As employers look for solutions to control specialty drug costs, alternative funding programs such as Manufacturer Assistance Programs(MAPs), Patient Assistance Programs (PAPs), and Copay Assistance Programs(CAPs) are gaining attention.

Through our partnership with Navion, BRMS has been evaluating how these programs can support smarter pharmacy cost management. Navion provides deep pharmacy expertise, and as a nationwide third-party administrator, BRMS evaluates these strategies within the full context of the employer’s benefit plan.

These programs can deliver savings, but they are not plug-and-play solutions. Employers need more than a basic definition. They need clarity on:

• Member eligibility requirements
• Impact on pharmacy rebates
• Administrative and operational complexity
• Potential disruption to members
• Alignment with PBM contracts

A strategic TPA does not simply implement cost-saving programs. It evaluates how they fit within the broader plan strategy.

What Are Manufacturer Assistance Programs and Patient Assistance Programs?

Manufacturer Assistance Programs (MAPs) and Patient Assistance Programs (PAPs) are manufacturer-funded initiatives designed primarily to support uninsured or income-eligible individuals who need high-cost medications.

In a self-funded health plan environment, MAPs and PAPs are often used as part of an alternative funding strategy when specialty drugs are carved out or when a third-party vendor coordinates access.

How MAP and PAP Programs Work

• The drug manufacturer provides medication at reduced or no cost for eligible individuals
• Eligibility is typically income-based and requires documentation
• Third-party vendors often manage enrollment and compliance
• Savings are generated when members qualify and access manufacturer support instead of plan-funded benefits

While these programs can reduce employer pharmacy spend, eligibility limitations can restrict participation. Administrative coordination is also required, which adds complexity to plan operations.

MAP and PAP programs can be effective when member demographics and utilization patterns support eligibility. They may not generate meaningful savings if qualification rates are low or if rebate loss outweighs funding gains.

What Is a Copay Assistance Program?

A Copay Assistance Program (CAP) involves manufacturer-funded copay cards that reduce member out-of-pocket costs for brand-name medications.

CAP strategies are frequently paired with accumulator or maximizer programs within pharmacy benefit designs.

How CAP Programs Affect Employers

• Members experience lower out-of-pocket costs at the pharmacy counter
• The plan may capture savings through structured benefit design
• CAP strategies typically integrate with existing PBM structures, but benefit design elements (such as accumulators or maximizers) should be evaluated for alignment
  • Member communication should focus on how copay assistance interacts with plan design, particularly when accumulators or maximizers are in place

Copay assistance programs can support both affordability and plan savings when aligned with overall benefit design.
Clear structuring, particularly around accumulators or maximizers, helps ensure the program delivers intended savings while maintaining a predictable member experience.

When Do MAP, PAP, and CAP Programs Work Best?

Alternative funding programs can reduce specialty drug costs, but only under the right conditions.

Before recommending implementation, BRMS evaluates:

• Specialty drug utilization trends
• Member income eligibility likelihood
• Existing rebate structures for high-cost medications
• PBM contract flexibility and alignment
• Member experience and medication adherence risks

Savings projections must account for net financial impact, not just gross reductions. In some cases, forfeiting high-value rebates may offset alternative funding gains. In other cases, operational complexity may create member disruption that affects adherence.

A data-driven evaluation ensures that projected savings translate into measurable results.

The Role of a Strategic TPA in Pharmacy Cost Management

Employers managing self-funded health plans need more than access to alternative funding programs. They need a strategic partner who understands how pharmacy benefits, rebates, PBM contracts, and member experience intersect.

At BRMS, pharmacy cost containment starts with claims-driven analysis. In partnership with Navion, we assess real plan data before implementing MAP, PAP, or CAP strategies.

Our approach includes:

• Reviewing historical claims and specialty utilization
• Evaluating rebate impact before implementation
• Ensuring PBM contract alignment
• Coordinating vendor relationships
• Monitoring performance and savings outcomes
• Supporting member communication to reduce disruption

Alternative funding programs are precision tools within a comprehensive pharmacy management strategy. They are most effective when implemented thoughtfully and monitored consistently.

Managing Specialty Pharmacy Costs in Self-Funded Health Plans

Employers need practical, sustainable solutions to manage specialty pharmacy spend without compromising member care.

