Healthcare “Syntopical”: The CEO’s Guide to Restoring the American Dream 2 (part 10 of 15)

The CEO’s Guide to Restoring the American Dream
Dave Chase


Chapter 9: You Run a Health Care Business Whether You Like It or Not

The reality is most companies wouldn’t hire their present benefits leader to run a multimillion dollar business unit or product. So why do they run a multimillion dollar benefits spend?

So, what’s different about employers who are winning the battle to slay the health care cost beast? It’s all about mindset. It’s about waking up to the understanding that improving the value of health benefits is the best way to improve the well-being of their employees while boosting the company’s bottom line – then committing to that path.

In choosing care providers partners, wide-awake employers understand that the well-being of caregivers has a direct impact on the care of their employees. … Like Fair Trade coffee … I’m proposing that you likewise insist that halth care organizations exhibit fair and ethical treatment of clinicians and patients before you become one of the [mistreated]. Here’s what Fair Trade for health care should include:

  • Transparent Prices
  • Bundled Prices
  • A Culture of Safety
  • Staff Treatment
  • Ethics-based Organizations
  • Data Liquidity

What you need is a sophisticated health administrator, analogous to the person who’s administering your 401(k). This is someone whose skills and experience are commensurate with the magnitude of your investment in health benefits and the level of fiduciary responsibility it carries. … In short, you need someone to run a major business, your health business. Some skills are listed on pg. 99


Chapter 10: How to Pick a Benefits Consultant (Broker)

[Instead of the traditional 60 day notice for annual renewal process] Most consultants (although not all) that support self-insured plans are far more sophisticated than the brokers profiled earlier. If they’re not, self-insured plans can be a financial disaster of epic proportions. A consultant in this space needs to know (1) how to set up a plan and build it out component by component and (2) how to put protections in place for your company to ensure your liability is no greater than you can financially stomach.

Here are the main components of high-performing self-insured plans:

  • The third party administrator (TPA) that is responsible for paying claims (with your money) according to the specifications you set up and the supporting plan documents
  • The network (usually “rented” from a large carrier) the provides discounts off billed charges
  • Balance billing protection. Employers have a duty under ERISA to only pay fair and reasonable charges. After that price is determined and paid, some providers will try to get additional payments from an employee. A proper plan protects an employee against providers pursuing this. In extreme cases, that can include legal services for the employee.
  • A pharmacy manager to handle the pharmacy network
  • Pricing contracts
  • Stop loss protection to pay for large claims

A common first misstep to lower costs is workplace wellness programs. As we saw in Chapter 8, at best, only a tiny percentage of such programs have a real ROI. … Instead, a progressive consultant brings you a multiyear health care plan designed to lower the quantity of care consumed, built on a proven approach to lower the actual cost of care for ALL employees – whether they are healthy or not.

The plan will generally reflect the following:

  • Serious thought for ERISA fiduciary responsibility
  • An emphasis on value-based primary care
  • An emphasis on the highest-cost outlier patients
  • Transparent medical markets / reference-based pricing (ie ways to know the actual prices you’ll pay for services)
  • Transparent pharmacy benefits
  • Data proficiency

The plan will also include payment arrangements with providers and, importantly, complete disclosure of the consultant’s sources of compensation.

As you can see, the actual “insurance” is a smaller and smaller piece of what the nontraditional benefits consultant brings to the table. In the self-insured model, stop-loss is the only insurance policy purchased, generally accounting for less than 20 percent of the overall costs. This person should be able to provide you with all the information you need to identify the best renewal options for noninsurance administrative functions and, critically, the right strategies to positively impact both the cost and quality of your employees’ care over the long term. … You don’t necessarily want to pick your consultant based on how low their fee is.


Chapter 11: The 7 Habits of Highly Effective Benefits Professionals

Habit #1: Insist on Value-Based Primary Care

Habit #2: Proactively Manage Pharmacy Benefits

Habit #3: Have Specific Plans for Uncommon (But Predictable) Gargantuan Claims

Habit #4: Deploy Evidence-based Musculoskeletal (MSK) Management Programs

Habit #5: Refuse to Sign Blank Checks to the Health Care Industry

Habit #6: Protect Employees by Sending Them to Providers With First-rate Safety Records

Habit #7: Avoid Reckless Plan Document Language that Costs Millions

All your moves to implement these habits should be properly documented for two reasons. First, you want your entire team (not to mention your successor) on the same page. Second, not doing so can leave you and your company vulnerable to litigation related to health plan design and administration.


Chapter 12: Centers of Excellence Offer A Golden Opportunity

What to look for in a Center of Excellence:

  • Patients are seen by multiple specialists
  • A multidisciplinary team does the diagnosis
  • That same team prescribes treatment the treatment plan
  • If surgery is required, it is done at the highest quality available
  • The patient experience is excellent
  • Health care is integrated, collaborative, and accountable
  • Bundled payments and global fees rather than fee-for-service payments

Remember that organizations are usually only a center of excellence for certain procedures and specialties, not everything.

