Fixing a Challenging Healthcare System: Exploring Captives with Pareto Health
Overview
This session shed light on the rising costs of employer-sponsored healthcare, which currently average between $14,000 and $18,000 per employee annually, with a projected 5-9% annual increase. Key factors driving these costs include concerns over specialty medications and the intense scrutiny of Pharmacy Benefit Managers.
Tommy Lipner, GBA highlighted the benefits of captives and self-insurance as powerful strategies for managing these escalating costs. These approaches promote transparency and enable data-driven decisions, providing a clear path to cost containment.
Pareto Health’s expertise in managing large employee benefit group captives was showcased, illustrating how they help employers reduce costs and mitigate risks effectively.
?
Pareto Health is an employee benefit captive manager that manages the largest employee benefit group captives today in the country. A captive, for those who don't know, is really just a fancy way of saying we find a bunch of like-minded employers who are sick and tired of where the traditional market has left them, who have all decided to band together to drive down healthcare costs.
Challenges of Fully Insured Healthcare plans vs Self-Insurance
Tommy explained that insurers often start renewal rates high, expecting brokers to negotiate them down. This leads to consistent cost increases and declining benefits, which hampers talent attraction and retention.
He pointed out that while self-insurance might cost more during a bad claims year, it offers immediate savings during good years, as employers no longer pay for previous bad years.
Tommy encouraged employers to consider the long-term benefits of self-insurance, emphasizing its potential for more sustainable and cost-effective healthcare management over the next decade.
Escalating Costs of Fully Insured Healthcare Plans
For a 200-employee organization, starting at $2 million with a 9% annual increase, premiums would more than double over ten years. This translates to over $30 million spent on benefits in that period.
Tommy urged employers to shift their focus from merely reducing the initial $2 million premium to finding ways to retain as much of that $30 million in-house. By investing those savings back into the benefit plan, organizations can enhance value for their employees.
He noted that while self-insurance can be advantageous over the long term, concerns about risk and the unpredictability of new treatments can be daunting for smaller businesses. This is where Pareto Health plays a crucial role, helping to manage risk and volatility through innovative cost containment solutions, making self-insurance more accessible and effective for employers.
领英推荐
The Power of Captives and Self-Insurance
With over 2,700 captive members covering nearly 950,000 lives across the U.S., captives wield significant market power. However, each member retains full control over their plan design, including the choice of third-party administrators and provider networks.
Tommy explained the mechanics of self-insurance compared to fully insured plans. Instead of paying fees for administration, taxes, and profit, self-insured members pay fixed costs for a third-party administrator and reinsurance (or stop loss premium). This setup involves selecting a specific deductible, such as $50,000, which determines the amount of risk the employer retains. Claims exceeding this deductible are covered by stop loss insurance.
Stop Loss Insurance
Aggregate stop loss protection further caps the total potential expenditure on claims below the deductible, ensuring that employers avoid excessive costs. Tommy emphasized that while self-insurance may sound complex, it largely mirrors existing plan designs with minimal disruption for employees, offering a more controlled and potentially cost-effective alternative to traditional insurance models.
Tommy compared self-insurance to car insurance, where higher deductibles reduce premiums. Just as you wouldn't insure routine car maintenance but would cover major accidents, Tommy suggested treating benefits similarly: cover every day medical expenses out-of-pocket and use insurance for major events like serious illnesses.
Traditional stop loss insurance protects against large claims within a single year but can be problematic for ongoing conditions that span multiple years, such as cancer or long-term treatments. This can lead to unexpected increases in individual deductibles, known as "lasers," which can deter small and mid-sized businesses from self-insuring.
Tommy highlighted that Pareto Health’s captives, with over $1.3 billion in stop loss premiums, offer a solution by eliminating the risk of lasers. Captive members benefit from a 30% cap on stop loss premium increases, spreading risk across the group and avoiding substantial premium hikes.
Importantly, Pareto Health’s captives are employer-owned, ensuring that the programs are tailored to benefit the members without conflicts of interest. This setup allows businesses to enjoy the advantages of self-insurance while mitigating the risks of large, unexpected costs.
The Benefits of Captives and Self-Insurance
Tommy explained that while each captive is unique in its structure, Pareto Health’s model ensures that every member becomes an equity owner. Profits are reinvested into members’ capital accounts, and any non-profitable stop loss policies use this capital to backstop the insurance program. The goal is not to generate massive profits but to maintain stable fixed costs and effectively manage claims.
He highlighted that transitioning to self-insurance often results in immediate savings, with first year fully insured transitions saving about 7.5% on average, and over 82% of transitions saving money. Even if there’s a slight loss in the first year, the savings over time and the reduction in premium volatility can outweigh the initial costs.
He emphasized the importance of cost containment strategies, such as examining pharmacy benefits management. Tommy suggested starting with basic cost containment measures and gradually implementing more as you become familiar with self-insurance. The key is using data to drive decisions and focus on high-impact areas.
Tommy concluded that self-insurance, supported by a captive, offers a way to manage costs effectively over the long term, avoiding the volatility of traditional insurance and providing tools and resources to enhance cost management and employee benefits.
Final Remarks from CEO Jonathan Anders
Jonathan emphasized the critical importance of detailed claims data in effective plan design. He noted that many reports only validate the carrier's cost increases without providing insight into the specifics of individual claims or recurring issues. This lack of granularity hinders meaningful adjustments to deductibles and other plan elements.
Jonathan highlighted that without accurate measurement, managing healthcare costs becomes challenging. He criticized the traditional fully insured model for its failure to control costs and advocated for a shift towards more proactive risk management. Instead of merely reacting to cost increases by changing plans or contributions, he urged for a more strategic approach to managing and reducing risks.