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The Real Enemy in Healthcare Benefits: Fighting Disease, Not Just Managing Costs

By Mike Adams and Scott Conard MD When it comes to healthcare benefits planning, companies often get sidetracked, thinking that the main challenge is controlling costs. But here’s the real truth: the true enemy isn’t high premiums or rising deductibles; it’s the disease itself. Disease is what drives up healthcare costs, disrupts productivity, and takes a toll on both employees and employers. By refocusing our efforts on fighting disease and supporting long-term wellness, we can create a sustainable, effective healthcare benefits strategy that benefits everyone. Empowering Employees to Fight Disease: A Partnership Approach In the fight against disease, employees and employers need to align their efforts. Employers play a crucial role in providing the resources, financial assistance, and tools employees need to manage their health effectively. But it’s not just about giving access to healthcare services; it’s about fostering a proactive health mindset. Employees need to take ownership of their health. This partnership means that while companies provide the tools, employees must also put in the effort to use them effectively. Moving from Transactional to Relational Healthcare One of the biggest obstacles to creating a sustainable healthcare strategy is that too many people still view healthcare as purely transactional. In the traditional model, employees go to the doctor when they’re sick, get a prescription, and call it a day. However, this approach doesn’t solve the root problem; it merely addresses symptoms as they arise. The solution is a shift from transactional to relational healthcare. Just as financial advisors moved from selling stocks and bonds to holistic wealth management, healthcare providers are starting to focus on population health management. This approach prioritizes long-term health and wellness over short-term treatment and one-off doctor visits. Population health management looks at the bigger picture—helping individuals stay healthy and preventing disease from occurring in the first place. The Problem with Cost-Centered Benefits Planning Many companies have relied on brokers, insurance providers, and pharmacy benefit managers (PBMs) to reduce costs. However, focusing only on cutting costs without addressing the underlying issues—namely, disease and lack of preventive care—leads to a broken system. Often, these brokers and PBMs are incentivized by rebates, prescription volume, and other revenue-driven structures. This creates a conflict of interest, where decisions may prioritize profit over the well-being of employees. Year after year, this results in a steady increase in healthcare costs, with the average annual rise in premiums hovering around 5% to 10%. To break this cycle, companies must shift their focus from short-term savings to addressing the real issue: preventing and managing disease. Only by aligning incentives toward long-term health outcomes can companies sustainably control healthcare costs. Disease is the Enemy: The Path to Sustainable Healthcare Benefits The true solution lies in approaching disease as the primary challenge. When employers focus on health improvement instead of just managing expenses, they can create a benefits plan that is both cost-effective and impactful. This involves: When employers and employees work together, supported by a healthcare benefits plan that prioritizes fighting disease, the benefits extend beyond the bottom line. Healthier employees lead to a more productive, engaged workforce, reduced absenteeism, and ultimately, lower healthcare costs. Building a Healthier Future: Fighting Disease Together By recognizing disease as the real enemy, companies can begin to reshape their healthcare benefits strategy in a way that truly serves employees’ needs. Empowering employees to take charge of their health, focusing on preventive care, and partnering with providers who share a commitment to wellness can transform healthcare from a transactional system to a relational, proactive one. Disease is the real enemy in healthcare benefits planning, and by uniting against it, we can create a system that doesn’t just manage costs—it improves lives. Let’s move past broken incentives and focus on what truly matters: building a healthier, more resilient workforce.

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Health Risk Engagement Strategies: Driving Change Before It’s Too Late

