Price
The same service, by comparably credentialed providers, priced very differently across facilities in one market. Nothing about the care explains the gap.
In action
What intervention
What intervention
actually looks like.
Managing a plan sounds abstract until you follow it down to one person and one claim. The example below is the clearest version of it, and the shape it takes is the same wherever it applies: notice the situation in time, ask whether a better route exists, and make the better route the easy one to take.
Notice it in timeWhile the care is still ahead of the member
Ask the clinical questionThe treating physician decides, or nothing moves
Offer, never imposeThe member always chooses
Make it happenCoordinated across administrator and vendors
The clearest example
A hospital chair,
A hospital chair,
or a kitchen table.
Identical medicine, identical prescriber, a radically different price — and the less expensive option is frequently the one the member would have preferred all along. That combination is what makes site of care the most instructive place to start.
Illustration · site of care
Biologic infusion therapy
During the plan yearThe situation
What the plan is billed
A member on long-term biologic infusion therapy receives it in a hospital outpatient department. The drug is not the reason the claim is large — the setting is. A hospital outpatient department carries facility overhead and a markup that a lower-acuity setting does not.
How it surfaces
The gap becomes visible while it still matters
The analytics compare what the plan is paying against what the same drug, dose, and protocol costs in other settings. That happens while the therapy is ongoing, rather than in a review conducted after the plan year has closed.
The clinical question
Whether an alternative is appropriate
A medical decision, and one that belongs to the treating physician. Many infusion regimens can be delivered safely at home or in an ambulatory setting; some cannot. Nothing moves unless the prescribing physician supports it and the member wants it.
The coordination
Getting the alternative in place
Where it is appropriate, the practical work follows: the authorisation, the provider, the schedule, coordinated with the plan’s administrator and the vendors involved. Same drug, same dose, same physician overseeing the therapy.
The member’s side
Usually the option they would have chosen
A hospital infusion consumes most of a day: travel, parking, check-in, waiting, then hours in a chair. A home or nearby ambulatory visit is scheduled around their life. And because the setting costs the plan less, the plan has room to reduce or remove what the member pays.
The timing
Why none of this works later
Once the sessions have been billed at the hospital rate, that money is spent. There is no retroactive version of this. The only version that changes the number is the one that happens during the plan year.
The economics
Same therapy. Two prices.
The differential between a hospital outpatient department and a clinically appropriate alternative is wide enough that waiving the member’s cost-share entirely can still leave the plan far better off. That is what makes this a purchasing problem rather than a benefits problem.
Same therapyThe drug, the dose, and the prescribing physician do not change.
Lower costThe plan pays for the care rather than for the setting’s overhead.
Less disruptionFor many members, a scheduled visit instead of most of a day at a hospital.
An illustration of the kind of situation active management is built to find. It is not drawn from a specific client engagement, and the size of the differential varies by drug, market, setting, and contract. Bar widths are conceptual.
Where it applies
The same discipline,
The same discipline,
six places to point it.
Site of care is the clearest illustration, not the only one. These are the categories where a plan’s money reliably goes somewhere other than into care — and each of them responds to being managed rather than negotiated.
Setting
Care delivered in the most expensive venue available rather than the one the clinical situation calls for. Infusions, imaging, and routine procedures are the usual examples.
Pharmacy
A small number of drugs driving an outsized and accelerating share of total spend, purchased through whichever channel the contract happened to specify.
Sequence
Care that arrives in an expensive order — an emergency department visit that a same-week appointment would have prevented, a complication that follow-up would have caught.
Vendors
Programs billed for every employee every month whose actual use nobody has measured lately.
Timing
The largest category of all: waste that was entirely addressable while it was happening, and became permanent the moment it was billed.
The pattern
Four steps,
Four steps,
in that order.
The situation changes; the sequence does not. And the member says yes or no at step three, every time.
01
Detect
Reading claims and pharmacy data continuously rather than quarterly, so a situation is visible while something can still be done about it.
02
Verify
Whether an alternative is genuinely appropriate is a clinical judgment, and it belongs to the treating physician. Where the answer is no, it stops here — which happens more often than the industry likes to admit.
03
Offer
The member hears the option in plain language and decides. Making the better pathway the easy one usually means reducing or removing what it costs them.
04
Coordinate
Authorisations, scheduling, records, and the vendors involved — the practical work that stands between a good idea and a change that actually took effect.
Traditional brokers manage your renewal.
We manage your plan.
Nothing described on this page could have been influenced by a renewal negotiation. All of it depends on somebody paying attention during the plan year, while the money is still unspent.