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Transforming Healthcare Benefits: Insights from Josh Richter

Kyle Roed, The HR Guy Season 5 Episode 222

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Unlock the secrets to revolutionizing your healthcare benefits with insights from Josh Richter, a senior sales executive at Medical Associates, recorded live from the Iowa State Sherm Conference. Discover how HR professionals can transition from cumbersome traditional plans to flexible self-funded and level-funded options. Josh illuminates the rising importance of Individual Coverage Health Reimbursement Arrangements (ICHRAs) and tackles the thorny issue of prescription drug costs. Learn how Pharmacy Benefit Managers (PBMs) are key to cost management and why local providers like MedOne Benefits can be game-changers by passing rebates back to employers.

Our conversation doesn't stop there. We dive into the importance of expert advice in health plan management to ensure employees receive top-quality care. With a meticulous quality control process involving NCQA and CMS ratings, customer feedback, and direct reviews, Medical Associates sets high standards. Hear about the critical roles of the quality control manager and customer service director as they stay current with healthcare trends and regulations. Finally, we wrap up our conference experience with heartfelt gratitude to our guests and a reminder to stay engaged with us on social media for more insightful discussions. Tune in for an episode packed with actionable takeaways for navigating the evolving landscape of healthcare benefits.

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Speaker 2:

This is the Rebel HR Podcast, the podcast about all things innovation in the people's space. I'm Kyle Rode. Let's start the show.

Speaker 3:

Welcome back HR community. We are here live podcasting at the Iowa State Sherm Conference. With us today we have Josh Richter from Medical Associates. He is a senior sales exec and we're going to be talking all about some of the innovations in care providing and we're going to talk a little bit about networks and all sorts of fun and exciting stuff for a very specific HR audience. So we are talking to the right folks here. Josh, thanks for joining us yeah, thanks, Kyle.

Speaker 3:

Appreciate it. Thanks, patrick. Thank you, yeah, we have Patrick Moran with us as well here. Thanks for helping out at the conference, patrick. So, josh, we've already talked quite a bit here and, for a side note, a little plug Josh has an award-winning podcast as well. It is not specifically in the HR space, but we'll have a link to that as well as we link this out. So, josh, just tell us a little bit about yourself and what excites you about the world of HR and some of the changes you're seeing.

Speaker 4:

Yeah, well, thanks again for having me on. So I've been in the insurance industry going on 22 years now. I've always been in the P&C side of things and just got into group benefits about nine years ago with a large broker out of Des Moines, Iowa, and I've lived in the Dubuque area for the past 12 years and we've transitioned from association group benefits now over to I'm on the health care side. So working with a provider, working with an insurance carrier, has been a different change for me and it excites me because I know the background of what HR professionals do in their daily lives, what they're looking for. So it's helping us tailor, make our brand to alleviate pains on their side with administration, especially on the claims and the service that they tend to get questions on from their employees. So we have an in-house TPA customer service claim center as well as our sales centers on the same floors underwriting and finance. So we're kind of a one-stop shop for your insurance needs.

Speaker 1:

Nice you know we have so many HR groups and departments and employers that are very traditional in their healthcare benefits to their employees. What things are you seeing as from an innovation standpoint in healthcare, that we're not thinking about or should be thinking about and that our brokers should be bringing to us, but maybe they just don't know?

Speaker 4:

Yeah, I mean for the longest time, fully funded plans have been. Fully insured plans have always been the traditional norm. A few years ago, level funded used to be a thing. I think level funding isn't the right fit for a lot of employers nowadays. I think the self-funded option is probably the best option that we have right now available to employers. It gives them more autonomy to do what they want within their plan and also to provide to their employees and the benefits they do.

Speaker 4:

I think one exciting thing that started to take off after the past couple of years are ICHRAS, and if you haven't ever learned about an ICHRA, it's basically like or a health plan market, just like you would see from Obamacare. You'd be able to go out and get on the exchange and find a plan for yourself, so that employers are now, through ICRA is providing cost basis to their employees to go out and find their own plan. This way the plan is isolated to that individual for claims and not the company as a whole. So if you have a person that has disease management or has a ton of comorbidities, they're seeing the increase on their own plan, but the company isn't seeing it on the entire pool. So I think that's one neat thing that is coming up and I think a lot of brokers have been talking about Icarus. I don't think it's fully caught on in the entire HR world yet, but I think in the next couple of years you're going to see that kind of be the way that most of the brokers tend to lead their clients.

Speaker 1:

So one question I have, I'm just curious on with this topic is because we're going through renewal season with our broker and that sort of thing, and you're talking about self-funded plans, which my organization is, you know. On the topic of prescription drugs, that's the cost you know so medical associates, how do you combat or tell a story as these drugs start to continue to constantly increase, like there's no solution? But how do you handle that?

