How Employers Can Reclaim Control with Community-Owned Health Plans

Speaker A: For most employers, health insurance looks like something that happens to them. A renewal shows up, the numbers go up, the explanations get more complicated, and somehow, despite spending more every year, nobody feels more in control. But what if the real problem isn't just cost? What if the problem is that the plan was never built for your company, your employees or your community in the first place? What if health plans were designed locally around actual care, actual providers and physicians, and actual incentives, instead of national templates and carrier logic? Welcome to Healthcare Americana. I'm Christopher Habelig, the CEO of Freedom healthworks and your host. Today's episode is brought to you by Freedom healthworks, helping physicians and employers build direct relationship based care, but by the Free Market Medical association, advancing transparency and accountability in healthcare. And by Dose Direct, helping direct care practices offer vaccines without inventory risk, bulk ordering or insurance chaos. And today we are talking about a different way to think about employer health plans. A continuation of our Free Market Medical association podcast series. And that includes one community at a time for these health plans. Joining me today is our fantastic guest, Nico Caparisis, program architect and community owned health plans, or CoHP. Nico, welcome to Healthcare Americana. It's a pleasure to finally have you on the show.

Speaker B: That's right. Took a minute. Glad to be here, Chris.

Speaker A: I want to start with the core idea. It's a strong phrase and I think I want a very clear, uh, explanation around this question of what if your health plan was actually built for your community, not some, um, national level actuarial or metrics or anything along those lines. So Nico, walk us through here. When you say that you are a program architect for community owned health plan, what exactly does that mean to you? What is a community owned health plan?

Speaker B: Sure, yeah. So a little bit back to basics, right? You know, these, these health plans that are, ah, legacy in nature, again, they were built with a, uh, certain thing in mind and that was to SC and to have profits at the center and to eventually become publicly traded. And now obviously these objectives are misaligned, uh, with what most employers and their folks want to see. Right? So that's basically what is um, the riddle of response to what's wrong. And so kind of when I had the notion to be able to build a custom health plan, taking it back to the community is exactly what needs to happen. And the fact that that's not a model that a lot of folks know about is really a shame. And so I established a community on health plans in 2020 because I realized that by assembling vendors together that were independent by way of their operation, uh, that are mission aligned in reducing claims and improving the venue and avenues of care within the plan that employers could ultimately be better served. Right. So while there's bifurcation in the idea of what a COHP needs to look like, the ethos and the foundation should be the same. Right. Bringing control locally, introducing care, trying to remove many, as many third parties as possible. Right. And the result is that you have a plan where there's an ecosystem where everybody's driving towards the same thing, which is to control health care costs, to improve the health care experience. Right. And there's a lot of different ways to slice that, but at the core, more businesses that are able to adopt that because we know, Chris, the primary function, the primary means through which people purchase insurance is through, is through their employer. Right? And so to me, right, Because I know we've seen over the years, the top down approaches don't really work very well to control costs. Right. There's typically a, uh, general absence by way of care, you know, being involved in that discussion too. You know, when I said about to do something different, I said, look, the employers are the one purchasing their insurance. They're the biggest purchasers of insurance. Right. And they have to be the audience. And it has to be a grassroots from the ground up movement as opposed to, again, trying to approach it from the top down. We've seen that fail, frankly, time and time again, uh, either through legislation or private companies trying to band together to kind of do something different at scale. It's very, very hard to push that boulder up a hill, especially when people are actively pushing it back down at you. Right. But that said, you know, especially with our involvement in the fmma, right. And my sitting in the Georgia chapter presidency, I know that employers can affect change and they just need to know what, what it is that they can do for their people. That, that does look dramatically different and, and to actually adopt into it. Right. Cause it takes a village. It really does.

Speaker A: I think that's the key is illuminating just the companies and really by extension communities have options out there. You don't have to just continue to go in there in October or November for your dual conversation, beat your head against the desk. And there's a massive amount of frustration with the employer world out there and by extension by employees and individuals and families. Rising premiums, the renewals are confusing. There's a lack of control, there's really a lack of input. Uh, I don't know if it's a hearing or a listening problem, Nico, coming from Two people with young kids here. So when you are talking about your plans and you're talking to prospective customers, is the pitch kind of, hey, stop buying these nationally boxed programs that are kind of a one size fits all because you have real needs and take your needs, analyze them and then build a plan around your own community instead of just grabbing something that is kind of quote unquote, off the shelf.

