Executive Summary: Plus: Active Cost Management as a Standard Feature, Not an Upsell
LFP-15.03, The Product Architecture#
The design decision that defines Plus is classification: cost management programs are standard features, not add-ons. The distinction matters because the add-on model produces adverse self-selection. Employers who need maternity management most are the ones who decline the $10 to $15 PEPM line item because the cost feels discretionary against a known but unlikely need. Universal inclusion changes the dynamic. Every Plus employer receives every program. The pharmacy formulary produces savings whether or not the member knows it exists. The facility steering conversation happens when the procedure is scheduled, not when the employer made a separate purchasing decision months earlier.
The six programs bundled as standard features each carry documented savings profiles. Domestic facility steering through programs like Carrum Health reduces unnecessary procedures by up to 30% and saves employers up to 45% per surgical episode, with Lantern reporting 50% lower plan costs for steered members; one successful steer per hundred enrolled members per year produces material savings against the Plus PEPM differential. Pharmacy optimization through a pass-through PBM eliminates spread pricing and rebate retention, capturing savings across the 20% to 30% of total claims that pharmacy represents for most populations. Maternity management through programs like Maven Clinic reduces NICU admissions by 27% to 28% and C-section rates by 15% to 20%, with average savings of $9,600 per birth; one avoided NICU stay, which typically runs over $3,000 per day, can save $50,000 to $200,000. MSK pathways through virtual physical therapy providers like Hinge Health and Sword Health produce validated savings of $3,177 per engaged member per year, with the Peterson Health Technology Institute’s October 2024 analysis finding net spending decreases of $737 to $1,306 per person in year one. Chronic disease programs through Livongo reduce medical spending by approximately $83 PMPM for engaged diabetes management participants; Omada Health reports average savings of $1,338 per participant at 24 months. Enhanced member navigation and enhanced employer analytics providing near-real-time cost driver dashboards complete the stack.
Plus also occupies the tier best positioned for AI-augmented distribution. Core is simple enough for fully digital self-service. Black is complex enough to require consultative human sales. Plus sits between: population analysis and program recommendations can be delivered by an AI agent ingesting a census, identifying MSK exposure in a construction workforce or maternity probability in a cohort concentrated between ages 25 and 38, and explaining which programs activate based on the analysis. That distribution logic imposes a product design constraint. Every Plus program must be explainable through codifiable recommendation criteria tied to population characteristics, not broker judgment that cannot be systematized. Programs that cannot be explained by an AI advisory layer cannot be distributed through the AI-augmented channel, which shapes the product backward from distribution to design.