, you know, a heart attack, a stroke or cancer or you have a couple of those, like this group I looked at yesterday with the there were four people on there with cancer, or heart attack and stroke issues.

00;12;27;25 - 00;12;43;14

Cary Hall

So they blew the plan up for 149 people. So talk a little bit about why the, you know, those level level benefit level, funded level, premium plans, whatever you want to call them. Why they're not a long term solution for the small group employer.

00;12;43;16 - 00;13;05;01

Todd Houston

The way the carriers run them is not a long term solution. The way we're proposing them is, is different. So with most carriers, you're giving up a portion of any unused claim dollars. So in your example, you had two good years and then a year where claims went bad but you forfeited, you know, sometimes up to 66% of your claim fund to the carrier for the benefit of doing business with them.

00;13;05;03 - 00;13;23;19

Todd Houston

And then there's things like, PBM rebates, pharmacy benefit manager rebates that the, that the carrier keeps, they never tell the employer that they exist. And so those, those plans, that's why they tend to blow up. There's ways to structure those so that it's, it's it's much fairer for the employer. And that's what we're trying to do.

00;13;23;19 - 00;13;32;22

Todd Houston

But it, it is an issue with small group when you have it, if claims turn bad, there's not a lot you can do. Yeah. You know.

00;13;32;22 - 00;13;58;22

Cary Hall

So we talked about the Pareto model and Pareto is a fabulous. You know, I was one of the first brokers to work with Pareto years ago. And Pareto has got a great program. It's wonderful. The problem is that that you've got to have 100 lives or more or $1 million in premium to, to qualify, and then you've kind of come in and make a capital contribution to get in, and a guy that's got 25 employees or 40 employees or 50 employees or 60 employees, he's not going to qualify.

00;13;58;22 - 00;14;14;23

Cary Hall

He's not going to be a big enough fish into the Pareto model to make that work. So they are really kind of boxed in right now without a lot of solutions. And the brokers don't have a lot of resources to go find those solutions. What's one of the reasons why we're doing this broadcast and talking about this?

00;14;14;25 - 00;14;42;11

Todd Houston

Yeah, it is. And that's what we did when we when we built this program, we looked for employers the all the way down to three that can come into this product, into this program, which is, which is a huge difference. And we can go up to however large an employer needs to be. We build all of the costs into a monthly fee structure so that they don't have to capitalize upfront, which is one of the problems for a lot of these, trust in captive models.

00;14;42;13 - 00;14;58;20

Todd Houston

The employer has to capitalize upfront. They don't have the cash, they don't have the money to do it. So they're left out. And then by removing that size requirement, you know, that you don't have to be over 100 employees. You don't have to be $1 million in premium and all those other parameters. We've we've opened it up to a lot more employers.

00;14;58;20 - 00;15;18;15

Cary Hall

The Wall Street Journal had a huge editorial day on PBMs and, Lina Kahn, who is the Health and Human Services, or FTC, whatever. I can't remember which part of the alphabet soup in the government she's the head of, but she's coming down really hard on PBMs and making the, you know, making it look like the PBMs are the problem here.

00;15;18;17 - 00;15;32;23

Cary Hall

And when you talk about rebates and all the rest of it. So let's address that a little bit about the and how our model differs on the PBM side from the model that you see typically from the carrier or, you know, even even Pareto. As far as that's concerned.

00;15;32;25 - 00;15;39;17

Todd Houston

Look at one thing about health care that's insane, right. You had you know, Aetna acquired by CVS.

00;15;39;18 - 00;15;43;03

Cary Hall

You got a drug store running an insurance company that's the way I like to call it.

00;15;43;09 - 00;15;50;15

Todd Houston

And you had Cigna buy Express Scripts. Yeah. So, they understand that there's a lot of money in the pharmacy, you know, benefit world.

00;15;50;16 - 00;15;52;12

Cary Hall

There's a reason CVS, bought Aetna.

00;15;52;15 - 00;16;13;18

Todd Houston

Yeah. And so, you know, I always say like the, the PBM is the black box that nobody ever knows what the heck happens. You have no idea. You have a contract that says you get a certain price structure, you have no way to go in and and, you know, audit that to make sure that you're actually getting AWP, average wholesale price minus a percentage.

