Latest / Bill of Health / Your Hospital Bill Isn’t Final — Why You Should Negotiate It (Bill of Health Ep.4)

Transcript

Your Hospital Bill Isn’t Final — Why You Should Negotiate It (Bill of Health Ep.4) · Bill of Health

• 0:00
  As an employee of a company or as a self-employed individual, you have
• 0:05
  to re-enroll in your healthcare and benefits packages annually,
• 0:08
  and that's coming up pretty soon.
• 0:10
  The employee out there has probably received a 75-page PDF in an email
• 0:16
  with all of your options and a link to click on when you're ready to enroll.
• 0:20
  Oftentimes, you're really on your own because HR either can't or
• 0:23
  won't be of much help to you, right?
• 0:25
  If you're self-employed or working for a company without health insurance
• 0:28
  benefit, you might be navigating the marketplace, and doing that feels
• 0:32
  like a terribly complicated chore.
• 0:35
  Maybe you have help, but most likely you're on your own as well.
• 0:38
  Frustration builds.
• 0:40
  It's always, always, always more expensive year after year.
• 0:43
  The coverage options seem worse from the employee's perspective,
• 0:47
  from the self-employed viewpoint.
• 0:49
  This feels like an expensive scam.
• 0:52
  I know you've been there because I've been there as well.
• 0:55
  But there's also another party in this story who needs to be understood.
• 0:59
  They're oftentimes just as confused, just as mystified, and just as frustrated.
• 1:03
  And that, my friends, is the employer.
• 1:14
  Welcome back to The Bill of Health, my friends.
• 1:16
  I am your host, Bill Feigh, the health insurance guy.
• 1:18
  Today, I wanna spend just a little time talking about health insurance
• 1:21
  perspectives from all sides, from the consumer, the insured, the
• 1:26
  employer, the self-insured, everybody.
• 1:28
  Everybody has a story, everybody has a place here, and I
• 1:30
  wanna understand it better.
• 1:31
  I think it will help us all become smarter and better healthcare consumers
• 1:35
  if we know just a little bit about what each other's going through,
• 1:37
  and actually, what's at stake.
• 1:39
  Now, this podcast was put together to help individuals become
• 1:42
  smarter healthcare consumers.
• 1:44
  However, we tend to forget that employers are consumers as well.
• 1:48
  Trying to attract and retain quality staff and having a quality benefits package is
• 1:51
  becoming more and more an impossible task.
• 1:54
  There's insurance complexities, confusing markets, increasing costs
• 1:58
  for both the employer and the employee.
• 2:01
  So I thought it would be good to dive into some perspectives from all of those sides
• 2:06
  And I have a little quick story here.
• 2:08
  I've always been client-facing.
• 2:10
  What does that mean?
• 2:11
  That means I'm across the table from the employer or the employee helping
• 2:15
  them make tough decisions, and one non-negotiable for me is that I
• 2:20
  absolutely insist on making sure the people helping me bring that proposal to
• 2:23
  life are the smartest, most ethical, and the most trustworthy that I can find.
• 2:28
  So consequently, I love, love, love talking to smart people,
• 2:32
  and we have someone with us that fits the bill nicely today.
• 2:35
  We have Lynn Carter with us.
• 2:37
  Lynn is Vice President of GetAdvocacy at Health Admins.
• 2:41
  Over her career, she's worked on nearly every side of healthcare.
• 2:46
  She's been a hospital leader, she's been an insurer, she's worked with third-party
• 2:50
  administrators and an employer advisor.
• 2:53
  She's led teams, she's negotiated major contracts, she's helped build programs
• 2:56
  from the ground up that have saved employers and patients real, real money.
• 3:01
  Lynn holds a Master of Public Health from Michigan State.
• 3:04
  Go Spartans.
• 3:04
  Outside of work, she's happily married, a mother of two, and a sheep farmer.
• 3:10
  I would love to delve a little bit more into the sheep farming, but
• 3:12
  I'm not sure we have time for that.
• 3:15
  That is really interesting to me . But GetAdvocacy is an organization that's
• 3:20
  dedicated to navigating healthcare for consumers and for businesses as well.
• 3:25
  And most importantly, and not most importantly, one of the things they do
• 3:27
  is negotiating medical bills, and on The Bill of Health, we've talked about
• 3:30
  that before, how important it is to look at those bills and to make sure
• 3:34
  that there's not errors and mistakes and things that can help us save a lot of
• 3:37
  money, and that's what Lynn is doing.
• 3:39
  So who better to help us tackle this subject than Lynn?
• 3:42
  Lynn Carter, welcome to The Bill of Health.
