Model Optimal Care: End US Healthcare Waste, One Health Plan at a Time - Tapa blanda

Sinopsis

America spends more on healthcare than any other nation. It gets less in return. US healthcare waste totals an estimated $1.6 trillion every year. That figure exceeds the GDP of more than 180 countries. The waste is not accidental. It is built into third-party contracts with employers, protected by opacity, and perpetuated by vendors with no financial incentive to fix it. Employers who self-insure their health plans sit at the center of this problem. They also hold the most direct authority to solve it.

Model Optimal Care is a practical, data-driven guide for all stakeholders in the self-insured space who are ready to act. Jude Odu draws on twenty-five years of direct experience across payers, providers, and healthcare technology to give plan sponsors a structured framework for identifying waste, eliminating inefficiency, and achieving significant reductions in annual healthcare spend.

The book introduces Model Optimal Care, a brand-new framework Odu positions as the next step beyond value based care. It is a care delivery model that is individualized, technology-enabled, methodical, measurable, and results-driven. It rests on five core principles: Transparency, Accountability, Integration, Engagement, and Technology Enablement. Every strategy in this book flows from those five principles.

What You Will Learn

Part I covers non-technology strategies that any self-insured employer can implement immediately: educating and engaging employees to make cost-conscious decisions; redirecting non-emergent care away from the emergency room; structuring benefits to steer members toward high-value providers; and building onsite and near-site clinic programs that reduce total plan costs.

Part II covers the technology layer: how to use AI-powered claims auditing to identify overpayments and duplicate claims in near real-time; how to apply price transparency tools to audit payments and negotiate from a position of data strength; how to detect and recover dollars lost to fraud, waste, and abuse; how to optimize formularies and shift pharmacy spend toward fiduciary PBMs that operate on a transparent pricing model; and how to build a predictive analytics strategy that anticipates risk months before it becomes cost.

Inside This Book

1. A comprehensive implementation framework for each strategy, complete with measurable outcomes
2. Field-tested logic and specifications for reporting on medical and pharmacy savings
3. A 90-day AI implementation blueprint for employer-sponsored health plans
4. Templates for executive narratives that effectively communicate findings and inspire behavior change
5. Case studies documenting identified overpayments and recovered losses
6. A vendor accountability model for auditing third-party vendors, such as TPAs, ASOs, and PBMs, while ensuring they meet performance guarantees
7. Implementation checklists for benefits teams, brokers, and consultants poised to act on the data

Who This Book Is For

This book is written for anyone with fiduciary responsibility for an employer-sponsored health plan: benefits directors, HR executives, CFOs, CIOs, self-insured employers, TPAs, ASOs, PBMs, PEOs, stop-loss carriers, benefits brokers, healthcare consultants, policymakers, and all those working to reduce the cost burden of employer-sponsored care in the United States.

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