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Empowering Plans: P62 - Obamacare is Still the Law, Right?

On January 10, 2019
Ron and Brady dissect the Texas decision that challenges the legality of the ACA, what it actually means, and what is next – as well as what you could (should?) be doing now.

Empowering Plans: P61 - Leather Patches & Pipes

On January 2, 2019
The Phia Group’s foray into higher learning! Ron discusses with professors Silverio and Jablon the forthcoming master’s degree program in plan development they will be teaching. If you’re up for the challenge, prepare to learn!

Faces of Phia: Episode 3 – Flying High with Judy

On November 29, 2018
In this episode, Ron and Adam sit down with Judith McNeil. Judith is the most recent winner of our “Employee of the Quarter” award, as well as our second Face of Phia. Judith’s story goes from inspiring to hilarious, and is one you certainly won’t want to miss. Expect to see things differently by the time you’re done with this episode.

Empowering Plans: P59 - Talkin’ with TPAC

On November 16, 2018
In this “Partners in Empowerment” episode, Ron and Brady enjoy chatting with Michael Meloch, President of TPAC Underwriters and valued member of The Phia Group’s own advisory board. Michael isn’t shy when it comes to diagnosing the issues, boiling healthcare cost containment down to simple basics we can all appreciate, and telling it like it is. His employer based perspective and focus on the bottom line (a/k/a “risk”) is as refreshing as it is informative. Don’t miss this one!

Faces of Phia: Episode 2 – Not Your “Norma-l” Employee

On November 16, 2018
In today’s episode, our hosts chat with Norma Phillips… our first official “Face of Phia;” (sorry Matt). Norma explains what makes her different (and special) as well as what makes The Phia Group so unique. From Friday night films, to saving the American workers’ job… Norma and the team touch all the bases.

Empowering Plans: P58 - Special Edition: Talking Politics, Elections, and Healthcare

On November 1, 2018
Like it or not, healthcare is on the ballot – nationally, statewide, and locally. The questions asked and people we elect will have an impact on how we receive and pay for healthcare – and for those of us in the benefits industry – failing to identify the trends, issues, and opportunities is tantamount to waving the white flag. Stay in the know and get ready to go; don’t miss this episode of Empowering Plans.

Empowering Plans: P57 - AHPs: Will They Live Up to the Hype?

On October 22, 2018
Have you heard? In 2019 it will be easier than ever to form a self-funded “Association Health Plan” (AHPs) … So what? In the words of Jurassic Park’s Dr. Ian Malcolm (a/k/a Jeff Goldblum), we have been so preoccupied with whether or not we could, we didn’t stop to think if we should. This podcast discusses the pros and cons, as well as benefits and hurdles the final rules have created for these new AHPs. From compliance with State MEWA laws to obeying federal laws such as ERISA’s consumer protections (including the Mental Health Parity and Addiction Equity Act [MHPAEA]), we dissect why we must slow our run towards AHPs to a measured walk.

Empowering Plans: P56 - 2019 - Fly Ball or Home Run?

On October 15, 2018
In this episode, Ron and Adam discuss the many issues, changes and challenges 2018 has lined up for 2019, and how the outcomes we witness in 2019 are certain to change everything by 2020. Tune in, or suffer the consequences!

Empowering Plans: P55 - Learn from the Past to Shape the Future

On October 1, 2018
In this episode, our hosts sit down with industry legend and innovative leader, Jerry Castelloe of Castelloe Partners, to dissect the state of the health benefits universe, identify new issues, repeat offenders, and determine what trends, risks – and victories – from the past are shaping the future.

Empowering Plans: P53 - The View from Nova Healthcare

On September 5, 2018
In this episode of Empowering Plans, Adam Russo and Jennifer McCormick interview Laura Hirsch, President of Nova Healthcare Administrators. They discuss the latest stop-loss trends, patient assistance programs for prescription drugs, and other issues facing the self-funded industry.

Empowering Plans: P52 - The View from SIIA’s Political Perch

On August 15, 2018
In this episode, Adam Russo and Brady Bizarro speak with Ryan C. Work – Vice President of Government Affairs at the Self-Insurance Institute of America (“SIIA”). They talk politics, D.C., and more importantly, about the efforts of the Government Relations Committee to advocate for the self-insured industry. From stop-loss protections and an updated “ERISA Notebook” to new wellness program rules, Ryan reveals the top issues on SIIA’s political agenda and explains how member engagement can really make a difference.

