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AMS Co-Founders invited to Shiftshapers Podcast

AMS Co-Founders invited to Shiftshapers Podcast

AMS co-founders Dr. Stacy Borans (CMO) and Peter Borans (President) were recently invited to the Shiftshapers podcast. Hosted by David A. Saltzman, Shiftshapers showcases industry leaders who are taking the transformative shifts in the insurance and employee benefits industry and shaping them into new business models, products and best practices.

In the two-part podcast Stacy, Peter and David discussed the self-funded landscape: It’s biggest cost drivers, the importance of both case management & employee risk management, cost containment, and predictive modeling.

Highlights of Part One:

Changing from fully insured to self-funded

  • Pros and cons
  • Rising premiums
  • Risks
  • Case management/administration
  • Complexity

The $375000 hospital bill

  • Outrageous? Nope, completely normal!
  • Who pays?
  • What constitutes a high dollar claim?
  • Mark-ups on implantable hardware

What concepts advisors need to understand

  • Understand their client population: healthy (exercisers) or risky (smokers)
  • Incentivizing employees to become healthier …so premiums go down


 Highlights of Part Two:

The importance of plan advisors and the impact of chronic disease

  • Identification and management of most at-risk employees
  • Proactive intervention – the spectre of surveillance
  • Massive disparity between R&C and vendors/databases/provider charges
  • Plan documentation can also tie hands
  • COST CONTAINMENT (reasonable and customary):
    • Specialty Drug sourcing – specialty pharmacy
    • Negotiate drug prices/claims from provider
    • Auditing claims to REASONABLE charges

How reference based pricing (RBP) and narrow networks impact claims

  • Providers still game the system by increasing percentages
  • What references one can use other than Medicare
  • What providers are willing to accept
  • Networks serve two masters: You and the provider

The view thru the windshield—not the rear view mirror

  • Predictive modeling & analytics
  • Brokers can get in touch with those who do have predictive modeling data
    • 200+ diagnoses
    • 400+ specialty pharmaceuticals
    • Networks
    • Treatments
    • Geographical area
  • Value comes through
  • Knowledge is power


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