Benefits

HR Director’s Dilemma: How Corporate Financial Incentives Impact Employee Healthcare Costs and Access

Employer Healthcare Solutions /

As an HR director, managing employee benefits is one of the most impactful ways to support your workforce. Yet, navigating the complexities of healthcare costs and access has never been more challenging. Corporate financial incentives—the unseen forces behind many decisions in the healthcare system—play a critical role in shaping the quality and affordability of care for your employees. These incentives, while often intended to improve efficiency, can unintentionally lead to higher costs, reduced access, and a focus on profit over patient outcomes. Understanding how these financial incentives affect your employees’ healthcare experience is essential. Here’s a breakdown of key factors and potential solutions: Employer-Sponsored Health Plans: Navigating the Balancing Act Provider Incentives: A Double-Edged Sword Pharmacy Benefit Managers (PBMs): Misaligned Incentives Insurance Companies: Limited Competition, Rising Costs Lack of Transparency: A Barrier to Better Decisions The Ripple Effect on Employees and the Economy Charting a Path Forward: Solutions for HR Leaders A Call to Action As HR leaders, we have a unique opportunity to influence not just the lives of our employees but the broader healthcare system. By understanding the unintended consequences of corporate financial incentives and advocating for innovative, patient-centered solutions, we can create a system that prioritizes care over costs. It’s time to step up, ask the tough questions, and champion changes that benefit our employees, organizations, and communities. Together, we can transform healthcare from a source of stress into a cornerstone of employee well-being and organizational success.

HR Director’s Dilemma: How Corporate Financial Incentives Impact Employee Healthcare Costs and Access Read More »

Primary Care for All

1 Comment / Clinical Consulting /

An initiative that will transform the U.S. health system so that it is driven by Advanced Primary Care by Scott Conard, MD There is a group of us who are working together to bring a foundation of advanced primary care to every American. With this foundation we can establish a “system” of care for America that will significantly reduce the confusion, disorganization, low health literacy, inappropriate navigation, and excess costs. At this time our initiatives are:To Renew the commitment to a primary care system: Create a renewal process that will stimulate deep reflection that leads to re-discovery and embrace of the core values, goals and sense of purpose that underlies the Family Medicine movement To Revitalize those believing in the value of advanced primary care: To inspire and to articulate a vision for the next stage that engages a community of innovators and early adopters who will act on the vision. To Transform the system: To advocate and act on systems change: from models to networks to systems to institutions. All of this is based upon primary care that makes a difference. Running patients through 40/day, handing out referrals and scripts at a record rate, at 7 minutes a visit or spending an hour with every patient, ordering every possible test – regardless of evidence base and/or pre-test probability. Nor is it about ignoring what is going out outside of the office and just caring for those who call and make an appointment. Advanced primary care calls us to provide a higher level of service and care. Truly in the old “Marcus Welby” vision of caring for people as they age – having a trusted relationship – and ensuring patients get the right care, at the right time, in the right place, and at the right cost. What are your thoughts about this? Is it realistic? Is it fair to ask primary care providers to do more without providing better tools, better data and information, proactive reimbursement, or other support? 

Primary Care for All Read More »

The Hidden Cost of Overutilization and Lack of Primary Care: A Call to Action for CFOs and HR Directors

Employer Healthcare Solutions /

As leaders responsible for balancing the financial health of your organizations with the well-being of your employees, you face a complex challenge: managing escalating health insurance costs without compromising the quality of care. Two often-overlooked factors significantly driving these costs are the overutilization of medical services and a lack of primary care engagement among employees. Overutilization of Medical Services: Paying More for Less Overutilization occurs when medical services are provided with a higher volume or cost than is appropriate. This includes unnecessary tests, redundant procedures, and avoidable emergency room visits. While these services may seem beneficial on the surface, they often do not contribute to better health outcomes and can, in fact, expose patients to unnecessary risks. For example, an employee with a minor headache might receive an expensive MRI scan when rest and over-the-counter medication would suffice. Such instances not only inflate individual claims but also contribute to higher premiums for the entire organization. Overutilization can account for up to 30% of healthcare spending, a staggering figure that directly impacts your bottom line. The Role of Primary Care: The First Line of Defense Primary care physicians (PCPs) serve as the gatekeepers of health, providing preventive services, managing chronic conditions, and coordinating specialist care. However, a significant number of employees lack a strong relationship with a PCP. This absence leads to fragmented care, delayed diagnoses, and increased reliance on specialist and emergency services—all of which are more costly and less efficient. Without primary care guidance, employees are more likely to self-refer to specialists for issues that could be managed by a PCP at a lower cost. They may also overlook preventive measures, resulting in advanced-stage diagnoses that require expensive interventions. The lack of primary care exacerbates overutilization by funneling employees into high-cost healthcare settings unnecessarily. Connecting the Dots: How These Issues Compound Costs The interplay between overutilization and lack of primary care creates a feedback loop that drives up healthcare expenses. Employees without primary care guidance are more susceptible to overutilization, and overutilization further discourages the establishment of primary care relationships due to the complexity and frustration it can cause. This cycle leads to: A Strategic Approach: Investing in Primary Care to Reduce Overutilization To address these challenges, consider implementing strategies that encourage primary care engagement and reduce unnecessary medical services: 1. Promote Primary Care Relationships: 2. Educate Employees: 3. Implement Value-Based Insurance Design: 4. Partner with Providers: Conclusion: A Call to Action As CFOs and HR directors, you have the opportunity to transform these challenges into strategic advantages. By fostering a culture that values primary care and actively combats overutilization, you can reduce healthcare spending while enhancing the well-being of your employees. Investing in primary care is not just a cost-saving measure; it’s a commitment to the long-term health of your workforce. It leads to better health outcomes, increased productivity, and a more sustainable financial model for your organization. It’s time to take a proactive stance. Let’s work together to build a healthcare ecosystem that delivers value, promotes health, and ensures that every dollar spent contributes meaningfully to the well-being of our employees and the vitality of our organizations.  Dr. Scott Conard is a physician and healthcare strategist dedicated to improving organizational health outcomes through innovative approaches to employee wellness and healthcare management.