In health benefit plans today, about 6 to 8 percent of plan members are spending 80 percent of the plan dollars. Outliers may have wildly different medical conditions, but they have a lot in common. (see pg 120)

Admittedly, contracting directly with health systems that qualify to be centers of excellence usually takes a lot of effort, and you have to be a pretty large employer to get their attention. The good news is that “aggregators” are available today … to get prepackaged access to top-notch centers of excellence.



Healthcare “Syntopical”: The CEO’s Guide to Restoring the American Dream 1 (part 9 of 15)

The CEO’s Guide to Restoring the American Dream: How to Deliver World Class Health Care to Your Employees at Half the Cost

by: Dave Chase
c: 2017

Pigeonhole: Social Science – Public Administration


Acknowledgment & Author’s Note (p ix)
Forward (p xvii)
A Note From A Fellow Traveler (p xxi)
Introduction (p1-12)
Part 1: The Current Situation (p13)

  1. America Has Gone to War for Far Less (p14-24)
    Case Study: Pittsburgh (Allegheny County) Schools (p25-29)
  2. Health Care Prices: Hyperinflation or Flat? (p30-38)
  3. What You Don’t Know About the Pressures and Constraints Facing Insurance Executives Costs You Dearly (p39-46)
  4. Millennials Will Revolutionize Health Benefits (p47-55)
    Case Study: Rosen Hotels & Resorts (p56-60)
    Part 2: How and Why Employers Are Getting Fleeced (p61)
  5. 7 Tricks Used to Redistribute Profits From Your Organization to the Health Care Industry (p6269)
  6. PP Networks Deliver Value – and Other Flawed Assumptions That Crush Your Bottom Line (p70-76)
    Case Study: City of Milwaukee (p77-79)
  7. Criminal Fraud Is Much Bigger Than You Think (p80-84)
  8. Are Workplace Wellness Programs Hazardous to Your Health? (p85-90)
    Part 3: Doing It Right (p91)
  9. You Run a Health Care Business Whether You Like It or Not (p92-99)
  10. How to Pick a Benefits Consultant (p100-107)
    Case Study: Langdale Industries (p108-111)
  11. The 7 Habits of Highly Effective Benefits Professionals (p112-116)
  12. Centers of Excellence Offer a Golden Opportunity (p117-121)
  13. Independent Claims Administrators vs. Insurance Company Claims Administrators – The Trade-offs (p122-134)
    Part 4: Health Rosetta (p135)
  14. Value-based Primary Care (p136-143)
  15. Transparent Medical Markets (p144-150)
    Case Study: Enovation Controls (p151-155)
  16. Concierge-Style Employee Customer Service (p156-160)
  17. High-Value Transparent TPA (p161-167)
  18. Transparent Pharmacy Benefits (p168-175)
  19. “ERISA Fiduciary Risk Is the Largest Undisclosed Risk I’ve Seen in My Career” (p176-185)
  20. The Opioid Crisis: Employers Have the Antidote (p186-199)

Conclusion (p200-209)
Appendix A: Detailed Case Studies on the Failures of Workplace Wellness Programs (p209-219)
Appendix B: Client Notice, Plan Sponsor Bill of Rights, and Code of Conduct (p220-225)
Appendix C: Sample Compensation Disclosure Form (p226-231)
Appendix D: Health Rosetta Principles (p232-246)
Appendix E: Health 3.0 Vision (p247-256)
Appendix F: Health 3.0 Vision: Implications for Providers, Government, and Startups (p257-262)
Author Bio (p263-264)
Bibliography & Endnotes (p265)

Healthcare “Syntopical”: The Grassroots Health Care Revolution 4 (part 8 of 15)

Chapter 7: Centers of Value: Companies Move Business

 If you are looking for an elective surgery, consider looking for the cheapest price. … The more procedures a medical team performs, the better it gets. The better it gets, the more surgery it attracts. … Second, the highest-quality providers are often the ones that are the most serious about lean disciplines. … Higher quality begets more volume; less waste begets lower costs and prices; lower prices and high quality beget more volume and higher profits.


Chapter 8: Restructured Pricing: Companies Demand Better Models

If Safeway can offer its employees the choice of five accredited endoscopy shops where they can buy colonoscopies for $1500 or less, and they are within a reasonable distance, why would they ever pay more? Whey indeed. So they don’t

Safeway and a number of other payers have developed what is called Reference-Based Pricing (RBP) to keep a lid on health care costs. They simply say to their employees, “You can go anywhere you want, and we will cover the costs up to $1500. If you pick an uncompetitive clinic, and the charge is higher than that, fine, but you pay the difference out of your pocket.”

Another provider uses a plan they call TrueCost that sets payments at Medicare rates, plus a 40 percent “provider bonus.” … another provider uses a cap of 175 percent of Medicare if an employee chooses to go outside of network.

