Episode 13: Strategic Vendor Choices with Niko Caparisos

Join us for another amazing episode of Bending the Trend hosted by Norm Volsky, this week I sit down with Niko Caparisos, founder of community-owned health plans, reveals the inside scoop on how strategic vendor choices and streamlined management can slash costs and boost member experience.

This episode exposes how small changes in setup—like choosing the right PBMs —can save your organization millions without sacrificing quality. Imagine transforming your healthcare spend with proven frameworks that prioritize quiet efficiency and flexible vendor engagement. Niko shares tangible results: from lowering pharmacy costs by structuring better PBM relationships to creating health plans so intuitive members barely notice they're using them. You'll discover specific vendors like Covet Health and Angle Health that stand out in their ability to deliver cost-effective solutions—plus the insider tactics for building scalable, reliable health plans that anticipate and solve issues before they escalate. Beyond numbers, you'll learn how a thoughtful, integrated approach to member education and tech development can double down on savings. Niko discusses the current gaps in healthcare tech—like the lack of seamless, embedded advocacy tools—and invites entrepreneurs to tackle this opportunity head-on. 

“This industry is in flux all the time.” We all know solutions are a moving target so let’s talk RESULTS TODAY! Niko shares some of his favorite solutions moving the needle: 

-Covet Health
-Angle Health
-Caprx
-Makorx 

Niko Caparisos is the founder of community-owned health plans, known for his innovative restructuring of health benefits to maximize cost savings and member value Ready to rethink healthcare from the ground up? Hit play and subscribe to join us for a conversation! 

📉  Cost Savings: Learn how strategic vendor choices can slash costs.
🤝 Vendor Engagement: Discover the power of flexible vendor relationships.
💡 Innovative Frameworks: Implement proven frameworks for efficiency.
🏥 Member Experience: Create intuitive health plans that members love.
🚀 Tech Opportunities: Explore gaps in healthcare tech for new solutions.

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Transcript

SPEAKER_01 0:00

We have to find real solutions, and this is bending the trend. Hello and welcome back to Bending the Trend with your host, Norm Bolski. And today we are thrilled to have the founder of community-owned health plans, Nico Caparizos.

SPEAKER_00 0:19

Got it.

SPEAKER_01 0:20

How are you? It's going to be good.

SPEAKER_00 0:21

I'm doing good, buddy.

SPEAKER_01 0:22

How are you? I'm good. I'm good. We're just, you know, fighting the good fight, fighting for employers and employees to uh spend less money on their health care. So excited to have you. And you know, you've built an amazing organization, you know, down in the southeast and would love to, you know, just ask like what's working. You've got you know a bunch of employees, you know, all kind of grouped up into a health plan. You've created some great efficiencies, you're driving some really nice cost savings. You're a fiduciary consultant validated by the validation institute. So tell us which vendors have you worked with at community-owned health plans that have done really well and have helped you, you know, save your clients money on their healthcare spend.

SPEAKER_00 1:07

Yeah, yeah. So uh again, happy to be here, more than more than glad to elaborate on the vendors that really shine. Um, you know, as a GA and someone who created a health plan, I was always looking to solve for broker level challenges, right? Alongside group level, population health, right, streamlined, easy to do business with, you know, kind of areas as well. So, you know, the vendors that I've really liked in the past couple of years, especially, because it's always kind of a moving target, right? We know this industry's flux all the time. Covet Health and Angle Health, both both self-funded, level-funded um, you know, health plan offerings uh within their product portfolio. Angle's a little more turnkey, covet's a little more customizable. They do traditional stuff as well. Um and then CapRx and Mako RX, right? So two PBMs that just really have shown uh to be very proficient, right? It's awesome. Um yeah, that those those are the vendors as of late that have really kind of stood out and struck out to me, and for some reasons I'll elaborate on. Next question.

SPEAKER_01 2:01

Awesome. So talk to me about what the results are of implementing those solutions and how it's been beneficial for you as well as your members.