Speaker 4:

There isn't. I think the biggest thing that you have to look at is your PBM. You have to look at your PBM contract, how long it is, how many years you signed up for. And you have to look at is your PBM. You have to look at your PBM contract, how long it is, how many years you signed up for, and you have to have a good PBM partner to be able to tailor your own. So we go through OptumRx right now. We're looking. Our contract renewal is coming up here in 2025, so we're looking at other options.

Speaker 4:

Our mantra, being in the tri-states area, is we're a local brand. We want to shop local MedOne Benefits. Medone Pharmacy is in Dubuque, iowa. It's a great partner that we haven't had a chance to partner with because of contracts, but it is a company that we're going to be seeking out. Their rebates are a little bit different than most PBMs. We like to pass our rebates on to our employer groups, so that's one thing that's going to put more money back into their pocket versus a company that's going to keep those rebates and keep that cost high for their employer groups. Medone does a really good job. I'm really excited to see what we partner with them on if we do take that contract.

Speaker 4:

But for PBMs. Right now we actually have a clinical pharmacist that works in-house for us with medical associates and that's really hard to find. Usually on PBMs it's still the salespeople or the directors that are getting those contracts and Kate Kurt is our clinical pharmacist. And I tell you what in the world of HR, when we have events, people come just to hear her speak about PBMs and about drug costs. So she consistently evaluates our tiered plans and what drugs we can include in there for generic, if there's an option for it, so that we can keep the cost of the drugs down for the for the employees themselves um where a lot of other companies they just want to provide you that brand name drug versus any other generic cool, yeah, I'm just sitting over here smiling.

Speaker 3:

Let these like uh Comp and benefits experts.

Speaker 1:

I apologize in advance. Josh and I were talking a little bit about this before he jumped on the podcast. Yeah, yeah, so full disclosure.

Speaker 3:

If you're a comp and benefits nerd, this one's for you, yep, but I think it's you know as we talk about. You know, the focus of this podcast is primarily on, you know, innovation and thinking differently, and what are the things we need to be aware of in the, you know, the HR space that we need to be aware of, I think yeah, I think a lot of people in the HR space working for companies tend to focus on price and tend to focus on the cost of their employees going to have to pay.

Speaker 4:

The worst thing you want is when you roll out an OE and you've got your employees calling you like I can't afford this, I can't afford this. Like, give me options. You know that's probably your guys' biggest complaint during OE is like what can I do? I can't afford this. And that's what's really hard nowadays, especially in our economy inflation's hit. I think having a good partner I feel like Medical Associates is a good partner with our employer groups.

Speaker 4:

We work with the HR representatives to tailor a custom plan for them that works for their employees. So we want to be part of the open enrollment conversation with your groups. We want to come in, we want to explain the benefits. You know, because as much as HR people know about benefits, they're people, persons. You know they're people, people. That's what they're there to do is. They're there to manage the people of their company. We're there to manage the benefits. The brokers are there to manage the benefits.

Speaker 4:

So we want to come in and we want to have full transparency with your employees and let them know what they're getting, and we're going to get real-time feedback from them so that we can take back to our underwriting and financial analyst team to really tailor what the needs of your employees are and then come back with an offering for that. And that's really what I think sets us apart. Also, our care and coordination. We keep costs down within our clinics and hospital systems and networks by contract that you have to follow our SOPs procedurally with medical associates if you're part of the network, and I think that also keeps the overall cost of insurance down year after year versus running unneeded tests, unneeded labs that have already been run a week or two prior. That's kind of really where our care and coordination help out.

Speaker 3:

Yeah well, you hit on a couple of really important points I want to call out here. Number one is this big question of cost versus service, and I think it's so easy for us to get focused on cost and full disclosure. We made some decisions in my company a number of years ago specifically related to cost, and it sold that it's going to be much better for employees, it's going to be cheaper, it'll save the plan a lot of dollars. What ended up happening is employees got significantly poorer service because there were some issues with networks and doctors.

Speaker 3:

There was things like multiple tests and some tests not being approved. It was an extremely restrictive plan.

Speaker 3:

Being aware of the actual service, the actual delivery, is really, really critical. I think the other thing, too, that I'll call out. You know, I'm an HR professional and I've been managing plans for decades, but I am not an insurance expert. I am not a health insurance expert. I rely on my brokers to help advise and I would encourage HR professionals don't let your ego make these decisions. There are new and different ways that things should be happening and you should be leaning on these experts to help you make these decisions.