• 3:45
  Thanks for having me on.
• 3:46
  So glad to have you.
• 3:47
  We're gonna dive right in here, Lynn.
• 3:48
  A couple of weeks ago we were having a conversation, and you said something that
• 3:51
  was really, really interesting to me.
• 3:53
  In the course of your career, you have basically seen how a dollar flows
• 3:58
  through the system from start to finish.
• 4:01
  And to make a coarse analogy, you've seen how the sausage is made, and that's
• 4:05
  not perspective that a lot of us have.
• 4:07
  I don't have that, my clients don't have that, and I think this is really
• 4:10
  valuable, and I'd love to get your feedback and love to have you tell
• 4:13
  us some stories, maybe provide some insights that we don't normally get not
• 4:17
  having had the experience that you have.
• 4:19
  Think you can help us with that?
• 4:20
  100%. So I feel from my perspective that a lot of people focus on
• 4:25
  healthcare from one side of the house.
• 4:27
  So people can be career hospitalists or career payers.
• 4:32
  But to have somebody sit on different sides of the table brings an immense
• 4:35
  value because of the fact that not only is there empathy, but you also understand
• 4:39
  how the systems are fitting together, both directly as well as on the fringes.
• 4:43
  When I was 18 years old, my grandfather was on his deathbed, and he looked at me
• 4:49
  and he said, "Man, this system is broken.
• 4:52
  I think you should fix that." Now, I'm 18 years old, so I don't know
• 4:56
  exactly what that means, but I said, "Okay, Grandpa, um, sure, I'll work
• 4:58
  on that right after lunch," right?
• 5:00
  Like, what do you do there?
• 5:01
  But fortunately, one of the first organizations I was an
• 5:04
  intern with was an organization dedicated to Certificate of Need.
• 5:08
  And for those of you at home that don't know what this process is, it's an
• 5:10
  approval process to make sure that the right amount of resources are going
• 5:15
  into the right places in the community.
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  And what that means is we don't just want the biggest hospital on the hill
• 5:21
  to get a bunch of cardiac units, and nobody else can get cardiac units.
• 5:25
  We wanna be able to spread that out geographically so that folks way out in
• 5:28
  the country can get cardiac care as well.
• 5:30
  So it taught me a lot more about not only the political lines, but
• 5:34
  also the legislative strategy around healthcare, which was very interesting.
• 5:38
  From there, I was- Yeah … recruited to one of my board of directors,
• 5:41
  which was a community health plan, which was also a TPA.
• 5:44
  I learned how to adjudicate claims, how not to adjudicate claims, and
• 5:49
  how to build good benefit design.
• 5:51
  I was recruited from there to work for a benefits consulting agency, i.e. a
• 5:55
  broker, as a strategist and an analyst.
• 5:58
  So back then, I didn't realize it was actuarial work, but we were looking
• 6:02
  at claims from the pharmacy, from medical, from biometric screenings,
• 6:07
  other forms of data, and I was creating projections of risk.
• 6:10
  I was pulling in the right vendors.
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  I
• 6:13
  staved the bleeding.
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  I was engaging with these employers in a way that they were willing
• 6:16
  to understand by using data to drive those conversations.
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  And this is back, I don't know, 12 years ago, before this was as much
• 6:23
  of common practice as it is today.
• 6:25
  Had a lot of fun, had a lot of golf outings, had a lot of catered lunches,
• 6:29
  but ultimately, I felt I wanted to do something bigger within the
• 6:33
  four walls of the hospital system.
• 6:35
  I called up my buddies at Trinity Health, and they said, "Hey, we're
• 6:37
  starting to build this direct contracting program with our employers.
• 6:41
  We're calling it Employer Health Solutions, and it's starting here in
• 6:44
  West Michigan, and it's gonna be growing out, hopefully, across the state soon.
• 6:48
  We would love to have somebody come and lead this program." And that
• 6:51
  was my first entry into the four walls of a large hospital system.
• 6:55
  In this ecosystem, I learned more about care management, how to engage with
• 7:00
  people from a navigation perspective, meeting people where they're at,
• 7:03
  redirecting care, not 'cause of dollars, but because of what makes most sense
• 7:07
  for the member, and wrapping around the right human element to redirect
• 7:10
  that member in ways that make sense.
• 7:12
  It was a ton of fun, negotiated a ton of contracts.
• 7:15
  Ended up, yes, growing it across the state, and eventually
• 7:17
  went to take it national.
• 7:19
  From there, my VP, who I loved and adored, said, "My life's goal has been to work
• 7:24
  in Medicaid." You should come." And I said, "You know, I don't know anything
• 7:28
  about Medicaid." She said, "It's okay.