Empowering Plans: P51 - A Healthcare Homerun

On August 8, 2018
In this episode, Adam Russo, Brady Bizarro, and Ron Peck (yes - he’s back!), chat with Mark S. Gaunya – Chief Innovation Officer and Principal of Borislow Insurance. As an author, innovator, and passionate industry advocate touting more than 25 years of experience, Mark doesn’t pull punches as he addresses the biggest opportunities and threats facing employers, employees, and their plans. If you want to know what’s wrong with the nation’s healthcare system, what we need to do to fix it, and enjoy it when someone teases Adam – this episode is a must listen.

Empowering Plans: P50 - Where is Ron? A Very Personal Podcast from the SVP

On July 26, 2018
In this episode, our Senior Vice President & General Counsel dials in to describe where he's been, what major health issue is impacting his family, and what he hopes we can all learn from their experiences thus far - as members of the industry, potential patients, and human beings.

Empowering Plans: P48 - Make Cost Containment Great Again

On July 17, 2018
Brady Bizarro and Adam Russo discuss the hot topics impacting the insurance industry today.

Empowering Plans: P46 - You’ve Gotta Fight, For Your Right, to Try!

On June 29, 2018
Welcome to Empowering Plans a show dedicated to identifying waste and undo expense in the health benefits industry. Discovering ways to maximize benefits while minimizing costs, and empowering employers, administrators, and consultants to emphasize once again the benefit in benefit plan. Today’s episode is brought to you by the Phia Group Empowering Plans Since 1999, now here are your hosts the Phia Group’s own CEO Adam Russo, and senior vice president and general counsel Ron Peck, and Brady. ADAM: Hello everybody, and welcome to another episode of Empowering Plans with the Phia Group. Hello everybody! Hi-lo audience! I am your co-host, and the CEO, and co-founder of the Phia Group, Adam Russo. With me as always is our general counsel, senior VP Ron Peck. Say hello Ron RON: Hello Ron. ADAM: And what else can you say about Jen? Everyone just check. Just look at Jen. What can you say? Our amazing, the smartest, the brightest, the wonderful, the LinkedIn superstar, once we put Jen’s picture on anything the views go up. RON: You’re giving away my secret weapon. ADAM: That is Ron’s secret weapon. RON: That’s how I get all those hits. ADAM: Our vice president of our recovery services, Jennifer McCormick. Say hello Jen. JEN: Hello. ADAM: She always does the “Hello” that’s it. So folks Jen is a little freaked out. This is our first, I guess, it’s not a podcast, what do you call these Ron? RON: A vlog? ADAM: A vlog? We are videotaping live. Pat our producer is here, he is sweating too. Pat has multiple jobs today. RON: Funny too because he is off the camera, I mean he could actually be naked right now. ADAM: He might actually be on camera; I don’t know how wide this lenses is. Folks, we appreciate you all joining us on a short notice. This is a big, big, big deal for us for two reasons. One, you can see our beautiful faces. But two, this right to try law that was recently passed by President Trump. People have already reached out to us many times in regards to the impact. We figured, just based on the amount of responses, the amount of impact we feel this has on our industry we thought we would bring in our expert. And as she likes to say, “The right to try, is it right for you?” And we will talk to you about it a little bit. Jen, do you want to give them a little background, and we will take it from there guys. JEN: Sure. The right to try while it is a new law that was actually just issued in May of 2018, so it’s about a month old or so at this point, this is not a new concept. This concept has been along for about ten years at this point. And this was an FDA expanded access program that was giving individuals the right to receive certain treatments that were not otherwise FDA approved throughout the entire process. ADAM: So if is not something new, then why is it new? JEN: So the caveats to the right to try act are that now instead of having to go through FDA approval you can get your physician to sign off on it. And you can get it through that process instead of having those extra steps of that FDA red tape. ADAM: So I was reading about the FDA red tape, and that fact that 99% of the time the FDA approves it anyways. Again let’s be honest if I have a terminally ill family member, and I’m meeting with our doctor, and they can approve it right then and there, let’s be straight up like having to go through the FDA process in my mind even though at the time I’m assuming no one knows that it’s 99% approved, it’s daunting, right? To go through that process. JEN: It is intimidating. RON: I think, Adam actually you make a good point. ADAM: Oh Ron, everyone check