00;16;13;18 - 00;16;31;29

Todd Houston

You just can't. And so that's one of the problems that employers run up against. They just don't know. And there are a lot of rebates that are offered on drugs. But if you're getting a rebate on a drug, that means you're not using a generic equivalent. So I mean, there's there's a lot of things to think about when you have, you know, drug cost.

00;16;32;01 - 00;16;54;11

Todd Houston

But rebates can be pretty significant. And so like a lot of the, carriers, what they do is they'll keep all the rebate dollars. That's right. You know, and then they'll also make spread pricing on the cost of the drug. So all of a sudden, what you thought was a great deal and, you know, you're getting a good deal, you know, through this pharmacy network, you really not you know, and it's just driving your costs.

00;16;54;11 - 00;17;02;05

Todd Houston

So we're starting to see the spend portion on prescription approach, 40% of the total health care spend.

00;17;02;07 - 00;17;27;05

Cary Hall

And, you know, ten years ago it was 20 to 25%. And it's climbing. It's it's continued to climb, which is why there's all this focus on it. Right now. And by the way, PBM is pharmacy benefit managers. They're the people that put the descriptions, you know and yeah, that that's where you get the the conduit. Whether you go to a CVS pharmacy or you go to a Rite Aid or whatever you may do, those PBMs or pharmacy benefit managers, they manage those benefits.

00;17;27;05 - 00;17;32;00

Cary Hall

And then when you go to get them, you're getting them through that PBM. So people understand what that is. Yeah.

00;17;32;00 - 00;17;58;26

Todd Houston

No. Absolutely. And so that 40% number is going to continue to grow is you know the specialty drug pipeline is huge right now. You're finding a lot of people on specialty meds. I always say to people, if you see it advertised during a sporting event, it's expensive. And so it's pretty, it's pretty standard. But, you know, they, we're seeing a lot of drug costs that are, you know, $10,000 a month, $15,000 a month.

00;17;58;26 - 00;18;02;21

Todd Houston

And it's, you know, it's it's really crippling health plans. So, yeah.

00;18;02;23 - 00;18;19;23

Cary Hall

And so and there are solutions to that. And we have some of those solutions at Bravewind, and with a lot of that has to do with drug importation. So and there are also programs like the Pip and PAP program where you can actually apply to the pharmacy, and and and get the product at a very low cost.

00;18;19;23 - 00;18;40;24

Todd Houston

Right there is. Yeah. And you know, again, I always say to people, you have to do something different if you want to control cost. And so one thing is to create a formulary. So that's what drugs are covered under your pharmacy benefit manager. Create a formula that excludes certain medications so that you can apply for foundational assistance to get that drug covered.

00;18;40;27 - 00;18;43;06

Todd Houston

Or you can import that drug at a lot lower cost.

00;18;43;06 - 00;19;03;02

Cary Hall

And so what we're just to be clear, we're not saying that you set this formulary up and you take Humira out and then nobody can get Humira. What we're saying is you have a formulary that covers 90% of what people need. Then there's another 10 or 15 or 20%, whatever it is, it's not in that particular formulary. Whether growth hormones pick one.

00;19;03;02 - 00;19;24;14

Cary Hall

All right. And what what our plans do, what the Bravewind plans do is they set up a method where you either apply for assistance direct from the from the farm, from the from the, the pharmacy, whoever you know, created that particular drug or you you do the importation from Canada, New Zealand, Australia. And they are equivalent to what we have here in the States.

00;19;24;14 - 00;19;40;26

Cary Hall

So that's a little bit of information about that. When we come back from the break, we're going to actually get into the plans and talk about what we see as the solution at Bravewind benefits. Stay tuned. We've got more. You're listening to America's Healthcare Advocate broadcasting here on the HIA Radio Network. Coast to coast across the USA.

00;19;40;26 - 00;19;50;24

Cary Hall

Don't go anywhere.

