Imagine only paying for a service if a vendor saves you money on the front end. Wouldn't that be nice? The truth is, this is not only possible with a health plan, and a benefits advisor for that matter, but the message hasn't been shared widely enough. Programs exists, especially in the self-funded arena, wherein clients see real dollar savings and remit a portion of this back to the vendor that executed the solution on their behalf. There are several areas in which this is possible:


In self-funded health plans, and by virtue of working with independent TPA's, employers can elect to work with transparent pharmacy benefit managers that significantly reduce the price of prescriptions for members. Imagine 30% or so of your claims dollars being cut by 70% in total costs....would this be a considerable savings in your health plan? Yes, of course it would be! What's more, the price of the prescriptions for the members that use the health plan is also reduced, and can be eliminated altogether depending on the structure of the plan and how the employer would like to incentivize the employees. If diabetic medication adherence has caused costly claims to arise, it may be wise for the employer to cover the maintenance costs of diabetic treatment entirely.


Bundled surgery pricing has increased in popularity lately, and there are even technology platforms available that let physicians bid on procedures from across the country to create more competition. We know that market competition drives prices down, and this is true also when it comes to healthcare. Not only can this lead to better outcomes by choosing providers and facilities that have stellar track record, but it also lowers costs for the member AND the health plan. Again, because spend is a factor of claims, bundled surgery pricing and market competition create an advantage for savvy employers.

Case Management

Hindsight is 20/20, and many brokerage houses are used to reviewing past claims data in pretty reports and use them to justify a renewal increase or that they have an eye on plan performance. A better approach is to have the health plan engage members at time of diagnosis to assist them in their healthcare journey. Case managers can be instrumental in assisting employees when it comes to navigating the system and can also help the health plan by steering members to high-quality providers and facilities that may also help reduce claims. The best approach is to have a health plan partner that works to proactively engage members that may be at risk for specific illnesses given the fact that a large percentage of claims are avoidable and due to lifestyle-related choices. Your cost curve is bent downward with a proactive approach.

Telemedicine/Health Advocacy/Decision Support

Members that use telemedicine for minor illnesses save health plans money every time they use the service. In instances of high adoption and an engaged employee population, a health plan can see considerable reductions in their office visit claim charges. Because of the low cost of telemedicine, it is easy to have the cost of the program justified, and members get a $0 copay as a result (for many plans).

If an employee receives an EOB they don't understand or need help comprehending their benefits, they can reach out to a healthcare concierge for assistance. These professionals can help negotiate bills, find errors, and more when a member has a healthcare event. Your HR department is not inundated with claims and plan calls, and members get a high level of care and support. Because of the service's ability to reduce claims after the event and help members avoid more costly treatments prior to the event, health advocacy again saves real dollars for the employer and provides members with personal support. At times, this service is included as a value-add from a carrier partner.

Decision support tools can help members estimate the costs of care and steer them to network-vetted facilities and providers that have below market pricing. By enabling the members to become healthcare consumers, they spend less, and the health plan also benefits. I feel like a broken record at times with this message, but all these services reduce claims. Lower claims equates to lower healthcare spend for the members and employer.

In Closing

Your health plan is an asset, but if it is considered as a liability, the only metric that is measured will be premiums. If the conversation is premium driven, then the employer will be stuck shopping for cheaper insurance every year, but we know that costs continue to rise and that carriers act very similarly when rating cases (why do they ask for the renewals, you may ask?), so this approach is inherently flawed. By investing in the health plan as you would a workplace safety program (to reduce worker's comp), or a maintenance program for your technology (to ensure your equipment is performing optimally and for as long as possible), an employer can finally see that programs that appear to be 'additional cost' can be the very solutions that lower their costs in the end.