So just start with a couple easy
questions.
So if I'm doing this,
is that hidden?
Yes, sir. OK.
It's from about here.
Oh, perfect.
Um, so just start
with your name title and
we'll go from there.
All right, Mike Roach, Director of
Business Development at the
Alliance.
And can you tell me what
the Alliance does?
The Alliance is a network, so think
of networks like
Anthem, UnitedHealthcare,
Quartz, Dean.
Where we're a little different is
we're not-for-profit cooperative
that believes the data that
we collect from claims repricing
belongs to the employer.
Um,
is that it?
Can you tell me a little bit about,
I mean your subhead here
is Self-Funding Smart.
We believe that one of the reasons
that an employer will self-fund is
to get access to their data
because you can't control what you
can manage and if you don't know
where your money's going, how can
you control it?
So, when we reprice the claims,
we gather all that information and
when an employer or
a consultant asks for it, we give it
back to them so that they can see
where do we have all
of our MRIs, where do have all our
knees replaced and is there
another...
Provider that can do that same
service for a better
value with equal quality.
Can you describe what repricing
a claim means?
We have contracts with
39,000 providers.
I have to check that number.
So, if the provider charges
$100, and we have a contract
with them that says any alliance
member will only pay 50, we
get the claim in with the $100 on
it, we reprice it based on
our contract of 50, and
then we send that off to their third
party administrator to be
adjudicated based on their plan
design, and then they'll send out an
explanation of benefits to the
employee to let them know if they
owe any of that to the
provider based on how their plan is
set up.
And how do you interact with
third-party administrators?
We work with about
42 different third-party
administrators.
The connection we have with them is
really twofold.
One, we get eligibility files
from them so that we can
know if we get a claim in on
Bob Smith from
Nick's Towing in Rockford,
is he an actual employee there?
If so, we reprice that
claim, and then on a daily basis,
we send those out electronically for
the most part, to the TPA so
they can adjudicate it.
So it's making sure that we
work in conjunction with each other
to make sure the claims are getting
repriced just for the employees
who are on the plan.
So you are not providing
plans per se, you are providing
kind of
a wrap around service.
So you're correct.
We do not provide
plans.
We provide the network.
So when an employer sells funds,
they get to make the decision on
how to all those pieces of the
puzzle come together.
One of those pieces and a very
important one is the network.
So when employers look for
a good network partner, they want
someone who has a broad network,
who allows them to put
their plan together the way they
want from a network structuring
perspective?
We need to make sure that we
can work with as many different TPAs
as an employer may be interested in.
Um, so describe
a little bit between the
difference between self-funding and
fully-insured.
This is my favorite one.
So one of my favorite analogies to
use is a puzzle.
So both fully insured
and self-funding have all
the same pieces.
When you fully insure it,
they come all put together.
You do not have to worry about your
third party administrator, your
pharmacy benefit manager, your
network, your stop loss
vendor. That's all
encompassed in one easy package and
you write a check every month
and you're ready to go.
You being the employee.
Being the employer.
With Self-Funded, and it's important
to have a really good consultant
when you do this, you get to
pick who all of those partners
are.
So you can find
the network that fits
your culture best.
I want to tier my benefits
and help my employees find value.
I want a fully transparent
PBM, my pharmacy benefit
manager. I want to understand where
my rebates going.
And am I getting the best price on
these prescription drugs?
I want a stop loss vendor that
gives me credit for the things that
I'm doing to help control costs.
And I want to third party
administrator who is
progressive and helps me
control those dollars, making sure
that they are paying.
And when they say they are playing,
they're taking the money out of my
account, just the things it should
be paid.
Are you also helping
work with like alternative funders?
Alternative.
Alternative funders like for
prescription benefits.
Oh so we do not.
So we've been around about 35 years
and we recognize that
being the best network we
can be is the biggest benefit
to the
now north of 500 employers
that we work with.
The pharmacy benefit
segment of that puzzle
is incredibly complex.
If you look at
the contract from a pharmacy benefit
manager, even if you've been in.
The self-funded arena for a long
time, you may not understand
it because they have their own
verbiage and their own nomenclature
and acronyms and AWS
and it is
quite complicated.
Um, and so, uh,
again, that's one piece of the
puzzle and you help consult
on that.
So we will.
Give a recommendation.
So if a consultant comes to me
and says we have an
employer in Janesville, they're
looking for.
Hold on one second.
Sorry, should I?
That's okay.
Hold on, he's gonna.
Apologies. That's Okay.
I don't want you to be giving an
amazing answer.
The team's
message comes up in...
And then while we're paused,
can you just do a quick, yeah.
I don't want you to look at that
later and be like, ugh.
Just start from the beginning of
that question. What was the
question?
Do you consult on
the PBM part of the
puzzle?