• 7:30
  You're gonna be the director of provider contracting." I said, "I
• 7:32
  don't know anything about provider contracting, not from the payer side."
• 7:35
  They're like, "You'll figure it out.
• 7:36
  We're gonna do this together." Come to find out, in my perspective, I think
• 7:39
  managed Medicaid sometimes has a lot of you'll figure it out mixed into it.
• 7:44
  Learned a lot about value-based care contracting, about the shenanigans
• 7:48
  from inside of a payer, and how those interact with the shenanigans
• 7:51
  from inside of a provider.
• 7:53
  It was a lot, immense amount of work and really good people in that space.
• 7:57
  But I'll be real with you, working 65, 70-hour weeks with
• 8:00
  two young kids just wasn't my bag.
• 8:02
  And when I was recruited- Mm-hmm … to work for Tendo, which
• 8:04
  we'll talk about more in a second, which was a bundled care platform.
• 8:08
  Mm-hmm.
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  It was for the first time in my life I could see national contracts,
• 8:11
  completely transparent, all laid out for both the consumer, MDsave, as well
• 8:17
  as for employers on Tendo Care Connect.
• 8:20
  And the idea of having fully transparent contracts that are
• 8:23
  cost-contained blew my mind.
• 8:25
  I had lived within the hospital space, I had lived within the payer
• 8:28
  space, and both of them have these, like, funny money games, which we'll
• 8:31
  talk about more in a few questions.
• 8:33
  So being able to see that dollar flow from this, like, weird confined,
• 8:38
  in a dark space, in an antiquated contract from 75 years ago with
• 8:41
  15 addendums into this light of a bundled space I thought was fantastic.
• 8:46
  I ended up working for a stop loss industry data vendor, so understanding
• 8:52
  the super high dollar claims and how those can become inflated, whether that's
• 8:56
  implant costs, really bad negotiations, or just duplicate line items.
• 9:02
  Those things happen.
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  Mm-hmm.
• 9:03
  And figuring out how to negotiate both sides of that.
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  And now I'm very happy to have landed exactly where I am now in care navigation.
• 9:11
  I bring all this up to say a dollar touches each one of those components
• 9:15
  at some point in the self-funded and in the consumer healthcare system.
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  And if we don't understand how that dollar is jumping from each company, then we
• 9:24
  don't understand how our $1 gets chewed up to pennies within a matter of months.
• 9:29
  And I think it's important for folks to keep as close as they can to
• 9:32
  transparent care shopped well, and that's why I'm at Good Advocacy.
• 9:38
  That's awesome.
• 9:39
  Well, one of the mantras that we have here is shop smart,
• 9:41
  and obviously you're prepared.
• 9:43
  You're part of that program, part of that process, which
• 9:45
  is gonna be critical for us.
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  Just a couple of just definitions for us and for some of the
• 9:49
  folks that are listening.
• 9:50
  You've talked about payers quite a bit.
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  Define a payer for me.
• 9:53
  Insurance company.
• 9:55
  Insurance company.
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  Okay.
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  Now, there's different types of payers.
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  There are payers that are focused on Medicare and Medicaid.
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  There are payers that are strictly in the commercial space, and when I say
• 10:03
  commercial, I'm thinking, like, the BUCAHS, Blue Cross, United, Cigna, Aetna.
• 10:08
  Yeah.
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  Anybody who's paying claims.
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  And now I'm gonna have to start saying Buca.
• 10:13
  I like that.
• 10:13
  Thank you.
• 10:14
  No problem.
• 10:15
  Well, folks, I told you, I told you I love talking to smart people.
• 10:18
  We could talk all day.
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  Unfortunately, I try to keep the podcast to a manageable bite-sized chunks,
• 10:22
  and I just have so many questions.
• 10:24
  And as she was talking, I'm thinking about 15 different questions I wanna ask her.
• 10:28
  Lynn, my audience is primarily made up of employees and consumers looking to
• 10:32
  navigate their benefits packages, right?
• 10:34
  Looking to navigate their insurance From all sides that you've just talked
• 10:39
  about there, what is one of the biggest disconnects you see between how companies
• 10:42
  put, or brokers even, put healthcare plans together versus how employees
• 10:46
  actually experience them or use them?
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  Can you provide some insights there?
• 10:50
  100%. There has never been a better time in today's world to find cost
• 10:55
  containment vendors to support high-cost parts of your health plan.
• 11:00
  Whether you're a smaller employer and you're fully insured, or a larger
• 11:03
  employer and self-funded, there is a vendor out there to suit the problems
• 11:07
  that's causing you money, right?