out Ron’s suit RON: Hey hey, feeling good ADAM: Is that a new one, Ron? RON: Uh no.. this is one of ADAM: Why are the tags still on the suit, Ron? You should probably take those tag off before RON: I just figured if someone tries to take it away, I could always get it back, you know? You gotta label everything these days. But anyway, you mentioned the FDA and the existing expanded right use rules and the fact that in essence it mirrors the RTT or the right to try up until a certain point when all of a sudden the FDA has to basically make an exception on a per case basis. And Adam your point that they say, “Oh but we make an exception 99% of the time, so why do you need to get around it?” When it’s basically going to pass right through. I think that there are a number of people who didn’t even try because they knew either they weren’t going to get approval, or they didn’t have the time, or they were daunted by it. ADAM: Or they were scared! Obviously, it is a process. You have family member, a loved one is dying, and you have to go through the FDA to get approval to take a drug that may or may not work that just passed phase one. I get it. RON: That is why they say 75% of statistics are made up, right? ADAM: Right RON: Because ultimately, you know the only people who are submitting it for FDA approval are the ones who know they are going to get it passed, which is why you have a 99% success rate. JEN: Right, the other thing here that’s complicating is that ADAM: We actually should let Jen talk, Ron. This is her expertise JEN: Right RON: Alright JEN: Well the cost, right? Previously, you would assume that if you have to go through the FDA approval process it is going to be expensive. Right? RON: Sure JEN: New drugs are always expensive. So now, under the new RTT regulations the drug manufacturers actually have to provide the drug at actual cost. ADAM: So you actually know, again transparency, you actually know the cost of the drug? RON: That’s true ADAM: If there was a drug, again, these are all trial right, they are first phase or past phase one testing so you know the cost of it. Here is my question, okay: one, who pays for it? Who is actually paying? So even if it’s the cost and that cost is a thousand dollars, who is paying that thousand bucks? JEN: The patient. Right, so right now, there is no requirement; no obligation for anyone (health insurance, self-funded plan) no one is required to pay this cost. This is on the patient. ADAM: So as a self-funded employer, there is no negative effect on me. I don’t have to cover this. If anything, if I care about my employee I can decide I guess if I want to cover it. But I might actually save their life. JEN: Right ADAM: So what is the negative? JEN: The negative potentially could be “I’m going to cover the drug, but it’s only gone through phase 1 of the FDA trails. So we don’t know what happens in phase 2, what happens in phase 3.” ADAM: What if there is a side effect? RON: Yup JEN: Right. Exactly ADAM: Who pays for that? RON: Good question JEN: And what about the complications? Right. So that piece of it has made people a little bit wearied to add this to their current plan because they say “Great maybe this is a super alternative…” ADAM: Okay, let’s say it’s not added to the plan again we are going to use our self-funded plan. Knock on wood, I get really sick. I go “Alright, the plan is not going to pay for it, nor should they; I get it you’re going to cover FDA approved drugs.” I pay for it myself. I have side effects. Whose responsibility is it to pay for the complications? RON: Right ADAM: The plans? JEN: Right now, under the current regulations, the plan has zero obligation to do that. But, how can you tell what is an obligation, or what is a side effect of that particular drug? It’s only gone through phase 1 testing, how do you know? ADAM: Right. So let’s say I get the flu afterwards. RON: Is flu a side effect, or did you just get the flu? That is one of the difficulties ADAM: Bingo. That is some of the areas where there is difficulty. RON: A lot of people have said when you look at most plans usually, not only do they exclude a certain treatment or service, but then they also exclude side effects or complications of that excluded treatment. So people are hanging their hat on that. And the thing is if it is something you know is excluded; let’s say plastic surgery, cosmetic surgery that’s absolutely excluded. The person goes in for cosmetic surgery, next thing you know they have some sort of infection, a surgical infection. You could draw the line, one to one and exclude that too. But you are right because these things are so unknown, how do you know that is a complication? ADAM: So, Jen. I guess my question for you is you know, we are an empowering plans podcast, right? What advice do we have for our self-funded clients? What advice