Speaker B: Yeah, so. So, um, it's a great question because, you know, I did for a couple of years work directly with employers in that capacity, right. Where I knew I could change one employer's mind at a time perhaps, but there was the friction of potential disruption of, of, you know, eliminating the current incumbent broker, right. Who may or may not be very, very hard charging towards innovation, may or may not know a lot about underwriting and plan design, may, uh, or may not be receiving overrides from legacy carriers left and right. Right. It could be a continuum of things. Right. And so When I established CoHP, the reason why that's relevant is because I wanted to bring together partnerships. My audience is the brokers who already have the ear of said employers. They already have the desire, a lot of them, to do the right thing by their clients. It's just they may not know that these options exist. Right. So when I design community on health plans, it's technically what's called a general agency where I partner with brokers and I say, look, if you don't know about these health plan models, let me educate you on how they operate and how the options exist relative to what the legacy options look like. Because that was my background and has been for the past 18 years working as a broker, learning what the problems and challenges are, learning what the friction points are, working with employers, hearing the complaints, the dreaded annual renewal cycle where it's, hey, 12, 20%, I kicked it down to five, didn't I hang the moon for you? That's a huge reduction, but that was just paying lip service and it wasn't really affecting change. Right. So my, my entire model has been built upon working with brokers, consultants with a new and differentiated product that is truly built around the communities. And to have that at least be an option. Right. If we can't change the world all at once, which, you know, we just can't do, at least again, one broker at a time, one group at a time, uh, one community at a time. And that's, that's how, at least in my view, we're going to be able to scale.

Speaker A: So let's, let's, um, look at those traditional when, when a broker's fed, uh, up or somebody's like, hey, I, I need an option here because I'm going to lose this book of business because this customer is just begging me to save them money. Or look at something and they come to you and say, nico, help me, help me out here. What do you think is like, give me the top one and if you want to cheat a little bit, give me the top two reasons why. And a broker would approach you.

Speaker B: Sure, absolutely. So, so there's, there's always the, the cost issue, right? I mean we know that that's the pressure, typically pressure, number one from clients that brokers see, right. Directly save me money. It's an inherently competitive landscape because there are a lot of brokers, right? They're 1099 contractors. They can represent whatever carrier solution they wish. And it comes down to the fact that if they can't save their client money but someone else can, there's the pressure that a broker consultant has to be able to, you know, save enough money for the client for them to stay with them, right? So there's that financial pressure. There's also kind of the market based pressure. So if someone else is bringing in a new solution and you haven't even spoken about it or you don't know about it, then you're going to have one step down, right, Relative to your competitor. So, so really it circles down to, you know, what my outreach is, is to try to open up eyes to that degree and, and to say, look, I'm going to send a marketing email or I'm going to go to FMMA conferences or similar ones throughout the country, you know, meet brokers consultants, uh, have an online presence with LinkedIn, let people know that there is another option. Kind of what I'm about as a human being because I try to live what I do and be representative of that. Right. So my outreach is always, you know, there is something better, there is something new and if you don't adopt into it, I'm not really a doom, a doomsayer, right. If you will, um, do this or else, right. But it's more so, you know, look, this, this is an option, this is something that can help your community. I've even thought, Chris, to the degree that to give an exclusive right to brokers consultants in a certain community and area, right? Like I have a first in only out quote base proposal, uh, process where someone sends me the same group, it comes from two different people. First person who sent it is the only one that gets A proposal. So if and when there's, you know, economies enough of, of pressure and scale in a certain area where everybody wants to start selling a nuanced, differentiated plan like this, um, um, it's going to take a lot of people to be involved. Right. But I try to partner with deeply these brokers, consultants who get it. Because the reason why we're talking to said audience is because so many people don't get it. And once someone kind of turns the page and they say, hey, look, I understand healthcare is broken, I hate insurance. If I'm a, uh, uh, practicing, you know, physician, clinician, they're in that space. They know, they know the kind of games that are played directly. They don't want to practice insurance, they want to practice medicine. A lot of times they just don't know what else is out there. And so again, I just, I back into the conversation by talking to brokers and just trying to tantalize them with, hey, save your client money, help your community. Why don't you think about what your competitors are doing? And this is how I try to raise enough eyebrows to get people to say, what is this? I'm interested, or here's a case, right? Or let's, let's take a look at this group together. And that's where the dialogue begins.

Speaker A: So I'm going to speak directly to brokers that are out there. You know, Nico, in your opinion, at what point should an employer, a broker's client, should the employer stop thinking, hey, how do I negotiate a slightly better version of this plan? Or how do I lower my cost here? And when do the employer start asking themselves, should I be buying this model at all?