MAPs, PAPs, and CAPs can be valuable components of a cost containment strategy. However, their success depends on strategic evaluation, contract alignment, and ongoing oversight.

Working with a TPA like BRMS, alongside pharmacy specialists such as Navion, ensures that alternative funding programs are implemented in away that:

• Increases net savings
• Protects rebate arrangements
• Maintains compliance
• Supports positive member experiences

With more than 30 years of serving self-funded employers, BRMS builds trusted and valued relationships and delivers strategies that work not just on paper, but in practice. 

For employers and employees alike, this month is an opportunity to move beyond awareness and take action. Supporting women’s health isn’t just a personal priority; it’s a workplace imperative that drives stronger teams, better outcomes, and healthier communities.

Why Women’s Health Matters in the Workplace

Women make up a significant portion of today’s workforce, yet many still face gaps in care, delayed diagnoses, and competing responsibilities that impact their health.

• Preventive care utilization
• Cardiovascular health (often underdiagnosed in women)
• Mental health and burnout
• Hormonal and reproductive health
• Caregiver stress and work-life balance

Organizations that prioritize women’s health see improved productivity, reduced absenteeism, and stronger employee satisfaction.

• 1 in 3 women live with cardiovascular disease, the leading cause of death among women ¹
• Women are nearly twice as likely as men to experience anxiety disorders ²
• 1 in 5 women experience a mental health condition each year ³
• Women spend 25% more of their lives in poor health compared to men ⁴

April is World Health Month, recognized globally with World Health Day on April 7. This observance encourages individuals and communities to focus on prevention, access to care, and sustainable health practices.

Many leading health risks, including heart disease, diabetes, and stress-related conditions, are influenced by everyday behaviors. Consistent, practical habits can improve physical health, mental well-being, and overall quality of life. A proactive approach to wellness supports both personal health and workplace productivity.

This month’s Workday Wellness highlights key statistics and actionable tips to help support whole-person health.

• 6 in 10 U.S. adults live with at least one chronic condition and 4 in 10 adults live with two or more. *
• 1 in 5 adults experiences a mental health condition each year. **
• Up to 80% of heart disease and type 2 diabetes cases may be preventable through lifestyle changes. *
• Only about half of adults receive recommended preventive services. ***
• Regular physical activity can reduce the risk of depression by up to 30%. ***

1. Stay Up to Date on Preventive Care

Preventive care remains one of the most effective ways to protect long-term health. Annual exams, age-appropriate screenings, and routine lab work help identify concerns before symptoms develop. Early detection allows providers to recommend treatment or lifestyle adjustments that may reduce complications later. Review your health plan benefits and speak with your provider about screenings based on your age, medical history, and risk factors. Preventive visits are valuable even when you feel well.

2. Build Consistent Movement into Your Routine

Regular movement supports cardiovascular health, joint function, and energy levels. It also plays a role in reducing stress and improving mood. Health experts recommend at least 150 minutes of moderate activity each week, yet many adults spend long periods sitting. Consider practical ways to stay active during the workday. Take brief walking breaks, stretch between meetings, or choose stairs when available. Small adjustments practiced consistently can strengthen endurance and overall health.

3. Support Mental and Emotional Well-Being

Mental health is closely connected to physical health. Ongoing stress may contribute to sleep disruption, elevated blood pressure, and reduced immune function. Building habits that support emotional well-being can improve resilience and focus.
Setting boundaries around work time, taking regular breaks, using available PTO, and staying connected with supportive people are meaningful steps. Many employers also offer behavioral health benefits or Employee Assistance Programs. You can explore additional insights in our recent blog on Supporting Mental Health and Wellness.

4. Choose Balanced Nutrition to Fuel Your Day

Nutrition influences energy, concentration, and disease risk. A balanced approach that includes vegetables, fruits, whole grains, lean proteins, and healthy fats supports heart health and metabolic function. Gradual improvements are often more sustainable than drastic changes. Increasing fiber intake, reducing added sugars, and maintaining steady hydration can positively influence overall health over time.