SPEAKER_00 2:10

Yeah, so so there's a couple year period there for I think a lot of brokers, consultants, plan builders, right? Where it's like point solution madness, right? And it's so confusing. And for things to operate well and quietly, at least what I what I have found is that it makes a lot of sense for things to be structurally set up a certain way and to embed vendors that you know were going to basically execute on the various things needed to to actually control costs, right? So that's that's been that's been huge, right? So like setting up the PBMs and making sure that they can fulfill their promises because everybody has a nice slick and marketing message, right? But to actually know that they are engaging members, right? And then same thing on the the health plan side, right? Like ease of business, capability, robustness, if they're responsive, if um they're very innovative and they're walking walking alongside you in some of these things that are outside the box in terms of strategy, but also quiet, right? Quiet on the TPA and health plan side, quiet on the pharmacy side, because it doesn't sound very exciting, but if you've spent a lot of time structuring something a certain way so as to then save claims, the last thing you want is a ton of noise. And like these four vendors in particular, yes, issues arise in healthcare and claims and just in general, like it's a complex field, but for the most part, and by and large, right, when there are issues, they're easy to solve for, and then there are less frequent issues relative to other vendors that I've worked with past. So, you know, two thumbs up for those. I'm pretty sure the BUKAs also have those issues. I think so. And the problem is is like it it's it's less apparent, right, when things go wrong. It's more like people are overcharged and providers are clawed into with their reimbursements, and that's a huge issue, right? But no one notices because the norm, of course, is hey, uh this this is just how healthcare is. But then when you have like a bundled surgery and something doesn't go right, and then you've got to investigate and unpack things, you know, at least it was an error that you could actually solve for cost-wise. And they were doing the right thing on the front end, as opposed to with again the BUCA contingent, you know, people are just overcharged for services and providers are just paid less than they should be most of the times. And no one notices those issues because it's just it's just so legacy and it's so entrenched in our mindset. So the issues when they arise are testament to the fact that we're actually controlling costs and things are actually trying to connect, and then sometimes it takes a little bit more, you know, to put the pieces together.

SPEAKER_01 4:29

Totally. At bending the trend, we are really trying to educate people that there are cost savings to be had by trying new things. Can you walk us through just like high level where creating a new PBM structure and creating a new health plan structure has driven cost savings? Like what's being in the data on uh the savings side.

SPEAKER_00 4:52

Yeah, absolutely. So a lot of it involves a dialogue, right? And also in knowing where plan spend areas are, right? So like PBMs, low-hanging fruit, right? Like a lot of Americans are prescribed medicines, right? A lot of them are costly. It's maybe 20 to 30 percent of plan spend, right? Just generally speaking. So in approaching um, you know, PBM relationship, you want to make sure that, you know, the TPA understands that model. You want to make sure that the underwriters properly decrement and discount for having vendors involved. So a lot of what I did preemptively and like laying the groundwork for the plan, you know, in terms of the foundation, was to make sure that everybody was on the same page, right? It took a lot of conversations. It's like, hey, look, I'm not just gonna bring in any PBM that has a shiny message, right? Or something appealing, but it's new and it's untested, right? I was able to actually produce discounts with my product in underwriting by having set dialogues and by being open and by being flexible, right? Because I had a choice to choose any PBM, right?

SPEAKER_01 5:49

Yeah.

SPEAKER_00 5:49

But when the message back was it's gonna produce a higher premium, and you're gonna have at least I circled this together in my mind, right? I'm gonna have a harder time selling something, right? And so if the underwriter believes there's cost savings associated with a vendor, that's a pretty strong message and something you can take to the bank because it's their money and their risk on the line. And like, let's be frank, like, we're not underwriters. A lot of people are not. A lot of people don't have that level of skin in the game. And so that's where the rubber met the road for me is like having these dialogues, making sure things are set up properly on the front end, and then triaging issues as we have to, you know.

SPEAKER_01 6:24

Do you have like a percentage of cost savings from switching to that PBM or switching to that alternative?

