EP452: Fiduciary Duty vs the Healthcare Status Quo, With Cora Opsahl

Relentless Health Value™

Last time Cora Opsahl was on the show, Michelle Bernabe, RN, KAT, wrote a comment on LinkedIn I thought encapsulated the gist of it all so well. She wrote, “[Cora] first became a mentor/ally through Relentless Health Value episode 372. … It opened a doorway to a whole group of very relentless people.”

For a full transcript of this episode, click here.

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I want to start there because it’s a nice comment, but it’s also a call to action. Think about this and think about it not in the context of being a “stakeholder” and not in the context of being an organization but in the context of humans who work at these various organizations who, combined, comprise the bucket of companies that we lumped together using the old stakeholder word.

All of these individuals are making choices every day, and all of these choices, they could be made with integrity and with the patient or member in mind … or not.

In real life, right now, the overwhelming majority of members/patients in this country get their clinical care and the pleasure of paying for that care or drugs within the current ecosystem we have here in the USA. For any of us, or all of us who work within that traditional ecosystem, it is up to us to choose our own legacy here. It’s probably why you listen to this show in the first place, actually. There are so many RHV (Relentless Health Value) listeners who are pushing for patients against the riptide that is the profit motives of the organization that they work for. It’s hard. But yeah, it’s all about finding our people and supporting each other.

Okay, so let’s get to the “between a rock and a hard place” portion of this discussion.

Hospitals and ASOs (administrative services organizations)/carriers/TPAs (third-party administrators) often enter into or sometimes enter into what amounts to anticompetitive contracts with each other. Listen to episode 395 with Brennan Bilberry for the rundown on that one. But meanwhile, the CAA, the Consolidated Appropriations Act from 2021, holds employer plan sponsors accountable and responsible to ensure that plan assets are spent prudently, that costs paid are reasonable, and that there’s no conflict of interest (COI). This is the definition of what a fiduciary is supposed to do, by the way—prudent, reasonable, and no COI.

Anticompetitive contracts between a carrier and a hospital are the very definition of COI. And when that COI results in higher, maybe unreasonable, prices and non-prudent spend, well, plan sponsors are put between a rock and a hard place if they stick with their existing vendors.

Rosa Novo from Miami-Dade County Public Schools put this really succinctly on a panel at a 32BJ event recently. She said what amounts to, I have no choice but to actually do the right thing here, for many reasons, but one of them is I do not look good in orange. She said, my personal butt is on the line here.

And furthermore, who do class action lawsuits make look bad when their company or CEO or CFO are personally sued over conflicted benefits? See the Wells Fargo lawsuit, J&J lawsuit, etc. It sucks that employers or plan sponsors get put into this pickle by their own vendors. And that’s what we’re talking about today.

This is a conversation that starts out talking about rates (ie, prices), edges into rights (ie, plan sponsor rights), and ends up all about power. And by the way, if you’re a plan sponsor, especially in New York City, maybe doing the right thing here means hatching a plan to steer and tier in your benefit design, figuring out how to, for reals, help support the efforts of 32BJ to advantage pretty much every patient near and far.

The pushback I often hear to doing something like this often involves the perception that plan members are too rich to care about reasonable prices, prudent plan spending, and COI. And yeah, to state the obvious, these same people are also sophisticated enough to smell a fine opportunity for a class action lawsuit; and also, they probably do care, as more and more studies suggest.

Sorry if I just stumbled onto a sacred cow.

Cora Opsahl, my guest today, is the director of the 32BJ Health Fund, serving over 200,000 folks. Their ability to kick NewYork-Presbyterian, a big, consolidated, very expensive hospital, out of their network in 2018 enabled them to offer maternity benefits for $40 in total out-of-pocket for members.

And also, employees got their biggest raise ever; employers got a premium holiday and a 3% rate increase for a bunch of years after that; and yeah … this is where we start the conversation today. And yeah, it’s a freakin’ tangled web we weave; and this tale is a perfect case study of it. It makes me even more invested in remembering my own manifesto (that was episode 400) to ensure that I can feel good about what I personally have accomplished and what I have been a part of and the net impact of my own personal actions, since I, too, very often work in the belly of the beast.

Furthermore, you will find links to a template health savings calculator for plan sponsors and also a template contract (again for plan sponsors) that 32BJ has made available. More on that in the show that follows.

Also mentioned in this episode are 32BJ Benefit Funds; Michelle Bernabe, RN, KAT; Brennan Bilberry; Rosa Novo; Marilyn Bartlett; Cynthia Fisher; Zack Cooper, PhD; Claire Brockbank; Andreas Mang; Chris Deacon; Elizabeth Mitchell; and Purchaser Business Group on Health.

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

Cora Opsahl is the director of the 32BJ Health Fund, a self-insured Taft-Hartley benefit fund that sets comprehensive design parameters to ensure the 200,000 members and families of Service Employees International Union 32BJ have easy and sustained access to affordable, high-quality healthcare. Since becoming director of the Health Fund in 2021, Cora has prioritized a data-driven approach to healthcare, focusing on reducing trend; solving the affordability challenge on behalf of union members; and most important, keeping members at the center of every decision.

Under her leadership, the 32BJ Health Fund has saved more than $35 million annually—which it has reinvested in new and better benefits, including the first fertility benefit for members—by removing NewYork-Presbyterian hospitals and physicians from its network, transitioning to a new pharmacy vendor and pharmacy group purchasing coalition, and establishing an expanded Centers of Excellence program. Most recently, Cora conducted an innovative medical request for proposal (RFP), stipulating that all finalists must have a signature-ready contract drafted by the Health Fund prior to award. By including the Health Fund–drafted contract in the RFP process, the Fund was able to negotiate an agreement that brought unprecedented visibility and increased accountability to the 32BJ Health Fund benefit.

Cora is regarded as an expert in pharmacy benefit management and previously worked at Express Scripts, where she held a variety of roles, ranging from Medicare Part D to operations to strategy and acquisitions. She earned an MBA from Saint Louis University.

06:16 Why is it imperative for employers to do something differently when it comes to being plan sponsors?

09:22 How analyzing claims data allowed 32BJ Health Fund to reshape their benefit design.

12:09 What anticompetitive rights did 32BJ run into that limited 32BJ Health Fund from managing their benefit design?

14:12 How do these anticompetitive rights have quality implications as well as cost implications?

18:43 How did 32BJ Health Fund remove NewYork-Presbyterian from their network, and how much did it save 32BJ Health Fund per year?

19:46 What did the healthcare savings allow the unions and employers to do?

20:46 Study by Zack Cooper, PhD.

21:26 Why rising healthcare costs has pushed 32BJ Health Fund to move beyond benefit design to manage healthcare spend.

24:15 Why 32BJ Health Fund wants to control the contracting process.

26:00 EP419 with Andreas Mang.

27:18 What are 32BJ Health Fund’s four non-negotiables?

33:17 Wall Street Journal article on health insurance contract.

35:30 Upcoming episode with Claire Brockbank.

36:14 What is the challenge that exists in our current healthcare environment?

37:43 Cora’s advice on how to get high-quality healthcare at an affordable price.

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

@CoraOpsahl discusses #fiduciaryresponsibility in #healthcare on our #healthcarepodcast. #podcast #financialhealth #primarycare #patientoutcomes #healthcareinnovation

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