June 12, 2023

Better Care, Lower Costs

Better Care, Lower Costs

It’s here! The 2023 We the Patients Fly-In is THIS WEEK and we have several Health Plan Hero Winners on the podcast to discuss their health insurance success stories as they get ready to accept their awards in person in Washington D.C. Plus, Terry...

It’s here! The 2023 We the Patients Fly-In is THIS WEEK and we have several Health Plan Hero Winners on the podcast to discuss their health insurance success stories as they get ready to accept their awards in person in Washington D.C.

Plus, Terry and Bob lay out all the policy priorities patients will be advocating for on Capitol Hill during the Fly-In, including reforms to PBMs, copay accumulator programs, and the QALY metric. 

Meet the 2023 Health Plan Hero Winners

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The views and opinions expressed herein are those of the guest(s)/ author(s) and do not reflect the official policy or position of Patients Rising, nor do the views and opinions stated on this show reflect the opinions of a guest’s current or previous employers.



Terry Wilcox  0:03  
It's here. This week our advocates are in DC for the 2023. We the patients fly in on this episode will cover what pro patient health policies will be advocating for on Capitol Hill. Plus, we'll talk with companies who are true healthcare disruptors. Our health plan Hero Award winners will also be with us in DC. And we hear from some of them today about how they are delivering better care at a lower cost for their employees. That's all up next. Welcome to the patients rising podcast. I'm your host, Terry Wilcox, CEO of patients rising. I'm joined by my co host, who is also joining us in DC this week, he Senator Bob. He's Senator Bob Goldberg, co founder the Center for medicine in the public interest. Senator Goldberg, who are you taking over for? Oh, well, Booker Menendez?

Bob Goldberg  0:58  
Well, listen, I first of all, I like it better than OB, which I guess did not test very well. Terry, listen, who has time for elections and amendments to the Constitution? You know, we've got a lot to talk about on the show. And Senator Bob is excited to be with you in the patient's rising community in DC this week. And for our advocates who couldn't join us this week in DC. Don't worry, we have you covered on today's show. Senator Bob Goldberg is with you every step of the way. Thank you. Thank you, America. Thank you and God bless. Oh, sorry. Sorry. Sorry, Terry. I was reading from the script.

Terry Wilcox  1:36  
Absolutely, Bob. And today's episode is one of my favorites. Because admittedly, a lot of topics we discuss are hard to hear, or they're sharing stories of negative situations. But today, we get to hear stories about some true healthcare successes.

Bob Goldberg  1:53  
Terry, you know, there's a lot of good news. In fact, good news comes in two episodes, because since we have so many health plan heroes this year. Today, we're going to highlight the first batch of this year's health plan heroes. And this designation was created by patients rising to recognize companies with health plans that expand access to care, while lowering costs for patients and also for the employers, it's really quite remarkable. And the fact that we have twice as many as we had last year, is a very good sign that changes in the works.

Terry Wilcox  2:26  
Well, it truly is a win win for everyone involved. So how is this possible, you're saving employees money, while at the same time giving them better coverage? seems too good to be true. And we will get to some of that in a minute. But the first step all of these companies took as they became self funded plans. They ditched the big name insurance carriers to fund and craft a plan unique to them and their employees. Drew Leatherberry
  is a benefits designer who helped to have our winners Fox Brothers Construction and Midwest carriers. He explains what these plans look like. self funding

Drew Leatherberry  3:03  
itself is not really that different, except for the fact that the employer is taking on more of the financial risk and obligation of paying for the medical bill, while also having much more control and flexibility with how they can set up their plan. And that oftentimes concerns the average plan member up front when they don't know anything different that their employer would somehow have more control. But what we have found is that employers who have control who want to do the right thing, oftentimes end up doing the right thing, much more so than an insurance entity because they have a direct relationship with their plan members. And so they want to do things like removing a deductible, where it makes sense or making the path to high quality, low cost care, very easy for a plan member or providing access to nurse navigation or partnering with high quality physicians and making all services at those physicians clinics available at no cost.

Bob Goldberg  4:08  
But as you can imagine, Drew says an employer taking on more financial risk and that can sound and actually be scary. So John Schneider, the chief of the Westfield Fire Department in Missouri, another health plan hero said the debt fear went through his head when they thought about making the switch.

John Schneider  4:26  
I think there was a very big fear from our benefits committee, which was made up of my assistant chief and myself and then three to four labor reps. We all felt like this was unknown territory, we're going to be dragging not only our 64 employees, but their spouses and families to something that none of us had ever navigated before. So there was that fear of jumping. But after the fifth or sixth renewal, in double digits, we knew like we were scared We're scared to stay where we were at. So we had to make a move. And I think that within a month, we were very comfortable. Once we started getting feedback from our heavy users that things were going well, and things were okay, and just getting people used to a new way of doing things.

Bob Goldberg  5:22  
This is how doing it yourself can work to the company's benefit and employees benefit. By eliminating all the denials and all the coverage and discouraging the access to follow up care, which is sometimes more cost effective and actually can reduce long term costs, the company's premiums can actually fall.