We don't really consult on
anything other than the network
piece. However, if a consultant
comes to us and says, we
need a good PBM, we needed
a TPA that works in the
Chicago market, we'll
give them two or three that we work
with who do a really good job for us
and let them decide which is
best for their situation.
You know, it can come down to
everything from the pricing to
what's available for the extra
bolt-on services.
That may save them money in the long
run, it may come down to a
personality of who do we think we'll
work best with.
So we know what we don't know,
so we want to give them an
opportunity to make that decision
for themselves, but we'll definitely
give them some options.
Um, and so
would you say self-funding is better
than fully insured or just
different?
Well, now, I may be a little biased,
but I'm gonna say it's better.
So when we were formed 35 years ago,
the companies that started us wanted
a couple of things.
One, they wanted access to their
information.
And two, they want to understand
why they got the increases
they got every year.
Well, what self-funding does is,
one, it gives you access to all your
information.
So that when you look at your
renewal every year, you can see
exactly why you got...
The increase or decrease that you
received.
You know, I think self-funding lets
the employer take control of
the second or third biggest light
item on their budget.
You know, if you're not trying to
manage it and you're fully insured,
you're gonna get an increase
probably every year.
The last few years, that's been a
double-digit increase and
it's getting more and more difficult
for employers to
find a way to control
that cost and then determine
how much are we gonna pick up and
how much we're gonna pass along to
the employees.
So I think self-funding
gives you much more.
Flexibility and how you put your
plan together, and if after
the first year one of those pieces
isn't working like you thought it
would, you can exchange it
without having to upset the rest of
it.
So what are
one or multiple pieces,
kind of the big advice that you give
to employers if they're looking
at self-funding?
The word transparency should be
asked as many times as you can.
I think that's the thing that is
setting the market apart now with
all the laws that have been passed
on hospital price transparency.
There's a number of really good PBMs
out there that are fully
transparent.
It's making sure that the employer
understands where all those dollars
go.
I mean even things like the
consultants have to report how much
they made in a commission from
a vendor so that you know
exactly what you're spending.
You know when I started doing this
35 years ago.
There was none of that information
available to an employer.
You just took it on faith that your
consultant and your network and your
PBM were all doing the right things
for you.
And what do you think
employees should know, especially
when a lot of
times they don't even
know self-funding is different
from fully insured?
From an employee perspective,
and whether you're fully insured or
self-funded, it's understanding your
plan and how you can make it work
for you.
At the Alliance, we are big
proponents of tiering networks.
So if we know that a
provider is going to bring value,
we will encourage an employer to
put them in a tier above the
rest of the network.
And we use MRIs because it's
easy and everybody knows what an MRI
is.
There are a couple of vendors in the
greater Madison market now that will
do every MRI they can,
and that's all of them, for less
than $1,000.
The same scan at a
system will probably run
you 2,200 or more.
So, if I've got a high deductible
plan and I can get the same
service for $1500 or $1600
less, why wouldn't I do
that?
You know, I think the other thing
that they need to be aware of.
That's what getting old does for
you.
Employees, what do they need to
know?
Well, if you're self-funded, what
employees need to know is that your
employer has now become
the insurance company because being
self- funded, you pay the claims
every month.
So if you as the employee
are good stewards of the plan
and seek value,
that should have a trickle down
effect so that the next year you
don't see your
part of that premium go up.
You may not have to change
deductibles or co-insurances so
you can get some stability in your
plan.
Knowing that you're self-funded and
that there's value to be found for
a number of different procedures,
seeking them out will help you in
the long run as well.
Um, so
some of the patients
that I have been speaking with,
um, have had issues with
their medications and
these are kind of higher
need patients.
So, um.
Maybe some tier four or all
tier four drugs aren't covered.
Um, and these more expensive
medications.
So cancer, Crohn's,
rheumatoid arthritis, MS
HIV aren't
covered under
plan X,
even though those meds might be
fully insured under a plan that's
regulated by the ACA.
So what do you
say to these employees or
patients when then they're
on the hook for 100%
cost share?
So, we don't have anything to do
with the pharmacy benefit and how
that plan design is structured.
That's one of the things that I
think an employer
can make
sure they find in that PBM vendor
is how are we gonna address those
things? As you see more
and more biosimilar
and gene therapies coming out,
this is gonna be an even bigger
question for the employer.
There's a couple of drugs coming
out. They're gonna be $3 million a
piece.
How am I gonna cover those?
And how does that trickle down to
the humeras and the stellaras that
folks need on a more
regular basis, but are still
thousands of dollars a
month?
So it comes down
to educating the
employer and the employee about
the risk.
Um, I don't know if it's a
risk. I think what
a good consultant will do is
mirror the plan.