Speaker B: Yeah. So, uh, that, that's where I've taken a lot of talking points from some folks that have really pushed direct primary care in the past, to be honest. Because the model in which DPC thrives the most is in a more elegantly outside the box built health plan, if you will. It's less legacy, right? Because you can't get a discount on your premiums from the national legacy providers and health plans. If you offer direct primary care, they

Speaker A: throw away primary care. They're like, well, we only value primary care at like maybe 15 bucks a month. And you're like, this is insane, right?

Speaker B: It's capita. Yeah. I mean, and that's what it is, right? Because it's like that's the lower dollar item M. But that is the foundation of care. Right? And the thing is, these legacy programs do not feature that as an important component to the plan. And it's not really PCP forward, right? Or direct primary care forward, or it's not in the spotlight at all. It's really an incidental and after effect they're more concerned about larger ticket items or specialty care. That's where the dollars hide. So that said, it's funny and to answer your question in a very long way, talking about DPC is a huge way to just open someone's eyes and maybe it's even through, ah, an uh, expository of sorts, um, a personal story where it's, hey, listen, I had a direct primary care experience where my first visit was two and a half hours long. And we talked all about my life, not just about my chart or my blood work or whatever is going on in a traditional typical setting. It's, we talked about my sleep, you know, my nutrition, my stress, how I move my body, things that might be bothering me, my professional life, my personal life, right? Like, uh, how I build my days. All of these things kind of culminated together and it would have been impossible to get that level of insight and result in a more legacy based model. Right. That, that was not direct primary care. So that's the thing. I mean telling these stories where the level of care is just so much better and in depth, that opens the door for an employer to say, like, I want that for my people, I want my folks to have a, uh, doctor who's basically on demand, like that concierge level of care. Not we've got to wait two weeks to get in to see a doctor and then you'll either be sicker or, or better by then. Right? That's just fragmented. So I think that that's what hits home. Um, and it opens the dialogue to talk about these plans.

Speaker A: And I'm glad that you, you, you put a little bit of spotlight right there on the actual employees and their families and the plan too. I mean, I can't tell you how many times over the last year, over the years doing this where, you know, we'll talk to a company and they're like, yeah, we want to take care of our people. There's no way that we could possibly change this plan because Susie's cousins, grandma's sister, friends, neighbor, um, she can't. She needs it. Right? Or they're the doctor or we need it. And it's like, why? You can't force my people to do that. So they're coming across as this very altruistic, oh, well, we don't want to rock the boat because the pitchforks and torches would come out for us. But then, you know, 15 minutes later they're like, yeah, let's, let's put more cost, you know, let's take more of his paycheck away from the employee and raise their deductibles to levels that most employees aren't going to ever touch if something even bad did happen to them. So I get tired of kind of that, that, that double speak of. We want to take care of every, all of our employees, yet paychecks are going to be shrinking along the way. And so it has to be very refreshing to, from your standpoint to say, hey, look, here's how you actually have your cake and eat it too.

Speaker B: It's great that you highlight that, Chris, because that's the thing. I mean, employers, I don't know that because health care has not been in the spotlight for so many years that they understand the questions to ask of their staff or that they know where their staff lie. Uh, with respect to certain questions, right? Like would you like a better healthcare experience with your provider? Would you like no cost options to go get care? Would you like to be able to see your doctor more immediately when you need them? Right? Like these are the level of questions that people need to hear. And it's kind of an inception based idea, I guess, but at the same time it's the truth, right? Everybody wants a better healthcare experience. And I think where the employers may or may not realize this is that I just don't think that the questions are being asked. I think when it comes to a different health plan design and dpc, it's like people don't want to change doctors. They may not know the reasons to change. Right? And they may not know that their people are grasping for that to actually happen because they need a better healthcare experience. Or they're taking 10 different medications and four different specialists and nothing is centralized or communicated and they're stuck in the middle of the, they're like a pinball. And so if an employer realized that their people could have such a better experience, they just need to ask the right questions of their staff. And that could be a simple survey, like some very simply crafted questions. Hey, we're doing a survey. We're just taking a look at our health plan. Respond to these six questions. Even a Google form, right? Like anybody can do it and it's at no cost. I think that's what really needs to happen to open the dialogue up. Because again, if you say people don't want to change doctors or we don't want to leave this legacy plan because people won't like it. Would they like more money in their paychecks? Would they like a better healthcare experience? Right. Like they would say yes, yes to these things. And it's just, it's almost as though the spotlight's in the wrong direction and we just need to like it takes a lot of effort, right, to get it just moving a little bit, but it almost needs to just turn all the way around. Right? It's like what kind of questions are we asking?