Terry Wilcox  5:41  
Well. And absolutely, I think that there's a real wide berth of what's going on in the self funded plan movement. But I always defend the employers, even if their plan is in particularly when I'm on board with that there are some that are different. A lot of the ones that we looked at here are not, they are really taking care of their employees. But I have to tell you, it is scary. But in a lot of ways they've had no choice. But to go down this road, because standard insurance is very opaque, you don't really know what you're paying for. So how does this actually work? How do companies and their employees save money while getting better coverage? Now? Here's Drew, again,

Drew Leatherberry  6:20  
I think the answer is obviously a very complex one. But simplistically, I would say, the major difference is that one, you get access to data, data that allows you to make more informed decision as the buyer of healthcare and the buyer is really the employer. Many people use the term payer when they're referring to an insurance company, an insurance carrier. But the reality is, the payer is ultimately the employer, the employers in this country are funding the majority of the cost in one way, shape, or form. So access into data so that you can make good purchasing decisions, and to actually taking apart the box that is insurance, and looking at the components there in that drive the cost of health care. And then ultimately, just like any supply chain management process, an employer is able to go through and look at the links in the chain and say, You know what, it doesn't really make sense for us to buy insurance from an entity that is going to take anywhere from 30 to 60% of the net cost of drugs and put it in their own pocket when they're not dispensing your manufacturing drug and, of course referencing many pharmacy benefit managers in the marketplace.

Terry Wilcox  7:33  
Now on top of data, which is so important, as you know, Bob, yes. Mike Andrade, CEO of maverick benefit advisors, says that a hands on approach to health plans involves much more like nurse navigators to help patients find the best care. Mike is the adviser to winner to pray logistics, and explains how these plans are different.

Mike Andrade  7:56  
Depending on the client, where they're at right now, in there wanting to shift. Still having a traditional plan isn't it's not a bad thing. It's just more how do we equip people, if that's the place where they're going to be having their health care paid for? What can we do to help patients navigate within that system, then so many times I couldn't be access to a nurse navigator that will help to point people in the direction of quality first. And that also could be when something happens like a hospital bill or any type of bill that we think is done unfairly. What resources do we give to the patients so that any program that's available, whether it be some type of advocacy program through patients rising, whether it be something through another source? How do we give them information so that they can properly get either access to charity like programs or people that help like to help you dispute a bill. And so I still use traditional health insurance programs that my outcome is to say, Okay, let me see how I can help you when you're sick to go to the right place for you. 

Bob Goldberg  9:09  
Yeah, well, listen, what's happening is that the navigation is unitary with the patient's rising navigation services, that getting people from point A to point B is sometimes the biggest cost. And what I mean by that is not out of pocket, but it's the delay is the confusion. It's the inability to fight for a stupid denial of coverage, which takes hours. So this isn't, oh, wouldn't it be nice. This is working as we speak. And Stacie Harrell, who's human resource director at Cosmos Corporation, tells us how their switches gone.

Stacie Harrell,  9:47  
Before we switched, we had a Health Reimbursement plan for the employees so they were only responsible for their first $1,000 deductible and then we reimbursed $5,000 We had a high deductible plan so we could keep the premiums down for our employees. So it was a disaster to keep track of for the employee, they had to always have their explanation of benefits. Some of their bills would not come in for a year later. But the HRA plan that we did not design, you had to submit everything 90 days, within the time that you went to the doctor, it was just, it was very hard for the employees to understand. So when we made the switch, we were able to get rid of the HRA. And now our employees go to the doctor for free. They don't have to pay a copay, there's no deductible. And none of them have received a bill. Not a single person has received a bill.

Terry Wilcox  10:51  
It's absolutely amazing when you hear these stories, because I can't tell you how many times have we heard speeches about everybody needs a high deductible plan with an HSA and we're gonna sell plans across state lines, and we're gonna, we're gonna do this, right? Yeah, yeah. So there is a personal side to all of this that we're talking about as well, which we always like to highlight. Jen Metzger actually works at Cosmos corporation with Stacey and Jen's daughter lives with a rare genetic condition that requires her to attend a therapeutic school. And when Cosmo switched their health plan, the school services were supposed to be covered. And there were some hiccups in getting this coverage ironed out. But it was the personal hands on approach of cosmos and simple IRA, the company's benefits advisor that made all the difference. Now here's Jen story.

Jen Metzger  11:39  
On the first day of the switch, I got a call from her school saying things were not worked out yet. And Jessa wouldn't be able to attend. I guess technically, I got a call the day before the switch and said Jessa can't attend school tomorrow. And she can't until everything is approved. This could take weeks, it could take months. And for a little girl who thrives on routine. I was panicking as her mama. And so I went into Stacy's office crying. You know, she got some power looped in right away. I got the school connected with them. And they worked all day, I was getting calls and messages from some Parra. And even beyond five o'clock until they had it worked out that day. And so just I could attend school the next day, which was huge, the fact that they were easily reachable, responding right away, going above and beyond to work it out. And then not only that, that evening, I got a text from Adam saying what does your daughter like, we're sending you dinner. And they did they sent us pizza and salad and breadsticks and dessert, and just really over and above. And we have gone through a lot with Jessa with insurance since her diagnosis, which we got at 21 months. And never have I had that kind of service, that kind of response, that kind of care. And then obviously no one from an insurance company had ever bought us dinner before. And so it was just an incredibly positive experience.