For executives managing health plans, one of the biggest challenges is engaging individuals who are in the early stages of disease risk progression but feel perfectly fine. These individuals, often unaware of the looming consequences, present a significant opportunity—and a unique challenge—to healthcare strategies. Once someone becomes symptomatic, behavior change is much easier; they’re desperate to feel better. However, by then, it’s often too late to reverse the damage. Instead of cheaply and effectively addressing the issue, we’re left managing a chronic condition for the foreseeable future. The key question: How do we engage people early, before symptoms appear, and inspire them to take meaningful action? This is where cutting-edge health risk engagement strategies, driven by predictive data and real-time activation technology, become a game-changer. Our algorithms utilized by the MyPHA team is your solution to this problem. Shifting the Paradigm: From Retrospective Cost Analysis to Proactive Risk Engagement The status quo in healthcare analytics relies on retrospective cost-based reporting. Most organizations are equipped with tools that answer questions like: These data points are useful for understanding the past but do little to impact the future. They focus on individuals who are already in the high-cost, high-risk category—individuals whose health trajectory has already caused irreparable harm. What’s missing from this equation is predictive engagement—the ability to identify the individuals who are trending toward risk before they become symptomatic and to intervene effectively in real time. Consider this: 70% of today’s high-cost individuals won’t be the same people next year. If you’re only looking at historical data, you’re blind to the emerging risks within your population. Why Predictive Engagement Matters Let’s look at the CFO perspective:“I’ve already got reports. I know I have 384 diabetics and 264 people with hypertension. I have programs in place for them. Why do I need anything more?” Here’s why: Traditional reports don’t tell you who your next high-cost individuals will be, nor do they provide actionable insights about how to prevent them from becoming costly. They miss the nuances of health risk drivers—factors like comorbidities, social determinants of health, geographic influences, and behavioral patterns—that determine whether an individual can avoid a serious medical event. Predictive engagement goes beyond labels and costs. It examines the whole person—integrating data about: This holistic approach enables organizations to answer the most critical question: How can we prevent costly and emotionally taxing events before they occur? Engagement, Activation, and Support: The Pillars of Early Intervention Effective early intervention requires a three-pronged approach: For employers, early intervention is not just a health imperative; it’s a financial one. But this requires a shift from reacting to past costs to proactively managing future risks. By investing in predictive analytics and engagement technology, organizations can reduce costs while improving outcomes for individuals. Conclusion: The Future of Health Risk Management The old approach—focusing on retrospective cost and disease management—is no longer enough. Health risk engagement strategies must evolve to focus on real-time insights, whole-person care, and proactive prevention. The stakes are high, both for individual lives and corporate budgets. But with the right strategies, tools, and commitment, we can make a measurable difference—shifting the focus from managing disease to building health and resilience. As executives, the question isn’t, “Why should I care about your data?” It’s, “How can I afford not to?” By embracing proactive engagement, activation, and support, you can ensure your organization is leading the way in creating healthier, more productive populations. That’s a future worth investing in.

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Realigning Incentives for Better Health Outcomes and Lower Costs

Clinical Consulting, Employer Healthcare Solutions / Converging Health Website

For executives responsible for managing their organization’s health plan, there’s a crucial question worth asking: Is our current system really designed to treat each individual and improve their health? On the surface, the answer might appear to be “yes.” After all, the system has data, information, resources, and influence at its disposal. But take a step back and ask yourself: How is it working for you? If the system truly prioritized individual health, the numbers would tell a different story. Healthcare costs in the U.S. would be at least half of what they are today. Instead, costs continue to rise at a staggering rate of 5% to 10% annually, leaving organizations and their employees struggling under the weight of increasing premiums, higher deductibles, and diminished outcomes. The Misaligned Incentives Here’s the hard truth: The current system is not designed to treat the individual effectively. Why? Because misaligned incentives drive it. Many players in the healthcare ecosystem profit more when costs go up. In fact, rising costs are often baked into their business models. This misalignment has created a scenario where nearly one-third of healthcare spending is wasted on fraud, waste, and abuse. These inefficiencies enrich middlemen and other unnecessary stakeholders while leaving employers and employees to foot the bill. Worse yet, 70% of high healthcare costs could have been prevented if root causes were addressed earlier. A Smarter, More Aligned Approach What if we could use the same intelligence—data, information, and systems—but act on it differently? What if we focused on making people healthier and tackling waste at its core? This approach is not only possible but also financially and operationally realistic. By investing in high-quality care that addresses the root causes of health issues, organizations can achieve better outcomes and lower costs. High-quality care is the least expensive care because it prevents the need for costly interventions and reduces the churn of treating symptoms without resolving the underlying problems. A Path to Sustainable Savings Consider this: if we worked to eliminate a portion of fraud, waste, and abuse each year for the next five years while improving the health of employees, could we stabilize our costs? The answer is a resounding “yes.” Here’s what that path looks like: The Payoff By realigning incentives and focusing on root causes, companies can break the cycle of escalating costs. Over time, this shift leads to a healthier workforce, more predictable expenses, and a competitive edge in attracting and retaining talent. As leaders, it’s up to us to ask the tough questions and take bold action. The fly in the sauce isn’t going to fix itself—but we can. Together, we can create a system that works for individuals, organizations, and the bottom line. Are you ready to take the first step toward a healthier future for your team and your company?