BidRx is using direct dynamic pricing (online auction) for pharmaceuticals. It allows patient and doctor to go to its website, call up any prescription drug, look at a baseline price, check out all the valid substitutes, including generics and their lower prices, ask for an auction price, punch a button, and order at the low, “dynamic” price. The inexpensive drug arrives by mail a few days later from the low-bid pharmacy.

Smart employers have made generic drugs free to employees because they are so cost effective. … pharmacy benefit management systems that offer incentives for generic substitutions and disincentives for high-priced brand drugs generally work well. They often have three tiers for generics, low-price drugs, and high price drugs. Copays are set highest for the high-price brands.

Smart purchasers also use a “step system,” in which employees are asked to try lower-price alternatives before moving step by step to more expensive, still-patented pharmaceuticals.

Yet another payment reform is moving rapidly across the country. Employers pay a retainer to contracted doctors and nurses for primary care. They are paid a set amount each month per member, so they cease to be worried about pumping up volumes for procedures as promoted by CPT codes. … That is called a capitated plan, in this case for primary care only.

Still another reform is the simplest of them all: straight cash payments. … some convenience clinics and other providers are offering low, fixed prices for cash payments.


Chapter 9: On-Site Clinics: Companies Take Over Primary Care

Essentially, the on-site primary care turns the existing business model upside down. Instead of the specialist at the center of medical attention, the primary care doctor becomes the quarterback – just like he or she was in the family-doctor era a couple generations ago.

It is the employer’s doctor, not the big system’s captive doctor, who controls key medical spending decisions.

  • The company doctor orders tests and screenings at the best prices and quality
  • The company doctor orders up the specialists, but only when warranted by patient condition – not as routine protocol
  • The company doctor or nurse practitioner orders prescriptions, with generics as the first option.
  • The company doctor orders, in collaboration with employees, admissions to hospitals or outpatient clinics.

In short, the employer and its on-site team (nurse practitioner, or physician’s assistant, nurse coaches, dietician) offer proactive, intimate, convenient, cost-effective, integrated care in wat is called “a medical home.” The primary care doctor could be seen as the CEO of the medical home.


Chronic Diseases: Companies Go Where the Money Goes

Safeway has installed targeted programs and incentives to get its employees and their families to adopt healthy behaviors. Safeway hones in on five conditions: tobacco usage, healthy weight, blood pressure, blood sugar control, and cholesterol. If an individual passes metrics tests in those five areas, he or she wins a premium reduction of $1040; $2080 for a family that passes. Progress towards goals also earns premium rebates.

A new frontier for proactive primary care is mental health. Levels of mental illness can be elicited in the annual assessment process through a simple, proven eight-question screen, called the PHQ-9. … Remove any stigma attached to seeking help for such illnesses as anxiety, depression, and addiction. … adding behavioral treatment professionals to the on-site teams will be the next step.



  • $6000 deductible ($2,500 is the median threshold to incentivize behavior change)
  • Split savings 50/50 found by shopping around for service that costs more than the deductible, or for finding overcharges.
  • Give a cash bonus / rate reduction for using a pre-determined Center of Value
  • Make 2ndopinions on elective surgeries free
  • Need to shop Stop-Loss and Insurance to protect against catastrophic claims ($35,000 median premium) and Aggregate-Loss Insurance to protect against a bad overall year. (125% of expected)
  • Need to shop around for a healthcare network
  • Need to shop around for Claims Processing (ASO)
  • Search for a joint clinic to act as an “on-site” provider of primary care ie “Medical Home”
  • Set prescription co-pays to a 3-tier system based on price and availability of generics
  • Get warranties on top of bundled prices so there are no readmission costs
  • Negotiate low primary care prices for using cash
  • Consider an “in-house” doctor to direct all medical decisions with cost and quality for the consumer in mind. Ie create a “medical home”
  • Reduce premium prices for passing (5) health tests



  • Anthem and Humana for visible pricing
  • QuadMed for on-site clinics
  • Costco for Prescriptions
  • UnitedHealthcare for Stop-Loss insurance for 10-person company
  • Alithias for transparency tool
  • UnitedHealthcare myHealthcare Cost Estimator for transparency
  • Auxiant FocusHealth transparency tool
  • Castlight for transparency
  • Compass Professional Health Services for transparency
  • Mutual of Omaha mpower360 for transparency
  • New York made public the charges on 1,400 procedures in 2013
  • Wisconsin has the Wisconsin Health Information Organization (WHIO) All-Payer Claims Database (APCD) and “Datamart” for hospital level transparency
  • Par80 for “direct dynamic pricing” which is essentially an online auction for medical procedures
  • BidRx for direct dynamic drugs
  • RxCut by Free For All inc for direct dynamic drugs
  • Walgreen’s Take Care Health Systems for worksite primary care clinics
  • Humana’s Concentra for primary care clinics
  • ModernMed renamed Paladina Health for concierge primary care
  • Safeway Health consulting services

Healthcare “Syntopical”: The Grassroots Health Care Revolution 3 (part 7 of 15)

Chapter 4: Self-Insurance: Companies Keep Their Health Savings

Aggressive executives don’t want to be lumped into an insured pool of passive payers who are doing little to control their health care costs.  … They want to keep offering a health care benefit, but they can’t afford the double-digit annual premium increases levied by fully insured plans.