5. Protect Time for Sleep and Recovery

Sleep supports immune health, cognitive performance, and emotional regulation. Most adults benefit from seven to nine hours of sleep per night. Insufficient sleep is associated with increased risks of chronic disease and workplace fatigue. Establishing a consistent sleep schedule, limiting screen use before bed, and creating a comfortable sleep environment can improve rest quality. Recovery allows the body and mind to function more effectively each day.

 

Healthy Habits Built a Stronger Foundation

World Health Month serves as a timely reminder that global health efforts connect directly to individual action. Prioritizing preventive care, movement, nutrition, mental well-being, and sleep supports sustainable health over time. Health employees contribute to safer workplaces, stronger families, and more productive communities.

 

Want more health tips and insights?
Check out our previous blogs!
Learn More

Sources:

* CDC Chronic https://www.cdc.gov/chronic-disease/index.html
** CDC Mental Health https://www.cdc.gov/mental-health/about-data/index.html
*** CDC Prevention https://www.cdc.gov/chronic-disease/data-research/facts-stats/index.html

Congress and federal regulators are advancing new PBM transparency compliance requirements that increase reporting obligations, expand fiduciary accountability, and elevate oversight expectations for employer-sponsored health plans.

For employers, brokers, and TPAs, this isn’t just regulatory noise. It represents a structural shift in how pharmacy benefits must be monitored, documented, and defended.

At BRMS, we believe transparency isn’t just about access to data. It’s about the ability to validate it, interpret it, and act on it. That requires the right knowledge and strategic partnerships.

What Is Changing in PBM Transparency?

Federal proposals aim to increase visibility into how pharmacy benefit managers operate and how compensation flows within employer-sponsored plans.

At a high level, new requirements would:

• Require PBMs to provide more detailed prescription drug cost and performance reporting to plan fiduciaries
• Expand disclosure of PBM compensation, including rebates, incentives, and financial arrangements
• Require rebates and negotiated discounts to be passed through to plan fiduciaries
• Broaden the list of service providers that fiduciaries must monitor under ERISA

These efforts signal a clear direction of greater transparency, stronger accountability, and defensible oversight in pharmacy benefits.

The full legislative proposals can be reviewed here:

• https://www.congress.gov/119/bills/hr7148/BILLS-119hr7148ih.pdf
• https://public-inspection.federalregister.gov/2026-01907.pdf

Why Is PBM Transparency Compliance a Fiduciary Responsibility?

Under ERISA, plan sponsors have a duty to act prudently and solely in the interest of plan participants. As pharmacy costs continue to represent a growing share of total healthcare spend, PBM arrangements can no longer operate in a “black box.”

Increased disclosure requirements mean employers will receive more data from PBMs, but more data alone does not equal better oversight.

Employers must now be prepared to:

• Evaluate rebate pass-through structures
• Understand spread pricing and compensation models
• Audit PBM contracts and financial arrangements
• Demonstrate active monitoring of pharmacy vendors

Transparency is quickly moving from a best practice to a baseline expectation.

The Hidden Risk: Receiving Data Without Interpreting It

As reporting and audit expectations increase, the ability to validate and interpret PBM data becomes just as important as receiving it. This is where many organizations face risk.

Raw claims files, rebate summaries, and financial disclosures can be complex and highly technical. Without expertise in contract language, performance guarantees, and rebate mechanics, plan sponsors may struggle to determine:

• Whether contractual terms are being honored
• Whether rebates are fully passed through
• Whether pricing aligns with market benchmarks

Compliance requires more than compliance documentation. It requires insight.

Why Partnership Matters: BRMS + Navion

At BRMS, we focus on delivering transparency through advanced plan analytics and plan performance visibility. But when it comes to independent PBM evaluation and contract oversight, partnering with subject matter experts strengthens fiduciary protection.

That’s why we value our partnership with Navion. They help us work through new and emerging changes through:

• Independent PBM evaluation
• Contract oversight
• Ongoing performance monitoring
• Audit validation

As PBM transparency compliance standards evolve, Navion is closely monitoring regulatory developments and keeping partners informed as details unfold. Together, we can help ensure employers understand, validate, and use it strategically.

Turning Compliance into Competitive Advantage

The regulatory environment is clear: greater scrutiny is coming. But forward-thinking employers see this as an opportunity. Transparency is no longer reactive. It’s strategic.

