Encore! EP379: How Much Money, Really, Are Employee Benefit Consultants and/or Brokers Making From Plan Sponsors? With AJ Loiacono
Relentless Health Value™February 15, 202435:1348.35 MB

Encore! EP379: How Much Money, Really, Are Employee Benefit Consultants and/or Brokers Making From Plan Sponsors? With AJ Loiacono

For a full transcript of this episode, click here.

Here on Relentless Health Value, we have done a bunch of shows lately on how some weird PBM (pharmacy benefit manager) and pharmacy goings-on impact plan members, patients, and also independent pharmacies. During the conversation with Benjamin Jolley, PharmD (EP422), for example, Benjamin mentioned that he thinks some of these contract terms that really hurt independent pharmacies are signed by employers at the urging of their brokers or employee benefit consultants (EBCs).

Think about this. You have these huge vertically integrated PBMs who own their own retail pharmacies and/or mail order. You have EBCs that work with employers who, a lot of times, do not understand the contracts that they are signing. This is a recipe for what AJ Loiacono talks about on the podcast encore today: just how much those EBCs and brokers are, in some cases, being compensated to get employers to sign contracts that allow PBMs to corner the market and take all the profit.

Even if you listened to this encore in 2022, you might want to revisit it and consider what AJ says in the context of these recent shows with Ge Bai, PhD, CPA (EP420); Joey Dizenhouse (EP423); Mark Cuban and Ferrin Williams, PharmD, MBA (EP418); and Benjamin Jolley, PharmD (EP422), as I just mentioned. Also keep in mind the shows with Scott Haas (EP365) and Paul Holmes (EP397) from earlier … Olivia Webb (EP337) as well.

This show with AJ Loiacono is different than others you may have heard with him because in this healthcare podcast, we are not talking about PBMs. We’re talking about brokers and EBCs.

So, say I’m a self-insured employer. Here’s the big question: Is my broker or EBC helping me make the right decisions, or is he or she helping me make decisions that will make them the most money?

While there are some amazing and totally above-board EBCs and brokers out there, unfortunately, caveat emptor is a thing. Buyer beware, that is. Too many self-serving and I’m sure very charming sharks are out there circling plan sponsors.

It is currently a fact that some EBCs and brokers and even TPAs (third-party administrators) or PBMs or others take hidden kickbacks or fees or percentages. They make a lot of money, maybe the most money, in these secret ways. All this money, money paid in secret backroom deals—let’s not lose track, these dollars increase the total prices paid by plan sponsors and employees.

Now, I say this to say that my guest today, AJ Loiacono, calls 2022, right now, a “magical moment” for plan sponsors—and for straight-shooting EBCs and PBMs and all the others who are actually doing the right thing by their clients also. It’s because of the Consolidated Appropriations Act (CAA), which states quite clearly that plan sponsors can ask their healthcare and benefits service providers to disclose the money that they are making off of the plan—all of the money, not just the direct fees.

The CAA went into effect December 2021, and contrary to what some people have said or may believe, it is in force right now. The field memo went out on 12/31/2021. So, the CAA is the rule right now.

And in fact, the CAA makes it imperative under ERISA (Employee Retirement Income Security Act) to do what I just said: Plan sponsors must disclose the monies that they are paying out on behalf of employees and ensure that those fees are reasonable and free from conflict. If you’re the fiduciary of the plan, you gotta disclose all these indirect and direct compensations of the people that you are paying or the people that you are paying who may be kicking back dollars to other people you are working with, unbeknownst to you. The Department of Labor is putting as much emphasis right now on healthcare as they put on 401(k) plans in the early 2000s, so this is a big deal—or it should be—for plan sponsors.

So obviously, in order to comply with the CAA, self-insured employers should be requesting from their EBCs and brokers or others that they disclose, in writing, how much money they are making off the plan. You can see why this disclosure would be necessary if the plan sponsor is responsible to determine if those payments are reasonable and seem to be free from conflict, right? You can’t evaluate something you do not know about, and if you don’t know about it, the plan sponsor is the one at risk. Ignorance is not an excuse here.