The enabler for smaller companies is to shop for what’s called stop-loss insurance at the right level to protect themselves against catastrophic medical incidents or a rash of claims. … We stop our losses at $200,000 and pay a premium of $250,000 per year to do so. … For companies with fewer than 50 employees, the median stop-loss (or deductible) was $35,000 in 2012

In an unexpected twist, some small employers with healthy workforces will use ObamaCare to their advantage: they will move to self-insurance to save money. Then, if they have a bad year with a couple losses that exceed their stop-loss limit, and they are faced with premium hikes for the following year’s stop-loss coverage, they can bail out to the new health insurance exchanges. … In effect, the small companies have a backup plan mandated by the federal government. They have a safe harbor if self-insurance doesn’t work out.

Companies that self-insure still need a health plan that offers a network of providers and discounts. And they need an Administrative Service Organization (ASO) to administer claims. Almost no company wants to process its own claims. … Fortunately, the big health insurers like the ASO business, so they offer not only the stop-loss insurance but also the discounts obtained from their network of providers and their transaction services. They like group contracts for more than individual policies for health insurance.

Most small companies also cover themselves for “aggregate” losses to protect themselves against a bad year overall for medical losses. The most common policy is to protect at more than 125 percent of expected claims for a given year.

The main deal is to get your company self-insured. But self-insurance is just a launch pad for other reforms. By itself, it doesn’t yield big savings. … Once self-insured, a company can embark on other reforms, such as installing consumer-driven incentives, making prices and quality of procedures transparent, purchasing from Centers of Value, aggressively managing chronic diseases, and offering proactive primary care.


Chapter 5: Consumer Driven: Companies Engage Employees

Employees become real customers, and a company’s health costs are reduced by 20 to 30 percent. … When people spend their own money, even if their employer gives it to them, they consume much more wisely than if someone else pays. … Companies are working with employees to improve these five behaviors:

  • How employees utilize health care
  • How they purchase care when they need it
  • How they live their lives – their lifestyles
  • How they follow regimens if they have a chronic disease condition
  • How they collaborate with their doctor on long-term health

The immediate bang for the buck comes from reducing overutilization. For instance, instead of using a physical therapist for months of sessions after surgery at $600 per hour, the employee-turned-consumer quickly figures out when to end the supervised treatments and do the exercises at home.

A person might tough out a sore throat and avoid an office visit that costs $160. If it gets worse, she would go to a convenience clinic or a doctor’s office, but she wouldn’t even think of going to an emergency room, where she’d pay $600 or more for a visit.

Smart employers also contract for relatively inexpensive advocates for their employees to help weigh tough decisions on surgery or no surgery. … Smart employers offer incentives to plan members to audit medical bills for overcharges. Employees are allowed to keep up to half of any errors discovered, and they soon find that overcharges are rampant.

HSA vs. HRA Chart pg 74

The charm of account-based health plans for employees is at least twofold:

  • People like being in control of major parts of their lives. They are quite capable of buying homes, automobiles, computers, life insurance, and education for themselves and their children. Why would they not want to control their spending on health care?
  • Totals in HSA accounts, for which contributions, buildups, and withdrawals are tax free, are becoming real assets. A few have reached six figures.


Chapter 6: Transparency: Entrepreneurs Shine Light on Prices, Quality 

Transparency platforms are absolutely necessary for intelligent consumerism to take hold, because providers are woeful at best, and misleading at worst, at volunteering real prices and meaningful quality ratings. … the trick for employers is to get employees who need a procedure to use the site and to use the best providers. The best method is plain old cash.

Example: MedSave plan offers $2000 in cash to coworkers who select a Center of Value for a joint replacement of coronary bypass. It’s $500 for smart purchase of a colonoscopy and $250 for an MRI. … Other companies use the stick instead of the carrot. Employees pay more if they pick low-value providers.

Again, though, the trick is getting a high level of steerage to the best provider in the emerging marketplace for health care. That’s where the major dollars are saved.

Ultimate price transparency comes from what is known as bundled prices. Corporate payers are demanding all-in prices for an episode of care, and they are getting them.



Healthcare “Syntopical”: The Grassroots Health Care Revolution 2 (part 6 of 15)

The Grassroots Health Care Revolution
John Torinus

Unlike the current system that revolves around specialist doctors, hospitals, and insurers, the new model centers on the employee, the consumer. The new delivery model listens first to the voice of the customer. It is patient-centric.