00;19;50;26 - 00;20;21;09

Cary Hall

Welcome back. You're listening to America's Healthcare Advocate show. Broadcasting coast to coast across the USA. You can learn more about us by going to the website AmericasHealthcareAdvocate.com. In studio with me, Todd Houston. We're talking about the plans from Bravewind Benefits website is BravewindBenefits.com. And so today's show is focusing to brokers and employers out there that are in the small group market because, you know, everybody, you know, there are a lot of brokers out there that, you know, want to do that 100, 200, 300 life group.

00;20;21;11 - 00;20;43;26

Cary Hall

But there's a gap here for the small employer, the employer that you heard Todd say, you know, these plans go down to three lives. Okay. So, you know, to give you an idea of how small, but you can put these same tools in place that will lower the cost and make sense out of this. So you actually understand what you're doing with your health care dollars or your health insurance dollars, whichever way you want to call it.

00;20;44;01 - 00;21;06;14

Cary Hall

And we left a minute ago talking about, you know, the cost of prescription drugs, 40%, 40% of your spend of your claims dollar that's going out the door is on medication. So let's go back to this for a minute. You know, people always are concerned. Well, if I, if I, if I get that drug from Canada, New Zealand, is that going to be as good as the drugs here in the United States.

00;21;06;17 - 00;21;24;23

Todd Houston

It it's the same one. It's. Yeah, it's the same. It's the same manufacturer. So it's the same brand drug. It's going to read the same. So if you're if you know, you use the example of Humera, if you get Humera from Canada, it's going to be Humera. It's just where it comes from. And so, it's it's absolutely safe.

00;21;24;23 - 00;21;27;16

Todd Houston

It's the same exact drug.

00;21;27;19 - 00;21;46;25

Cary Hall

Talk a little bit about these assistance programs. The the acronym is PIP and PAP. And those are prescription drug assistance programs PAP, if you will talk a little bit about how that works. And we do the work for them. You know, we're not saying you here, here's here's the paperwork. You go file it. But we do the work. So that's the difference here.

00;21;46;28 - 00;22;04;16

Todd Houston

Yeah it is. So the the strange thing about health care, it just in general is, nobody understands what the cost of it is, including the physicians. So if you go in and your doctor write you a prescription, he has no clue what it's going to cost your health plan. When you walk out that door.

00;22;04;18 - 00;22;27;27

Todd Houston

And a lot of times, if you explain that to the physician, you know, they sometimes will help you apply for the foundational assistance. But, you know, most of them don't, and most people don't know that they don't want to deal with it. Yeah. And they walk out the door and they're left, you know, holding the bag. What we do is work really closely with the different pharmacy benefit managers that we have contracts with, to, reach out to us when they have what's called a prior authorization.

00;22;27;27 - 00;23;01;26

Todd Houston

So anytime you're going in for a high cost medication, they're going to reach out from the pharmacy or, you know, to the, to the PBM. And if they stop that drug at that fill, we can then step in and help that person. But it's about knowing when that happens. So that's one of the things we do is forging really strong relationships with the PBMs so that we know before that person ever fills that drug that this high cost drug is coming down the pike, and then we can get involved in trying to either handle it through importation or what they call foundational assistance or pap.

00;23;01;29 - 00;23;17;11

Todd Houston

If it's, going to be covered under PAP, it has to be excluded under your health plan. There's no way to have your cake and eat it too. So what we do is create a formula that excludes it. But we'll be able to source that drug either through importation or through foundational assistance. And it saves the plan all that money.

00;23;17;11 - 00;23;34;13

Cary Hall

So do you see what we're doing here by putting a formulary in that takes those drugs out? You're not denying people the access to the drug. What you're doing is using a different methodology for getting the drug, and you're not jacking up the price of the health plan to cover that specific med for 1 or 2 people, maybe on the plan.

00;23;34;13 - 00;23;50;10

Cary Hall

So that's an especially if you're a small group, you know, when you're dealing with those kind of medications. And that's driving your cost up. You don't have that many people to spread that cost a month. You know, 25, 30 employees. You've got somebody taking a growth hormone. They're going to knock you out of the ballpark.

00;23;50;10 - 00;24;10;03

Todd Houston

Oh, yeah. Yeah. We we used to see that. I mean, with groups that were 25 and 30 with, a person who was on, Humana and, you know, the condition would be psoriasis. So no, nobody would show up on any trigger diagnosis report. No, no, there would be no red flag that this is a high cost, like a high cost claim.