do we have to their advisor brokers? On what do they need to talk to their clients about? If anything. What changes are there in the plan design, if any? How does this affect stop loss? I know it’s a lot of questions but run us through the whole thing JEN: The first step is right to try, this means that there is now an opportunity for people to have access to drugs they did not have access to before. ADAM: Potentially, good JEN: Potentially a good thing. ADAM: Potentially, bad JEN: So is this an opportunity that as an employer you want to take advantage of? Yes or no? Regardless of whether it is yes or no, you still need to look at your plan document. If you say yes, you need to make sure you are revising the plan to accommodate a non-FDA approved drug. You are making sure you are potentially modifying- ADAM: For critically ill patients JEN: For terminally ill patients. RON: You want to mirror the law ADAM: How do they define terminally ill? JEN: It is a life threatening disease where there is not otherwise a clinical trial that’s going to be available for that individual, and your physician otherwise agrees that this would be the path for you. ADAM: Well, I didn’t know she would have the answer so fast. RON: Yeah there you go ADAM: I thought I’d get her.. it didn’t work RON: In essence, Adam well, if you mirror the definition in the law, I think that is the best way to go. JEN: Right ADAM: So, you are looking at plan definition changes, exclusion changes if any? JEN: So, the exclusion you are going to want to caveat is “the complications of a non-covered service” to make sure that the references are not to non-FDA approved drugs. You are going to want to potentially look at your definition of drug. But when you are covering this there is no requirement that if you cover it you have to cover the whole thing. So maybe you want to cover up to $5,000. Maybe you want to cover one dose of treatments. Maybe you want to have precertification requirements. You can add those types of caveats and conditions on this drug because this is not an essential health benefit. ADAM: Got it JEN: You can put any of these limitations in place that would be the most appropriate for the plan, while still helping. But, you still really need to address the side effects and the complications issue. I think that is going to be the trickiest piece. That is going to require some sort of clinical analysis to decide on a case-by-case basis whether that particular drug has side effects that cause some sort of illness. ADAM: My last question: stop loss. How does it affect your stop loss policies and the interactions with the carriers? JEN: Yeah, when it comes to stop loss similar to those RIO writers that we started seeing five, six, or seven years ago, this is going to be a similar situation to that. Cause right now, every stop loss carrier has in their policy an E and I provision. In that E and I provision it says non-FDA approved drugs are E and I. ADAM AND RON: Right JEN: So this is a non-FDA approved drug. ADAM: So, even if the plan wanted to cover something chances are their stop loss carrier is not going to reimburse them. RON: You are going to need to coordinate with them ahead of time. ADAM: But, even if the plan decides to cover this experimental drugs, the plan can still say “But we are not going to cover any complications.” I mean, let’s be honest what self-funded plan is going to say “Yeah, not only are we going to cover this experimental drug, {hey fyi patient I am going to do you a favor, I’m gonna cover that cost].” No one is going to say, “I’m going to cover every side effect too.” RON AND JENN: Right. ADAM: From a standpoint of expenses, the plan will know if they decide to cover these. Again, these are rare things that happen; if you have a 1000 employees, our typical self-funded employer has 250 employees, if you include the all dependents and everyone it’s about 600 lives. You’re not having, there is no multiple, there are not multiple people in a 600-life plan that are going to have life-threatening diseases where there is no available treatment on the market. JEN: Right ADAM: It is rare. This is a rare event. RON: I mean, Adam think about it. The expanded use program, that’s already been out for nearly a decade, if you are a self-funded planner or you’re an administrator, how many instances have you seen where a plan participant wanted the plan to pay for that? ADAM: Have we ever seen that, Jen? JEN: No. RON: No, never. ADAM: And we represent millions of lives RON: Millions and millions! ADAM: Millons! RON: Now, so let’s say RTT ends up seeing 10 times the amount of people, which is big but I don’t think it’s going to be that. But let’s say, so one person. I mean, again, you are absolutely right. I don’t think it’s going to be this earth shattering number. JEN: No. ADAM: But, again here’s what