Chapter 1: Go or No-Go Under ObamaCare?

Best-practice employers in the private sector deliver health care for a total cost between $8,000 and $10,000 per employee. … Employers who haven’t applied management disciplines to health care often pay more than $20,000 per year.

Soft Costs: Legal Fees, Turnover and Recruiting

Hard Costs: Suppose an employer currently delivers health care at a total cost of about $8,500 per employee, which is tax deductible to the employer and tax exempt to the employee. If it drops the benefit, it would have to give an employee a taxable raise of more than $14,000 to buy an equivalent policy.

Suppose, instead, that a company wanted to drop coverage but be cost-neutral with its current expense of $8,500 per employee. In that scenario, it would limit the raise it gives to an employee to buy a policy to only $5,700. … Unfortunately, in most cases, that added compensation of $5,700 would not be enough to buy an equivalent policy on the exchange.

ObamaCare is insurance reform, not health care reform.


Chapter 2: Private Payers Forge Disruptive New Business Model

That means:

  • Elevating their employees from passive, entitled recipients to engaged consumers
  • Insisting on transparent prices and quality
  • Creating incentives and disincentives and a culture of smart consumerism
  • Moving business to the highest-value providers
  • Treating health care vendors with respect, but demanding performance
  • Creating a culture of fitness and health at their companies
  • Making workforce health and health costs a strategic priority

Employers and employees are the only health care players with a deep mutual interest in a long-termgame plan. They are in a health care compact for many years.

The Steps Companies Are Taking

Companies with work forces as small as ten people are racing toward self-insurance as a first step, thereby assuming the risks, responsibilities, and rewards of keeping costs in check.

Their second step has been to roll out consumer-driven plans that engage employees in becoming responsible users and buyers of medical services.

That, in turn, requires data sleuths, known as transparency and analytics vendors, who collect and slice and dice the medical charges and outcomes from many health care transactions to shine a light on prices and quality. They offer clear comparisons of costs and quality. It is a new lens that allows consumers to make sound decisions on where to get care.

The payers’ fourth step is to contract for rigorous on-site providers to manage health. Their health teams tackle chronic diseases, believed to cause 80 percent of health costs.


Chapter 3: Three-Year Game Plan Can Flatline Company Health Costs

First, it does little good for a company to adopt innovative practices that save money if it is fully insured. The savings go to the pool of insured companies, of which it is only one member. The pool structure does spread the risks of expensive cases, but the insured company gets only a sliver of its own savings. You’re married to stuck-in-the-mud companies.

Ergo, as Play One, private companies need to wean themselves off indemnity plans and move to self-insurance. … They offset the risk of getting hit with an expensive episode of care by buying stop-loss insurance to protect against catastrophic claims.

Play Two injects incentives and disincentives into the behaviors of employees. … When the deductible is set higher – the median appears to be about $2,500 – employee behaviors change on a dime. A Health Savings Account (HSA) or a Health Reimbursement Arrangement (HRA) usually offsets the high deductible, so the out-of-pocket expenses by an employee can stay about the same. But it’s the employee’s money in the accounts, and that makes all the difference.

Example: Why would an employee spend $3000 of his own money for an MRI when the same procedure can be purchased for $525? Or go to an emergency room for $600 when he could go to a clinic for $160?

Self-insurance takes some planning time because the company has to pick the best network of providers for its employees. The network can be acquired through a health plan, through a TPA – Third-party administrator – or can be put together through a collaboration of employers. Claims processing can also be bought from multiple sources. … The big deal is choosing a high-value network with lots of choice and the right geographic alignment.

Play Three needs to follow shortly behind the engagement of the employees as smart buyers of health care. It’s the transparency piece. … You can’t ask people to be intelligent consumers without giving them good information.

The next step, Play Four, is to promote Centers of Value. Play Five is to Price in Bundles, and Play Six is to offer On-Site Health Clinics. Even though it hasn’t happened broadly yet, some smaller companies team up in joint clinics.

Play Sevenfollows from Play Six. With an on-site health team offering intimate, holistic care to members, rigorous face-to-face management of chronic diseases can be launched and attained. Ie Manage Employee Health

Finally, … Play Eight is to treat health as an asset – a personal asset, a corporate asset, and a financial asset.