Speaker A: So yeah, and that leads me to, you know, this question that kind of, it's one of those questions that keep you awake at night and kind of nags me and said at uh, what point is our entire economy, entire commercial base, industrial base going to move away from employer sponsored health plans? Nico, I have to think that the pressure is mounting and that tea kettle is about to start yelling at you and screaming at you because it is boiling and has been for a while. So yeah, curious, like at what point do you see reading the tea leaves where employers are just saying, you know what? F this, I'm done. I'm tired of paying for this. Here you go, here you go. Employee feds tax me, find me whatever it is, I'm not going to adhere by the ACA mandates anymore. I'm done.

Speaker B: It'll be cheaper, right? And it'll be simpler and like be damned with company culture to a degree, you know, I mean that. But that's the mindset, right? And it has to come to an inflection point because we, we've seen different financial vehicles occur or I guess ah, come through the woodwork, right? Like, like Icarus, right. Sometimes they have a great implication and they're an awesome fit. But it's a very, very complex and it's basically just a way to shift dollars around. So people are obviously struggling with controlling and reining in healthcare costs. Employers that have more than 50 people in most states, that's what's called a uh, uh, ale an applicable large employer, right? Or an experience rated group. Their claims matter no matter what kind of insurance they buy or what kind of insurance they don't buy. Maybe they're partially self funded so they get some visibility into what the heck is going on so they can say, hey, we've got 20 diabetics in our group of 60 people. Like why don't we have a care program embed within our plan to address this risk, right? Or our MSK spend is off the charts, right? We need to get some bundled surgery in here to reduce the cost of these singular medical events that we know are happening and will continue to happen frankly. So the thing is, I mean, you know, small employers kind of have this shield of guaranteed issue rates, right? And what that means is they can have a group that has everybody's on a biologic drug and they have some rare medical condition, but their rates are going to be be issued based upon the census, right. The industry type, the geography and the plan designs that they choose. They can't discriminate based upon health. But for a majority of employers, right, uh, over 50 or over 100 depending upon your geography, claims matter no matter what. And if you're under 50, you don't really have to do much by way of complying and offering a plan. But a lot of employers want to, right? They want to do the best thing for their folks. Right? So you're right. At some point it'll just get so ridiculous. And Chris, what I've seen in working with brokers is I see renewal rates all the time. I've probably seen 4 to 5,000 renewals over the course of my 18 year career in this industry. And the costs just keep going up. I remember $197 a month employee only rate when I just started and now that's, that's, you know, it. There's cost sharing programs that are still there and the absence like uh, uh, it's devoid of insurance and it's basically where risk sharing used to be and could still be for a lot of folks. And that's how I'm covered my family and probably your family in a similar fashion. But yeah, when I see $2,000 a month employee only rates, especially when it comes to like municipal level where they have much, much larger populations. Right. The biggest employers in a town have to subsidize almost all the costs and people have no idea. $2,000 a month for an employee only is $24,000 a year and then that gets multiplied by three for the families, family tier you're talking about $72,000 a year. And if I'm, if I'm relatively healthy and I have a DPC provider just because I'm hip to that.

Speaker A: Right.

Speaker B: And I just don't use my insurance, I could have gotten a huge salary bump right. For not having had this benefit at all.

Speaker A: So is that something you mentioned, cost sharing programs? And to answer your question, yes, I've, I've been a vocal proponent of cost sharing programs and uh, the majority of uh, my family has says the kids have been born on cost sharing programs and it's fantastic. I mean, are those plans and solutions that you are recommending to companies.

Speaker B: 100%. And the thing is, and there's one that I joined about a year and a half ago, right? After a little bit of back and forth, a little bit of, hey, how

Speaker A: is this going to go?

Speaker B: I'm, uh, an informed buyer beyond many because I sell insurance and I have a license. I understand to a degree the complexity of these financial vehicles. Right. But at the same time I said, what am I paying for? What, what are we actually getting? What, what does our care look like? We all have direct primary care providers, you know, and it took me a while to get over the hump of, you know, certain things wouldn't be covered in the sense that they would be if I had insurance. Right. At the same time, let's be honest, even contractually guaranteed things, in that environment of having insurance, a lot of times those things are denied, right.

Speaker A: Algorithmically, they're denied according to a form.

Speaker B: Delayed, deposed. Yeah, and that's the thing. I mean, like, people are kind of savvy to the fact that not everything is covered, right. If I want cosmetic surgery, I'm not going to get it, right. If I need, um, you know, acupuncture, some, you know, um, Eastern medicine, right. Maybe that's going to be the best thing for me. I can't look to my insurance to necessarily cover everything anyway, so. So for us, we just had to dive in and just try it.

