Get Off The Hamster-Wheel: An Employer’s Guide to Controlling His 2nd Largest Operating Expense – Employee Health Insurance

© 2025 Charles W. Gragg CEBS, REBC, RHU. All rights reserved.

No part of this book may be reproduced, stored in a retrieval system, or transmitted by any means without the written permission of the author.

Published by AuthorHouse  02/26/2025

ISBN: 979-8-8230-4291-8 (sc)

ISBN: 979-8-8230-4290-1 (hc)

ISBN: 979-8-8230-4289-5 (e)

Library of Congress Control Number: 2025902241

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Contents

Foreword by Simon Sinek

Preface (Disclaimer)

Overview

Objective

Background

Solution

The Broken System

Insurance versus Pay-As-You-Go

Breakdown the Structure - The Elephant in the Room

Change the Narrative

Plan Design Features to Consider for Administration of the Plan

o Concierge / Medical Advocacy

o Medical Tourism

o Consumer Incentives / Compliance

o Wellness Benefits

o Out-Of-Network Costs

o Outliers

o Disease Management Programs

o Bundle (DRG) / Unbundle Claims

o Centers of Excellence

o 2nd Opinion Procedures

o Overcome the Network

o PBM – Pharmacy Benefits

■ International Mail Order

■ Manufacturers Assistance Programs

■ Specialty Drugs

o Based Pricing (RBP)

o Technology / Anaylitics

Health Plan Financing

What about Premium Accounting in a Self-Funding Plan?

Stop-Loss Captive Insurance

Summary / Finale

Build YOUR HealthPlan Checklist / Worksheet

About the Author

Endnotes / References

Foreword

Where does VISON come from

By Simon Sinek

Only after years of mistreatment and demand for change did American revolutionaries embrace the idea of starting their own nation. In other words, the vision came second.

The Drive to build a business from scratch is the same.

The desire to solve a problem or build a better mousetrap comes first. The vision came later. So, when so many people feel they need to have a vision before they can do their life’s work or find their passion, they will likely die searching.

Think of it like going to space – the goal may be clear, and the problems to solve may be in front of us, but the view of the planet from space is unknown until the spacecraft gets into orbit. It is that view that creates the vision for something more profound.

As almost every astronaut reports when they return to Earth, the view—a planet of infinite beauty and without borders—inspired them to become more idealistic and care more about world peace.

So, put the need to find a vision aside…for now…and find a problem to solve, a suffering to relieve, a person or people to help. And from the passionate drive to do good, the vision will emerge.

At that point, the vision will serve as a beacon for something even bigger than the original problem we set out to solve.¹

It is with this type of inspiration that I dedicate this manuscript to solving a century-old problem in the greatest country on earth, the USA. I hope you catch the spirit and are inspired to move. Enjoy!

Charles W. Gragg

Preface (Disclaimer)

I want to take this opportunity to disclaim any resemblance of the text and material provided in this manuscript to any other publications. Much of it is public information regarding healthcare in today’s economy, and much of it references insurance laws and regulations. The balance comes from no particular source but rather from knowledge accumulated during my 45-year career in the healthcare industry. My experience began in the self-funded segment of the industry, where I worked for no less than five third-party administration organizations and in other capacities as an insurance carrier representative. I earned my wings, so to speak, using the techniques and policies specified herein to the benefit of my clients and customers. Likewise, I have carried this torch, flag, and mantra as my own for most of that 45-year period and have had no intention of copying anyone else’s formula. Any similarity, therefore, is coincidental and not subject to copyright laws.

Please note that while this book provides information on health insurance policies and related topics, it is essential that each reader exercises personal responsibility when following any advice or recommendations enclosed herein. The information is provided for general educational purposes and should be considered in light of your own circumstances. Readers are encouraged to make decisions regarding health Insurance only if they feel confident in their own understanding and application of the content. The author cannot be held responsible for any outcomes financial or otherwise, that may result from following the guidance offered in this book.

Overview

As the old