Benefits Consulting

The Vital Role of a Physician Executive: More than Just Healthcare Management 

Employer Healthcare Solutions /

By Mike Adams and Scott Conard M.D. When we think about a physician, the classic image is someone in a white coat, caring for patients. But in today’s healthcare landscape, there’s a new kind of physician stepping into a very different role—one that’s shaping the way companies approach employee health benefits, healthcare costs, and workplace well-being. This is the physician executive, and they’re here to break traditional molds, offering insights that align medical expertise with business strategy. And the impact? It’s profound.  A physician executive isn’t just a consultant ticking off metrics; they’re catalysts driving companies to ask the tough questions about healthcare. They’re the ones who help employers understand not only what health benefits to offer but why these decisions matter to both their people and their bottom line.  Breaking the Benchmark Trap and Leading the Pack  Let’s talk benchmarks—a favorite topic in the world of employee benefits. Many companies measure themselves against industry standards, but is being “average” really good enough? Physician executives challenge this mindset. They encourage companies to stop aiming to be in the middle of the pack and instead set new standards that prioritize quality care and employee well-being.  One popular saying captures their philosophy perfectly: “Lead, follow, or get out of the way.” That’s the attitude physician executives bring to the table. They aren’t there to rubber-stamp the same-old solutions. Instead, they push companies to take an innovative approach, whether it’s in healthcare plan design, employee engagement strategies, or even how they measure success. The goal is to create a benefits package that’s not just comparable, but truly better—one that resonates with employees and delivers real results in terms of health outcomes and cost savings.  Aligning Employee Experience with Quality Care  Here’s a crucial insight from the physician executive’s perspective: employee experience doesn’t just mean giving employees everything they ask for. Rather, it’s about designing healthcare benefits that balance experience with top-notch clinical care. The focus should be on creating an environment where employees are engaged, healthy, and supported, not just momentarily satisfied.  This is where a physician executive’s clinical insight comes in. They’ve spent time in the trenches, navigating the patient care process, so they understand firsthand what high-quality care looks like and how to deliver it efficiently. They know how to blend the “wants” with the “needs” to create benefits that improve employees’ overall health and productivity.  The Converging Health Solution: Data-Driven Savings and Better Outcomes  If you’re a company leader looking to improve your healthcare strategy without breaking the bank, consider partnering with Converging Health. Physician executives from Converging Health specialize in using data to guide smarter healthcare choices, helping businesses focus on what really matters. With a deep understanding of behavioral economics and healthcare systems, they know where to trim costs without sacrificing quality.  Converging Health’s services, grounded in analytics and a comprehensive understanding of the healthcare ecosystem, help companies manage complex healthcare dynamics, from insurance to point solutions. They offer a blend of clinical expertise and financial insight that lets you see tangible savings—reducing unnecessary spending while boosting employee health and engagement.  In short, with a physician executive from Converging Health, you’re not just navigating the system; you’re setting a new standard for healthcare benefits. Ready to save money and elevate care? Reach out to Converging Health and see how an innovative approach to healthcare can benefit your company’s bottom line and keep your employees healthier, happier, and more productive. https://converginghealth.com/contact-us   

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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.

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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.

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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

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