healthcare advisory
RE-IMAGINING HEALTHCARE
Sustainable savings while improving benefits —redirecting millions back to classrooms, educators, and students.
THE CHALLENGE DISTRICTS FACE
School districts in Texas are grappling with escalating healthcare costs and mismanagement over their benefits programs. These challenges collectively strain budgets, erode trust, and expose districts to significant financial and legal liabilities.
RISING PREMIUMS
With annual increases ranging from 5-12%, healthcare premiums consistently outpace inflation and wage growth, placing an unsustainable burden on district budgets and forcing difficult trade-offs in other critical areas like salaries, facilities, and educational resources. This multi-year trend makes long-term financial planning nearly impossible.
LACK OF TRANSPARENCY
Districts often lack clear visibility into how their healthcare dollars are actually being spent. They don't know the true cost of services, the effectiveness of their plan design, or whether they're getting fair pricing for medical procedures and prescriptions. This opaque system makes it impossible to identify cost-saving opportunities or negotiate better terms.
RISK TO THE DISTRICT
The Consolidated Appropriations Act (CAA) introduced stringent compliance requirements for health plans, placing a significant fiduciary responsibility on districts. Failure to comply with mandates regarding price transparency, gag clause prohibitions, and broker compensation disclosure can expose districts to substantial penalties, class-action lawsuits, and reputational damage.
Without strategic intervention, these interconnected problems will continue to compound, leading to further budget crises, decreased employee satisfaction, and increased liability for school districts.
WHAT WOULD YOU WANT TO PAY
Variance in costs for an MRI at Memorial Regional Hospital in Florida:
$1,827
Cigna Plan
$2,455
Blue Cross Plan
$262
Cash
Direct contract pricing delivers significant savings while maintaining provider relationship
The UBF Solution Architecture
Our comprehensive solution addresses core challenges faced by school districts through an integrated, multi-pronged approach. By combining these four essential pillars, UBF empowers districts to regain control over their healthcare benefits, optimize spending, and ensure better outcomes for their employees. Individually, each component offers significant advantages. Together, these four pillars create a powerful, synergistic system that not only resolves current healthcare challenges but also establishes a sustainable, transparent, and employee-centric benefits program for school districts.
Direct Contracting
Partner with local health systems. This approach eliminates unnecessary intermediaries and allows for direct negotiation of services, driving down costs and improving the quality of care for district employees.
Transparent Pharmacy
Full rebates back to the plan. We ensure complete transparency in prescription drug costs, guaranteeing that all rebates are returned directly to the district's plan, which significantly reduces overall pharmacy spend.
Care Navigation
Guide families to high-value care. Our dedicated navigators help employees access the most effective and affordable healthcare services, improving health outcomes and preventing unnecessary expenditures.
Data Oversight
Claims audit & benchmarking. Continuous monitoring and analysis of claims data provide actionable insights, identify inefficiencies, and allow for proactive adjustments to benefit plan design.
RESULTS THAT SPEAK FOR THEMSELVES
PROVEN RESULTS
Our commitment to optimizing your healthcare strategy is reflected in tangible financial outcomes. The "Per Employee Per Year" (PEPY) cost is a critical metric for evaluating health plan efficiency. By significantly lowering the average PEPY to $6,780 compared to the industry benchmark of $8,435, we demonstrate our ability to deliver substantial savings for your district without compromising quality of care. This difference represents a direct financial benefit that can be reinvested into your educational mission.
$6,780
Client Average PEPY
$8,435
Industry Benchmark PEPY
100%
Healthcare-Focused
WHAT THIS MEANS TO YOUR DISTRICT
Every strategy is built to support your district's financial and educational goals—completely independent of carriers.
1
Funds previously allocated to inflated healthcare costs can now be redirected to critical educational programs, technology upgrades, or facility improvements.
2
Lower healthcare expenses contribute to budget stability, allowing for more predictable financial planning and resource allocation year-over-year.
3
Investing in a more efficient and effective health plan can lead to improved employee satisfaction and retention, attracting top talent to your district.
