Director of Business Development
Mike Roche joined The Alliance in 2015. He is responsible for working with prospective employers, their broker/consultant and their TPA partners to introduce them to self-funded health benefit strategies; sharing data-based information to manage their health care spend; and serving as a voice of The Alliance to expand our membership.
Mike has a strong background in health benefits and self-funding. He previously served as a regional sales advisor for Digital Benefits Advisors in Madison, Wis., where he managed the health benefits for more than 160 credit union clients across 14 states. Prior to that position, Mike worked at CUNA Mutual Group in their employee benefits division for almost 10 years as an employee benefits sales specialist.
Mike has a bachelor’s degree with a double major in marketing and business administration and is licensed in both health and life insurance in Wisconsin, Illinois, Iowa, Minnesota, Nebraska and Montana.
Self-funding (what’s known as self-insured insurance) is a health plan in which an employer is paying for their employees’ health care claims. In a self-funded plan, employers set aside money into a “fund” or trust that’s earmarked to pay their employees’ health care claims.
Although self-funding has been used by large employers for decades – at employers with more than 5,000 employees, 91% of their insured individuals are covered under their self-funded plan – smaller employers have been slower to take on that risk. Until now.
As traditional PPOs and HMOs carriers continue to break records in profits and growth, (and continue to cost more too,) employers are starting to view the pandemic as a breaking point and are jumping into self-funding. When employees don’t seek medical care – whether due to good health or a pandemic – employers don’t retain their savings, the insurer does. With self-funding, employers are rewarded for having a healthier workforce, and as a result, incent their employees to be healthier. And when employees have the resources, education, and support to maintain their health, they’re also happier and more productive.
Why Choose Self-Funding?
Employers choose to self-fund their health plans because they can benefit both their bottom line and their employees’ overall health and wellbeing:
Significant Savings: Self-funded employers no longer need to pay insurers or pay state taxes on their premiums. And when total health claims are lower than expected, the employer gets to keep their savings – which can be substantial.
Complete Customization: Every employee population has different demographics, and self-funded employers can design their health benefits to suit their unique needs. And because self-funded employers aren’t bound by the network of a traditional insurer, they’re not confined to using a single health system; large and jumbo-sized self-funded employers are free to contract directly with providers, while smaller employers often opt to join a group-purchasing coalition – like The Alliance.
Total Control: Another benefit of self-funding is that employers have unlimited access to their data because they own it as a self-funded business. Analyzing this data helps self-funded employers identify health trends (like common chronic illnesses) within their workforce, unlocking significant cost-savings opportunities.
Unprecedented Flexibility: Within the bounds of ERISA, employers can operate their health plan as they see fit, partnering with whatever vendors they wish. And by bringing together like-minded vendor partners, employers can save even more by reducing waste and improving their employees’ health and wellbeing.
What Are the Risks of Self-Funding?
So, what happens when an employee or family member incurs an unpredictable, financially devastating claim? Self-funded employers typically partner with a stop-loss insurer to cover individual claims that exceed a predefined maximum allowed amount per employee, defending against catastrophic claims. Self-funded employers also generally utilize stop-loss insurance for aggregate claims, which acts as a safety net if their total claims exceed the employer’s expectations.
If the employer does not have proper stop-loss insurance in place, they expose themselves to the potential financial risk of catastrophic claims. Additionally, particular employee populations can pose more risk for high-cost claims, and the employer should identify, understand, and plan for that potential liability.
Lastly, there’s a more considerable administrative burden on behalf of the employer to implement, maintain, and improve a self-funded health plan. That’s why employers work with partners to help them with their benefits. Self-funded employers often select a third-party administrator (TPA) to process their claims and a pharmacy benefit manager (PBM) to administer their prescription benefits.
Is Self-Funding Right for My Business?
As you’ve now read, self-funding can be a cost-effective alternative to the traditional fully insured approach. When your business self-funds, you take on the risks and rewards of paying your employees’ claims. You also take on the heavy administrative burden of implementing your plan and vetting TPA, stop-loss, and PBM partners.
Employers that choose self-funding aren’t just making a business investment, but an investment into their employees’ health and wellbeing. Naturally, with that comes an investment of time and resources, but engaged employers that make the switch can expect to save at least 15% on their health care costs in just a few years.
Self-Funding Smart: The Alliance Approach
By self-funding with The Alliance, you gain total transparency of your claims data, and while other insurers make little attempt to improve network quality, our ever-growing Smarter Networks span more than 31,000 doctors and providers across the Midwest, which saves you money and helps your employees avoid out-of-network surprise billing.