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The Critical Role of Health Insurance in Employee Wellbeing

Employer Healthcare Solutions / Converging Health Website

Jan 09, 2025 The state of healthcare in America today is far from ideal, with many employees struggling to access affordable, high-quality care. Health insurance plays a crucial role in employee wellbeing, impacting not only their physical health but also their financial stability and overall job satisfaction. Employers who recognize and prioritize the importance of a well-structured health plan can significantly improve employee wellbeing and their company’s bottom line. The Current Healthcare Landscape Many employers are self-insured, meaning they assume the risk of healthcare costs for their employees. This puts them in a position of essentially running a small health insurance company within their business. Unfortunately, many companies lack the expertise needed to manage these plans effectively. This often leads to overspending, wasted resources, and employee dissatisfaction. Additionally, the current system is often plagued with misaligned incentives where brokers and consultants may prioritize their own commissions over the best interests of the employer and employees. Impact on Employee Health and Wellbeing When health insurance plans are not managed effectively, the negative consequences are felt by the employees. High deductibles and out-of-pocket costs can deter employees from seeking necessary care, leading to delays in treatment or avoidance of preventative services. This is particularly true for employees with chronic conditions or those who require regular medication. The stress of financial burden from healthcare costs can lead to decreased productivity, absenteeism, and lower overall job satisfaction. Employees who feel that their health plan is inadequate may also experience lower morale and increased stress levels, which could impact their performance. In contrast, a well-designed health plan can support employees in maintaining their health, offering resources and support for chronic conditions, mental health, and access to quality care. How Employers Can Improve Employee Wellbeing Through Health Insurance Employers play a pivotal role in changing this dynamic and creating a healthcare system that benefits both the company and its employees. Here are a few steps to take: C-Suite Involvement: CEOs and CFOs need to get actively involved in the management of healthcare benefits. They must view it as a crucial part of their business, applying the same financial scrutiny as they would to any other significant expenditure.Transparency and Audits: Employers should demand transparency in all contracts with TPAs, PBMs, and brokers. Regular audits should be conducted to ensure that the plan is operating efficiently and in the best interests of the employees.Focus on Data and Risk Assessment: By understanding the health risks of their employees, employers can create targeted interventions and support programs. This approach enables more personalized and effective healthcare strategies.Value-Based Care: Move away from traditional fee-for-service models to value-based care, which incentivizes providers to focus on health outcomes. This includes partnering with providers who are committed to improving patient health and reducing costs through prevention and early intervention.Employee Education: Employers should prioritize health literacy and provide resources to help employees make informed decisions about their care. This also includes educating employees about their own health risks and encouraging proactive engagement in their care.Humanize the Problem: It is important to listen to employees, understand their challenges with the healthcare system, and use these stories to drive change. Personal experiences can help leadership recognize the real-world impacts of their health plan decisions. Ready to transform your health insurance plan into a powerful tool for employee wellbeing and organizational success? Take the first step toward a smarter, more impactful healthcare strategy today. Empower your team with a plan that reduces costs, enhances productivity, and prioritizes their health. Let’s create a healthier, more engaged workforce together. Contact us now to start building a plan that works for everyone. Written by Rob Thwaites Pathway to Zero Trend Contact us The Critical Role of Health Insurance in Employee Wellbeing

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