Speaker A: Yeah, which, which, you know, I do want to interject there when you mention those things that aren't necessarily covered by your cost sharing. Cosmetic surgery, acupuncture, I mean, you're, now you're talking about actual free enterprise type of markets for healthcare. And the quality. And the quality. And I, uh, define quality because I always have to say this. Every time the qword pops up, it's like buzzers going off in my head. You know, the quality is how good it is. Like, how are you pleased with your results? Right. So the plastic surgeons, the cosmetic surgeons are getting better, better, better, and those prices are coming down. Basic surgery is always the big one that pops up, never covered. But it's, it's. You let people choose based on their own, you know, educated consumerism, dare I say that phrase? But yeah, so, so in your example, I know you probably just named some things off the top of your head and didn't think I'd come back to that, but you're exactly right. Like there's a reason why we probably don't want those things to be covered. You know, here's another story. My wife's going to kill me. But uh, so she had her first cavity recently and um, the dentist was like, hey, you're paying cash, it's like 200 bucks. But we give you a 50% discount or something on that, right? And so she's like, comes back, she's like, well should this be covered in a health plan? And I go, sweetheart, we're saving like 5x that a month. Just pay the damn bill, get it fixed right away again, no waiting. And I, away we go. And also like that was a light bulb moment because she came from a uh, very traditional, like hey, after college you get a job and you go get benefits and that's what it's all covered, right? Kind of the, the cradle, the grave type of coverage, type of aspect. I'm like, it's a whole new world and you gotta know where to, where to look and what questions to ask. So I, I do have a qu. And I want to uh, keep going on that. When you start talking to brokers or employers about implementing these really non insurance health plans, I mean they look at you like you're nuts or they have

Speaker B: they heard of them before, you know, so, so the way I built my custom community and health plan product is to kind of look and feel a lot like a plan that people are used to purchasing from the legacy providers. Because as many barriers as I can remove, obviously that's why I want to work with instead of against brokers. Right. I took that hurdle immediately out. So with my product in particular, you know, you can rent a national network or you can have a direct contract with a hospital system in your own community if there is one to choose from.

Speaker A: Right.

Speaker B: In Savannah, Georgia I created the Savannah plan and it has a direct contract with one of two different hospital systems. So there are still ways to get it where it looks like insurance, but then there's also, you know, reference based pricing which is basically providers are able to get paid more than what they get from Medicare and they know what that number is. And then there's, there's margin on top of that. And so a lot of these models that, that I've kind of thought through over the years, it has to be easy enough for an employer to understand and a broker, it has to have a fixed monthly premium or people are going to get scared about fluctuating cash flow and paying for claims as they go, which is basically traditional self funding and traditional uh, self insurance. The policy that I created has network optionality as mentioned. It has one fixed monthly bill which is easy and approachable. On the employer side. It has some features that again, employees are used to seeing, like telemedicine.

Speaker A: Right.

Speaker B: Like there's, uh, care management included. Right. There's obviously the underlying insurance for when things get heavy in terms of claims and costs. So I've tried to meet people where it looks and feels really like a legacy health plan, because that is what they're used to buying. And if it was so dramatically and radically different, I would be scaring away an audience when I'm really trying to bring people together. And it's not just the diehards that we want. I mean, we want everybody to learn what DPC is. We want everybody to know what paying a cash price looks like. Right? What the actual unit cost of healthcare should be, as opposed to a copay or a desensitized deductible amount that you have to pay because you just, you leave with no understanding. You're like, I guess I just paid five grand. Is that a good deal? Is that a bad deal? Could I have paid $2,000 if I was a cash patient?

Speaker A: So do you get strange looks when you compare plans like that and you say, hey, Instead of paying $2,000 a month, you're going to pay $500 a month? Does anybody ever look at you and say, yeah, um, this feels too good to be true?

Speaker B: Yeah, that's the notion, right?

Speaker A: Yeah.

