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Deb Ault and some of her fellow RNs were against managed care when they were working at patients’ bedsides – but now she thinks it could help innovate and improve care while saving money.  

Nurse Deb is the President of Ault International Medical Management and a pioneer in the medical management field. As an advocate of proactive and predictive case management, she helps patients and their case managers navigate the diagnosis, treatment, and financial aspects of healthcare.

Deb defines and discusses the four types of medical management and explains why she thinks predictive management is the model of the future. She shares how she realized care management could both improve care and reduce costs when done correctly. Deb also emphasizes the importance of employer engagement in health plans, and why they must balance the cost of care with the health of their employees.

What You’ll Learn From this Episode:

  • Why Deb had a change of heart about medical management and how she discovered its potential.
  • The four types of medical management and which Deb finds most effective.
  • The monetary advantage of each type of case management.
  • Why it’s difficult to lead Americans with a carrot or pay them to behave the way you want.
  • How to get employees and employers alike more engaged and compliant in healthcare.

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Episode Transcript:

David:      How can understanding the four modes of medical management help you to deliver exceptionally better value for your clients? We’ll find out, on this episode of Shift Shapers.

Change either paralyzes, or energizes. The choice is yours. You’re listening to the ShiftShapers Podcast. You’re about to learn firsthand from businesses and entrepreneurs who have successfully shaped the shifts in their industries. Get ready to become the change that you want to see. Here’s your host and chief transformation strategist, David Saltzman.

David:        This episode of the Shift Shapers Podcast is brought to you by Captivated Health, a captive insurance arrangement that help small and mid-market companies escape the fully insured marketplace and deliver stability, control and savings without watering down employee’s benefits or increasing their premium share. If you have clients in the educational institution or the engineering vertical, go to our website at captivatedhealth.com or click on the company logo on the Shift Shapers website.

We often think about medical management as something that’s kind of a behind the scenes activity, but it’s starting to move to front stage and for some very, very good reasons. One of the people who’s making that happen is our guest on this episode of ShiftShapers – Deb Ault, otherwise known to those near and far as Nurse Deb. Deb is president at Ault International Medical Management and so with that, welcome Deb.

Deb:           Thank you for having me.

David:        It’s our pleasure. You’ve had an interesting path to get to where you are today and I think that informs a lot of our conversation. So if you wouldn’t mind, would you spend a minute or two talking about how you got to where you are?

Deb:           Well sure, I’m happy to do that. I am first and foremost a registered nurse. That’s how I started my career at the bedside. Worked in the ER, ICU, critical care kind of areas, moved around as a lot of nurses do exploring other areas, home health and doctors office. Landed at a telephonic nurse on call program, which was kind of good because it gave me an opportunity to further my education. It also was my first experience of working with patients over the telephone and I was always intrigued with the kind of impact that you could have not being face-to-face with patients. So that’s how I wound up on the telephone side of working with patients.

I got laid off from there unfortunately when some cost-cutting initiatives came into play. You guys probably remember that time of the market when all of the big hospitals were having all these great big consulting companies come in and show them how to cut their costs. At that point in time, I was very convinced that managed care was the reason that cost-cutting was necessary on the provider side. I was very vocal about it and was involved in the nurses’ union. I had been interviewed for television, spoke with many politicians about the cost-cutting that hospitals were doing, and became more and more dissatisfied at the bedside because of that, and feeling more and more pressure like a lot of nurses do to compromise patient care. So I was very anti-managed care, but then when I got laid off, having been so vocal about the cost-cutting that the providers were doing, I found myself having difficulty getting a job at any of the other large hospitals in the city.

So my husband pushed me to apply for managed care position. I kept telling him, “No, they’re the evil ones. They’re the reason were having to cut all these costs.” To make him be quiet, I applied. Fortunately, I wound up at a company that was nurse-led and they were following the teachings of Catherine Mullahy and were doing good case management. The problem that they were having was that they were having difficulty explaining to the bean counters, especially in the self-funded major medical health plan world which is where I am, how that was having a positive financial impact for the plan.