HIGH COST CLAIM MITIGATION
How UBF Reduced Shock-Claim Exposure from >$1.2M to $69K
High-cost claims pose a significant threat to self-funded organizations, driving up premiums and creating financial instability. Traditional insurance models often fall short in proactively managing these catastrophic events, leaving districts vulnerable to unexpected financial burdens and undermining employee trust. UBF's innovative approach tackles this challenge head-on, transforming risk into predictable outcomes
01
Voluntary Program
Confidential support for members with severe conditions. Our care navigation team engages directly with members facing complex or chronic health issues, offering personalized guidance and support. This proactive intervention ensures members receive appropriate, high-quality care, often preventing conditions from escalating into more expensive treatments.
02
Premium Funding
Help eligible members access coverage assistance. For qualifying high-cost claims, UBF identifies and facilitates access to alternative funding sources or programs. This strategic approach offloads portions of significant claim costs from the district's self-funded plan, directly reducing exposure and preserving plan reserves.
03
Claims Exit
High-dollar claims move to separate solutions. Once alternative funding or specialized programs are secured, specific high-cost claims can be transitioned out of the primary self-funded plan. This protects the district from future liability for these particular claims, ensuring that ongoing costs do not impact the core benefits budget or stop-loss limits.
04
Lower Premiums
Reduced stop-loss costs and future claims. By proactively mitigating and exiting high-cost claims, the district's overall claims experience improves significantly. This favorable claims history leads to substantial reductions in stop-loss insurance premiums in subsequent years and lowers the likelihood of future shock claims, creating sustainable savings.
3-Year Gross Savings: $4.5M – $5.3M
Real-World Impact
- Enhanced Member Well-being: Employees with severe conditions receive dedicated, confidential support, leading to better health outcomes and a higher quality of life.
- Predictable Budgeting: Districts gain greater financial predictability and stability, minimizing the impact of unforeseen catastrophic health events on their budget.
- Improved Plan Sustainability: By effectively managing the most expensive claims, the overall health plan becomes more sustainable, allowing for continued robust benefits without increasing premiums.
Proactive high-cost claim management is not just about saving money; it's about protecting the long-term health of both employees and the district's financial well-being. By taking control of these significant expenses, organizations can ensure a more secure and healthier future for their entire community.
MITIGATING PHARMACY COST TREND
The Challenge
A mid-sized public-sector utility health plan faced rising specialty drug costs and lacked the staff to regularly verify whether its PBM was pricing drugs correctly and adhering to the contract.The plan faced significant pharmacy cost increases driven by brand list-price inflation and exponential specialty drug growth. This led to budget volatility and the risk of missing out on valuable PBM guarantees, rebate terms, and effective specialty channel management.
Marketplace Procurement & Contract Optimization
UBF initiated a structured PBM procurement and contracting process to foster competition and secure better economic terms, including robust discount and rebate guarantees, clear definitions, audit rights, and specialized provisions for high-cost drugs.
Independent, Ongoing Program Oversight
A continuous oversight model was implemented to systematically monitor PBM performance and identify discrepancies against contractual guarantees. This proactive approach supported timely remediation and recovery of overcharges through detailed claim review and reconciliation.
"Controlling the Controllables" Program Governance
UBF operationalized five strategic levers: timing, optionality, competition, independent oversight, and member education. This framework minimized leakage and ensured sustained savings long after initial contract negotiations.
Illustrative Results
A market check revealed a modeled first-year improvement potential ranging from 4.89% to 14.38% in total pharmacy spend across various options. The analysis also highlighted significant gaps in retail brand discounts and rebate levels compared to market averages, indicating substantial negotiable upside.
RICK NILES
Vice President, Client Strategy
RICK'S BACKGROUND
- Led teams and product development at UHC, Aetna, Cigna, and ADP
- Product development in 800+ Texas school districts
- Assisted 100+ districts transitioning from TRS ActiveCare
RICK'S APPROACH
- Partnership Focus: Builds strong, collaborative relationships with clients to understand unique challenges and objectives.
- Data-Driven Strategies: Utilizes in-depth analytics to inform decision-making and develop effective, measurable solutions.
- Proactive Risk Management: Implements forward-thinking strategies to mitigate client financial exposure and ensure long-term plan sustainability.
- Employee-Centric Design: Crafts benefit plans that prioritizes member well-being and access to high-quality care.
REDEFINE HEALTHCARE
Partner with UBF Consulting to unlock significant savings, enhance employee well-being, and ensure the long-term sustainability of your benefits program. Let us help you navigate the complexities of healthcare with proven, predictable solutions.