And working with partners who stay ahead of evolving healthcare, benefits, and economic changes is essential to protecting both plan performance and fiduciary integrity.

Looking Ahead

PBM transparency compliance is not a one-time adjustment. It’s an ongoing discipline.

As healthcare economics shift and federal oversight expands, employers must move beyond passive vendor relationships toward active, documented oversight supported by analytics and independent expertise.

At BRMS, we’re committed to helping our trusted and valued clients navigate this complexity with clarity, confidence, and defensible strategy.

Because in today’s environment, transparency is foundational – not optional.

Connect with one of our experts today to learn more!

March is Save Your Vision Month and a great reminder that protecting your eyesight is essential to your overall health and daily performance. Increased screen time, aging, and chronic conditions such as diabetes and high blood pressure all raise the risk of vision problems. Yet many serious eye conditions develop gradually and without early warning signs, making preventive care and routine eye exams even more critical.

This month’s Workday Wellness promotes healthier vision, emphasizing key statistics, insights, and proactive approaches to help safeguard your eye health at every stage of life.

• Approximately 12 million Americans aged 40 and older have vision impairment, including 1 million who are blind. *
• Nearly 93 million U.S. adults are at high risk for serious vision loss, yet only about 50% visit an eye doctor annually. *
• An estimated 6.8% of children under age 18 have a diagnosed eye or vision condition. *
• About 1 in 3 adults does not get recommended eye exams. **
• Digital eye strain affects more than 50% of people who use computers regularly. *
• By 2050, the number of Americans with vision impairment is expected to double due to aging and chronic disease trends. *
• Up to 80% of vision loss is considered preventable or treatable with early detection. ***

 

1. Schedule Regular Eye Exams

Routine eye exams are one of the most effective ways to protect your vision. Many eye diseases (including glaucoma, macular degeneration, and diabetic retinopathy) develop without early symptoms. Comprehensive exams can detect changes before vision loss occurs, allowing for early intervention and better outcomes. Adults should follow their optometrist’s recommendations that are based on age, risk factors, and existing health conditions, while children should receive regular screenings to support learning and development.

2. Practice the 20-20-20 Rule for Screen Time

With remote work and digital tools now part of everyday life, screen exposure has significantly increased. Prolonged device use can cause digital eye strain, leading to dryness, blurred vision, headaches, and neck tension. To reduce strain, follow the 20-20-20 rule: every 20 minutes, look at something 20 feet away for at least 20 seconds. Adjusting screen brightness, reducing glare, and positioning monitors at eye level can also help minimize eye fatigue.

3. Fuel Eye Health with Proper Nutrition

What you eat directly impacts your eye health. Nutrients like vitamin A, vitamin C, vitamin E, zinc, lutein, and omega-3 fatty acids help support retinal function and may reduce the risk of age-related eye disease. Leafy greens, colorful vegetables, citrus fruits, fish, nuts, and seeds are all excellent choices. A balanced diet not only benefits your eyes but also supports heart health and blood sugar control, which are two factors closely linked to long-term vision protection.

4. Protect Your Eyes from UV and Blue Light Exposure

Ultraviolet (UV) radiation from the sun can increase the risk of cataracts and macular degeneration. Wearing sunglasses that block 100% of UVA and UVB rays helps protect your eyes year-round. For those spending long hours on digital devices, blue-light–filtering lenses or dark screen settings may help reduce strain, particularly in the evening hours when light exposure can disrupt sleep cycles.

5. Manage Chronic Conditions and Lifestyle Risks

Conditions such as diabetes, high blood pressure, and high cholesterol can significantly affect vision health. Managing these conditions through regular medical care, physical activity, and medication adherence reduces the risk of complications like diabetic retinopathy or vascular-related eye damage. Avoiding smoking is equally important, as tobacco use increases the likelihood of developing cataracts and optic nerve damage.

 

Save Your Vision Month is a reminder that eye health is not separate from overall health. Clear vision supports productivity, safety, independence, and quality of life. Prioritizing things like regular exams, healthy habits, and early intervention, can help detect issues sooner and reduce long-term complications, preserving your sight for years to come.