I’d continued my education, and I’d gotten my bachelors in business with a minor in math and statistics. So they hired me essentially to learn case management because of that math background and being able to come in and define savings and explain how getting the right patient to the right care at the right time in the right place would naturally result in the right price for the health plan. So that’s how I started my career in managed care and have the typical spinoff sell merger acquisition moving around in different roles in the managed care industry.

Then about 15 years ago, we had gone through one of those buyouts by venture capital and said to my husband, “This is crazy. These guys are not the kind of people that I want to work for. I’m going to have to look for another job.” He said, “No I think it’s time that we do this for ourselves.” So he convinced me to open AIMM about 15 years ago. We’ve been working in the self-funded major medical health plan arena ever since.

David:        To level set a little bit, you break managed care down into four different types. I’d like to take a moment and explore each one of those. The first one is reactive. What does that mean?

Deb:           Reactive is what we kind of traditionally think of when we think case management. So something happens. A patient becomes ill, has a catastrophic condition. They’re diagnosed with something or they’ve had a huge amount of claims spend happen. Then a case manager steps in to react to that. I affectionately call this also a “paid historian” model, because once that diagnosis has already hit, once those claims have already arrived, it’s very difficult to do anything that’s going to be impactful on the clinical quality of care or on the financial control side. So reactive is kind of responding to things that have already happened, often very far back in the timetable.

David:        The next piece you talk about is real-time. What is that and how does that differ from reactive?

Deb:           Real-time hit the market about 20 years ago. It was predominantly nurses who were doing case management who were frustrated with reactive and who were saying, “Listen, I need to get out in front of this. I need to be able to respond right away.” So as soon as somebody gets diagnosed with cancer or MS or any kind of life altering condition, I want to get involved real time at that point in time. That was more effective than reactive, but not still not everything that it possibly could be.

Reactive – when I think of the reactive model and the impact that it’s going to have on clinically a patient, it’s minimal. The horse is already halfway across the stream; telling them to change paths is difficult at that point. It’s disruptive in a negative way. They’ve already established relationship with care providers. Financially, what you see happen in groups that have reactive case management is they follow trend. If the trend increases 8%, they’re going to financially perform at 8%, 9%. If they’re really lucky, maybe 7%.

When you get into real-time and you start getting engaged with members at the time of diagnosis, then you can begin to have an impact clinically because you’re educating them. At least getting them to understand what questions they need to be asking their care providers. You’re also able to have more of a steerage in that which specialists are going to be chosen. Yes, maybe the doctor who diagnosed them with cancer told them a doctor he was going to refer them to but they haven’t seen that doctor yet. So if there’s another option that they need to be thinking about, they’re more open and receptive to it.

It also has a better impact financially. So those groups typically are going to beat trend not by a huge amount, but they will come in a couple of points under trend in comparison to everybody else in the market. So it does have an impact. It’s better than reactive, but it’s still event-driven.

David:        Then there’s proactive, which I guess means what it sounds like, but how does that happen in practice?

Deb:           So proactive is, if you remember a couple of years ago, we went back to expanding the list of things that require precertification. So there’s been this big back and forth and back and forth in the market for things like imaging studies. So maybe you get a pre-cert request for somebody who’s going to have an MRI and that MRI is highly suspicious of a catastrophic diagnosis. At that point, you get the member engaged. Start having conversations with them and say, “Hey I have gotten your precertification completed. When will you get the results back?” You’re building rapport much earlier in the course of illness.

Now, of course, sometimes those will come back no big deal. It was negative. Everything is benign. It’s fine. They’re not going to need any treatment. So, yeah, there is a little bit of “waste” there, but the benefit of doing it that way is in those instances where it does truly come back important, catastrophic, serious, you’ve already got rapport built with the patient. They already know that you’re there to help them. Making sure that they’re getting the right care, making sure that the timing is flowing smoothly, making sure that they’re getting care in the right place.

So because you’re able to do that, you’re able to have a more active role in helping them get the care that’s right for them. Doesn’t always mean that they’re going to do what I would do or what you would do David, but they’re going to make an informed decision. They’re going to have all of the tools and resources and support and guidance at their fingertips to help them through that. So you’ve become proactive because you’ve gotten in front of that date of diagnosis. Something is suspicious, there’s a high likelihood. There’s a potential coming down the pike, now we’re being proactive about getting that person engaged.