Speaker B: I mean, because like you mentioned, like, for my family, it would have been $2,500 a month for my family of five to have traditional insurance with the worst plan on the marketplace. And I say that generously, right? I mean, almost no coverage, limited network. Right. Like restrictions out the wazoo. No, uh, coverage until the deductible because it was HSA compatible. Right? And I, and I looked at it, I said, well, the cost sharing that, you know, we ultimately decided to pursue was $500 a month. I was like, so I'm already saving $24,000 a year. We actually had a major medical event. It did involve a hospitalization. It was a simple procedure, but it was still expensive. Like, we know, right? One night in the hospital, it was a, uh, $42,000 medical event. It was reduced to 14 grand. We paid 500 of that. We said, we're self pay. We had 13,5 ach to us. We paid all the different vendors, right? Radiology, uh, you know, the hospital bill, whoever read or was involved with that care episode. And it was maybe five or six statements that we got, and it was Easy. And I tell people this story and it's, it's incredible. People like, that's how it worked. It was, yes, maybe a little bit more involved. I wasn't like, here's my card. But I said, look, I'm self pay, just send us the bills. And then we got sent money and we paid and that was that. We're saving 24 grand. Yeah.

Speaker A: So, um, yeah, yeah. And I think it goes back to this. It's like you brought up regulatory and the mess that most people depend on Washington to do a one size fits all when they're actually talking about health insurance and actual health care. And I think you have to separate this between the sides. And I always tell people like, they're like, oh, healthcare in this country is broken. I'm like oh hell no. Healthcare in this country is excellent. It is world class standard. That's why people fly into the US if they can to get healthcare here. We have the best nurses, the best doctors in the world. The way we pay for it is broken. But healthcare is very cheap and very affordable and very accessible if you know where to look. And not enough effort has been put towards that for, I don't know, maybe if you want to go down the conspiracy rabbit, uh, holes, maybe there's a reason why, but there's just not a lot of us like this that have decided to say, look, we're going to not just go into work every day and do right by our communities, but we're actually talk about it and showcase and be an inspiration for others. So you know, I salute you on that one. Just actually bringing solutions to bear and showing people that there's options. Now I do have a question for you. So when we talk about community owned health plans and you know you mentioned the Savannah plan earlier. How do you handle cases in this day and age where you know, for the first time in human history people can go live where they want to live and then find work. Usually it's been I got to move to the city to find a factory. You know, you kind of dictated by your job. So when as workforces get further and further scattered and more dispersed, how does something that emphasizes local healthcare options, how do you square that with remote workforces?

Speaker B: Sure, yeah, it's a great question because you, you will see that. Right? Local direct contracts. But I have people spread out. Right. How are they going to use this plan? How does that even work? I can't even think how that could work. People live 500 miles from the hospital upon which the plan is direct contracted so there's a couple of different ways. The easy button is that typically there are what's called rap networks involved in plans, right? So in the Savannah plan, for example, uh, there's an HCA based hospital, Memorial, and their network is Memorial Health Partners. Right? But in those contexts where they know that there are people that live outside the service area, those people can be served by what's called a rap network. So think about the base layer of a cake being the network. M. Maybe it's Cigna, maybe it's a direct contract. Whatever the case may be on top, there's. There's a second layer, right? And that's, that's called the wrap network. And so for folks. So Chris, if you worked for an employee that was based out of Savannah and they had this direct contract, you would have access to either the first health network, which is the most commonly used one, and then sometimes out of area claims can be processed through reference based pricing, right? Which is again, what does Medicare pay providers? It's Medicare plus, uh, a percent. And that percent can vary. So in essence there's an easy button to it. Uh, but frankly, there are some plans that just have no network at all. As mentioned, they just pay the Medicare plus percentage and that's the reimbursement methodology. And in those instances, there's no network. So everybody's out of network. Uh, but everybody is available to take cash from the plan, right? Or to take and process the insurance card, even though they may not know what it is. Exactly. So a little bit of it comes down to education. You have to have the plan structured so that people can use it and you're, you know, positioning them for success. But so much of it comes to education. You and I have seen for decade, uh, or more, right? MRI is the most boring example. Let's talk about it. You know, MRI in the hospital, four grand MRI cash, 500 bucks. If the employee member knows, just to ask for the self pay rate, you know, they save money, right? The health plan saves money. The provider gets paid something adequate and they get paid immediately. So these are the features that are embedded within the plan to try to make it easy. But again, as mentioned, so much of it comes down to education and that's a tough nut to crack, right? People are more interested in what their neighbor just bought, right. Or like, what kind of purchase they're going to make next, right? They're not like, how does my health plan work? I really nerd out on this. You and me do, right? We read the books and we talk to People, we go to conferences and that's awesome, right? And these are like our people. Most folks are like, I just want it to be easy. So the educational component is critical. Uh, and that's where it does come down to the employer, you know, being aligned in the mission, the broker being beside their employer saying like, hey, who's going to be the champion of the program, right? Who's going to educate your people? Because it doesn't work like a traditional program, but it's all for the better. So it's, it's a tough nut to try to crack, but there's so much to it. If people are just smart consumers, as you alluded to, so much of these things that are problems and challenges with healthcare can just be solved immediately like say yourself, mate.