 

Looking for more health tips and insights?
Check out our previous blogs!
Learn More

Sources:

* https://www.cdc.gov/visionhealth
** https://www.nei.nih.gov
*** https://www.who.int/publications/i/item/world-report-on-vision

February is American Heart Month and a time to shine a spotlight on heart health awareness and disease prevention. Heart disease continues to be the leading cause of death in the United States, impacting the lives of millions of Americans each year. Our goal this month is to encourage learning about cardiovascular health, understanding risk factors, and adopting healthy habits to help protect your heart for life.

In this month’s Workday Wellness, we’ll recognize both the impact of heart disease and the many ways we can take proactive steps toward better heart health. Whether you’re just beginning your heart health journey or building on existing wellness goals, this blog offers the perfect opportunity to recommit to your heart.

• Heart disease is the #1 cause of death in the U.S. for men and women. *
• About one person dies from cardiovascular disease every 34 seconds in the United States. *
• In 2023, over 919,000 Americans died of cardiovascular disease, accounting for roughly 1 in 3 deaths.*
• Nearly half of U.S. adults have high blood pressure (a major driver of heart disease and stroke). *
• Coronary artery disease (CAD) remains the most common form of heart disease, resulting in death for hundreds of thousands yearly. **
• High blood pressure affects nearly 50% of adults, but only about one in four has it under control. *
• Heart disease and stroke together kill more people than all forms of cancer and accidents combined. ***

1. Get Moving: Aim for 150 Minutes of Activity Weekly

Regular physical activity strengthens the heart, improves circulation, and supports healthy blood pressure and cholesterol levels. Activities like brisk walking, swimming, cycling, or even taking the stairs count toward your weekly goal of at least 150 minutes of moderate exercise or 75 minutes of vigorous activity. Even short bursts of activity throughout the day can add up to big benefits, so finding movement you enjoy will help increase the likelihood of sticking with it long term.

2. Nourish Your Heart with Healthy Eating

A heart-healthy diet emphasizes whole, nutrient-dense foods like fruits, vegetables, whole grains, lean proteins, and healthy fats (such as those in nuts, seeds, and fish). Limiting sodium, added sugars, saturated and trans fats can help manage blood pressure and cholesterol (two crucial factors in heart disease risk). Preparing meals at home and choosing fresh ingredients whenever possible makes it easier to control what goes onto your plate and into your body.

3. Know Your Numbers: Screenings Matter

Understanding your blood pressure, cholesterol, and blood sugar levels is one of the most powerful steps you can take to protect your heart. These numbers are key indicators of your cardiovascular health and can help reveal risks before symptoms arise. Regular check-ups and screenings empower you to work with your healthcare provider to address potential issues early.

4. Don’t Smoke and Limit Alcohol

Smoking and tobacco use profoundly damage the cardiovascular system by narrowing arteries, increasing blood pressure, and reducing oxygen delivery to your heart muscle. Quitting smoking (or avoiding it all together) is one of the most impactful heart-protective changes you can make, with positive benefits beginning almost immediately. Additionally, while some may think moderate alcohol has protective benefits, excessive or regular use contributes to raised blood pressure and increased risk. Moderation and mindful choices are key to maintaining your heart health.

5. Manage Stress and Prioritize Sleep

Chronic stress triggers inflammation and hormonal changes that can raise heart disease risk over time. Incorporating calming techniques like deep breathing, meditation, yoga, or spending quality time with loved ones can all help regulate your nervous system and protect your heart. Likewise, quality sleep (about 7–9 hours per night for most adults) plays a vital role in cardiovascular health. Poor sleep contributes to high blood pressure, weight gain, and diabetes, all of which increase the risk for heart disease.

 

American Heart Month is more than a reminder; It’s a call to action. Heart disease is preventable in many cases, and small, consistent lifestyle changes can lead to big health improvements over time. Whether you swap sugary drinks for water, sign up for a walking challenge, or schedule a routine health screening, each step brings you closer to a healthier heart.

Let this February be a time to invest in your cardiovascular well-being, celebrate progress, and support others in their heart health journey, too. Your heart works hard for you every day and it’s time to return the favor!