David:        Now a word from our sponsor.

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So then we go from being in front of the date of diagnosis to actually in front of the diagnosis altogether with the fourth piece which you call predictive.

Deb:           Absolutely. I love predictive and I think that it is where everybody should be and probably everybody will be before too much longer. There are great tools out there and have been for quite a while. The problem has been that not a lot of people have wanted to adopt them. Some people are averse to the cost even though it’s a minimal cost to do any kind of claims data mining or predictive risk modeling. There’s been questions about, “Is this clinically valid? Is this mathematically valid?” I think we’ve overcome all of those hurdles with a couple of products in the industry. So you can now begin to actually do predictive risk modeling. Guess what? You can initiate case management based on prediction.

Again, is every person that you predict is going to spend $25,000 in claims next year, definitely going to spend $25,000 in claims next year? No. Nobody has got a crystal ball that’s 100% accurate, but it’s worth the time and energy to invest in doing predictive risk modeling and the medical management that goes along with it. That’s really where you can begin to have a maximum impact on people’s lives, on what happens to them clinically and what happens to the plan financially.

So with the proactive model of medical management, we talked about where a group is going to perform in comparison to trend. You can really begin to have a good impact on spend. If you do predictive, then you can not only have the impact of proactive which will continue, but you can also flatten that trend out long term. So if you think of reactive as being right about trend, real-time slightly below trend, proactive cutting trend off, cutting that in half or stopping the flow of dollars, and then predictive as leveling that out long term.

David:        You say there’s products that are out in the market that do a pretty good job with predictive modeling. I remember years ago when I was with Humana. It was one of the things we chased and the number we always looked at was R squared – more colloquially I guess, how often you predict correctly. Where are those numbers at today? I know there’s a lot more data that’s flooded into those models that should have increased that.

Deb:           So it depends on whether you’re looking at clinical prediction or financial prediction. Most of the ones that are really worth using are going to be at least 80% accurate both clinically and financially. There’s always going to be that 20% the guy who drives his Lamborghini around the curve too fast and ends up in the side of the mountain that you can’t predict. At least 80% accuracy should be the threshold that you’re looking for as you’re shopping for those.

David:        So one of the things we talk about a lot on the podcast – and you may have heard us talk about it – is compliance, and how you get folks to actually engage. I know that you feel that Americans are kind of unique in that they don’t really respond to carrots. So that being the case, what do you use? Sticks, or orange sticks, or some combination of the two or…?

Deb:           It’s different from group to group to group. I think that’s one of the key characteristics. If you want to be successful in continuing to provide health benefits, but being able to do that in a financially feasible way, you have to understand your population and what works for them. Don’t get me wrong. I’ve got a group or two that their members will respond to a drawing for a $5 movie coupon. But those are pretty few and far between. Generally speaking, as Americans, we’re pretty affluent. Even offering somebody a big-screen TV may not be enticing to them. For the most part, you’re not really able to buy behavior. You may be able to buy participation, but participation isn’t going to generate the outcomes that you want if people don’t change their behavior. So it’s a real challenge.

I think the only thing that has truly worked in my experience… what I’ve seen work is an intensive education campaign and a culture shift within the organization, the employer organizations, since the employer is the one that’s providing the health plan. When you begin to get that happening, then your engagement rates go up. Engagement results in behavior change. Behavior change results in cost reduction. So it’s really appealing to the nobler motive as Carnegie would say. That seems to work best with the most of our groups or most Americans.

In other countries, things are different. As we travel the globe, we find that different cultures have different motivations. Most of the people that I work with…again, I work in a self-funded major medical health plan arena. So these are all people who are gainfully employed and they can pretty much afford the things that you would offer. Although I will tell you that I have seen groups be very successful, especially with the younger generation….so if the population of the plan is very young, offering incentives for things like extra days off, because we find that a lot of people in that millennial generation are seeking better work life balance, but again that’s not always as effective at getting the behavior change which is the real outcome that you’re striving for.

So it really boils down to education and changing the culture of the organization. It really has to start at the top of the organizations. So the C suite has to be on board and they have to be focused on this. They have to be focused on a combination of a couple of different things. They have to be focused on how do we improve the health of our members and simultaneously control the cost of our health plan. So that’s a balance that they have to be focused on. If they focus just on cost, we’re back in the old HMO world and that’s not going to get us where we want to be.

