The Holy Grail of Taking Care of People Who Take Care of People

In this episode of The Quest for the GoodLife, Dr. Mike Strouse and co-host Ivo Ivanov welcome Todd Lewis, VP at IMA and a passionate advocate for those who care for others. Together, they unpack the complex world of ICHRAs—Individual Coverage Health Reimbursement Arrangements—and why these innovative benefits are gaining traction across the caregiving industry.

With over 400% growth in recent years, ICHRAs empower employers to offer flexible, individualized, and portable healthcare options for employees—especially critical for the hourly caregiving workforce. Todd and Mike discuss how these plans can break the one-size-fits-all model, ease the financial burden on staff, and stabilize a workforce under strain.

If you’re a CEO, HR leader, or policymaker navigating rising insurance costs and caregiver retention challenges, this episode offers a fresh perspective—and a path forward.

👉 Learn how to customize benefits, contain costs, and truly “take care of the people who take care of people.”

Transcript

Ivo Ivanov (00:16:23):

Hello and welcome to the Quest for the Good Life with Dr. Mike Strauss, among other things, a CEO of Good Life innovations. We don't call it a podcast, we call it a PO quest. That's WhatsApp kids. That's what we call it. And today we have a very, very special guest. Today we have one of the most interesting men in the great city of Wichita. Todd Lewis, vice president of IMA, and an expert of taking care of people who take care of people. Did I say it right, Todd?

Todd Lewis (00:17:17):

No, you said it great.

Ivo Ivanov (00:17:19):

This is one of your favorite phrases and we love this phrase, taking care of people who take care of people. So this topic today is very close to me. It hits home literally because for the past eight months or so, I've heard about ICHRA and choice plans and weekly at the dinner table on walks, late night brainstorming thanks to my wife who works for Sunflower Health Plan. And she's been talking to me about Tera and when she was trying to explain to me what it means, she brought up our fedora wearing host, Dr. Mike Strauss because she told me that he foresaw Ira about 15 years ago.

(00:18:26):

He was thinking about something like this. It was kind of a contour of the concept of Vira back then. But she told me that it was quite amazing that he kind of lived up to his pathfinding reputation that long ago because he felt that this one size fits all model doesn't work for today's workforce. And I think she mentioned how he was talking about high school cafeteria food and how what is better to have the high school cafeteria provide the same food for absolutely everybody or give the high schoolers the opportunity to have money in their hand and buy whatever foods they want to be their choice from nearby places. And I think this is a very good analogy because the ICHRA and choice plans, they give the opportunity, the flexibility to the employees to have their own autonomy when it comes to benefits. But this, I just wanted to tell you this kind of long overture was because I've been hearing a lot about it but still don't know how it works.

(00:20:09):

And I was kind of excited that you will be our guest today and you will be able to explain to us in detail why is it that we give the opportunity for people to choose their own health plan and kind of find the tailor made benefits for them. This is something that Dr. Mike Strauss, like I said, he has been talking about for many, many years and it's quite amazing to see it come to fruition right now. But before we start all this, I had a request from a listener to find out more about you because we've been told that your personal story is fascinating. So we'd like to know how

Dr. Mike Strouse (00:21:00):

Evo Evo, wait a second. I thought we always started by asking them one question. That's right. All of our guests, we always ask the same question because it enlightens us about who this individual really is before he tells us his background.

Ivo Ivanov (00:21:19):

Let's talk about your fedora first and he explain to Todd why you were a fedora then.

Dr. Mike Strouse (00:21:24):

Well, you know why we're fitori because it's my lifelong quest and Raiders of the lost arc and my love affair with the guy that led all of that. And it being a scientist and trying to discover things that nobody else is found and the ridiculous quest that somehow worked out. All of those sorts of things. I mean, that's what we're on. We're on a ridiculous quest for the holy grail here. We're trying to find all the silver bullets, all of the little inches, all the little bits of benefit we can get to help who help people. And that's really what it's all about and that's why we're the peta. But more importantly, I think he's cool.

Ivo Ivanov (00:22:17):

Yes, he's very cool. He's a doctor.

Dr. Mike Strouse (00:22:20):

I don't have a whip though. I don't do that part of it,

(00:22:23):

But I like his hat.

Ivo Ivanov (00:22:26):

Yes, yes. And he always knows where the treasure is buried. So you knew there's the ere somewhere out there?

Dr. Mike Strouse (00:22:36):

I did, and I can't remember when it started. You can tell us a little bit of about Todd, but I think we've been doing it for about five years now, so we've been doing it since probably the early parts of

Ivo Ivanov (00:22:44):

It. Yes. So Todd, what is your movie character? We found out that Dr. Mike Strauss likes Indiana Jones and he has a lot in common with this character.