Here’s one example: What if the EBC or TPA is collecting a $40 payment per prescription from the PBM? Wait … what? Some plan sponsor is paying $40 per script in, I guess you’d call it, a commission? Yes, that is a rumored example—$40/Rx. It is basically full-on arbitrage, and if anyone disagrees, let me know why and how it’s not.

Or let’s say the EBC is making, say, $6 per script payable by the PBM, and this sum should be mailed quarterly to a PO box in another state. This was a condition, by the way, for a PBM to win an RFP (request for proposal) that the EBC wrote and picked the winner of. Yeah, you as the plan sponsor really probably want to know that this is going on because it’s your butt on the line.

So, in sum, the CAA is in effect right now. Penalties can be levied right now against plan sponsors. For a deep dive into the CAA, listen to the show with Christin Deacon (EP342) from 2021.

So, what’s the process if I’m an employer plan sponsor? Step 1: Request in writing the dollars that your EBC or broker is making off of you. Similar to the advice that you’ll hear often on this show, ask for actual dollars, not a percentage of this or that. Ask for how much money did you (broker or EBC) make off each program that you recommended to us, and what did that total up to. Once you make that request, the EBC/broker/TPA (whoever you’re asking) has 30 or 90 days to respond, depending on who you ask. But if they do not respond, then you, the employer, should report them to the Department of Labor.

Keep this in mind: Once that EBC or broker is reported for failure to comply by anybody, meaning likely some other employer, it is only a matter of time before that information becomes public. And the second that info becomes public, I guarantee you that there’s some attorney out there just waiting to file a class action lawsuit against every other self-insured employer who uses that EBC/broker because everybody else out there is now out of compliance. Right? I’m not a lawyer and I am certainly not a class action ambulance chaser, but even I can figure out that strategy.

AJ Loiacono is the CEO of Capital Rx, which is a PBM 2.0, as they call it.

To see how the CAA is playing out, you can read about one real-life example of a school district’s lawsuit against an insurance consultant.

You can learn more at cap-rx.com and find resources through law firms.

 

AJ Loiacono is a serial entrepreneur with over 20 years of experience in pharmacy benefits, finance, and software development. As the CEO of Capital Rx, his mission is to upgrade America’s healthcare infrastructure to deliver the highest level of client service and patient engagement while reducing total cost of care. AJ has spent his career studying the pharmaceutical supply chain and developing solutions that have continually redefined the pharmacy benefit industry to achieve this goal. Before Capital Rx, AJ was a co-founder of Truveris, where he served for eight years as CEO, CIO, and a board member, leading the company to record growth (Deloitte FAST 500 and Crain’s Fast 50). Prior to Truveris, AJ co-founded SMS Partners, a joint venture with Realogy (RLGY), and in 2010 exited the partnership with a buyout. In his first venture, AJ started Victrix, a pharmaceutical supply chain consultancy, which was successfully sold to Chrysalis Solutions in 2007.

 

07:09 Who can get in trouble for mismanaging employee funds?

07:48 “When you talk about conflicts of interest, they’re everywhere.”

13:13 “You’re paying for access.”

13:34 Why is it important to request that they disclose direct and indirect compensation?

14:04 What are the layers to these hidden fees and compensations?

18:13 What is a reasonable fee for a good plan admin?

19:27 “I think people need to take a step back and say, ‘How many different ways are they getting compensated?’”

24:50 “The compensation is not just unreasonable, but if they were to move it, they would lose access to an entire column of revenue.”

25:06 “For every good broker consultant, there’s a horrible individual lurking out there and it’s easy to figure out: Ask for them to disclose their fees.”

28:08 “You can’t win if you can’t even pay the house fee to come in.”

31:35 Why do you need to ask for disclosure, and what do you need to ask specifically?

32:21 What are some of the characteristics of a good plan consultant?

 

You can learn more at cap-rx.com and find resources through law firms.

 

Recent past interviews:

Click a guest’s name for their latest RHV episode!