So if the plan that we had covered
all those prescriptions and
the new one, say, isn't going to
cover Humira,
digging into the claims file,
finding out who's on Humira and
helping them find an alternative
before it
jumps up and is a surprise to
someone.
Um
So I asked about alternative
funders.
So one patient advocate that
we spoke with said,
like in any kind of
job or field, there's good actors
and bad actors.
So some plans are better than
others.
Some brokers or third
party administrators are better then
others.
So how do you ensure that
self-funded plans are working for
employees and
you can trust what your broker is
saying?
And that goes to what we talked
about earlier, when someone says to
me, who's
a good TPA?
I'm never going to give them one,
because I
know who I think does a really good
job.
That's one of the upsides of
being self-funded.
Like I said earlier, you can take
those pieces and move them about
every year.
If you find that one of
them isn't working well, or somebody
new comes into the market, that is
just head and shoulders better.
The other thing about being
self-funded, you've got
a network who reprices the claims.
You've got TPA that looks at
the claims, you've gotta stop-loss
vendor that looks at the claim, so
it's kind of a checks and balances.
If I tell a group, we think
that using our network will save you
45% on your total
claim spend, they don't
have to take my word for it at the
end of the year.
The stop- loss vendor will tell
them, the third-party administrator
will tell them, same with the PBM.
So there's some checks and balances
in place. And at the head
of all this is the consultant.
And that's their job is to make sure
that they're gathering all that
information and making sure it all
checks out.
If an employee really
does need something that isn't
covered, let's say it's a tier four
drug,
should they consider
going to the marketplace
because their self-funded
plan is going to
leave them with a six-digit bill?
That's a tough question.
It gets outside of my expertise
on what is allowed.
Because it's.
Dipped on us.
Nope.
You think with technology they can
just put that bad boy up there for
an hour and a half.
Should someone who is
looking at having a five or
six digit bill move to the exchange?
You know, again, that's what a good
consultant will help you with.
Part of it's going to depend on what
kind of coverage is offered through
your employer, what do you have
access to, and
what can the
the exchange do for you.
So is it difficult
for human resources
departments to take
this on because all
of the sudden it becomes its
own field of expertise and
you have human resources people
you know answering to
for employees.
It seems like a lot.
You've heard me say this, I'm gonna
guess eight times.
If you have a good consultant,
self-funded is no more work than
fully insured. They will be there to
help with the claims questions,
doing all of the analysis to
make sure that the pieces of the
puzzle that you choose are gonna fit
together well.
In a manner that isn't gonna cause
you more headaches, because
when we look at
the HR teams that are some of
our clients, it may be
two people in HR for a 200 life
group.
They need to know that
the moving from fully insured to
self-funded isn't going to be any
more work because they just don't
have the capacity.
And that's why having a good broker
is key to making the whole
self-funding plan work.
So if an employee is
having difficulty like
Appealing a denial is
that something that they would then
go to the Alliance for
or Is
that something they can you know
theoretically work with you on?
So in that case, they'd go to the
TPA, because we
get the claim, we reprice it,
whether if it's in network and we
send it off to the TPA.
What the third party administrator
does is adjudicate that claim based
on their summary plan description,
which is, you know, about that
thick.
They're the ones who make the
determination to
process as in, you know,
um, in accordance with the plan or,
you know, this isn't covered.
If that happens, they work with,
one, I'd start with the broker and
have them help you figure out how to
appeal that with the TPA.
Um, and so like you said,
the plan documents can be this
thick.
Is it difficult to have
employees understand what's
in a plan?
Cause I mean, it's
really dense and it's complicated.
You know whether you're fully
insured or self-funded, that plan
doc is the same.
I think as long as an employee
understands the high level pieces
of their plan design, deductibles,
co-insurances, what's on their
formulary list from their PBM,
who's in network from a doctor and
hospital standpoint,
that's going to cover 95 to
98 percent of everything they do
during the year.
Once in a while you may run
into something in
summary plan description.
Is a rarity, but again there
it goes back to the working with
your consultant and the TPA.
So another patient advocate
said that elevating
a complaint for a claim denial
to the Department of Labor takes
a lot of bravery from the employee
because they
are kind of going up against their
employer and there might
be a fear of retaliation.
What's your response to that?
That's a tough one.
I think if the employee thinks
they're in the right and
has exhausted all other
avenues through the TPA and the
broker, that may be the last
opportunity they have.
But I think you're right.
I think that could be a little
intimidating.
Um, have you
had to deal with the Department of
Labor as you help employers
work through plans and
potential denials and appeals?
Knock on something that looks like
wood, we have
not. So I've been here 10 years
and we've never had to
escalate anything to that level.
Really, wow.
So a recent WMC
survey, I'm sure you know,
so the top concern for employers
is healthcare costs.
Are self-funded plants just
a necessity in this world
as healthcare prices
go up?