Looking for more health tips and insights?
Check out our previous blogs!
Learn More

Sources:

*  https://www.cdc.gov/heart-disease/data-research/facts-stats/index.html
** https://pmc.ncbi.nlm.nih.gov/articles/PMC5055577/
*** https://newsroom.heart.org/news/heart-disease-remains-leading-cause-of-death-as-key-health-risk-factors-continue-to-rise

If you’ve been in business as long as we have, you know that economic volatility isn’t a glitch; it’s a feature of the system. We’ve guided our trusted and valued clients through recessions, inflationary spikes, and massive labor market shifts. Through every cycle, we’ve noticed a pattern: Rigid plans break under pressure, flexible plans survive. The common thread among successful organizations? A willingness to rethink traditional approaches to employee benefits.

Right now, employers are facing a trifecta of pressure: soaring healthcare costs, persistent inflation, and a workforce that needs more support than ever.

In this environment, a fully insured health plan can feel like a trap. When the carrier raises rates to protect their margins against inflation, your only options are usually bad ones: absorb the massive hike or slash benefits.

There is a third option. Self-funding brings control to chaos and provides the elasticity required to weather economic storms without capsizing your budget.

Why Self-Funding Works in Uncertain Times

Traditional fully insured health plans often come with fixed costs and limited flexibility. In contrast, self-funded plans allow employers to pay for actual claims as they’re incurred rather than relying on pre-set premiums. This structure provides several advantages in turbulent economic periods:

• Financial Agility: Employers can better manage cash flow, adjusting contributions and benefits based on real-time claims data rather than historical averages and broad data.
• Tailored Benefit Design: Self-funded plans can be customized to meet the unique needs of a workforce, enabling employers to offer meaningful benefits without overspending on coverage that employees may not use.
• Data-Driven Decision Making: Access to detailed claims data helps employers (and their brokers) identify trends, implement targeted cost-containment strategies, and make informed adjustments quickly.

Adaptability is Your Safety Net

Resilience isn’t about predicting the future; it’s about being able to pivot when the future arrives.

If the economy dips, a self-funded plan allows you to adjust benefit designs immediately to preserve cash flow. If the labor market tightens, you can enhance specific benefits to attract talent without overhauling the entire plan.

This is where the “partner” aspect is critical in self-funding. Software can process claims, but only a seasoned TPA can offer the strategic counsel needed to make these pivots. We have the historical context to know what works when the market gets rocky.

For decades, we’ve partnered with employers navigating uncertainty and we’ve seen firsthand how adaptability is key to weathering volatile times. With the right guidance, self-funding provides the adaptability organizations need to thrive.

The Bottom Line

Don’t let a rigid health plan dictate your financial future. By embracing the flexibility of self-funding and the expert guidance of an experienced TPA, you turn your benefits program from a liability into a resilient, strategic asset.

From forecasting potential claims to negotiating with providers and ensuring regulatory compliance, an experienced TPA acts as both strategist and partner. The result is a plan that balances cost efficiency with employee satisfaction, bringing control to the chaos felt by employers.

Is your current plan flexible enough to handle the next economic shift? Reach out to us to answer any questions and explore your options.

October is a great time to pause and shine a spotlight on a health issue that impacts millions: diabetes. Whether someone has Type-1 or Type-2 diabetes, is newly diagnosed, has been living with it for years, or wants to reduce risk for themselves or loved ones, greater awareness and practical strategies can empower better health decisions.

In this month’s Workday Wellness blog, we’ll dive into some key facts about diabetes and share actionable tips to help manage it well in daily life. Take a few minutes to read through the blog and support diabetes awareness with BRMS while boosting your health literacy in the process.

• Over 38 million Americans live with diabetes*
• More than one in five adults with diabetes is undiagnosed*
• Prediabetes affects nearly 1 in 3 U.S. adults*
• Age-standardized prevalence of diabetes in the U.S. rose ~18.6% from 2012 to 2022 (from 10.2% to 12.1%)**
• The annual cost of diagnosed diabetes in the U.S. is estimated at $412.9 billion

Make a Personalized Self-Care Plan

Work closely with your healthcare team to build a realistic, individualized plan. Include your target blood sugar (A1C), medications, monitoring schedule, and lifestyle goals.

Monitor and Understand Your “ABCs”

Stay on top of your ABCs: A for A1C (average blood glucose over time), B for blood pressure, and C for cholesterol. Keeping these in check lowers the risk of complications from diabetes like heart disease, stroke, and kidney damage.