Healthcare “Syntopical”: The Grassroots Health Care Revolution 1 (part 5 of 15)

The Grassroots Health Care Revolution

by: John Torinus
c: 2014

Pigeonhole: Social Science – Public Administration


Introduction (p1-6)

  1. Go or No-Go Under ObamaCare? (p7-20)
  2. Private Payers Forge Disruptive New Business Model (p21-38)
  3. Three-Year Game Plan Can Flatline Company Health Costs (p39-56)
  4. Self-Insurance: Companies Keep Their Health Savings (p57-64)
  5. Consumer-Driven: Companies Engage Employees (p65-80)
  6. Transparency: Entrepreneurs Shine Light on Prices, Quality (p81-98)
  7. Centers of Value: Companies Move Business (p99-114)
  8. Restructured Pricing: Companies Demand Better Models (p115-132)
  9. On-Site Clinics: Companies Take Over Primary Care (p133-154)
  10. Chronic Diseases: Companies Go Where the Money Goes (p155-168)
  11. Health As Asset: Companies Come to New Understanding (p169-180)
  12. Other Payers Join the Marketplace Revolution (p181-192)
  13. Employees, Employers, Nation: Win-Win-Win (p193-206)

Acknowledgements (p207-208)
About Serigraph (p209)

Healthcare “Syntopical”: The Company That Solved Healthcare 3 (part 4 of 15)

Chapter 6: The Missing Link: Top Management as Change Agents

They charge smokers a 10 percent monthly premium

Employees can earn “wellness days” off for pursuing healthy lifestyles

To gain acceptance, they offered this plan as on option in its first year, as well as a traditional low deductible and co-insurance plan.

Chapter 7: Beer, Brats, Butterfat: Health, Lifestyle Can Be Managed

Our dysfunctional non-system pays providers to fix people when they’re broken, not to prevent those same health breakdowns.

They require a yearly mini-physical for each employee and their (covered) spouse.  A volume deal is cut with the provider to keep costs low ($45 pp). You can opt out of the physical, but you have to pay the full premium for health care.

Because it just makes sense to be serious about the health of your employees, we have adopted may best practices for our wellness and prevention program. The components include:

  • An elaborate point system for wellness rewards;
  • No paid sick days are allowed because they can be abused, but wellness days offset that need;
  • A 10 percent higher premium for smokers;
  • Coaching for co-workers who have health issues;
  • A free, on-site dietician, nurse practitioner, and chiropractor, who doubles as our ergonomics expert;
  • A free primary care doctor whose mission includes prevention, wellness, and chronic disease management;
  • Formal programs for chronic diseases;
  • Promotion of a fitness culture;
  • Tracking health metrics of our co-workers;
  • Walking paths around campus;
  • An on-site fitness center;
  • Sponsorship and participation in walking, running, and biking events.

Chapter 8: Primacy of Care Delivers Big Savings

Cost savings are not the only reason that companies are moving toward on-site medical clinics that they own or control. They do it so they can turn the upside-down delivery of healthcare right-side up. … If you manage the front end of the process, you have a fighting chance to put a tourniquet on the hyper-inflation inflicted by the industry on the nation.

Pyramid Example: Specialists over Primary Doctors over Nurses. Upside down because specialists deliver the highest amount of care in dollars, when it should be nurses.

QuadMed is about what works. Here are some of its important building blocks:

  • Doctors on Salary
  • All Electronic Records
  • Prevention Prominent
  • Inexpensive Office Visits
  • Medical Home
    • If employers don’t have enough critical mass to create on-site medical homes, they should insist that their providers do so.
  • Fitness Centers, Employee Assistance Program On-Site

Another huge benefit from having primary doctors dedicated to their patients is their ability and willingness to guide them to the best Centers of Value for other treatments.

Chapter 9: Quality Ratings Elusive, But Essential

Common sense tells us to ferret out which are the best and worst providers. To passively give our healthcare dollars to providers with poor outcomes amounts to dereliction of our duty as leaders of companies. … the important lesson is that you can dig out quality information if you are determined.

Chapter 10: To Reform: Educate, Communicate, Hyper-Communicate

The old plan: $300 deductible and 20 percent co-insurance. The new, high deductible plan nearly eliminated the bi-monthly premium and set up a personal health account.

The company makes second opinions on elective procedures free.

Chapter 11: Silver Bullet for Better Value: Lean Disciplines That Transform

  • Seek out lean providers of health care and send your health care business there whenever possible.
  • Insist on all three components of value: service, quality, and price.
  • Push for changes in the archaic procedure-by-procedure pricing system.

Chapter 12: Generics, Loss Leaders Provide Leverage on Drug Costs

Walmart, Target and Walgreen’s decided to make generic drugs a loss leader; selling dozens of drugs for $1 a week.  … Generics bought from any of these three retailers were reimbursed 100 percent.

Other restrictions: Only one ‘blue pill’ per week. No baldness drugs. Cover drugs for smoking cessation, but only for two attempts at quitting.

But, drug costs, which constitute 10-15 percent of a company’s health care bill, can’t be sufficiently controlled through competitive bidding. Use a three-tier system:

  • Tier 1 – co-workers pay 20 percent of a generic drug price, or a $5 minimum for a monthly regimen
  • Tier 2 – branded drugs for which the PBMs have cut a good deal is 20 percent of price or a $15 minimum
  • Tier 3 – unlisted branded drugs are 30 percent of cost with a $30 monthly minimum plus the cost of the difference between the drug and the effective generic.
  • Drugs with no generic substitute are covered

The secret, then, of keeping drug costs in line is to exploit the savings in the marketplace wherever they exist. At one-tenth of the company’s tab for health care, drugs have to be managed as aggressively as the other nine-tenths of the bill.