Speaker 3:

So one of the areas I want to talk about a little bit is on that service level. It's the quality of care that you get and it's related to this cost question. So how do you help, kind of innovatively, look at the quality of care that's delivered and make sure that that network is that high-quality network that employees need?

Speaker 4:

Yeah, great question. So we've got again. Everybody is director level within our company. We're all in one building, so we have our risk management, rick Walters. He's our quality guy. He works with NCQA ratings, he works with our CMS ratings and he really goes through the customer feedback that we get after each visit. You know, you always get those emails or those texts hey, how was your visit? You know, let's give your doctor a scale. We really rely heavily on our customer feedback because that's really who is telling us how we're doing, and so Rick is always reviewing every one of those and if it gets a bad score, he reviews it personally with the team and then maybe it was bedside manner, maybe it was a care and coordination he didn't follow the protocol on. So our controller, our quality control manager, rick, will then meet with the doctor, go over some not a performance improvement by any means, but he'll work with the provider and he'll say, okay, well, here's what we could have done better. This is a different solution that we could have had for this employee or for this customer, this patient. That's just one facet of it. We also have an in-house science director and then our customer service and care director for both the clinic and the health plan sit side by side. So, mark Koprich she sits just a couple doors down from me, a great lady, and she's always keeping up to date on the new trends and new changes in healthcare laws, procedures and what we can do with CMS guidelines.

Speaker 4:

One great thing about Medical Associates is we're one of the only five-star plans in the nation on our Medicare side through CMS. Kaiser Permanente is the only other one which, if you know anything about Kaiser Permanente, they are a larger version of us. They started off as a hospital and clinic system and then back in the day, they had a large employer come to them and say hey, we want to create a plan because all of our employees go through you guys. They use you as a provider. So that's really how Kaiser Permanente started off their health insurance world and, similar to Medical Associates, that's how we started A hundred years ago.

Speaker 4:

We were a hospital and clinic system and then John Deere Dubuque Works came to town, opened up in the late seventies and said hey, all of our employees go to medical associates, clinics and hospitals. We just want to contract a plan directly through you guys. We don't want to deal with the big, you know, the Walmarts of the world, the Aetnas, whatever it may be. We want to stay local. So we 42 years ago created a health insurance plan specifically for John Deere employers and that's how medical associates health plans came to exist.

Speaker 4:

We've obviously since expanded on that and are offering to other you know, large groups and small group ACA plans. But I think kind of back to your question, kyle, is it's all about our quality and the scores that are provided to us from our patients and how our quality manager dives in on each one of those scores to make sure that we maintain the highest that we can as five-star CMS rating. We want to keep that rating and you know we will work with our provider to make sure they follow the plan and especially a good, healthy career path.

Speaker 1:

What is you know if me, as an employer, had an interest in you know, switching my plan to you guys? You know, is that a full-on service suite or what does that look like? Is there a la carte pieces you could take, or yeah? Yeah, some of that can be confusing to employers and our listeners across the state of Iowa, so I just kind of yeah, that's a great question.

Speaker 4:

So we're not a true benefits broker, we're not somebody that can offer ancillary benefits. We have specifically just our health plan, our Medicare plans for your retirees and your businesses, and then we also have a TPA. So we handle our third-party administration in-house. We will all cart those three to meet your specific needs. So if you're working with a broker currently and have a TPA that you enjoy and you want to utilize just our healthcare system and you want to use our health insurance, that's perfectly fine. If you want to go all in for it and you want to provide the health insurance, the TPA, the claims, the analytics, the reporting and for your retirees, do the Medicare, we will do that as well. We have a broker we're working with right now that's kind of a la carte-ing everything that he does and only wants to use our TPA. We will do that as well. So we're really kind of an a la carte company for our HR members and for our brokers that we work with.

Speaker 1:

So within the state of Iowa, because we have people from 560 attendees here at the conference throughout the state of Iowa. What does that reach look like? Can somebody in Sioux City or Council Bluffs have that partnership?

Speaker 4:

It's a great question.

Speaker 4:

So within our health insurance side we do have starting 1-1 of 2025, it's called One Network.

Speaker 4:

It's going to get to the outer reaches of West Des Moines, polk County, dallas County, and then it's going to kind of run the vertical all the way up to, like, the Cedar Falls, mason City area. As far as the western part of the state goes, they're not considered part of our One Network, but we do have a RAP network with First Health that's going to cover that. We also have some contract negotiations with UnitedHealthcare to be part of that RAP network as well, so we do have the extension beyond that. One of our requirements internally, though, is that no more than 20% of your employer group can be outside of our area of network coverage. So if you've got a pocket of population that, like you, have an off-site location in Arizona and that exceeds our 20% threshold, it might not be a good fit for us, because we really can't control the care and coordination off-site like we can here locally, and that's really what separates us and sets us apart. But I mean for the state of Iowa we'll reach all 99 counties.