If they focus just on health – especially if the tenure of the population isn’t a long one – they may be investing in making that person healthy for their competitor when they leave and go to work for somebody else. So there’s a real balance there. The C suite has to be involved in setting up what that balance is going to be for their organization.

David:        There’s a lot of conversation going on around a topic that you may have bumped into called noncompliance. Where do you stand on noncompliant and working with noncompliant individuals as a tool to help move trend and to move claim spend?

Deb:           So that’s an interesting topic because as nurses we work with patients. The whole noncompliance issue is continual. You have to really step back and start thinking about things like Prochaska method and where somebody is on the stages of change scale and those kinds of things. There’s noncompliance for a lot of different reasons. We have to determine whether that noncompliance is what I call the result of free will. “I’m fully educated about the ramifications of my choice but I’m going to make this choice anyway,” versus noncompliance that comes from a position of lack of knowledge.

When it’s coming from a position of lack of knowledge, there’s a lot that can be done, by case management and in particular, medical management, to make sure that that person is equipped with all of the information, resources, support, guidance that they need so that they can make the best choice possible. I talked a little earlier about the HMO world. Most self-funded health plans at least don’t want to dictate treatment. They don’t want to be in the business of practicing medicine for their employees. They’re in the business of making widgets or whatever their core business is. They do want their people to have the information to make the right choices for them.

So distinguishing noncompliance into two different categories, the categories I call it a free will versus lack of information and education and then applying Prochaska method and motivational interviewing techniques and things to make sure that that patient has everything that they need.

David:        So we’ve got about a minute or two left. We always like to wrap up by asking our guests where they see the future. You certainly are out on the edge and doing some things that other folks maybe haven’t embraced yet. Where do you see your field going? Where do you see the future?

Deb:           I really feel like we’re at a great crossroads right now. I’m not sure that everybody in the industry recognizes it. I think especially with everything that’s happening politically, one of two things will happen. Either we, meaning those of us in the industry, will step up and revolutionize healthcare or we’ll end up with a single-payer nationalized healthcare kind of system. I think were at that point that in the very short term we’re going to have to make a decision as a country and go one way or the other.

I think that we as an industry have the capability. We have the tech. We have the mind power. We have the resources to truly revolutionize healthcare. I think that the tools are there. The question will become whether those who are providing health plans, the employers that are sponsoring health plans will get on board with it and will grasp it, and whether the big carriers will embrace it or not. Whether the big hospital providers will embrace it or not. I think that’s yet to be seen. I think we’ll go one of two ways. We’ll either revolutionize it and it will be a beautiful thing or we’ll end up in a nationalized system.

David:        Well that certainly is a stark choice and we’d love to have you back as that unfolds and talk to you more about where the direction is. Deb Ault, president at Ault International Medical Management. Nurse Deb, thanks for sharing your expertise with the Shift Shapers audience.

Deb:           Thanks for having me. I look forward to talking again sometime soon.

The Shift Shapers Podcast is a production of Strategic Vision Publishing and David Saltzman. This podcast may not be reproduced in any form, in whole or in part, without the express written permission of the producers. All rights reserved.

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Transparency is the single topic with the most potential to transform every aspect of health and health insurance. We’ve decided to devote two episodes to this potentially innovative topic.

For part one our guest is Ralph Weber, President and CEO of MediBid. Ralph is a passionate subject matter expert and serves as a member of NAHU’s Healthcare Cost and Quality Transparency Workgroup. In this interview, we explore his belief that current healthcare pricing schemes purposefully withhold information from consumers, and why Millennials in particular won’t accept the current status quo on transparency (or lack thereof).

Ralph also describes the effects transparency has on the U.S. healthcare system, the marketplace, and the competitive environment. He shares why transparency alone won’t affect the needed changes to our healthcare system. We also learn why some hospitals charge more for the same type of treatment than others as we discuss the differences between static and dynamic pricing.