Chapter 13: Better Model for Desperate Small Companies

Small companies pool together to spread risk; because of that, the benefits for an individual, well-performing company, are never improved. In addition, one bad incident can increase rates as much as 50 percent.

  • Buy a plan with a high deductible and co-insurance
  • Facilitate the use of flexible spending accounts by employees.
  • Offset the high deductibles and co-insurance with a Health Reimbursement Account (HRA)
  • Hire a Broker
  • Put your business out to bid every couple of years
  • Be serious about prevention, wellness, and chronic disease management for your employees and their families.
  • Pay for an annual mini-physical for your covered adults.
  • Look for an insurance plan that makes prevention tests free
  • Encourage fitness for all employees
  • Look for a well-run primary care clinic to set up a medical home for each family
  • Even if your premiums are set for the year, encourage your people to seek value
  • Encourage your people to look at the transparency web site put out by your insurer to find the best values for price and quality.
  • If you have a drug plan, use a three-tier or four-tier system that encourages the use of less expensive drugs.

Healthcare “Syntopical”: The Company That Solved Healthcare 2 (part 3 of 15)

The Company That Solved Healthcare
John Torinus


For the sake of clarity, I have chosen to group the successful reforms in the private sector under three platforms:

  • Consumer Responsibility
  • Centers of Value
  • Prime Role for Primary Care

Consumer Responsibility

Companies that have used what are called consumer-driven health plans have enjoyed savings of 20-40 percent. That’s because their employees have their own skin tin the game. Behaviors change on a dime when companies give their people personal accounts that are tied to high deductibles and co-insurance. They become more personally responsible. … Communication and education must be clear, consistent, and easy to access.

Centers of Value

The second platform for reform helps people find the best providers. That means identifying and promotion what Serigraph calls “Centers of Value,” where value means the best combination of service, quality, and price. … Most Americans have almost no idea whether their doctor or hospital system is good, bad, or average for performance. The information has been nearly impossible to track. In contrast, Serigraph makes available to its co-workers the quality ratings that are available. The performance variation is huge.

Prime Role for Primary Care

The third reform platform is a model that centers on primary care, a little like it was in the good old days when doctors and patients had a personal relationship, both for care and for the economics of care. … A large swath of costs can be cut by re-establishing the role of primary care. Big, complex medical systems have homed in on the higher reimbursements offered by the government and insurance companies for specialty care. They put high-priced specialists at center stage. … As a business strategy, the big corporations have hired or acquired primary care physicians to feed patients upstream to their monstrously expensive specialty units.



Chapter 1: Rampant Health Costs Can Be Controlled

We tried all the obvious tactics to lower health costs. Those included a wellness and fitness program; an annual quoting and bidding process to land a percentage point or two more in discounts from health providers; some rationing (only one Viagra pill per week, for example), and a standard plan that shifted some costs to co-workers with a deductible of $300 and a 20 percent co-insurance. These anemic attempts throughout the 1990s may have mitigated the rate of increase, but at the end of each year, we still showed staggering cost hikes. … Trying to use our buying power against the larger selling power of increasing consolidated providers did not work.


Chapter 2: Get Employees’ Heads in the Game

Classic story: 45 minute procedure would cost $8,900. Employee shopped around and found the same procedure for $1,130. Serigraph shares a 75/25 cost with an employee pool. Premiums have been reduced by $1250 per person.

What we have learned is that the winning formula for moderating health cost inflation comes down to:

  • Behavior change by individually responsible users of health care;
  • Aggressive and intelligent management by the company;
  • Creation of marketplace dynamics to help people find good value; and
  • Keeping people out of hospitals.

Health cost savings is not about saving a couple points on the hyper-inflated annual bidding process.

We have learned that keeping costs in check is all about behavior change. That is where the savings lie. Specifically, employees need to be asked to change five behaviors:

  • How they utilize medical services;
  • How they buy healthcare;
  • How they live their lives in terms of personal health;
  • How they follow regimens if they have a chronic disease; and
  • How they relate to their doctors

Prescription: Go to a consumer-driven high-deductible plan, offset by personal health accounts. Those plans unequivocally have been proven to work. Dump plans with no or low incentives and no disincentives.


Chapter 3: Utilization Drops Sharply with Individual Responsibility

HRA = Health Reimbursement Account.
Company has a pool of money for employees to draw from. Company reimburses pool (pre-tax) when it’s drawn against.

HSA = Health Savings Account.
Each individual has a tax-free savings account that grows as monthly (pre-tax) deposits are made by the company. Funds are tax-free to remove if used for medical purposes.