Todd Lewis (00:22:59):

Yeah,

Ivo Ivanov (00:23:00):

Yeah. So what would be yours?

Todd Lewis (00:23:02):

Oh gosh, man,

Ivo Ivanov (00:23:08):

We put you on a spot here.

Todd Lewis (00:23:10):

Yeah, you did. Honestly, if you'll indulge me, I think I'd like to think about that a little bit. Maybe we come back to that at the end of the conversation. It has got me stumped.

Ivo Ivanov (00:23:31):

Absolutely. Absolutely. Think about your favorite movie and your favorite.

Todd Lewis (00:23:36):

Yeah.

Ivo Ivanov (00:23:38):

Alright, well tell us a little bit about yourself then. How did you end up in the most populous in the great state of Kansas and became one of the most interesting men in Wichita?

Todd Lewis (00:23:54):

I'll tell you how I got here. I'm not sure I can live up to the middle. Second.

(00:24:00):

I was born here in Wichita, but moved away very early, grew up in Oklahoma and then made my way out to the southeast, a little junior college in the Blue Ridge Mountains in Georgia. I got recruited to play football back here in Kansas and had zero desire, pardon me, told the coach no twice. He called a third time. And I remember thinking at that time, I'm probably one call good likely not two call good am not three call good. But he called back a third time and a lot of different belief systems out there. At that time, I think the universe was just saying there's something for you in Kansas, not sure of what. So the intention was play a year, maybe two, and then get the heck out of here and never looked back, no rear view mirror, if you will. I met my wife a few months in working at a nonprofit child welfare organization that had a psychiatric residential treatment facility and group of homes there in the little town where I was playing football.

(00:25:20):

And so I would work there in the off season and just, I fell in love with the kids and it started me on a path to what I thought. I mean, it caused me to change my college major to social work. And I carry that organization close to my heart. Even to this day, if you'll look over my shoulder, you'll see a piece of just remembrance of my time, my 10 years at that organization. But I just fell in love with at-risk youth at that time. But it was very quickly that I realized that while I cared about them deeply, it was not in my DNA to do the actual work with them. So anyway, that's maybe a little bit more than how I got here, but it certainly maybe sets the stage for my career.

Dr. Mike Strouse (00:26:21):

And Todd under the category, it's a small world. That agency that you worked at, actually, if I remember right, implemented a model of care called the Teaching Family Model, which is a model that we helped pioneer with Boystown in Omaha and went to all the other programs across the nation for my little work at KU as a analyst.

Todd Lewis (00:26:44):

That's right. We implemented elements of that model both in the residential treatment component of the work we were doing and also in the on-campus school. So it was an affiliation with that public school district in that town, but implemented multiple elements of that model that you talked about.

Dr. Mike Strouse (00:27:05):

Yeah, it's always good to know. You always have a cross connection with people.

Todd Lewis (00:27:11):

Yeah, that's right.

Ivo Ivanov (00:27:14):

So let's talk a little bit about ER and start. Let's start with the acronym. What does it stand for and what is the difference between, is there a difference between ICRA and choice plans?

Todd Lewis (00:27:30):

Choice plans, at least as I know them are a pretty broad term, but I A stands for individual Coverage health reimbursement arrangement, or you may hear it referred to as a reimbursement account, but a reimbursement arrangement. Essentially what it does is it allows an employer group to set aside a certain amount of money each year and on a monthly basis, but each year to allow their employees or a subsection of their employees to go out to the healthcare exchange. So whether it's state or federal exchange and purchase their own plan, so choose their own plan. And that in and of itself, it really speaks to what you mentioned earlier in giving people choice to choose their own path, choose their own adventure if you will,

(00:28:30):

Or to budget to say, okay, here are the elements that I need in order to be healthy. Here's the type of service or these are the services I need, and so I'm going to purchase this type of service out on the healthcare exchange, but then maybe I'm going to choose this over here with my own dollars and I'm going to allow my employer to pay for or at least a large part of my healthcare exchange plan. So great opportunity for people to pick their own plan. The challenge becomes that there's not a whole lot of employee benefits nerds like me that are choosing their own coverage. And so what is absolutely essential with an ICRA is to have a third party, so that is hired by the employer that can walk their employees through that selection process, that can educate them on the different options that they have on the healthcare exchange that can facilitate the payment of those premiums both with the employer and any part that's not subsidized by the employee. And so you have seen this cottage industry pop up with the popularity of IRA's, and I think the popularity is over the last five or so years, I don't know exactly the year that the legislation was passed.