00;24;10;03 - 00;24;14;21

Todd Houston

And then all of a sudden, because of the drug cost, you know, you buy $120,000. Claim.

00;24;14;21 - 00;24;21;02

Cary Hall

Now, connect the dots. Now we get back to the end of the year and it's time for the renewal. And you're on that level premium plan. Guess what. It just blew up.

00;24;21;08 - 00;24;22;26

Todd Houston

It just blew up.

00;24;22;28 - 00;24;33;23

Cary Hall

So now let's talk about why ours are going to be different on the level premium model, why they are different. And then we'll segue into the topic of reference based pricing, because there's a hell of a lot of confusion around that particular topic.

00;24;33;23 - 00;24;52;01

Todd Houston

Oh yeah. Yeah. So I mean, I think the first thing that makes us different is we'll go down to three lives so that right out of the bat is something that's completely different. Most of your level funded plans really cut off at 25 lives. And like you said, it's really hard to get competitive or things can blow up really fast if you have 25 lives.

00;24;52;03 - 00;24;59;26

Todd Houston

You know, that's one thing. The other is speed, to quote. So we've created a quoting mechanism that we can, for the most part, turn quotes around in 72 hours.

00;24;59;26 - 00;25;00;22

Cary Hall

That's remarkable.

00;25;00;22 - 00;25;02;24

Todd Houston

Yeah. And for level funding that's big.

00;25;02;27 - 00;25;08;20

Cary Hall

For brokers out there. This is a huge deal 72 hours and you get a quote employer. It's the same thing okay.

00;25;08;20 - 00;25;30;01

Todd Houston

So the other thing is we like we've created turnkey solutions for employers. So for that small like group trust in captive product, we've built a series of plans. We can customize it, but we've built a series of 11 or 13 plans. They have all of the the PBM is built in. The telemedicine is built in all the audit functions are built in.

00;25;30;01 - 00;25;53;21

Todd Houston

Everything's already turnkey. It's completely, completely included. And we do that on the level funded for the larger groups too. So it's you know, there's an option to get that turnkey product or to customize it. So, you know, that's one thing. The other is we use AI underwriting tools. Right now. We we have one that we utilize. We can use that for groups over ten, so we can use the census to start the underwriting process.

00;25;53;24 - 00;26;11;02

Todd Houston

That doesn't guarantee that we can bind it with that, information, but at least it's a starting point. And then we're looking at other options, always exploring other options to look at, a tool to even quote smaller groups on a, an AI tool so that we can get groups quoted without having to do applications.

00;26;11;03 - 00;26;28;27

Cary Hall

Yeah. And that's that. And your broker, you're listening to this, you know, what a pain, doing applications is trying to get the employees to fill them out, and then they've got to come back, correct it. If they're not correct. You can't submit the you can't submit them, you know, because these are all done digitally now online.

00;26;28;27 - 00;26;46;28

Cary Hall

So you miss a line and it won't go any further. It'll stop, you know. And so those are the things that get eliminated here by doing the underwriting using AI we're able to put these things in place. We know what what the group looks like. We have a pretty good idea of what their health overall picture is, and that helps us understand how to rate.

00;26;46;28 - 00;27;04;10

Cary Hall

It also helps us direct different tools. For instance, as Todd just talked about, I keep going back to this PBM thing. But when you look at the pharmacy side, if you're running, if you do the AI and the AI comes back and says, you've got you've got people on, you know, 4 or 5 medications that are $10,000 a month.

00;27;04;12 - 00;27;05;22

Cary Hall

You've got an issue here.

00;27;05;23 - 00;27;24;05

Todd Houston

Yeah, absolutely. And, you know, the interesting thing to me is when you take that back to the broker or to the employer, they don't know, they have no clue what's going on. And so, you know it, they may say, well, Todd shows up to work every day. Well, that's great that I show up to work every day, but I may be on a med that's $10,000 a month.