Nina Lathia, Marshall Allen, Stacey Richter (INBW39), Peter Hayes, Joey Dizenhouse, Benjamin Jolley, Emily Kagan Trenchard (Encore! EP392), Cora Opsahl (Encore! EP372), Jodilyn Owen, Ge Bai

 

Employers,PBMs,compensation,capital rx,plan sponsors,pbm,drug cost,benefit consultants,caa,erisa,

Recent Episodes

EP463: Medicare Advantage Policies—Which Will Stay and Which Will Go Now? With Betsy Seals
February 13, 2025
463
35:1132.2 MB

EP463: Medicare Advantage Policies—Which Will Stay and Which Will Go Now? With Betsy Seals

Every Gen X’er listening to this is gonna be singing that Clash  song in your head for the rest of the day. So, let’s turn our attention to Medicare Advantage policy. And on the show today, I grill the one and only Betsy Seals to find out which policies she thinks are going to stay and which a...

Encore! EP384: How Shareholders Impact Carrier Behavior, Exactly and Specifically, With Wendell Potter
February 06, 202535:0132.05 MB

Encore! EP384: How Shareholders Impact Carrier Behavior, Exactly and Specifically, With Wendell Potter

I am drowning in all things Q1 right now. So, this week we’re going with an encore. But this is a great show to go back and reflect upon, as it’s about carriers and how shareholders impact the actions of said carriers. For a full transcript of this episode, click here . If you enjoy this podcast, b...

EP462: Managing Populations of Whole, Actual People Who Are Not the Sum of a Bunch of Different Body Parts, With Scott Conard, MD
January 30, 2025
462
33:3430.73 MB

EP462: Managing Populations of Whole, Actual People Who Are Not the Sum of a Bunch of Different Body Parts, With Scott Conard, MD

Hello, Tribe. I hope everyone is holding up in this Q1 where there is so much going on. I feel like I’m juggling 10 plates while running on a treadmill that keeps stopping and starting at random intervals. How you doing? For a full transcript of this episode, click here . If you enjoy this podcast,...

INBW42: A Philosophical Rabbit Hole of Considerations for Plan Sponsors and Others
January 23, 202527:3925.31 MB

INBW42: A Philosophical Rabbit Hole of Considerations for Plan Sponsors and Others

There have been two episodes lately that have sent me down a rabbit hole that I wanted to bring to your attention. Now, disclaimer: I know you people; you’re busy. You listen on average to, like, 26 minutes of any given episode. So, yeah … look at me being self-aware. I say all this to say welcome ...

EP461: Pick Only One, Plan Sponsors: Do You Want to Control GLP-1 Volume or Control GLP-1 Unit Cost? With Chris Crawford of RxSaveCard
January 16, 2025
461
22:4220.78 MB

EP461: Pick Only One, Plan Sponsors: Do You Want to Control GLP-1 Volume or Control GLP-1 Unit Cost? With Chris Crawford of RxSaveCard

This episode with Chris Crawford , CEO of RxSaveCard , is not about the when, why, or how of GLP-1s for weight loss or best-practice prescribing; and we do not wade into anything about lifestyle changes or who is adherent or clinical considerations and needed support. There are a plethora of shows ...

EP460: Rushika Fernandopulle, MD’s Theory of Change Starts With Status Quo Healthcare
January 09, 2025
460
41:0437.6 MB

EP460: Rushika Fernandopulle, MD’s Theory of Change Starts With Status Quo Healthcare

This is one of those episodes where we consider top-line strategic imperatives and key drivers. I thought there was no better person to do this with than Rushika Fernandopulle, MD, who, in case you were unaware, was the founder of Iora Health, an advanced primary care group that was sold to One Med...

EP459: Cost Containment by Co-Pay Maximizer or Co-Pay Accumulator: Points to Ponder, With Bill Sarraille
January 02, 2025
459
39:4736.41 MB

EP459: Cost Containment by Co-Pay Maximizer or Co-Pay Accumulator: Points to Ponder, With Bill Sarraille

If you have zero clue what co-pay maximizers and/or co-pay accumulators are and the financial incentives involved for PBMs (pharmacy benefit managers) and plan sponsors here, after you’re done listening to this episode, go back and listen to the show with Joey Dizenhouse ( EP423 ). Also, the episod...

Listen and Follow

Sponsored by Aventria Health Group
©2025 BD Bridges LLC. All Rights Reserved.