As the voice for more than 285 self-funded employers, we find savings where others can’t – or won’t – using deep data mining and analytics to unlock steerage, bundled payments, preferred pricing, inflation protection, pay-for-performance contracts, usage-based fees, and other self-funding opportunities.
Finally, The Alliance is a not-for-profit cooperative that’s member-owned and led, which means your priorities are our priorities. For over 30 years we’ve been growing our network, building our purchasing power, and upgrading our provider contracts to help you achieve better value for your health care dollar – focusing on your bottom line – not ours.
To learn how The Alliance can help you make the transition to a self-funded plan, contact our Business Development team.
Most employers have recognized the strain that the pandemic has placed on their employees and renewed their health benefits plans without significant changes to cost-sharing and network plan design. Efforts to improve delivery systems and networks to improve outcomes, quality, cost, and the overall health care experience will continue to be overshadowed in 2021 by more critical issues associated with the pandemic.
What Employee Health Benefits Are Employers Prioritizing?
Remote Work Arrangements
86% of survey respondents in a QTI HR survey said they have and will continue to offer remote work arrangements after the pandemic. While return-to-work plans vary widely, 75% of respondents have some employees working on-site or have given employees the option to work on-site.
Health Spending Accounts (HSAs)
With nearly 50% of large company employees moving into high-deductible health plans, health reimbursement and HSAs are expected to rise sharply.
Diversity, Equity, and Inclusion (DEI) programs
The pandemic has produced powerful data emphasizing the need to prioritize DEI, particularly as it relates to inequalities in race. Data from the Centers for Disease Control and Prevention (CDC) show that Black and Latinx people are three times as likely to become infected and two times as likely to die from the virus as their white counterparts. Employers who identified DEI as a strategic priority were two-and-a-half times more likely to report high employee engagement and satisfaction levels.
Telehealth, Virtual Care, and Mental Health
The pandemic has certainly placed a spotlight on telehealth, virtual care, and mental health benefits for employers, forcing them to evaluate the effectiveness of their respective programs; this is likely driven by COVID-19, which has increased anxiety and depression and highlighted the connection between employee well-being and overall business performance.
In a Mercer Global survey, 32% of employers said they were expanding virtual or telehealth programs, while 25% said they were enhancing their mental health support. As a result, Employee Assistance Programs (EAPs) are likely to increase in 2021 and beyond.
Financial Wellness Programs
Hoping to reduce financial stress and boost productivity in their employees, companies are focusing on financial wellbeing as well. According to a survey analysis by EBRI, the top financial wellness initiatives for employers post-pandemic will remain health care costs and retirement preparedness (with retirement planning and basic finance and budgeting as key areas of focus). However, personalized credit counseling, planning, and debt coaching are rapidly growing areas of focus for employers.
Health Care Cost-Containment Strategies Are Still King
Despite employers focusing on critical priorities related to COVID-19, their sights are still set on long-term cost control strategies. Specifically, per NAHPC’s survey, employers are still showing strong interest in:
Direct Primary Care / On-site and shared-site clinics
9 in 10 employers are considering value-based design approaches.
Better managing high-cost claimants
7 in 10 employers are considering strategies to reduce high-cost claimants and bundled payments.
Better managing high-cost prescription drugs
87% of employers indicate drug price regulation is helpful.
Implementing high-value provider networks
Addressing patients avoiding/deferring care due to personal costs inherent to high-deductible health plans (HDHPs).
Payment Reform strategies
79% of employers want surprise billing regulation, and 75% want improved hospital price transparency and hospital rate regulation.
Other Trending Employee Health Benefits Topics
The pandemic has resulted in the closure of many traditional childcare resources, placing parents in a balancing act between work and family responsibilities and forcing employers to address their policies related to sick leave, childcare, and elder care. As a result, employers are open to changing childcare assistance for employees with children and flexible work scheduling.
Additionally, employers are expected to evaluate whether their policies of bundling vacation and sick time into a shared bank endangers their workforces by encouraging “presenteeism” – or showing up to work while sick. (Currently, Wisconsin does not have laws that require employers to provide paid leave; legislative proposals to change this could be expected in the near future.)
Other well-being priorities for employers include enhancing behavioral health, diabetes, nutrition, weight management, and physical activity.
We know it seems early, but The Alliance is already thinking about employee health benefits for 2022. If you’re considering changes to your health plan, we can help you analyze your data to help make small changes for a big impact. Reach out to our Account Management team!
As you begin the new year, you’re probably reassessing your benefit plan and vendor partners to help improve your employees’ health and wellbeing.
If you want to enhance your employee experience, reduce spending waste, and improve vendor efficiency, consider holding a vendor summit for all your health benefit programs.
What is a Vendor Summit?