Dr. Mike Strouse (00:30:04):

Yeah, it was probably 20 in that range.

Todd Lewis (00:30:11):

Yeah. Yeah. It was really was an enhancement to the A CA, because as you all may know, and some of your listeners may know, employers over 50 employees do have a mandate to provide health plan or health coverage to their employees. So this allow them to say, Hey, this satisfies that requirement, but what it does is it allows an employer group to one, give their employees choice. I loved how you said it's not a one size fits all trying to apply broadly because everyone has different needs, but it does allow them to go out and choose their own. And the employer group can budget the same amount of dollars per year for every employee regardless of the plan that they choose.

Dr. Mike Strouse (00:31:04):

So I almost want to go up a little higher than this because I will tell you first of all, my shameless plug for you is that we were so attracted to IMA as a company for lots of reasons, but good life has a group plan which we offer our employees, a portion of our employees, and I'll talk about that in a minute. And we have an ICRA plan that we offer our hourly people. And this is the unusual part of it. And I think first the irony, I think the truth is, and I have a bit of a statistic or two, but in our industry and roughly 31% of all the employers in our industry pay a hundred percent of the individual rate of a group plan, but 35% pay only half the premium for that. And if I can, before you get into the weeds of an,

(00:32:12):

I really just want to talk about the truth of the matter is there's really two, at least two parts, two sets of our workforce. There's sort of the salary people that are paid a little bit more and we haven't had the instability issues with the salary people. And then there's the people who are caregivers that are generally hourly. That's not always true in life, but generally hourly, the turnover is higher. Although we work hard to reduce that and we have in many ways. But really what I've always felt as a gut and Evo, I think this is what you're talking about by seeing things down the road, is that I felt like there were two workforces in essence, and they had different needs. The mid to top hats, their long-term employees, they made me making a little bit more money. They have some stability. And so they kind of want what normal company employees of that stature want, which is they want 4 0 1 Ks and they want health benefit plans are really attractive and those sorts of things and everybody wants it. But here's the thing, when you get down to the working class, and by the way, that's not true in orange, it is literally all industries.

(00:33:46):

You Got this other group and I call it, it's a base of the pyramid of the workforce, the widest part. So our workforce may be of that may be 65 or to 70% is that working class group and they're making now 35,000 a year or so hourly or more, a little bit more sometimes. But in that range and that group, when you get down to budgeting for that group, Todd, if you sit there, we do a little exercise out with people when we talk about this kind of stuff. And it's kind of like monopoly money and say, okay, let's take some money out for rent and let's take some money out for your car. I mean just like food, I mean literally when you get done with the basics, just the Basics,

(00:34:39):

It's like they don't have hardly enough to live on. And just other democrats or demographics is that 65% of all the people who are in the care industry are the head of the household. For goodness sakes. 81% are female of childbearing age. I mean, they got so many responsibilities. They're multitasking on our level and they're making every cent count.

(00:35:06):

And the bottom line is I'm getting at is when somebody is only paying 50% of the premium, which is 35% of the agencies out there, that's not a lot of money for these people to make health a priority in this. So they're really struggling with this and their priorities literally are different in what we found, and one of the reasons we were so attracted to IMA seriously IMA was because we had two parts of the work workforce, and I don't know if you know this Todd, but I actually had a good friend that was in insurance. I was so befuddled about insurance, I asked if I could just go through the training as an insurance agent, and I was certified to do that just so I understand how it worked. But when you get and go out and the people who listen to this podcast are CEOs and CFOs and they're all walks of industry and this, and it's like you should know when you go out to get a bid, when you guys go out to get a bid, if you have half of your workforce, that's like a hundred percent participation, the top or a top high level of participation, and the bottom half is low participation and you're going to the market with 40% participation, your premiums are going to take a hit with that

Todd Lewis (00:36:27):

Usually. Yeah. And typically I, and I don't want to get too down the weeds with underwriting algorithms, but your younger population in your industry, and let me use your industry broadly, let's talk about the caregiving industry because that can encompass social service, healthcare, senior living. There's a lot of young people in that demographic that is not electing coverage and that leads to adverse selection and higher premiums to your point. But I want to go back also two points to what you mentioned. I thought it was interesting you use the analogy of a pyramid because that's exactly, and after realizing that it was not in my DNA to do the work with our clients, with our patient's residents, I did, I made that shift to human resources because that was the best way that I could find to take care of those people who I admired so much who I desperately wanted to be, but knew I wasn't.