Adopt Smart Nutritional Habits

Choose whole, minimally processed foods that are rich in fiber, along with lean proteins, healthy fats, and complex carbs. Be mindful of portion sizes and carb timing as eating carbs later in a meal can help blunt blood sugar spikes.

Move Daily, Even in Small Increments

Physical activity helps insulin work better and keeps blood sugar more stable. The best part? You don’t even need long workouts. Frequent and consistent short bursts or activity, walking breaks, or light resistance training add up and contribute to improved outcomes.***

Manage Stress and Emotional Well-Being

Stress, poor sleep, and emotional strain can all push blood sugar out of balance. Develop coping strategies (meditation, journaling, support groups), prioritize an adequate amount of rest each night, and seek mental health resources when needed.

Looking for more health tips and insights?
Check out our previous blogs!
Learn More

Sources:

* https://www.cdc.gov/diabetes/php/data-research/index.html
** https://www.ajpmonline.org/article/S0749-3797%2824%2900136-3/fulltext
*** https://www.mayoclinic.org/diseases-conditions/type-2-diabetes/diagnosis-treatment/drc-20351199

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From Back Office to Brain Trust

For the most part, third-party administrators (TPAs) operate behind the scenes. From processing claims and enhancing benefits, to supporting health plan renewals for employers and brokers, TPAs serve more as administrative engines than figureheads. But with the rise of artificial intelligence, that seems to be changing. TPAs are now being pushed to the forefront of healthcare spending strategy for employers because of the evolving tools that we’re seeing in the marketplace.

So where does that road lead us?

The Potential for Plan Design

When we look at the benefits AI brings in regard to TPAs, one of the biggest opportunities to consider lies in plan design. Instead of relying on generalized templates or squinting at last year’s performance, AI can simulate the financial and clinical impact of multiple benefit scenarios in real time, potentially giving a far stronger viewpoint for making decisions.¹

Backed by this information, AI could be used to help tailor benefit plans based on the unique demographics and health risks of a specific workforce.¹ A tech company with a younger workforce based in the city will likely have considerably different needs than a manufacturing company in a rural region. AI tools can give the ability to detect those nuances and provide guidance for customized plans that meet those unique needs.

Additionally, AI could support TPAs through the use of predictive modeling to anticipate challenges and circumstances surrounding specific groups. Instead of just adapting benefit plans after problems arise, AI could assist TPAs in preparing and adjusting for these issues before they happen, allowing for improved cost savings and employee well-being.²

Elevating Patient & Member Care

Speaking of employee well-being, AI also has the potential to help TPAs redefine how employers support plan members directly. Just look at the improvements made in chatbots and virtual assistants, now available 24/7. Instead of working from simple FAQs, these tools are being trained on specific plan documents, helping members understand treatment options, navigate provider networks, and receive support for health issues and plan guidance.¹

Behind the scenes, predictive analytics can identify members at risk for high-cost incidents like hospitalization or disease. With that information in mind, care managers can proactively reach out, assist in coordinating care, and ensure timely interventions.

The Human-AI Balance

With that in mind, when it comes to big question of whether machines replace the human touch, we’re confident that the answer is no. AI seems poised to play the role of co-pilot, rather than a replacement. Automated tools can handle repetitive tasks and analyze vast datasets, allowing humans to focus on high-value, empathetic interactions. Striking the balance between leveraging the advancements in technology and maintaining an interpersonal approach appears to be the key to moving forward in the future.

A New Era of TPA Value

AI is reshaping just about every part of the benefits industry, and TPAs should heed that movement. The important thing to keep in mind is the role each part can play, rather than losing sight of the end goal. While TPAs might have been seen as the quiet administrators of yesterday, we now see them taking a vital role in tomorrow’s health plans—delivering efficiency, intelligence, and humanity.

As healthcare benefits grow more complex and costly, the potential advantages AI are poised to give TPAs increased time to focus on bringing in the human element that employers and members want. It’s up to each company to determine whether AI can make that difference or not.

Sources:

1. https://www.ancileo.com/how-ai-enhances-tpa-operations-and-reduces-costs-for-insurers/
2. https://www.insurancethoughtleadership.com/claims/case-tpas-ai-claims-environment

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