• 11:09
  However, some brokers can plug in the best vendor stack in the world to support
• 11:13
  their members to get the care that they need, but if people don't know about
• 11:17
  it, you're just throwing money away.
• 11:20
  And I firmly believe that the best-made health plans have some form of
• 11:24
  connector that sit in the middle that connect the member to those resources.
• 11:28
  And in some small companies, that's gonna be HR. They're gonna reach out to HR,
• 11:31
  "Hey, you know, I've been having trouble at home." They're gonna connect you with
• 11:34
  your EAP, employee assistance program.
• 11:37
  That's cool.
• 11:38
  However, in a lot of situations, you're gonna have to outsource that time 'cause
• 11:41
  you don't wanna cut somebody short, and that's where navigation comes into play.
• 11:45
  So the biggest difference that I see right now between these well-made plans
• 11:49
  and these plans that are well-made but they're not performing, is how
• 11:52
  you're connecting the end user, that employee, to the benefits that you're
• 11:56
  giving them at open enrollment.
• 11:58
  Okay.
• 11:59
  Okay.
• 12:00
  That's interesting.
• 12:01
  Having worked at companies with rather large footprints before, had benefits
• 12:06
  packages with multiple pieces to it, to me, it was always the HR team
• 12:11
  that was the quarterback of that.
• 12:13
  But now what you're saying is that there are firms that are helping to drive
• 12:17
  that and helping to connect more, maybe even, I don't wanna say advertise it
• 12:20
  from a PR perspective, or at least make people aware of it, but are actually
• 12:23
  quarterbacking that versus the HR team.
• 12:26
  100%. And each of these sorts of navigation companies all have a
• 12:29
  different flavor, and it's, to me, it's the spectrum of how much AI
• 12:32
  you want injected into the mix.
• 12:34
  So if you want a lot of automation, but you can serve hundreds of
• 12:38
  thousands of people, great.
• 12:39
  There is a navigator for that.
• 12:40
  If you want real human boots on the ground, there's navigators for that.
• 12:44
  And what matters most is that you're picking a navigator that suits the
• 12:48
  culture of the folks on your team.
• 12:50
  I'm gonna go off-script here just for a second, off the ranch here just for
• 12:53
  a second, but those firms, those cost containment vendors, those firms that
• 12:57
  can help with that, is that something that the broker would plug in?
• 13:00
  The employer would plug in?
• 13:02
  Who's finding those vendors?
• 13:03
  Typically speaking, brokers are gonna have a lot more insight as to the right
• 13:08
  navigator choice because they've met with these folks either at conferences
• 13:11
  or at various different Skype calls.
• 13:13
  Skype calls, I just threw us back there.
• 13:15
  But sometimes some employers are pretty engaged.
• 13:17
  IFEB, International Federation of Employee Benefits, a lot of employers go to that
• 13:22
  conference where they get introduced to a lot of vendors, like navigators as well.
• 13:27
  But generally speaking, a broker is gonna be a great resource for aligning
• 13:30
  the right navigator to that employer.
• 13:32
  So for my employees out there who may not have had any exposure to this, when
• 13:36
  they're putting your health plan together for the coming year, you've got a broker
• 13:40
  working with the employer, and that employer and that broker, they're putting
• 13:44
  together these individual component pieces into this package that you see right now.
• 13:49
  Like, you've gotten your 75-page PDF that you just had emailed to you.
• 13:53
  And so one of those pieces, more and more it sounds like, are gonna
• 13:56
  be those cost containment vendors.
• 13:57
  I love that.
• 13:58
  I love it Here's a big one, and Lynn, it's something that is pervasive
• 14:03
  and ongoing, and many people say that, "Hey, the system is broken.
• 14:07
  We can't do this any longer.
• 14:08
  There has to be a change.
• 14:09
  There has to be a disruptor." But business owners are in a constant,
• 14:13
  constant battle between rising insurance premiums and trying to be competitive
• 14:17
  with the benefits package that they offer.
• 14:19
  How does your work with bill negotiation and healthcare navigation, how does
• 14:24
  it lower the cost for the employer without just shifting burden maybe
• 14:27
  to the employees to be smarter?
• 14:30
  You say shifting burden, I just immediately hear high
• 14:33
  deductible health plans.
• 14:34
  Is that what we're referencing today?
• 14:35
  Ah, is that what we're referencing today?
• 14:37
  Yeah.
• 14:38
  So we've already referenced how navigation brings everybody together.
• 14:40
  It's helping use the stuff that you're already spending your money
• 14:44
  on as an employer, as a broker, to pull this plan together.