(00:37:40):

And so it was my way to take care of people who take care of people as we talked about earlier. But as I began to hire and I began to build relationships with those direct care workers in residential treatment facilities with at-risk youth LPNs, not as an RNs, but LPNs, CNAs, CMAs and Senior Living, they were making decisions on food, shelter and safety. So they were on that basic rung of Maslow's hierarchy of needs. And so those are the things that were dominating their thoughts, dominating their decision making. And so to the second point, and you mentioned earlier for those that are covering 50% and saying, Hey, that's what I'm budgeting for. Well, if you look at Kaiser Family Foundation and every year they do a healthcare study, I think the average single premium right now across the country is somewhere around $12,000 a year. So even though you're paying 50%, they are still of that 35,000, 6,000. So they're not netting 35, but $6,000 of whatever they net is going to healthcare if they choose that. And I think we all know,

Dr. Mike Strouse (00:39:06):

By the way, Todd, a fifth or a sixth of their salary.

Todd Lewis (00:39:10):

That's right.

Dr. Mike Strouse (00:39:10):

And all I'm pointing out is that some people are in that, well, I mean 50%, another statistic is 50% of the people in the caregiving workforce are eligible for the same public subsidies as the people we serve are. So it's like mostly they're poor people in general, or not affluent people for sure. And so they have to make basic choices on what they can pay for, and that's what leads to the fact that they often don't participate as much as we wish we could, and I would encourage everybody to invest as much as you can in health coverage, but at the end of the day, I know what's going on with public funding right now. I mean, it's flatlined. I think today good life is, I think when the waiver started, that's our funding system in Kansas when it started in 1991 and then was adjusted in 1999. But from 1999 forward, if you do cost of living adjustments, our current reimbursement rate is about 85% of the rate. It was in 1999, and our responsibilities are endlessly greater than it was then. So we're, as you know, Todd Insurance goes up on, its not based upon our revenue. It just goes up based on a lot of factors out There.

(00:40:35):

And when that goes up at a higher rate than our revenue, then we're farther back than we were in 1999, then even 85% in many ways. So agencies struggle with this, and so they do the best they can, I think, I mean, we help them do better. In all sincerity, that's part of our work with agencies. We work with that workforce and we can do a lot of things to improve their situation, which isn't the topic of today. But the point of all of this is that a lot of well intentioned, good minded community service programs are always behind the curve. They're trying to do the best they can, but at the end of the day, it's a weird situation that actually IMA help us with and help other people, but we want good group plans, but we also for the people that we think can have them, and then we want to give maximum flexibility to the other people who really can't necessarily afford it. That's the place that we were in.

(00:41:45):

And you can do with an ICHRA. The one thing I want to point out is, which is unusual, you can do both the rules of an ICHRA, which we'll get into a little bit later, but the bigger ones, kind of the AHA with a lot of people that watch a show is that you can offer a group plan to certain classes of employees and offer an ICRA to other classes of employees. So you can't offer both, both, but you can carve out your workforce in different ways. And there's all kinds of ways that there's issues with that Todd like and before getting into what ICHRA does, but it lets you have two offerings to different classes. And I think that's important as an example, that could be, I think there's 11 class divisions of an ICHRA, But

(00:42:40):

You can offer to hourly workers in ICHRA versus salaried workers group plan. Or you can say if you're in a geographic area that doesn't really participate in the network, you can offer another geographic area in IRA and offer a group plan to everybody that's not part of it. We have remote areas of Kansas or a small group of employees in another state or things like that that can't get access to our network, for example. So it offers this flexibility where you can carve out people differently and offer them something that is more valuable for them. And we'll get back into the ICHRA now, but I wanted to make sure everybody understood that the benefit of that, let's say just on the hourly versus salary, is that if you're going to market with 35% participation combined, and the insurance company sometimes looks at as a problem and there will raise your rates as opposed to going to the market with 75% participation.

(00:43:47):

And so when you find yourself in that challenge, what IMA did for us is they helped us preserve a group plan. We were at different times had been at risk of that and helped us offer everybody kind of what they needed. And I think that's a cool approach. It's not for everybody. This whole message is all, this isn't for everybody, but the creativity is important to have and the analysis can be important to do to make sure that you're offering the best for everybody given your geographical areas and all kinds of factors that we can get into that won't get in this show. But ICHRA does allow you to carve out people and give both people more of what they want. Now we can go back into what really is an ICHRA, but the ICHRA allows you to go out on the market and get individual plans and a group plan, of course, you usually have one, two, sometimes three offerings that you can give to your employees and they have to pick from those three offerings. And the rates are pretty set with an ICHRA. The class of employees that gets that, let's call 'em hourly just for the fund now can go out and they can get a plan on the market and it could be the one that fits their family and personal situation best. It's also portable should they leave and has some other factors to it if they want kind. The thing is to be compliant, if I remember, it has to be you have to pay at least for that employee what the right percentage is.