The Hidden Cost of Overutilization and Lack of Primary Care: A Call to Action for CFOs and HR Directors Read More »

Exposing Hidden Waste: Out-of-Network Payment Schemes

Employer Healthcare Solutions /

As a senior executive, you’re constantly focused on efficiency, transparency, and maximizing the value of your company’s investments. Healthcare benefits—often one of your organization’s largest expenditures—should be no exception. Yet, many employers unknowingly bleed money due to hidden fees and opaque out-of-network payment arrangements. If you think a polished benefits package guarantees fairness and cost control, think again. Pulling Back the Curtain on Out-of-Network “Savings” ProgramsConsider a scenario: You have 5,000 employees. Your broker partners with a major carrier that promises a cutting-edge out-of-network cost-management program. On the surface, you’re shown impressive statistics: “We saved you X%!” “Your plan saved hundreds of thousands of dollars!” But ask a crucial question: Saved compared to what? Suddenly, the narrative isn’t so clear. One leading carrier’s program, One of the major insurance carriers offers out-of-network “payment integrity” solutions. The carrier presents data showing significant reductions in billed charges—numbers that look like heroic cost containment. Yet, behind these reported “savings,” the carrier often takes a percentage cut for themselves, effectively turning your plan’s supposed cost control measure into a revenue generator for the insurer. Real-World Example: The 13-Hour Office VisitImagine a provider billing over 50 increments of a single 15-minute service in one day—implying a marathon 13.5-hour visit. Under standard Medicare rates, this service might only be worth about $32 each time. Yet the provider’s billed amount was thousands of dollars, with the plan paying only a fraction. On paper, this program would claim massive “savings.” But in reality, the carrier charged the plan a hefty percentage of that “avoided” cost—far exceeding what the doctor actually received. In one particularly egregious case, the provider was paid a mere $61 while the insurer pocketed $3,700 in “fees.” The question executives must ask is: If the insurer knows these questionable billing practices are happening, why don’t they stop it? Quite simply, they profit from the difference. Where the Waste Happens—and How to Fix ItThis kind of wasteful spending arises when employers accept opaque arrangements without fully understanding the underlying payment mechanics. To address this problem, organizations must: 1.     Renegotiate During RFPs:Start strong by establishing clear contract terms that prohibit the carrier from earning more than what is paid to the provider. Demand transparency and define “savings” in measurable, meaningful terms. 2.     Limit Out-of-Network Services:Consider eliminating or tightly restricting out-of-network benefits. Handle exceptions individually to ensure members get needed care without giving carriers an open invitation to pad their margins. 3.     Engage Expert Negotiators:Partner with advisors who understand these complex billing games. They’ll ensure plan language and fee structures minimize the potential for misaligned incentives. Implementing these strategic approaches can reduce your per-employee per-month (PEPM) costs significantly. In fact, by addressing just one out-of-network program, some employers have seen immediate reductions of up to 7.5% of total healthcare spending. Data-Driven ResultsEmployers who actively root out these hidden fees and adopt transparent payment models have achieved substantial cost reductions. Data shows that organizations employing robust payment integrity strategies and strict out-of-network controls can drive down total health plan costs by as much as 15%. Your Next Move: Take Back ControlAs an executive, every dollar counts. In a landscape where healthcare spending spirals ever upward, protecting your plan from hidden charges and self-serving “savings” schemes is critical. Don’t leave your organization’s financial health to chance. Take the first step toward total transparency and meaningful savings. Contact us to learn more and schedule a consultation. Our team will review your existing arrangements, identify hidden waste, and help you negotiate a plan structure that truly prioritizes cost control. Stop letting opaque deals drain your resources—act now and put your company on the path to zero trend. Written by Rob Thwaites

Exposing Hidden Waste: Out-of-Network Payment Schemes Read More »

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

Clinical Consulting, Employer Healthcare Solutions /

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.

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

Realigning Incentives for Better Health Outcomes and Lower Costs

Clinical Consulting, Employer Healthcare Solutions /

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?

Realigning Incentives for Better Health Outcomes and Lower Costs Read More »

The Critical Role of Health Insurance in Employee Wellbeing

Employer Healthcare Solutions /

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

The Critical Role of Health Insurance in Employee Wellbeing Read More »

Scroll to Top