EP453: Running a TPA (Third-Party Administrator) RFP Process That Is Less of a Wild West Fiduciary Shootout, With Claire Brockbank
Relentless Health Value™October 17, 2024
453
37:0033.87 MB

EP453: Running a TPA (Third-Party Administrator) RFP Process That Is Less of a Wild West Fiduciary Shootout, With Claire Brockbank

TPA stands for third-party administrator. RFP stands for request for proposal. I’m kicking off the show today with a review that we got recently on Apple Podcasts, and not just because it’s a really nice review. It’s because it’s relevant on about nine levels to the show today with Claire Brockbank from 32BJ Union, which is all about contracts and the importance of using your own paper for contracts during the RFP process.

For a full transcript of this episode, click here.

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Here is the review: “[I am] the CEO of a large senior living company who has always geeked out on Medicare payment innovation but was … bored and disengaged from our own health insurance spend on a self-funded plan. It wasn’t until I listened to several episodes of Relentless Health Value that were focused towards C-suite audiences that I began to understand that population health and the triple aim should be viewed in all aspects of insurance and health coverage. I have since consumed the show frequently, while driving my health insurance brokers crazy with questions and accountability.

“The show has not only given me the knowledge that has created confidence in guiding our strategy but has given me the actual tools to be able to make impactful change. I have reached out to several experts interviewed to utilize their services and ideas and have been able to use the CAA [Consolidated Appropriations Act] details to get transparency from my vendors.

“Thank you … for giving me what I need to provide the best possible care at [reasonable prices] for my coworkers and get beyond the insurance ‘noise’ and smoke screens to understand the opportunities at hand.”

Thank you very, very much.

This review, in and of itself, I’m gonna say, is kind of a crib note for C-suites for the why, the what, and the how to think about their health plan. Population health and the triple aim and getting reasonable, affordable prices really should be viewed in all aspects of insurance and health coverage. Otherwise, there’s 160 million Americans with commercial insurance right now who are not gonna get the aforementioned.

Now, you know what they say: A small key can sometimes open a very heavy door. In this metaphor, the door is population health at an affordable price for plan members, as just discussed. The small key we’re talking about today is what’s going on with the plan at the contract level. What’s in those contracts that the plan sponsor is signing, in particular, the one with the TPA or ASO (administrative services organization) or carrier—terms I’m kind of using interchangeably here.

One guest on Relentless Health Value after another has said this about the importance of the contracts the plan sponsor is signing: Paul Holmes (EP397), Andreas Mang (EP419), Cora Opsahl (EP452) from last week. It’s the contracts that give a plan sponsor the rights and ultimately the power to get the rates they’re looking for and also is a big leg up to get the quality and population health they may be seeking, nothing for nothing, because contracts give access to the data needed to get plan members to the care settings that are quantitatively the best.

But now I’m gonna say a hard truth. The stuff that Cora Opsahl talked about last week (EP452), what Claire talked about this week, what the CEO who wrote the review above was saying, and I have talked to plenty of plan sponsors with lots of grievances about the downstream impacts of what basically goes back to a bad contract. And once that bad contract is signed, there’s not a whole lot that can be done to fix whatever egregious things are going on as a result of that contract.

As but one example—and Cora and Claire talked about this—it’s about how allowing upside-down payments, for example, that are in a lot of ASO contracts, this allowing of upside-down payments. I mean, it turns out that 32BJ spent, I think, $10 million paying more than the bill was for one year. If somebody signs that contract as handed to them by the carrier, then the plan is now contractually obligating themselves to pay more than the price the clinical practice was charging. So, doc sends bill for $100, and the carrier pays that practice $200, right, on behalf of the plan sponsor.

So now the plan sponsor is paying $200 for a $100 bill, right? I don’t know. Is this conflict of interest? Is it imprudent? Is it not reasonable? Said another way, is that a bit of a fiduciary breach on the plan sponsor?

So, I get why the team at 32BJ pushed back and pushed back hard. I get why the leading edge of plan sponsors and more and more C-suites are hotfooting it into conference rooms to plan their RFP process and doing it in the way that Claire Brockbank talks about today.

For an open-source contract and some other free tools, please do head over to the 32BJ Insights Web site.

Also mentioned in this episode are 32BJ Benefit Funds, Paul Holmes, Andreas Mang, Cora Opsahl, Justin Leader, National Alliance of Healthcare Purchaser Coalitions, Health Transformation Alliance, Purchaser Business Group on Health, Julie Selesnick, Dave Chase, and Shawn Gremminger.

You can learn more at health.32bjfunds.org and by following Claire on LinkedIn.

Claire Brockbank is the director of policy and strategy for the 32BJ Health Fund, a Taft-Hartley fund serving almost 200,000 covered lives. She is responsible for the Fund’s efforts to drive down hospital prices, including a multistakeholder campaign to draw attention to the central role that hospital prices play in healthcare costs and to drive action to lower those prices through public policy, operational innovation, and direct interaction with hospitals. Claire’s expertise in healthcare pricing was also instrumental in steering the Health Fund’s radical approach to its recent RFP process and developing a model contract that firmly establishes the rights an employer should have with its third-party administrator.

Prior to joining 32BJ Health Fund, Claire served as CEO of Peak Health Alliance, a healthcare purchasing cooperative in Colorado. As the lead architect of the development and launch of Peak, Claire was responsible for leveraging data and community organizing to lower premiums by approximately 35% in its first two years of operation. Peak also pioneered innovative benefit designs to channel access to more value-driven services. Claire earned a master’s degree in health policy and management from Harvard University.

05:36 How does the initial contract writing affect how events in your healthcare plan will go?

06:56 What happens if a plan sponsor or employer doesn’t do the contracting right?

10:42 How much could be saved by doing contracting right?

11:01 EP433 with Justin Leader.

12:22 How do you start an RFP process with your own contract?

14:06 What Claire Brockbank recommends doing to do a TPA RFP process in a way that’s best for you.

19:46 What factors do carriers need to get an ASO or TPA to respond to using your contract?

21:11 Open-source contract available from 32BJ.

21:57 Why it’s important to really probe brokers, despite loyalty to your broker/consultant.

24:30 Who are the reliable agents and experts when carriers are looking to start this process?

26:24 EP428 with Julie Selesnick.

27:56 What’s the silver lining to this effort?

29:17 Why is it important to make it clear why you’re doing what you’re doing for your lawyers and any other support team you need?

31:39 What does “good” look like in this process?

34:15 Why is it important to continue to hold your ASO accountable?

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