Speaker A: Yeah, going in asking for a cash price. Right. Novel, uh, concept. So do you think that, you know, we talked about national, national um, plans, national networks, one size fits all approaches in your professional opinion? I mean do you think the real future of employer health care is on that national scale or do you think it's kind of what we've been talking about where it's more of a, less of a national scale and more of like a regional intelligence is what I'm going to call it.

Speaker B: You know, I think it's, it's so hard to see top down change, uh, be affected right. At scale. We just seen it happen, right? We've seen the aca, what has that result been? Higher costs and just more, more games of like let's play with the charge faster and let's charge for as much as we can because we know a lot's going to be denied anyway. Right. And uh, it's just really hard, right? So, so for me, like what, what my heart says the answer is is literally one community at a time. And for that to start, like it has to be one employer at a time and it has to be a very diligent effort. I mean you might be able to find fix a community that has a rural community, maybe you know, a few hundred or a couple thousand, you know, in the population, but if they have one hospital in their town, they can literally fix their entire healthcare ecosystem by themselves. And that can happen.

Speaker A: Yeah. So, so uh, if I'm listening to this and I'm involved in a local chamber of commerce, why am I not picking up the phone to say, nico, help us put this in here and then get everybody involved in there as well. I mean this seems like this is the fix towards like association health plans that we used to Be able to have, uh, where common people could come together, common audiences. I mean, what is to prevent a community like that of, I don't know, small businesses coming together and saying, hey, let's do this all together, not run a foul regulations, but stop trying to just purchase and figure this out in silos.

Speaker B: Yeah, you're right. I mean, I think the challenges are many. Um, when you mentioned the Chamber of Commerce, I mean, I think a lot of people will know and in listening to this, that they're members of the chamber. Typically there is a chamber based health plan that is offered and it is from one of the largest national health insurance companies in the country. And I'm not going to say that they are a name of a color. But that said, I mean, you know, the chambers of commerce get what's called a marketing fee for promoting said program. Does it help the community? Does it ultimately hurt the community? I think we know the answer to that. And without dancing around too much because I'm getting tired, it's almost impossible, like to have people without this long form discussion know what the root causes and the issues are of why health insurance and even health care, not to conflate and confuse the two terms. Right. Are so fundamentally fragmented and just broken and frankly expensive. Um, so for people to understand what the fix is, they need to know that there's a big problem. And I think a lot of people are desensitized to that. And if, yes, chamber of Commerce did realize that they can partner with independent health plans instead, then they could do a lot of good work in helping their own communities. Right. I think it's just that the fact that people just throw their hands up too quickly without understanding the root challenges of health care and health insurance and how it's purchased through companies and through brokers advice, who again, may or may not have different objectives than their clients. Right. And we can just keep it there. That said, I think most people just say it's messed up, it's expensive, and it's not my problem to fix. Right. So I think again, if more people listen to like your podcast and they're like, run to the chamber, run to their broker. Like, we need a community and health plan. Go find one and let's do this.

Speaker A: So giving you, um, you know, the reins, the reins of the world, the magic wand, I guess, is the keys of the kingdom. There we go. I'm trying to get my, my metaphors right here. And you're talking to these employers, you're saying, all right, we're going to design the perfect, you, uh, know, player health benefit from the ground up. How many different components are there? Like what actually needs to go into it to say, yes, you have an actual real benefit now.