Example: Standard state employee coverage = $19,000 per year vs. $1,500 deductible and a $3000 HAS = $12,000 per year

Most co-workers come to think of the health plan as their plan. They own it, at least part of it. And they start to view their health as a personal asset.


Chapter 4: Piercing the Fog of Medical Pricing and Promoting Transparency

Use transparency sites to understand and compare the true cost of a procedure.

  • Doctor fees are included with hospital and clinic charges
  • Other line items that were unbundled before, such as anesthesiology, are included
  • Prices are shown for whole episodes of care, from beginning of treatment to the end, including physical therapy after surgery
  • Information on quality is added to identify what we call high-value providers. Some call them centers of excellence; we call them “Centers of Value.” We steer our co-workers to those winners.

Another part of the pricing opacity is overbilling. It is systemic.

Anthem now publicly lists almost fifty procedures with bundled prices, including doctors charges. Humana has a similar site for one of its networks.


Chapter 5: Motivate Employees to Seek Centers of Value

Most health plans, including high-deductible plans like ours, have a large flaw when it comes to major procedures. It’s the out-of-pocket maximum for co-workers. Once a person hits $6,000 in out-of-pocket costs, Serigraph steps in to cover 100 percent of the remaining charges. It’s back to free lunch and no consumer discipline.

We decided to use the carrot approach: cash rewards if co-workers would go to the three or four providers we had selected as offering good quality, excellent service, and low prices.

Example: “MedSave Program” company splits the difference of the money saved for an elective knee surgery. $4000 saved by shopping around; $2000 for company, $2000 for employee.

One of the major hurdles for moving business is that patients are used to following doctors’ orders. That makes some sense on purely medical issues, because the doctor is an expert. But doctors don’t usually place business for best price or value. They almost always assign patients to the systems that employ them, regardless of price.

Consumers have the right to buy their healthcare where they choose. And the prices for health care have gotten so high and so financially painful that many of them have to move their business to save money.


Healthcare “Syntopical”: The Company That Solved Healthcare 1 (part 2 of 15)

The Company That Solved Healthcare

by: John Torinus
c: 2010

Pigeonhole: Social Science – Public Administration


Introduction: Real Reform of Health Care Still to Come (p1-10)

  1. Rampant Health Costs Can Be Controlled (p11-18)
  2. Get Employees’ Heads in the Game (p19-30)
  3. Utilization Drops Sharply with Individual Responsibility (p31-42)
  4. Piercing the Fog of Medical Pricing and Promoting Transparency (p43-58)
  5. Motivate Employees to Seek Centers of Value (p59-82)
  6. The Missing Link: Top Management as Change Agents (p83-92)
  7. Beer, Brats, Butterfat: Health, Lifestyle Can Be Managed (p93-110)
  8. Primacy of Primary Care Delivers Big Savings (p111-128)
  9. Quality Ratings Elusive, But Essential (p129-140)
  10. To Reform: Educate, Communicate, Hyper-Communicate (p141-158)
  11. Silver Bullet for Better Value: Lean Disciplines That Transform (p159-172)
  12. Generics, Loss Leaders Provide Leverage on Drug Costs (p173-184)
  13. Better Model for Desperate Small Companies (p185-194)
  14. Private Sector Reforms Trump Government Efforts (p195-206)

Appendix: 2010 Benefits at a Glance (p207-208)
About Serigraph (p209)


Healthcare “Syntopical” (part 1 of 15)

A “Syntopical” reading of the subject of healthcare means reviewing a category of books simultaneously, and extracting the key points from each, comparing and contrasting those points, and deriving a conclusion to the questions you had on the topic as a whole.

This review includes four books:

The Company That Solved Health Care
by: John Torinus

The Grassroots Health Care Revolution
by: John Torinus

The CEO’s Guide to Restoring the American Dream
by Dave Chase

Cracking Health Costs
by Tom Emerick and Al Lewis

The take on these four books is that the traditional healthcare system is broken, and there is a better way for companies to implement a program for their employees. Some of the thoughts and ideas come from the era before the Affordable Care Act (ACA / ObamaCare), but the approach and supporting methods have accelerated since the passing of that bill.

The main idea is that a Health Exchange that provides coverage for all individuals, regardless of health conditions, disproportionately benefits those with poor health conditions and burdens those with good health conditions. The idea is that companies can promote good health (sometimes called Wellness or Well-Being) for their employees, as well as adopting a consumer mindset that looks for high quality work at a reasonable price, thus reducing the utilization of overpriced and unlimited healthcare options, which will reduce the expense of healthcare on the employer.

In essence, the books above details ways for a company to move out of a high cost, low value program into a market driven (capitalistic) program in which the price and availability of products are based on quality and demand.

It is the intent of these authors to usher a new wave of healthcare, and the details illustrated in this Syntopical appear to be their first steps in a grassroots effort to fix healthcare.