What You’ll Learn From this Episode:

  • Ralph’s journey in the health insurance space.
  • The difference between dynamic and static pricing and its effect on the consumer.
  • How Ralph defines transparency.
  • Whether or not the most expensive care is the best healthcare.
  • What the future of transparent pricing and healthcare services might look like.

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Our ShiftShapers subject matter expert this week is Jessica Waltman. Jessica serves as principal at Forward Health Consulting, which she established after 16 distinguished years as Senior Vice-President of Government Affairs for the National Organization of Health Underwriters.

In this wide-ranging discussion,  Jessica discusses ACA reporting, the need for clients to have up to date plan documents, and the outlook and implications for the “Cadillac Tax”. She believes that all of these, while complex, provide an unparalleled opportunity for benefit advisors.

We also take a look into the future and the political realities in healthcare in the coming months. Since regulation and legislation never seems to end, we are excited to announce that Jessica has agreed to visit with us on a quarterly basis to keep the ShiftShapers audience current.

What You’ll Learn From This Episode:

  • Whether regulatory and legislative changes provide opportunities.
  • Whether there is an information vacuum.
  • The number 1 issue that faces employers today.
  • The two things advisors should focus on.
  • The prognosis for the PPACA Excise (a/k/a “Cadillac”) Tax.
  • The ramifications of the recent decision about defining group sizes.

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On this week’s episode of ShiftShapers, we’re excited to be speaking with Robin Gelburd, president of FAIR Health, a national independent non-profit organization that’s currently doing some interesting and effective work around the broad subject of pricing and transparency.

They have recently released a must-read study for anyone in the benefits field titled “Understanding Consumer Health Insurance Preferences” (use our SPECIAL OFFERS link on the right to download the entire study).   Robin joins us today to talk about the study and to discuss why she believes that transparency without clarity is like a sink full of dishes.

We will explore some of the most interesting findings of the study, such as how and why certain constituencies access care in different locales. We also explore common misconceptions consumers have about pricing and what they find most important when choosing a healthcare plan. You won’t want to miss  this informative episode.

What You’ll Learn From This Episode:

  • What FAIR Health and their mission are all about.
  • Significant differences in trends with diverse demographic groups.
  • Whether it is surprising that consumers find health care costs higher than imagined.
  • The most important factors to consumers when selecting a plan.
  • The recommendations that the survey suggests.

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  • Understanding Consumer Health Insurance Preferences” Study –
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This week we welcome Employee Benefit Adviser Magazine’s “Adviser of The Year” Tim Olson, the managing partner at The Olson Group.  He joins us today to share his journey to building a successful benefits practice and to talk about some of the innovations their agency is using to keep the at the top of their game.

We begin by discussing their beginnings and the way the agency has expanded to provide a deeper level of value to their clients. Tim chats about the variety of services they offer and how they use those to attract prospects with various needs to become full-range clients. Tim offers key insights into the powerful strategies they are using to stay on top of the changes in the industry.

From using different types of technology to the immense value of mastermind groups, you’ll discover great tips and game-changing advice that can help your agency become a powerhouse in the benefits marketplace. Don’t miss this opportunity to learn from the “Adviser of the Year.”

What You’ll Learn From This Episode:

  • How The Olson Group­­­ got its start.
  • How you can let prospects know about the full range of services offered.
  • What happens when you aren’t the “right fit.”
  • Why it is all about the value.
  • Why investing in technology is key – for all size agencies.
  • Why mastermind groups are crucial to continued development.

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In earlier episodes (see links below) we have spoken with physicians who are taking a very different, and more free-market approach to pricing health care. Their numbers are growing rapidly and while some may think that “free market medicine” is an oxymoron or an impossible dream, a new and growing association is beginning to prove otherwise.

On this episode of ShiftShapers podcast, we’re excited to welcome Charlie Sauer, co-founder and the executive director of the Free Market Medical Association. Their organization is dedicated to promoting transparency and forwarding the ideals and practice of medicine without the intervention of government and other third parties.

We invited Charlie to talk about the transformative nature of free market medicine. We asked Charlie how it can be possible to have free market in medicine in an environment where the government pays more than 50% of health care spend. We discuss the issue of whether consumers would be better off if artificial discount arrangements and multiple third parties were removed from the health care pricing landscape and why Charlie believes that our country is headed in that direction.