• 14:47
  So we've already discussed how navigation is really lowering the costs,
• 14:51
  maximizing that surgical carve-out that you know is gonna save you 60%
• 14:55
  of your spend on musculoskeletal.
• 14:57
  Well, now people actually know about it.
• 14:58
  So that's one side.
• 14:59
  So I'm gonna focus instead on the bill negotiation side.
• 15:04
  In the network bound world, i.e.
• 15:07
  you carry a Blue Cross card or an Aetna card, you can only
• 15:10
  negotiate out of network claims.
• 15:12
  Anything bound by a contract, negotiators can't really touch, or
• 15:15
  at least they're not supposed to, and I'm a sucker for good rules.
• 15:19
  So we really keep it within the confines of what we can negotiate there.
• 15:22
  And if you're familiar with out of network claims, there's nothing a hospital
• 15:26
  loves better than someone vacationing in their state and being out of network,
• 15:30
  because they can charge pretty pennies.
• 15:32
  It's true.
• 15:33
  That's where our team can come in, where we do negotiate on
• 15:35
  average about a 55% discount.
• 15:37
  However though, there's a huge outcrop of whether it's health
• 15:41
  shares, alternative health markets, association health plans, individual
• 15:46
  plans that are popping up especially in the last, I'd say, like 12 to 24
• 15:52
  months, where it's non-network based.
• 15:54
  And as long as I'm not bound by a network, I can negotiate all day long.
• 15:58
  And so we work- Yeah … with a lot of these alternative health plans, especially
• 16:01
  health shares, where people are submitting bills to us all the time, and we can go in
• 16:06
  and negotiate some really steep discounts.
• 16:08
  So the cash pay world, again, that transparent world, you
• 16:11
  can negotiate all day long.
• 16:13
  It's that network bound world where we have a little bit more limitations.
• 16:17
  But in both situations, we're reducing the cost, and we're doing
• 16:20
  it on behalf of the employee, not at the expense of the employee.
• 16:24
  That's a huge disconnect for me right there, because I don't think clients
• 16:27
  realize, and we've talked about it in other episodes, that you go in for an
• 16:31
  auto accident and you have a broken pelvis The chargemaster rate, whatever that
• 16:36
  hospital charges you, that's the sticker price, the same sticker price you see on
• 16:39
  an automobile at the dealership floor.
• 16:40
  They don't understand that there's even negotiations that take place
• 16:43
  on what they're going to pay for that orthopedist, what they're
• 16:46
  gonna pay for the anesthesiologist.
• 16:47
  They don't understand that's not the rate you're going to pay.
• 16:50
  And heaven forbid you're a cash pay patient or utilizing one of those
• 16:54
  alternatives that you talked about, which we're gonna sneak a question in about
• 16:56
  health shares here in just a second.
• 16:58
  They don't understand that everything is negotiable.
• 17:00
  And now maybe not as much in more of a rigid network model,
• 17:03
  but certainly in the alternative world, everything is negotiable.
• 17:05
  I don't think people really think when they see that hospital
• 17:08
  bill, they feel like, "Ah- I'm just stuck there, don't they?
• 17:12
  I think it's particularly predatory as well because you're getting this
• 17:16
  hospital bill because you're sick, you're vulnerable, you're healing, you're
• 17:19
  in a different place than you would normally be, and you don't know- Hmm
• 17:23
  what you can and cannot negotiate.
• 17:24
  How many times have you walked up to some sort of market and you're
• 17:27
  like, "Is this the kind of market I can negotiate with," right?
• 17:30
  I-
• 17:31
  right You wouldn't think you can walk into a vaulted ceilings, perhaps a
• 17:35
  fountain in the lobby place with white coats and think you can negotiate.
• 17:39
  It's a cultural disconnect.
• 17:40
  Yeah.
• 17:40
  So I totally hear you, but this is our message to the American
• 17:43
  public, you can negotiate and do it.
• 17:46
  And we're gonna be providing more and more resources here on the pod for that because
• 17:49
  I just think it's gotta be a bigger part of what we do as consumers, as employees.
• 17:54
  It has to be.
• 17:55
  You mentioned an alternative model that you've seen an uptick on, and the data
• 17:58
  would support that even though it's a much smaller component, but we're talking about
• 18:01
  cash pay models or health shares, right?
• 18:04
  Why, in your opinion, are they gaining traction?
• 18:06
  What's appealing about them?
• 18:07
  If not appealing, we're not trying to sell anything here, but what's
• 18:10
  appealing about that model, and tell me why they're gaining traction.
• 18:14
  Sure.
• 18:14
  So I do wanna do a quick subdivide.
• 18:17
  Health shares and cash pay aren't necessarily the same.