Again, I'm biased.
I think so.
If you're a
group that has more than 100
people on your plan and that number
has come down significantly,
we have groups, well, take the
Alliance, for example, we have,
I think, 40 people on our
plan who are self-funded.
Now, we're a bit of a unicorn
because this is where we live every
day. But even if you're group of
75 on the plan, you
can start to look at self-funding.
And again, it goes back to
the ability to measure.
Understand and control your
plan.
We have a number of groups
that have
gone six, seven, eight years.
No plan design changes,
no increases in premiums.
Because they are able to look at
the plan and structure it in a way
that helps the employee save money,
helps the employer save money as
well, and controls that
cost that continues to skyrocket.
So do you, I guess,
after this, do you have data you
might be able to share
to the best of your ability that
maybe shows
premiums
compared to fully insured plans or
anything like that?
That would be commode.
Like direct turn
think.
I mean, we have stuff in the chair.
So you're looking for a one-to-one,
like a.
Um...
I know that's difficult
So I guess any
kind of
kind of fact sheet you have that
maybe shows a little bit
of like cost savings
or something.
Because the idea is
that, like you said earlier,
if the employee is a good steward
of the plan,
the employer saves money,
but it also
keeps costs down
for employees, is that correct?
Okay. So just
curious
you know, as you said, data.
Anytime we can like show what
that means in numbers,
it can be helpful.
Yep, absolutely.
Yeah, anything you can think of,
just let me know.
Yeah, and there's a lot of
interesting stories by employer
by employer.
You could look at one employer and
say, like this employer
saved, like who we're giving, like
Amber Johnson.
They saved like a million dollars
by going self-funded,
I think it was, and they've
just reinvested that into their
facility and their employee benefits
and stuff like that.
So we could tell it from
one or
a broad way.
I don't know what would be helpful,
I can just send you as much.
Okay.
What Philip's done is,
you know, we talked about how
we let employers mold our
network.
He's identified with our help
a list of providers that we call
them preferred value providers
because we know that they're
going to give you a great value, a
great service, and almost
more importantly these days,
quicker access.
So he has those in a tier, and
if employees use them, it doesn't
cost them a dime.
Use direct primary care.
Independent direct primary care,
which is becoming almost
corner-to-corner in the state
something that's available.
You know, look, three years ago in
Madison, I don't think we had any.
I think we're up to eight, ten,
and they're, they
can really help quarterback that.
If you need an MRI, here's where
your employer thinks there's
value, or knows their value, and
that's where they'd like you to go.
And if the employer does a good job
of explaining to the employees,
we are now the insurance company and
we can't have a direct
effect on our premiums
next year.
You know, it's amazing what folks
will do when they know that
if I do these three
things, next year when I go to my
open enrollment meeting, I don't
have to hold my binder and go,
oh, please, less than a 5% increase.
Um, have, you
know, these large
Fortune 500 insurance
companies been
a contributor, do you think,
to increased healthcare costs?
Oh, I think there are
all kinds of folks who have helped
increase healthcare costs.
Say they're the sole reason,
but...
I'll talk to you later.
Oh see it saved me.
Let me think of a good answer.
Of course, I'm out there saying that
they are looking out for your best
entrance anyway, every day,
so.
You know, and I think.
I think a lot of it comes back to
transparency.
We are, I think, sometimes
transparent to a fault.
Are we ready?
So, I don't think you can pin the
increasing cost of health care
solely on the
Fortune 500 folks.
But I think their
lack of transparency contributes
to it.
You know, if they
were willing to share
all their prices and
help employers find value,
it would go a long way to helping
control that.
I think the medical field
and the increases in the
technology have contributed to
it. We talked earlier about
three million dollar
pharmaceuticals.
I think it all contributes
to it
What do you want to add that
I haven't answered?
Um, you know, I think
if an, like I said, if an employer
has 75 or more employees on
their plan, ask your
consultant about self-funding.
Is it right for you?
Even if it's not, start to
learn about what it is and how
it works and how can be effective
because then you've always got
that option ready
to go if you get an increase
from
foliar should carry that you don't
agree with.
Anything to tell me?
No, I mean, do you want to talk
about just, like, the general
interest in self-funding has kind of
increased a little bit?
Like, in the last couple years, I
don't know if you've seen that.
No, we don't talk about that.
No?
Um,
Yeah, so I think that I've
been here 10 years.
In the last three years, we have
seen more consultants
start to come to us and ask
questions about self-funding.
Who is it right for?
Because I think they wrestle with
the same things that employers
wrestle with.
A mid-sized company, we got
another 19% increase from a fully
insured vendor, we're in a
pool with a bunch of other
companies, and we had a really
good year, but we still got an
increase.
How can we address it?
So the number of
companies that have
sent us an RFP just to
see what it was like to