What You’ll Learn From This Episode:

  • Whether the health care in the United States is an economic Oz.
  • How you can promote free market solutions with the government paying more than 50% of health care expenditures.
  • How we can get out of this cycle.
  • Whether the ACA complicated the problem.
  • The tools do consumers need.

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From fully-insured to self-insured, a great deal of focus is on funding strategies rather than products. In previous episodes of ShiftShapers podcast, we’ve discussed everything from minimum premium to captive arrangements. In this episode Bill Hill, president and CEO of Visor Benefits, helps us take a deep dive into the defined contribution plans and some of the novel ways to deploy them with your prospects and clients.

We invited Bill to share his unique journey and some interesting things he has learned along the way about defined contribution and what role it plays in his practice today.  We explore the changes ACA has made in the design and deployment of this arrangement. We also talk about how geographic and specific market variations and needs influence plan offerings. Learn some of the insider tips you need to be aware of to best serve your clients when discussing defined contribution plans with employers.

What You’ll Learn From This Episode:

  • The regional differences of two companies Bill worked with.
  • How Alaska factored in.
  • Whether smaller groups should eliminate group coverage.
  • Whether advisors should lead employer conversations with plan design or concept.
  • Whether these approaches work in self-insured plans.

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Increases in personal responsibility, a need to control employer costs and a desire to improve the health of employee populations are renewing an interest in the area of on-site and near-site clinics. Karen Hjerleid, the Vice-President of National Business Development at Paladina Health shares her knowledge of the area and offers insight into an old concept that may make sense for an ever-increasing number of employers.

Karen joins us to talk about how the ACA has increased populations seeking care from smaller networks and overburdened providers. Those characteristics can often result in employees not receiving care when they need it.  Coupled with deferred care due to ever-larger out of pocket amounts, Karen believes a new model of the old clinic structure can offer answers to these and other system-related problems.

We explore the different types of arrangements and how advisors can best position them with their prospects and clients. We ask Karen about the reasons that traditional carriers have not warmed to this option are beginning to come around now that the interexchange of data has become more robust and real-time.

What You’ll Learn From This Episode:

  • The perverse incentives in the system.
  • What drives the interest in employer-sponsored clinics.
  • Whether the group size matters.
  • What the medical home is and why it is important.
  • Whether there is a robust data exchange between clinics and carriers within those clinics.

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More so today than at any time in the past, benefit advisors are looking for new markets to serve. In this episode, we discuss some non-traditional markets that may be new to many of our listeners and we discuss the techniques that resonate in those markets. There’s no better person to talk about this topic than our guest, Bob Gardner, the National  Business Development Coordinator of Freedom Care Benefits.

We invited Bob to talk about the new opportunities and imperatives in previously uninsured group markets and what advisors need to know to be able to capitalize on those opportunities. In this conversation, we define these traditionally uninsured market segments and discuss the reasons why advisors should consider serving them. Don’t miss this important episode that will surely open your eyes to some new and interesting possibilities.

What You’ll Learn From This Episode:

  • What these traditionally uninsured markets are.
  • What has made them a new priority.
  • Interesting ways to solve problems while mitigating costs.
  • Whether traditional group carriers participate in these markets.
  • What the advisor/client conversation looks like.

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In the post-ACA environment we have seen intensely increased interest in self insured financing arrangements. Some elements of self-insurance are now making their way out as stand-alone components, and are even being applied to fully-insured plans. Our guest and subject matter expert, Crystal Williams, President of RxReins joins us to discuss reinsuring one of the biggest cost drivers in any plan: pharmacy.

In this episode of The ShiftShapers podcast, Crystal explains the basics of stop loss coverage. We explore strategies and tactics that advisors can use when discussing this cost driver with prospects and clients. Crystal also gives us the carrier’s perspective on this unique strategy as applied to fully-insured plans. This is a novel conversation that will help you to differentiate yourself and deliver value-added intelligence for your clients.

What You’ll Learn From This Episode:

  • The basics of stop loss coverage.
  • Whether it is unusual to apply stop loss to pharma only.
  • How this can work with fully insured plans.
  • The impact of this type of arrangement.
  • What to benefit advisors need to know to discuss this with their prospects and clients.

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