Terry Wilcox  13:18  
Now, Bob, this is really above and beyond, I mean therapeutic, you know, needs at a school, she wasn't gonna be able to start school. I mean, would UnitedHealthcare jump through hoops for you for that? I don't know,

Bob Goldberg  13:30  
this is what happens when people who care get put in charge of the health care coverage of their workers and their families and their neighbors. So it's just, this is all possible,

Terry Wilcox  13:44  
right. And the number one thing you see in all these plans across the board, less pain from the patient. It's always a win win. And navigation. I would argue that navigation, especially for those patients who use their health care every month, who live with some sort of chronic condition, who aren't just going to annual wellness visits and getting a couple of colds and getting some antibiotics or whatever every year, but they're really using their health care. This is so important.

Bob Goldberg  14:15  
This is just part one of our health plan heroes focus episode. So we're going to have another one which highlights other businesses and employee success stories in just a couple of weeks.

Terry Wilcox  14:27  
That's right. So thank you so much to all those who joined us today. And a reminder that during the patient's rising now we the patients fly in, we will be honoring all of these amazing businesses in Washington DC. They're a prime example of health care done right. And we're thrilled that they could join us today. More information on all the winners can be found in the show notes.

Terry Wilcox  14:56  
This episode of the nation's rising podcast is brought to you by the patients Rising helpline. If you need help with an issue or problem, or anything related to you getting care, our team is here for you. And we want to help. 1000s of patients have worked with our staff of patient navigators over the years. This has allowed us to narrow down the best local, state and federal health care resources to solve your biggest challenges. There are a number of issues we can help with. But just a few include transportation, food or housing insecurity, overcoming insurance, obstacles, and so much more. For you to get help, all you have to do is leave us a voicemail, or send us an email using the link in the show notes.

Bob Goldberg  15:43  
Now let's get to more of what's happening at the We the patient's fly in patients, caregivers, advocates, from the patient's rising community are heading to Capitol Hill to meet with lawmakers about several policy priorities that are really important to folks living with chronic illness.

Terry Wilcox  16:02  
That's right, Bob. And those main issues are drumroll PBMs, the qaly and copay accumulator programs. So, Bob, we had more than 100 people register for our flying.

Bob Goldberg  16:21  
Because Senator Bob is going to be there right? No, it's because the last flying was great, great word of mouth. And there's more to do.

Terry Wilcox  16:33  
Our asks this year are a few one is very important, as we've talked about it a lot, which is support the protecting health care for all patients act of 2023. It's what we call the qaly ban bill, the drug price transparency and Medicaid act, it makes a pass through pricing model required for PBMs and Medicaid. Very important. The protecting patients against PBM abuses Act prohibits patient steering to financially aligned entities and the PBM sunshine and Accountability Act for PBM operating and commercial health care. Now this one strengthens reporting requirements for PBMs and the total amount they receive in rebates, administrative fees, and clawbacks from pharmacies. And finally, last but not least, help ensure lower patient co pays act. This requires health insurance plans to apply certain payments made by an enrollee toward a planned cost sharing requirements. So there you have it. It's a lot of PBM. Because this is Bob, I have to say, Don't you believe this is the PBM is moment on Capitol Hill. I mean, they are well,

Bob Goldberg  17:45  
it's only taken us. When did we start beating up on this important issue is probably 2016. So yeah, it's time it's finally

Terry Wilcox  17:55  
here. It's finally here. They're having their moment. Yeah. So while we're up there on the hill, talking about P VMs. We're also going to be mentioning a little bit about V VMs. And VMs. We've talked about on the show before folks, it's the vision benefit managers, and how that vertical integration drives up costs in the vision space, something that a lot of us use. Vertical integration is also the problem over on the PBM side. So we really like to look at the benefit manager space in its totality. And talk about that because that sort of middleman space is really driving costs in healthcare and patients are really starting to understand that and they want more transparency. Thank you for listening to today's episode of the patients rising podcast.

Bob Goldberg  18:41  
We have more episodes in the way so as always, do not forget to click the Follow button so you don't miss out.

Terry Wilcox  18:48  
We'll be right back here on Monday with another new episode. Until then, for Bob and everyone at patients rising. I'm Terry Wilcox, stay healthy.

Drew Leatherberry

Health Plan Hero advisor for Midwest Carriers and Faulks Bros. Construction

John Schneider

Fire Chief, Wentzville Fire Protection District, a Health Plan Hero winner

Mike Andrade

Benefits Advisor to Health Plan Hero winner Dupre Logistics

Stacie Harrell

Director of HR at Cosmos Corporation, a Health Plan Hero winner

Jen Medsker

Employee at Cosmos Corporation, a Health Plan Hero winner