Speaker 3:

So I think one of the things you know that's interesting here for the audience is, you know, just hearing the story and the heritage of the, the organization, is, you know it was prompted because hr professionals wanted a solution for their employees, right, that's ultimately where medical associates put together this, this, you know, kind of innovative approach specifically for an employer john deere. So, as you are thinking about that and you know going through these types of decisions, you know there are a lot of options out there and it doesn't just have to be the cookie cutter, check the box. Hey, you know, this is what we've always done, this is what we're going to offer to our employees. By being thoughtful and innovative and partnering with local medical providers, you can make changes and make a difference for your employees' level of service and make sure you're reducing costs. Because the reality is, if you've got a tighter network and you can be really, really targeted with the network, you're going to have better health outcomes. Ultimately, you're going to save the plan money, right?

Speaker 3:

I mean that's how you sell this to the CFOs Absolutely.

Speaker 4:

I mean, wellness is a big thing. Disease management's another big thing that's hit in healthcare. You know there's so many comorbidities that go along with diabetes. There's so many comorbidities that go along with, you know, heart disease. You know, obviously, cancer is a hard one to stay away from.

Speaker 4:

The other thing that most people kind of get a misconception on us about Kyle and I just kind of want to elaborate on, is that our style of health plan most would consider an HMO, and it is by design, though, and even though it's considered an HMO, we really act like a PPO. But we do have the HMO style of network that we don't let every doctor, hospital and clinic or provider into our network. We really vet them quite harshly. Again, you wouldn't want to go and have a triple bypass by a doctor that's got a 2.5 star rating on NCQA. Right, you know our rule is 4.5 stars.

Speaker 4:

If you're below that on your NCQA rating, we're probably not going to take you, and we just, you know, we take our vehicles to shops to get oil changes, we take them to get tires rotated, and then you know, those are simple jobs and those are fine, but when it comes to the severe, hey, I need to put a new engine in, or I need, you know, the can shafts milled out. I need to redo this. You're not going to take that to just anybody. You're going to take that to a provider that you know and you trust, and that's really why we vet our doctors so heavily. So that's, I think, one thing that sets us apart and why we're Network by Design.

Speaker 1:

Yeah, I think what helps with that is you know, as an HR person, that you're listening to this and you have to sell to your CHRO or your CFO. You know your employees trust you to pick the right benefits right. If you're working with a broker, just know brokers have these relationships with medical associates that can look at your health plan in a different way and probably at the end of the day, ideally it's better care, better service and maybe cost effective. If your broker is not bringing these opportunities to you, josh works with multiple brokers. Have a conversation with multiple brokers. Don't just stick to the one that you know. Have a conversation with multiple brokers. Don't just stick to the one that you know. Always keep a relationship with multiple brokers because you might learn something that your broker probably either doesn't know or is keeping from you. So I guess that's my last point for that.

Speaker 3:

Yeah, and with that we are closing in on our time together. Josh, how can our listeners connect with you? Learn a little bit more and understand a little bit more about Medical Associates and this spot.

Speaker 4:

Yeah, yeah, absolutely. So best way is to give us a call in the office. 563-584-4889 is my direct phone number. We have a website medicalassociatehealthplanscom. You can stop by and see us at booth 20 and 21, if this is going out. Today here at the SHRM conference, we brought Bob and Liz from Dubuque down here to provide you guys some nice cold brews but also some hot coffee drinks, so it's kind of a hit for us. But, yeah, or just reach out to one of your brokers. If you're an HR professional and you have a broker relationship that you're working with right now, just bring our name up. Ask them if they heard of us. If they haven't have them, reach out to us. You know we have a hybrid model that we can sell directly to an employer group. We'd rather not. We'd rather work through a broker, because brokers have those relationships. Plus there's other ancillaries that brokers can provide that we can't and we really would rather have that relationship in place.

Speaker 3:

Right, We'll have that information in the show notes. Appreciate your time here today at the conference and thanks. We'll have that information in the show notes. Appreciate your time here today at the conference and thanks for the coffee.

Speaker 1:

Absolutely Thanks, josh. Thanks, josh, thank you.

Speaker 2:

All right, that does it for the Rebel HR podcast. Big thank you to our guests. Follow us on Facebook at Rebel HR Podcast, Twitter at Rebel HR Guy, or see our website at rebelhumanresourcescom. The views and opinions expressed by Rebel HR Podcast are those of the authors and do not necessarily reflect the official policy or position of any of the organizations that we represent. No animals were harmed during the filming of this podcast.

Speaker 4:

Baby.

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