00;27;24;07 - 00;27;44;25

Todd Houston

So what we do is give them information that's actually actionable, like, here's information that you can use to control your costs, and we can tell them exactly the impact we can have on on that cost. So that $10,000 drug we can get for 1800, I mean, right there, it makes a huge difference. And so we can provide that information upfront to the employer.

00;27;44;25 - 00;28;09;25

Cary Hall

Yeah. And so you're what you're doing is you're putting tools in place that allow them to. And we're back to you can't manage what you can't measure. Yeah. And you know when you can measure what your spend is and what you're spending it on. Then you have a way to management in the back to the, you know, to the pharmacy situation by being able to do the drug importation or do the Pip or PAP program, you're not denying the people the opportunity to get those medications.

00;28;09;25 - 00;28;26;02

Cary Hall

Say it again, hem. You're taking them out of the formulary, lowering the cost and using another methodology to to cover that. We've also got, you know, the the my life doc. You know, video, online doctors could use and that's a pretty amazing program.

00;28;26;04 - 00;28;51;25

Todd Houston

It is. And so it's a zero copay. That's always one of the problems with, you know, the in the old, Teladoc world, which was one of the early, companies everyone knew about the second you I always say free cells based on health care. So if it's free, you know, people will gravitate towards it. So if you had, you know, a requirement where the person had to pay a co-pay, whether it was $5 or 10 or 15, you know, they tended not to use it.

00;28;51;25 - 00;29;17;23

Todd Houston

So what we did is created something that had zero copay, and it has, telemedicine, it has urgent care, telemedicine and mental health telemedicine. So there's three different components to it. And they're all zero copay. So what we do is really try to work with that, the, the entity we work with, with my life doc and driving and for me, driving knowledge because if people know it exists and use it one time, they're usually hooked on it.

00;29;17;25 - 00;29;22;19

Todd Houston

And if we can get people to use it and keep them from going to the urgent care or the E.R., we can really cut cost.

00;29;22;19 - 00;29;49;26

Cary Hall

So you see what happens here. You're the employer now. You're going to be able to go your place. You know what we've got my life, doc. You can go online, dial up the doctor. In fact, if you like the the primary care doc you get, you can actually keep that doctor and keep going back to them. So instead of running Johnny into the urgent care when he comes home 4:00 in the afternoon from school because he's got pinkeye or conjunctivitis, you can go up online, get your doctor, let him look at Johnny and say, you know what he needs penicillin, whatever that is.

00;29;49;26 - 00;30;09;02

Cary Hall

Okay? The meds ready at the pharmacy. You pick it up and you're done it. The convenience of it, the fact that you're not paying for it, and the fact that you're offering your employees something they don't have makes a big difference. And that's the whole idea. Here, again, is to offer solutions to the problems that are going to make sense for the employers and lower the cost of health care.

00;30;09;02 - 00;30;25;00

Cary Hall

It can be done, and this is one of the ways you do it. Stay tuned. We'll be right back after the break. You're listening to America's Healthcare Advocate Broadcasting here on the HIA Radio Network. bravewindbenefits.com is website. If you're a broker or you’re an employer, you want to learn more, go there, send us an email. We'll be happy.

00;30;25;00 - 00;30;32;08

Cary Hall

Chat with you. Stay right there. We'll be back.

00;30;32;11 - 00;30;50;22

Cary Hall

Welcome back. You're listening to America's Healthcare Advocate show broadcasting coast to coast across the USA. Here on the HIA Radio Network, you can find out more about us by going to the website AmericasHealthcareAdvocate.com. Hey, maybe you know, you're in a shop with 3 or 4 brokers and maybe you own the agency and this is something you want to tell them about.

00;30;50;28 - 00;31;08;06

Cary Hall

You don't have to go through the whole explanation, go up on the podcast platform or go on the YouTube platform, have them listen to it or see what the show is so they get an understanding of it, and then you can reach out to us at bravewindbenefits.com. We'll be happy to get you contracted and show you some of the plans and the offerings that we have.

00;31;08;06 - 00;31;28;12

Cary Hall

If you're an employer, reach out to us, we'll connect you with a broker that understands the plans and we'll get you set up. It's bravewindbenefits.com. That's the website. All right. So this this model on the health insurance side came out a number of years ago I don't know was it maybe 8 or 9 years ago Todd the reference based pricing and everybody kind of jumped on the bandwagon.