• 18:19
  They do fall- Yeah … into a similar bucket, but they're
• 18:21
  not necessarily the same.
• 18:23
  And I'm gonna focus on- Yep … cash pay just for a quick second.
• 18:26
  'Cause health shares- Mm … I do wanna address that.
• 18:28
  Cash pay is important because for the first time ever, we're starting to
• 18:31
  see what something actually costs.
• 18:33
  And what I mean by that is for most people- Yeah … they assume, like
• 18:37
  you said, the cost that you get is the cost that it actually costs.
• 18:41
  But what if I told you that not unlike Black Friday TV sales,
• 18:46
  the- … hospital will jack up the chargemaster so they can give Blue Cross
• 18:50
  Blue Shield that hefty 65% discount?
• 18:54
  Well, the reality is they're just moving their chargemasters here and there so
• 18:58
  they can give discounts to make the payers feel really happy about it.
• 19:01
  Again-
• 19:02
  Yep
• 19:02
  … it's like, whose line is it anyway?
• 19:04
  You know, the game is made up and the points don't matter.
• 19:07
  So when we- But
• 19:07
  the points don't matter, yeah.
• 19:08
  Exactly.
• 19:09
  So when we move into this concept of cash pay, especially if you can bounce
• 19:13
  it up against some reference that is an equalizer, and I say percentage-
• 19:17
  Hmm … of Medicare because to me, I think that is the easiest equalizer to
• 19:20
  use, apples to apples, for what the true value of something should be, right?
• 19:26
  And so- Yeah … that's why the cash pay world is becoming more popular.
• 19:29
  That said, there's never been more opportunities for entry into the cash
• 19:33
  pay market than there is right now.
• 19:35
  I was gonna reference it later in today's bit, but if you're a small employer
• 19:39
  or an individual, there are places that you can shop and get engaged with
• 19:42
  an orthopedist or a cardiac surgeon or whatever in a cash pay model with
• 19:47
  Health Me, MD Save, Fair Market Health.
• 19:50
  Those all three have a consumer component where you can just go and buy it.
• 19:54
  Yeah.
• 19:54
  As an employer, you can have corporate partnerships with Tendo Care Connect,
• 19:58
  with Coral, with, you know, Savos.
• 20:00
  There's a number of those out there that allow you direct access to
• 20:05
  cash pay without having to strike direct contracts all on your own.
• 20:09
  We're finally getting closer to the true value of that dollar
• 20:12
  I love that.
• 20:13
  Maybe one last time, you said you broke it out into the components
• 20:16
  of cash pay versus health share.
• 20:17
  Oh.
• 20:17
  Let's address health shares really quick.
• 20:19
  Health shares are getting very popular, especially in the
• 20:21
  last, like, eight to 10 months.
• 20:23
  They're growing- Hmm … like crazy right now, and there's for a few reasons why.
• 20:26
  Number one, what is more expensive now than it ever has been?
• 20:29
  ACA premiums.
• 20:31
  And I'm gonna give you my own little theory.
• 20:33
  You can cut this out a bit if you'd like to.
• 20:35
  What ended up happening is as all of the Medicaid expansions started to get peeled
• 20:41
  back away post-COVID, you've got all these people that were functionally- Yes
• 20:44
  being paid for by our federal government now having to go and seek
• 20:48
  individual care on the ACA marketplace.
• 20:51
  But were they really good- Right … quality risk?
• 20:54
  No.
• 20:54
  We have a lot of people who absolutely need care jumping onto the ACA
• 20:58
  marketplace, which makes the risk pool become more and more risky.
• 21:03
  And what I mean by that is in risk, if you can skip health insurance and not pay
• 21:07
  for it anymore, then you probably will.
• 21:09
  But if you have uncontrolled diabetes, if you have significant heart concerns,
• 21:13
  if you're a cancer patient, you can't just not have insurance now that your
• 21:17
  Medicaid, expanded Medicaid is taken away.
• 21:19
  So they're jumping onto the ACA.
• 21:21
  Well, what happens to the ACA risk pool as a spiral?
• 21:24
  Now we've got folks- Yeah
• 21:25
  insurers, whole insurance companies leaving the ACA marketplace.
• 21:30
  And in doing that- Right … we've got an increased risk which, when you
• 21:33
  have more risk, your premiums go up.
• 21:36
  Right.
• 21:36
  So now that we've got these relatively healthy but also very responsible
• 21:40
  people sitting on the marketplace, they don't wanna pay for that anymore.
• 21:43
  So a lot of them- Mm-hmm … as long as they don't have significant comorbidities,
• 21:46
  i.e., multiple chronic diseases, right?