Employers often organize health-related benefit programs separately, independent of one another. The result can be a patchwork of overlapping vendors, who often target the same group of employees and family members with chronic conditions.
Vendor summits bring together all partners for a meeting that can help employers get more from their health benefits investment; by having all your vendors together at the same table, you provide an opportunity for them to develop meaningful relationships with one another, which helps them work better together.
There are various focal points you can target when holding a vendor summit, but one The Alliance has seen work well is to pinpoint common, chronic conditions because those are typically the most costly and controllable items from a health spend standpoint.
Additionally, vendor summits highlight areas of accountability for your stakeholders and getting together as a team increases everyone’s effectiveness.
Which “Vendors” Should be Invited?
A vendor summit brings together all your outside vendors and partners to identify services and set goals as part of an integrated approach to health, disability, and absenteeism. Early in your plan year, you should send a meeting invite to all the vendors who help you manage health-related services. Those stakeholders could include:
Primary network (The Alliance)
Pharmacy benefit manager (PBM)
Third-Party Administrator (TPA)
Employee assistance program (EAP)
Disease management/care management
Other internal resources (on-site clinic, mental health, etc.)
If you are unsure on what services you should be including or who to invite, consult your broker – they should be able to help you gather your invite list and guide you through the process.
Preparing for the Vendor Summit
Before holding your summit, you should first analyze your benefit data to identify the top conditions driving your largest health care costs. This information will be invaluable in working with vendors and setting goals.
If you self-fund with The Alliance, contact your account executive to request a Smarter Health℠ analysis; its data includes claims history, provider utilization, cost trends, and more. Smarter Health reporting provides the foundation for a successful steerage program – one that guides employees to high-value health care – and the insights it provides would be invaluable for your vendor summit.
Additionally, you should ask each vendor to do some advance preparation. For example, in the invitation you could ask them to identify the top five conditions that impact your health benefit costs and employee productivity, and then ask them what (if any) stakeholders receive their vendor reports, and how often those reports are made available.
Create a “Shared Vision” for Your Vendors
The next step in preparing for your vendor summit is to create a shared vision to present to vendors. This vision typically has a dual focus:
Enhancing your employee experience – all the benefits and health programs in the world won’t make a difference if your employees don’t use them. You should work together with your vendors to make the services you offer more attractive and accessible to your employees, creating employee “buy-in.”
Reducing waste and inefficiency in your benefit program – The most important aspect of a vendor summit is to outline goals and roles, ensuring everyone knows the part they play and everyone’s aligned; this reduces waste and increases each of your vendor’s efficiency. These goals might include:
Establish a foundation for partnership
Identify a condition or conditions to focus on for the coming year.
Determine how vendors can help improve outcomes for those conditions.
Create communication and action plans for the coming year.
Integrated Health Management Opportunities
Based on the information provided by vendors and the goals set by the employer, the vendor summit group should reach a consensus on the top few conditions to target in the coming year.
After determining the target conditions, you should calculate how many employees fall into what “stages” of risk for each condition.
For example, you may all agree to focus on diabetes, obesity, and preventative health screenings. An employee could be healthy (low-risk), pre-diabetic (high-risk), or diabetic (has disease and complications). After determining those buckets, you should then decide for each category:
Which vendors offer services and support?
What are these services and support?
How does the vendor engage employees? How often?
What could make the vendor more successful in serving the employer and employees?
How will the employer determine, measure and communicate success?
Holding Your Vendors Accountable
Remember, your goal is to integrate data to maximize services and provide more value to employees and dependents. As part of that process, it’s important to learn how services are coordinated by multiple vendors. Here’s how that plan could look:
Key initiatives and goals to support targeted conditions
Prioritization of initiatives sorted by:
Plan to work with each vendor to describe services, set targets, and define measurements for the conditions you plan to target. (Ultimately, this could help you develop performance guarantees for vendor services.)
Envision Your Plan in Action
The final step for each vendor is reviewing likely, real-life scenarios they may face with actual employees. For example, how would Vendor A handle a call from an employee who is experiencing vision loss and is actively engaged in a diabetes-focused disease management program?
Completing exercises like that will help the vendor and employer visualize, map-out, and edit their processes.
Revisiting the Process
Ideally, you should regroup with vendors once or twice a year to evaluate your progress and adjust accordingly. Frequent touch-points also help you fine-tune your relationship with the vendors your employees. Plus, providing more opportunities between your vendors and your employees to interact strengthens their relationships and improve the overall employee experience.
The Proof is in the Payoff
Vendor summits tend to be real eye-openers for employers, who say that after hosting one, vendors are more likely to share vital information, align activities with the employer’s strategic goals, participate in an integrated health management approach, and deliver measurable results.