00;31;28;12 - 00;31;49;15

Cary Hall

And then the boogie man came out okay. Yeah, yeah. And they all blew up. They weren't being managed the right way. Employers jumped on it because it was kind of lower cost. Employees didn't understand it. There was huge dissatisfaction. And so they've kind of gotten a black eye. But there's a way to do reference based pricing where it makes sense and it can lower the cost significantly.

00;31;49;15 - 00;31;54;10

Cary Hall

So talk about that and the right way to do it, which is how we do it. We think it at Bravewind.

00;31;54;15 - 00;32;10;07

Todd Houston

Yeah. So I mean you're right. It did tend to blow up. And the biggest thing was lack of education. So if if you roll out a program and you say to your employees, it's just like what you had before, and they look at a schedule of benefits and they see a deductible and a copay, and it looks the same.

00;32;10;09 - 00;32;31;07

Todd Houston

And then they go and it's reference based pricing, it turns into a disaster. If it's not a if the employee isn't educated. So that's the the whole trick. We do it a little bit differently. So we utilize either PHCS or First Health where we have a network for the physician and ancillary facilities. So if you're going to get a lab work done or an MRI.

00;32;31;07 - 00;32;32;05

Cary Hall

Or green imaging.

00;32;32;09 - 00;32;56;02

Todd Houston

Green imaging. Exactly. So that helps about, you know, when we were talking earlier, your example, the four employees that blew up that health plan, most of your people, probably 90% of it is doctor office visits, urgent care and prescriptions. So, you know, something that has a network is going to take care of 90% of the visits.

00;32;56;04 - 00;33;21;27

Todd Houston

And then what you have to do is we get really involved from an advocacy side. We have advocates that are there again, education on the front end. But then when an employee is going into the hospital, we know through pre certification we're being informed that that person's going in for surgery. We reach out to the center, and then try to negotiate on the front end, like, a reimbursement schedule that, that matches.

00;33;21;29 - 00;33;45;24

Todd Houston

And generally we can save the employer a lot of money by doing that. Because we're doing it beforehand. A lot of times we pay for the surgery, so the person even shows up. So it's really convenient. But that hand-holding is what you really need to do with the employee. You don't want them to be surprised. You don't want them to walk out of the hospital and get a balance bill for $100,000, because then everybody loses, right?

00;33;45;27 - 00;34;02;07

Cary Hall

And scares the hell out of them. There's a hell of because. And they think they're responsible and they're not. So the key to this thing is making sure that that you and I've done these plans before with employees where you actually sit down, you hand down the material, you explain it and you explain how it works. So we'll go back to Green Imaging for a minute.

00;34;02;07 - 00;34;18;26

Cary Hall

The way the green imaging program works for us is they go in with a voucher. They don't have a copay, they don't have a coinsurance, they don't have a deductible. They have nothing. Because we've got a direct contract with this group of people that do these MRIs, Cat scans, X-rays, all of it all over the country. That's a cost saving tool.

00;34;18;26 - 00;34;40;19

Cary Hall

That's what we're talking about. Okay, the same thing with surgical centers. There's a surgical center in Oklahoma. And that particular surgical center specializes in reference based pricing plans, and it's one of the better surgical centers in the country. The funny thing is, they actually list every procedure they have online and the cost and the cost. And here's what you don't know.

00;34;40;21 - 00;35;04;21

Cary Hall

These hospitals are marking these these costs up two, three, 400%. That's that's and and yeah there's a discount the carrier gets. But it's not the same as us going in to negotiate upfront with the hospital. And you want to have a hip replacement done. And it's $35,000 as opposed to $120,000. And that's an example of kind of the thing that goes on, right?

00;35;04;21 - 00;35;23;09

Todd Houston

Yeah, that's a perfect example because that's exactly what happens. But you know, from our standpoint, it's really those advocates and how they interact with the employee is the most important thing. So being accessible, helping an employee and holding their hand so that it's not frightening. And that's what we do. Yeah. And that's how we make reference.