• 21:49
  They don't have cancer.
• 21:50
  They're turning for lower cost alternatives that are going to help
• 21:54
  them take care of their day-to-day care, which is where health shares
• 21:57
  have jumped in to be a great support.
• 21:59
  On average, we see the demographics of a health share be between families, almost
• 22:03
  always families, and people just before marriage between the ages of 25 to 45
• 22:08
  and low chronic condition prevalence.
• 22:10
  Like, that is the typical folks.
• 22:12
  So they were on the ACA, and now they're hopping onto health shares
• 22:16
  as an opportunity to support that.
• 22:18
  Relatively healthy.
• 22:19
  They're sitting there with a bronze plan with a $7,500 deductible.
• 22:22
  They know they're never gonna hit that, and so they're looking
• 22:24
  for, you know, I'm a cash pay patient whether I wanna be or not.
• 22:27
  So what's the alternative here?
• 22:29
  And the alternative would be to potentially go with a health share.
• 22:32
  That's right.
• 22:33
  And to bundle that, this is not a commercial, just a statement, to bundle
• 22:37
  that with direct primary health care, which is where 85% of your health
• 22:41
  care is gonna take place anyway.
• 22:43
  We've talked about that.
• 22:44
  What is it?
• 22:44
  It's my one song.
• 22:45
  I've been singing it a lot.
• 22:48
  So yeah, that's great.
• 22:49
  Outstanding.
• 22:51
  I told you she was smart.
• 22:52
  I told you.
• 22:52
  You guys have to trust me here.
• 22:53
  All right.
• 22:54
  Now is the part of the program where we are gonna address the jargon jar.
• 22:57
  The jargon jar.
• 23:00
  We're gonna open up a confusing topic, something that's intentionally
• 23:04
  muddy, language of the insurance industry, and we're gonna
• 23:06
  translate it into plain English.
• 23:07
  We talked about it today.
• 23:09
  Miss Lynn has sat on that side of the house as well.
• 23:11
  It's a T TPA, third party administrator.
• 23:16
  What the heck is that?
• 23:17
  You know, a health plan isn't just a claims form.
• 23:19
  It requires provider networks, pharmacy benefit managers, stop-loss
• 23:23
  insurance, customer service portals, all of these things.
• 23:26
  It's a package we talked about earlier.
• 23:29
  The third party administrator's role is to act like a general contractor.
• 23:33
  They bundle and coordinate all of the moving parts, connecting the
• 23:36
  plan to preferred provider networks, integrating those drug benefits,
• 23:41
  setting up member service desks so employees have a single place to
• 23:45
  call when their ID card doesn't work.
• 23:47
  They are record keepers.
• 23:49
  They are quarterbacks.
• 23:50
  They kinda run the show, if you will, the administrative side of the
• 23:53
  show once a plan is put together.
• 23:55
  That is a third party administrator.
• 23:57
  If you ever hear the word TPA, you're gonna hear it outside of
• 24:00
  the insurance industry as well.
• 24:01
  You're certainly gonna hear it over there on your retirement plan side as well.
• 24:04
  So that's what a TPA is.
• 24:07
  That is the Jargon Jar.
• 24:09
  Ms. Lynn, we're running out of time, and now it's time for a surprise.
• 24:15
  Ladies and gentlemen, it is time for Five for Fighting Five for fighting.
• 24:20
  Lynn, I'm gonna ask you a series of five rapid-fire questions.
• 24:24
  Don't think, just answer, and these can be topics that people might
• 24:28
  wanna have a discussion about.
• 24:29
  Number one, Detroit-style, Chicago deep-dish, New York thin
• 24:35
  and foldable, St. Louis Provel.
• 24:37
  Lynn Carter, who has the best pizza?
• 24:40
  Chicago, hands down.
• 24:41
  Chicago, hands down, she said without even hesitation.
• 24:44
  Kansas City, North Carolina, Memphis, or Texas.
• 24:48
  Lynn Carter, who has the best barbecue, and why is the correct answer Kansas City?
• 24:54
  I beg to differ.
• 24:55
  It's Texas all day.
• 24:57
  Oh.
• 24:57
  I'm sorry.
• 24:58
  That's gonna- I'm sorry, I'm gonna tell you right now … that's
• 24:59
  gonna hurt … it's Texas all
• 25:00
  day … really.
• 25:00
  If you were sitting with every employer in this renewal season,
• 25:04
  what advice would you give them to help them drive the best value for
• 25:07
  both the employee and the employer?
• 25:09
  What advice would you give an employer?
• 25:11
  Direct contracts.
• 25:12
  Direct contracts all day.