There’s certainly a lot of time and effort that goes into hosting a vendor summit – which is likely why few employers actually focus on them – but those that take advantage of those opportunities say the results make the investment worthwhile.
Just listen to what Merrill Steel’s Matt Ohrt, (who’s won a few awards recently,) had to say about vendor summits:
“We just hosted a summit where we brought all of our new partners together, which was the result of analyzing the key partners we previously had in place. We found out that only one of them really thought like us, so we switched TPAs, benefits advisors, PBMs, and we obviously changed employer coalitions to join The Alliance.
We have some big plans for 2021 – we’re going to change our benefit plan design, do a lot more direct contracting, incentivize employees to use high-value providers, and revise our wellness program to help employees earn significant HSA contributions.
With all these changes, it’s important to us that we all think alike and work together, so that way when we bring up new ideas or try new things, we don’t have any dead weight; we have to have people excited about the direction we’re going and be supportive of it.”
Summary on Holding a Vendor Summit
While vendor summits may seem complicated, it’s really just setting a meeting with all your stakeholders to get everyone together – you can do it! Just remember to follow these five procedures (then build the rest out with your broker to better suit your needs):
Employer sets goals based on needs of employee population.
Employer determines which vendors interact with these employees.
Vendors are invited to a summit to share information about their services.
Specific goals are set for each vendor for the targeted conditions.
Measurements for success are defined (and eventually revisited).
And if you self-fund with The Alliance, be sure to request a Smarter Health℠ analysis for your next vendor summit!
If you want to design a health benefits plan that saves your business money but don’t know where to start, begin by creating a corporate culture that educates employees on the plan and encourages them to use it. Why? Because you want to influence your employees to make behavioral health changes before they develop medical conditions that require costly, specialty care.
Whether due to lack of knowledge, motivation, or education, some employees may choose to ignore what they consider to be minor health symptoms. Things like hypertension, high cholesterol, and obesity are often minimized by the patient, but if these health risks continue to go unchecked, they can lead to more dangerous – and costly – medical conditions.
Beyond creating a wholistic company culture focused on leading a healthy lifestyle through education and empowerment, you can use Benefit Plan Design to influence where your employees seek treatment to care for their health – and your bottom line.
Health Benefits Plan Design in Action
By providing employees with financial incentives for utilizing high-quality, low-cost providers, employees are more likely to utilize care that saves them and the health benefits plan money. For example, you can design your plan to feature a multi-level network structure using our Premier Network. Multi-level networks (also known as tiered networks,) incentivize employees to go to doctors that are high value – good quality at a fair price – while still offering a broad network to give employees and families choice.
Here’s how it works – let’s say your company gives employees three options based on quality and cost.
Level 1: High-Value providers from a particular health system that has zero out-of-pocket costs for the employee but is located 25 miles from your workplace.
Level 2: High-Value providers from a different health system located 5 miles from your workplace that require $150 in out-of-pocket costs for the employee.
Level 3: The rest of the providers in the network that require $300 in out-of-pocket costs for the employee.
Based on these options, your employees are financially incentivized to choose Level 1, which saves both them and your health benefits plan money. However, they could pay more to choose Level 2 if the provider’s location is important to them, or pay even more to choose Level 3, which is possibly a provider they trust and may have chosen in the past.
This design structure gives employees more transparent options when making a decision and over time, saves money without limiting the health care options for your workforce.
What Makes Benefit Plan Design at The Alliance Different?
The Alliance has developed contracts with high-value provider systems that are based on a percentage of Medicare – what we call Reference-Based Contracting. Combining this strategy to produce transparency in pricing along with our membership’s purchasing power, The Alliance is able to negotiate deeper discounts with large providers than what would traditionally be possible – as long as they are added to the plan’s top tier of benefits. This results in savings for both employers and their employees.
Ready to Get Started?
Learn more about Benefit Plan Design.
If you want to incentivize your employees to use low-cost, high-value providers while still offering them the flexibility to choose within a broad network of providers, our Premier Network offers customized provider levels – all of which are within our Smarter NetworksSM.
If you want to learn more about how The Alliance can help you with your benefit plan design, including how to offer leveled tiering, contact Business Development or your Account Executive.
Joining a captive is a little like deciding whether to try a new entrée for the first time. No matter how many times you’ve been told it will be delicious, you’ll never enjoy the taste unless you’re willing to take the risk of ordering it. And if you’re not interested in taking that risk, you’ll likely settle for never learning just how tasty it could be.
Every bidder for your health plan’s business claims their network of hospitals, doctors and health services will save you money. But how do you know whether that’s true or just marketing hype?