Series
Cost Management Strategies
The TPA sits at the only position in the small group self-funded system with full visibility into the claims stream. This series builds the cost management case from that position: geographic price arbitrage across domestic markets and borders, pharmacy purchasing outside the PBM transaction, maternity management, MSK pathways, mental health access, SDOH intervention, and chronic disease interception. The synthesis models all of it stacked on the same 25-person plan.
LFP-10.01
The TPA as Cost Management Engine: Why Claims Processing Is the Floor, Not the Ceiling
The TPA sees the full claims stream in real time, the member demographics, the provider billing patterns, and the relationship between this year's utilization and next year's stop …
LFP-10.02
Geographic Arbitrage for a Mobile Workforce: Why Location-Based Care Steering Is the Biggest Untapped Strategy in Level Funded
The RAND Hospital Price Transparency Study found commercial payers paying an average of 254 percent of Medicare at US hospitals in 2022. Within a single metropolitan market, the …
LFP-10.03
Domestic Steering: Rural and Exurban Hospitals, Independent Surgery Centers, and the Price Variation That Creates the Opportunity
Hospital price transparency files now show negotiated commercial rates across facilities in machine-readable format. Within a metropolitan market, prices for the same procedure at …
LFP-10.04
Cross-Border Care: Medical and Dental Services at JCI-Accredited Facilities in Mexico, Canada, the Bahamas, and Beyond
Total knee replacement at a JCI-accredited Mexican facility runs $10,000 to $15,000. The same procedure at a US urban hospital runs $35,000 to $50,000. Including travel and a …
LFP-10.05
International Pharmacy Purchasing: Canadian Pharmacies, the Legal Landscape, and the Savings
Brand-name drug prices in Canada run 30 to 60 percent below US list prices on the same products from the same manufacturers. The FDA's personal importation policy and individual …
LFP-10.06
Pharmacy Programs: Manufacturer Assistance, Discount Cards, 340B Access, and Every Dollar Left on the Table
Manufacturer assistance programs, copay cards, discount networks, and 340B pricing flow around the PBM-mediated transaction and reach the plan only if someone is actively capturing …
LFP-10.07
Maternity Management: Coordinated Pregnancy Programs and What They Do to the Highest-Impact Claims Category
NICU admissions average $71,158 in employer-sponsored plans, with Level IV NICU care averaging $117,878 over the first 18 to 24 months. A complicated pregnancy can consume half the …
LFP-10.08
MSK Pathways: Virtual Physical Therapy, Surgical Second Opinions, and Steering to Lower-Cost Facilities
Musculoskeletal spend compounds through a predictable escalation from primary care to imaging to specialist to surgery. Virtual physical therapy reduces surgical volume for …
LFP-10.09
Mental Health Access and SDOH Intervention: Closing the Gaps Before They Become Claims
Domestic steering reduces the price of a service the member is already consuming. Mental health access and SDOH intervention prevent the service from becoming necessary. The member …
LFP-10.10
Chronic Disease Interception and GLP-1 Cost Management: Programs That Change the Trajectory
Chronic disease interception changes the cost trajectory before the complication arrives. Rising A1c, blood pressure medication escalations, and pharmacy refill gaps are visible …
LFP-10.C1
The Case Against Geographic Arbitrage: Complications, Liability, Follow-Up Care, and the Risks of Steering Members Away From Local Providers
Geographic arbitrage carries risks the affirmative case understates. A post-operative complication managed by an emergency physician who has no access to the operative record, no …
LFP-10.PRE
The Mobile Workforce Insight: Why This Series Is Not About Medical Tourism
The cost management strategies available to a TPA serving a mobile workforce are qualitatively different from those available to one serving a geographically fixed workforce. A …
LFP-10.SYN
The Combined Cost Impact: What Happens to a 25-Person Plan When You Stack Every Available Strategy
Series 09 modeled a 25-person plan under moderate cost driver convergence: claims pushing from $375,000 toward $450,000 to $500,000. This synthesis stacks every available strategy …