we know it is going to happen to somebody. RON: Uh huh ADAM: Somebody is going to mess this up, and probably we will be getting a phone call. RON: It keeps it interesting ADAM: Any other thoughts Ron? RON: Yeah, there are two more things that you have to take note of that are not necessarily tied into the plan document, but if you are thinking about RTT, these are the two things you need to think about. One, the law itself issues a waiver of liability; it basically protects from legal liability, the physician, the drug manufacturer, the patient, the person it does not protect is the payer. So, if you are a plan, and you want to either incentivize the use of an experimental drug, or you are just paying for the experimental drug, and then something does go wrong; you need to make sure you are protected to the same extent that the physician and drug manufacturer are by law. So, you are going to need something in writing ahead of time, some sort of whole harmless agreement. ADAM: So, Ron is basically telling all you folks at home to contact Ron. RON: So if you read between the lines there you go. ADAM: What was your second point? RON: The second point is when you talk about reasons to actually cover these drugs. I think people are looking at this and are thinking “Oh no, there is going to be all these people who want to use these experimental drugs. How do I avoid paying for it?” It is actually quite simple. The law allows you to do so. For those who start to think about “Hey, what are reasons to start to cover it?”One: the altruistic willingness and desire to help save people save their lives I think is absolutely a noble idea. The second, there may actually be a financial reason to do it. Because let’s say hypothetically somebody has a disease that is terminal; they are eligible for RTT, but its long, it’s drawn out. In the meantime taking in an approved drug, something that is covered. And that drug, a specialty drug, whatever, is extremely expensive. If this experimental drug actually results in them either being cured more quickly, or replaces that other drug it could be that, this is an in lieu of a much more expensive treatment that you are required to pay under law. ADAM: Right JEN: But you are still not otherwise excluding that other more expensive treatment. ADAM: Right RON: Right. That was one of the concerns we actually looked at is that can you make the willingness to pay for an RTT experimental drug contingent? ADAM: What Ron is saying is if you had (knock on wood) cancer RON: Sure ADAM: instead of taking normal drugs, he wants you to go to Chile, and meet with the witch doctor because it might cost 20 bucks. RON: Well, you know so the thing to remember though ADAM: That’s that non – not covered, but it might work! RON: Like Jenn said! ADAM: Maybe you won’t need chemo. You’ll save hundreds of thousands of dollars on the plan! JEN: You never know! ADAM: Let’s cover that guy! RON: It’s funny, I mean the thing is, like Jen said, you are going to have to continue paying for the chemo, but the hope is that this experimental drug will hopefully have a good result. And therefore you shorten the amount of time that the person is taking chemo. ADAM: Jen, any last words before we turn these cameras off? JEN: No, I think that it is important to make a decision about how you’re going to cover this plan or how this benefit is going to be covered. ADAM: So basically, she is saying contact Jen McCormick at the Phia Group in order to do that too. RON: I do want to make one point for our maiden voyage with the video podcast/vlog, isn’t it funny that we replaced Brady? ADAM: Because well, he’s not that good looking. RON: You are going to have to tune if you want to see Brady live. ADAM: However, we do want you to vote on who’s swag is nicer! This beautiful, nice batting helmet, little difference, nice Cleveland Indian paraphernalia with this beautiful family. Or Ron’s collection of…. Just very weird stuff. RON: Look, they jiggle. ADAM: And some random kid, we don’t even know who’s kid that is? It’s just.. That photo is actually a photo that they give you when you buy the frame. RON: That child is so beautiful it can’t possibly be real! PAT: There you go ADAM: Let’s vote online, if that’s actually Ron’s child! JEN: I was told I couldn’t even bring anything! ADAM: Do you notice that Jen has nothing. Yeah we just… you’re not that important though, Jenn RON: You’re subletting space from Brady Bizarro JEN: Oh, okay ADAM: Right we can have Brady’s stuff here. JEN: Right, oh god, yeah. ADAM: Which I would be afraid to even know what that be RON: If you want a bust of Nixon? You’re good to go. ADAM: Well everybody on behalf of Pat Santos, our producer, Ron Peck, our special guest Jen McCormick, and myself your host Adam Russo thank you for empowering your plans with the Phia Group. Have a great day.