00;35;23;12 - 00;35;44;10

Cary Hall

To our advocates going to reach out to the hospital. They're going to get everything approved so that you're not going at your employees, not going and think, oh my God, I'm going to get balance billed, or I'm going to get a bill from the hospital. And and if by mistake because hospitals do make mistakes, they do happen to get a bill from the hospital, all you gotta do is call, call us our advocate, get involved and take the thing over.

00;35;44;10 - 00;36;00;19

Cary Hall

And they have no responsibility for that. But the key is, Todd said, is you can make this model work and it can make a huge difference. You can lower costs 30, 40% sometimes. Absolutely. Yeah. I mean, tie that to the PBM we just talked about and ask yourself, what is that going to do to your spend.

00;36;00;21 - 00;36;12;03

Todd Houston

Yeah you'll see. You can see groups if they really embrace reference based pricing in the medication program, cut their cost by 50% easily by, on their, on their, actual claim spend.

00;36;12;06 - 00;36;29;13

Cary Hall

Let's think about that. Okay. If you could reduce your cost by that much, here's what I always tell employers when when I was doing this back in the day, where could you repurpose those dollars? Well, do you need newer equipment in the shop? Do you want to do you want to pay bonuses? Do you want to add a benefit?

00;36;29;13 - 00;36;42;26

Cary Hall

Maybe you want to add a vision or a dental plan or something and you've got money now to do that, because benefits are the second most important piece that an employee is going to ask when they come to work, first of all, what's my salary? And second, what am I benefits.

00;36;42;28 - 00;36;56;08

Todd Houston

Yeah. And it's to me it's interesting because with employers it like you just said, it's a it's the second most expensive thing on their, on their P&L, their payroll and then their benefits. And they have no clue how they're spending that money.

00;36;56;10 - 00;37;13;00

Cary Hall

Yeah. And so and I think that's kind of the theme of what we're talking about here. You know, if you understand what you're spending and you understand where it's going, then you certainly know how to manage it. We know it's really kind of funny. I heard this explained this way. I was at one of the Pareto conferences, actually, I think it was Cavanaugh.

00;37;13;00 - 00;37;31;02

Cary Hall

You know, if you're sitting out there in the audience, how many of you, you know, renegotiate, renegotiate your contracts with your suppliers every year. So you're in the roofing business and you buy shingles and you buy tar and you buy all the things. And every year those suppliers come in and you negotiate with them. You didn't do that with health care.

00;37;31;02 - 00;37;50;04

Cary Hall

That's not here because you can't okay. In the current models, it doesn't work that way. What we're saying to you is there's a better way to do this. There's a smarter way to do this. And you don't have to be 100, 200, 300 life plan to be able to do it. And if you're tired of doing it the way that it's working now and it's not working for you, and you can't control the cost.

00;37;50;11 - 00;38;07;20

Cary Hall

And you know what most employers do is they cost shift, they raise the deductible, they change the co-pays. They try to figure out a way to do it where they can keep the plan in place. And then you've got employees that are not happy, okay. Because you're constantly you're constantly changing their benefits. This is a way that you can eliminate that and it can make a big difference.

00;38;07;20 - 00;38;22;06

Cary Hall

BravewindBenefits.com is the website reach out to us, Tood will reach out to you will be happy to connect you with a broker. If you are a broker, we've got the plans that if you want to change the way you're doing business with your clients, we can certainly show you how to do that. Thank you for doing this.

00;38;22;08 - 00;38;22;29

Todd Houston

Thank you, I appreciate.

00;38;22;29 - 00;38;39;17

Cary Hall

It, but we got to do more of these. We've got more of these we're going to do is we continue to educate people on what we've got available. And now I leave you with this thought from Doctor Albert Einstein, the one who follows the crowd will usually get no further than the crowd. The one who walks alone is likely to find himself in places no one has ever been.

00;38;39;20 - 00;39;00;18

Cary Hall

Remember, friends, it's a funny thing about life. If you refuse to accept anything but the very best. You most often get it. Thank you for listening to America's Healthcare Advocate Broadcasting Coast to coast across the USA. Goodbye America.

00;39;00;20 - 00;39;02;25

Cary Hall