SPEAKER_00 6:30

No, I wish I did. I wish I did. I I'm less less organized to that degree, right? Now that I have standardized a block of business and I do have analytics, I could, you know, identify and and showcase you know trends over time. It's most of the time what I see as a result norm is like I will see, you know, massive pharmacy rebate checks going directly to the client, right? Or hey, you know, bundled surgery actually did happen and here's what has saved the plan, right? Or just a post mortem of post-mortem of those sorts, right? Where I'm getting this information after the fact, or maybe it's something is prior authorized and then it's sourced at a lower unit cost, and then I know that there's savings that are being generated there. So again, a lot of it's so structural because we don't have time to be involved in all these claims all the time. We just have to really, you know, make sure it's set up to be turnkey, smooth, and and cost effective at the same time.

SPEAKER_01 7:22

Yeah. And because you created your own health plan, like member experience is like very important to you. We've discussed it, you know, when we've uh you know gotten together over the last handful of months. Walk us through what you wish existed from a technology and services standpoint that doesn't yet. Maybe it inspires an entrepreneur to start something new and solve a issue that like people in your seat feel need solved.

SPEAKER_00 7:47

Yeah, and it's a little bit of a loaded question, which which makes me appreciate it, right? Because I know I might get messages afterwards, but uh, you know, that said in all seriousness, it's education I've really struggled with, and it's not for reasons that are necessarily solvable, you know, outright, because like there's a ton of great websites, right? And there's like mobile apps out the wazoo, and like everybody has a service team, right? But when you're building something complex, like it really has to be the education is part and parcel with using the plan, right? And so that's something that not necessarily uh it doesn't necessarily exist right now, right? Where like you could put in a concierge, right? Or you can build a website, you can have a mobile app uh you know requisition for your your setup and your stack, right? The thing that I've struggled with is you know high build times, right? It's it's really an investment of time. When you have so many irons in the fire, it's really hard to devote and say, hey, I'm gonna build you a website and like will your people use it yes or no? That's why I wish that there was a way to have everything integrated with as people use the plan, right? To have this advocacy kind of embedded into the process, whether it's medical or pharmacy benefits or surgery or choosing a direct primary care doctor, right? Because there's solutions that kind of fit all of these areas in a fragmented way. And it's not easy to envision what the solution is, right? Because again, there are these various different means and modes of communication, but the problem is the time investment, the replicability, integrations, making sure those could and will happen when you have especially like eight different vendors, right? Is it going to be functional? So I wish that that was something that could be more easily addressed, but I wish I had also the answer as to what that could look like, right? Because maybe it's on the ID card or something crazy where it's like a QR code, right? I mean, there's all kinds of ways to solve for it, and it's not like I'm reinventing the wheel here, but people forget about anything educationally speaking, like after open enrollment, right? Or they think about their health plan only when they have a problem or when they can't get a script filled, right? And we know that's an underlying issue. So even a slick app, that's great. It's like people aren't gonna think to use it unless there's a problem. So it's kind of a circular problem and argument, I guess I'm building, but at the same time, like I think there's a huge opportunity there because there's a ton of bespoke plans, right? And there's no one easy way to communicate all the benefits when you need to. And I think the last bit is the operative when you need to, right? Yep.

SPEAKER_01 10:04

Well, I'm constantly looking at new tech and what's coming out, and I think things will be coming soon, you know, that will get you pretty excited. So fingers crossed, execution is key in these things. And again, thank you for joining us on bending the trend. Keep saving your members and uh you know employer customers, you know, some significant dollars, which you have an amazing track record of doing, and keep passing along those savings to them as a fiduciary. So thank you, Nico, for being helping what you have and uh keep doing the good work. Appreciate it.

SPEAKER_00 10:37

Awesome.

SPEAKER_01 10:38

You too, my friend. Thanks for watching Bending the Trend, where we are looking to fight rising health care costs. We are asking benefits leaders what digital health solutions they've implemented that has helped them bend the trend.