Speaker B: Yeah. So you don't want to do too much too quickly. Right? Because like as mentioned, like your family and my family, like we were able to adopt into cost sharing and like we know that doesn't necessarily work in a group context because people have different needs. Right. And some people's medicines would not be covered or some people, you know, would have a very tough time using a plan or understanding it. Right. So in our silos it's very easy when it comes to an employer. I think that what the answer is is that they need to start to adopt into a plan where they have visibility. Right. They understand what's going on, they're able to modify and change the plan so it actually is centered around healthcare and their member based experience. And then each subsequent and progressive year in that program they are drilling down and controlling costs even more with Walmart and their Centers of Excellence program that Tom Emmerich had pioneered, uh, and championed years ago. Right. They realized they had to control the unit cost. And so they said if you don't go to a center of excellence where we negotiate a special contract with our milliad covered lives, Johns Hopkins for ortho, let's just say, right? Or Mayo for cancer or you know, whatever the case may be, Cleveland Clinic for heart, they said if you don't go here, we're not going to cover it or it'll be much more out of your pocket. And so that's the extreme. But to even have a plan where people know they can go to places that are of high quality, that are of reasonable cost to get there, I think it's a multi year approach, first year, pretty easy to use the plan. We're not going to have that many cost restrictions or throttles dialed up when it comes to like what's covered or what's not covered. We just need to get access to the data. We need to take the leap and enter this kind of plan that has a national network. Maybe that is easy. And then maybe the next year we say, okay, now we're going to start to tighten the pharmacy controls a little bit. It doesn't make any sense to have due excess on the formulary. That's just two cheap drugs combined and it's way more expensive now. Right. So you can do things like that progressively each year, start to incorporate bundled surgery, start to talk about in the first year, hopefully Direct primary care, where that is an option within the plan. You go to a website, you go to a portal and you choose, you choose a doctor and then you don't pay for that. That's part of the plan. So uh, I think too much too soon is where people get stuck, but they can go to a partially self funded health plan where they have visibility, right, where they actually have some control and then they can work with their broker, consultant to just refine it over the years because that's how anything is, is made better, right? Through iterations, through finding out what's working, what's not working, listening to their staff, having someone that's a benefits champion, let's just say locally within the group. I've seen that Chris, and it wasn't my original idea by any means, but I don't know why that's not required for any employer. Like someone needs to intimately know how the health plan works because this is a huge P and L line item and we have to control this cost and we have to have someone who educates our people as to how this works. It can't just be, here's your ID card, go to your member portal, figure it out. I know that's a long answer, but like I think you could do it in stages, right? And you don't just throw your hands up and continue to do the same broken thing every year. Because that's the definition of insanity. Again, not my original idea, Einstein, and it's in my proposals because it's great. It's like literally the definition is doing the same thing, expecting a different result. And we're not going to get a different result unless we make some, some changes.

Speaker A: Yeah, absolutely. And thank you for being solution oriented as we wind down our episode here. Uh, it's Nico Capor, Community owned Health Plans. Nico, appreciate you man. Thanks for coming on the show.

Speaker B: Pleasure buddy. Glad to be here.

Speaker A: And for those listening, Nico is available at cohp.info that's cohp.info check out his site. Uh, Nico, the website is a wealth of information and what I love is that it is not full of jargon and I feel like the normal anybody could get in there and say, okay, this actually makes sense, I understand what it is without try to gatekeep it behind vocabulary in industry speak. So appreciate you putting that out there. Any last words of wisdom for anybody saying, you know what, we do need to make a change and uh, oh, by the way, it's probably time to start making a change and looking forward to next year.

Speaker B: Yeah, I would say. Well, first of all, Chris, thanks for what you do. It's tremendous effort. You know, people getting involved, right? Like that. That's in and of itself is great. Step forward. Forward, Right. Finding what Fmma is, right. Fmma.org just taking a peek at the website like you did with cohps, finding people that believe in the same thing, have these conversations with business owners, with business leaders, folks in positions where they can actually affect change, right? And say, hey, look what's going on with healthcare. And just, just getting involved. And there are great ways to do it. A lot of great people that are, that are charging very hard towards change. And I think that folks can dial in. You know, FMMA is a great one. Your podcast is another one. I mean, there's, you know, as, you know, hundreds of different ways to engage, but I think it's just taking a, uh, realistic look at where people are now. What are you spending on health care? How do you buy your insurance through your employer? Is your employer buying the same kind of stuff they always have and just be vocal about it, right? Like, there are other options out there. Even telling an employer, like, go look at fmma, see who the people are in our area and just have conversations with them. Right? Like, I think that'd be a great place to begin.

Speaker A: Yeah. For our listeners, that's fma.org, the free market Medical association. Longtime partners, longtime supporters of the show, and really this industry helping it forget level. This is once again a big thank you to Freedom Health Works for their ongoing sponsorship. Ladies and gentlemen, I appreciate you listening once again, I'm Christopher Habig, CEO of Freedom healthworks and your host of Healthcare Americana. As always, thanks for listening. Check out healthcareamericana.com to hear all of our episodes. Visit the shop and learn more about the podcast.

Speaker B: Healthcare Americana is produced and managed by Taylor Scott and iPodcast Pro. Whether you're a patient, employer or physician, the Free Market Medical association can facilitate and assist you in your free market healthcare journey. The foundation of our association is built upon three price, value and equality. With complete transparency in everything we do, our goal is simple. Match willing buyers with willing sellers of valuable healthcare services. Join us in healthcare. Accelerate the growth of the free market healthcare revolution. For more information on the Free Market Medical association, visit fmma.org.