• 25:14
  If you're big enough, knock on the door of your local hospital system
• 25:17
  and say, "Hey, if I send my folks to you, what kind of rates are you gonna
• 25:19
  give me?" And they will be happy to talk to you, and they will be happy to
• 25:22
  talk to you at a 20% to 40% discount.
• 25:25
  I think direct contracts are gonna be what everyone's talking about in 2027, 2028.
• 25:30
  And if you're not ready to go knock on doors, leverage some of those
• 25:32
  platforms that I referenced before that can help connect you to those
• 25:35
  direct contracts without the legwork.
• 25:37
  And beyond just direct contracting what they would charge for a broken leg
• 25:42
  or a treatment of some kind, they're also direct contracting with primary
• 25:46
  health entities as well, are they not, working directly with those folks?
• 25:50
  DPCs, or direct primary care, are definitely a big trend that's
• 25:53
  been moving in the last two years.
• 25:56
  Have you already talked about DPCs on the air?
• 25:57
  Not quite yet.
• 25:58
  We're going to.
• 25:59
  It's gonna be a big topic.
• 25:59
  Okay.
• 26:00
  We can return to that later, then.
• 26:01
  I won't eat up too much of your- Yes, ma'am … five for five here.
• 26:04
  All right, Lynn, how many sheep do you have, and what is the
• 26:07
  favorite name you've ever given one?
• 26:09
  Oh, no.
• 26:11
  So right now we only have five.
• 26:13
  I sold off 35 last year 'cause I just needed to downsize.
• 26:17
  Favorite name was Precious, and the reason why it's funny is because When
• 26:22
  Precious hopped into the freezer, all of the meat was labeled with Precious, and
• 26:26
  I get a tiny giggle every single time.
• 26:29
  So we have what we call the friendliness waiver, and if you are
• 26:32
  a super friendly sheep, you can live on my farm for as long as you want.
• 26:35
  The second you charge me from behind, you hop into the freezer.
• 26:39
  So Precious had his one solid hit, and now he's my burger.
• 26:44
  I see . Precious made you challenge your health insurance, and now
• 26:48
  Precious is in the free- oh, wow.
• 26:50
  Love that.
• 26:52
  Looking at trends in the industry, thinking back on your vast experience,
• 26:55
  Lynn, if employees were shopping for health insurance, what advice
• 26:58
  would you give the employees?
• 27:00
  What would you like for them to maybe stop and think about?
• 27:03
  Finances.
• 27:04
  Healthcare is all a question of finance.
• 27:07
  How much cash can you pull forward if something goes wrong?
• 27:10
  And make sure that your health plan is suited to the cashflow
• 27:13
  that you have in your day-to-day life so that you're not hit with an
• 27:15
  unexpected expense or bankruptcy.
• 27:18
  Oh, I love that.
• 27:20
  I love that.
• 27:21
  Lynn Carter, thank you so much.
• 27:22
  She was our special guest today.
• 27:24
  Folks, if you have questions for Lynn, if you have questions for us, I want
• 27:27
  you to send them in via the email.
• 27:29
  I'll forward them over to Lynn, and I know that she'd be happy to get those
• 27:32
  back to us and get them answered.
• 27:33
  I just love talking to smart people, Lynn.
• 27:35
  Thank you so much.
• 27:36
  You have expertise that's worth sharing, and I am so glad that
• 27:38
  you agreed to be on the program.
• 27:41
  If you are an employer or an employee and you've ever thought about shopping plans
• 27:45
  or for coverage or becoming a smarter healthcare consumer, be sure to follow
• 27:48
  along, TikTok and YouTube and Insta.
• 27:50
  It's Bill Fy, the Health Insurance Guy.
• 27:51
  Subscribe to the pod, and this is shameless self-promotion,
• 27:55
  so I'm sorry, but subscribe to the pod on Apple or Spotify.
• 27:58
  Give us a review.
• 27:59
  Love to have your thoughts.
• 28:00
  If I could personally help you explore your options, head on over
• 28:03
  to Core360BenefitsGroup.com and schedule a 30-minute consultation.
• 28:08
  Thank you, thank you, thank you for listening to The Bill of Health.
• 28:11
  Be smart, shop smart, and protect your wealth, and we will see you next time.
• 28:24
  This podcast is provided for educational purposes only and
• 28:26
  should not be considered legal, tax, investment, or insurance advice.
• 28:28
  Individual circumstances vary, and the listener should consult qualified
• 28:30
  professionals regarding their specific healthcare and financial situation.
• 28:32
  Opinions expressed are those of the host and guests and do not necessarily
• 28:34
  reflect the views of any insurance carrier or affiliated organization