Todd Lewis (00:45:45):

Yeah. Yes. Have some safe harbors.

(00:45:47):

Yeah. The term safe harbor, so there's provisions on affordability. And so as long as you're meeting those provisions of affordability, that's determined by the A a. The different safe harbors you can use could use a rate of pay. And so you essentially look at the lowest hourly rate of pay in your organization, and then there's a formula driven way to determine what the highest employee only or single monthly premium can be for that for your employees. You can use the federal poverty level as a safe harbor guide to setting that as well. So there are a couple of different provisions, a couple of different safe harbors for being able to do that. But you're exactly correct, Mike, it is. You don't have endless choices as an employer group, but the guardrails are wide. And so as long as you meet some basic a a provisions, then it meets the A employer mandate for health coverage offering.

Dr. Mike Strouse (00:46:58):

Yeah. Well, you can also even have different premiums for people of different age classes if I remember as well. So really you can dial your support in. But one of the unique things, if I remember about an ICHRA is while a group plan, you come back to us and say, here's the cost of a group plan and we need to pay that premium and iris plan. An agency can decide much. It invests in that,

Todd Lewis (00:47:32):

Right? Yeah. Yeah. The federal exchange healthcare.gov for example, they're going to set that total, the total premium for that individual based on how many people that they want to ensure in their family based on their age, their demographics, so zip code, date of birth, those types of things. And those premiums are going to be set. And then yes, the agency, the employer group can say, I want to contribute $500 a month towards this premium. And as long as using Believe it's the silver plans on the exchange, as long as your base, that base offering on the healthcare exchange minus the $500 that you budget meets a CA affordability, you're in the clear. And so we could spend two podcasts talking about just the nitty gritty of that, and I don't think that's where we want to go today, but suffice to say wide guard rails, but to your point, Mike, it allows an employer group to say, this is what I can budget this year for employee healthcare premiums, $500 for an employee only, or maybe it's a thousand dollars for a family, whatever that number is, it allows you to do that and then you can set your budget, you can set it and go.

(00:48:58):

Now, we also know in the caregiving industry, the turnover rate is high. And so I don't want to pitch this as a set and forget it budgeting tool because your enrollment is going to shift over the course of a year, especially in senior living and social services, residential treatment, the areas that are going to have this population of employee. So you've got to monitor that too, but it allows you to budget easier, not having to worry year over year. It really makes an impact at renewal time when the only determination you have to make is are you going to increase the contribution by 4%, 5%, whatever you choose. You're not beholden to an insurance carrier saying, well, you had an okay year, but trend is 9% and you're not fully credible, and so we're going to take 40% of your own claims, 60% of trend claims, and that's going to equal this. And so all of a sudden you're staring down the barrel of a 25% increase and you started with, Hey, I had a decent year. So that ICHRA option is not for everyone to your point, but it does allow you stability in your budgeting as A-C-F-O-C-E-O.

Dr. Mike Strouse (00:50:25):

Well, but in many ways it can help because I will say this, Todd, is that with IMA, our few hundred people that we have for a group plan is less costly because we have a higher participation. Secondly, most agencies don't do claims analysis by class. They don't. They just say, here's your claims history. But in reality, one of the other factors of an ICHRA is when you go to the market, the claims don't affect your claims on the ICHRA don't affect your group rate at all. They're totally separate and going to market. Your claims don't affect the rates on the market either. I mean not directly. You just buy market plans and year after year, it's whatever those market plans are. Is your claims history for the people on your, I mean accurately with everybody else in the world on it? They do, but they don't really affect the market. They don't affect your group plans. So I think one of the studies you have to do is what are the claims rates even in traditional group claims, what are the claims rates of the hourly folks? I mean, and I've seen where that could be high with many cases. And if it's high, then

Todd Lewis (00:51:57):

Let's talk about

Dr. Mike Strouse (00:51:58):

That. It all plays into the analysis of what you should do. And that's why this is, I say this sincerely, this does not work for amateurs. You got to work with somebody that knows what they're doing to analyze all this, but it is worth looking at. And I would tell you that a lot of insurance companies don't do that because they are so driven to sell everybody the group plans. And my thing on that is that that's fine if you can afford that, but if you're choosing between that and not doing it or something else, or you don't have the money to do that, then when you go and help somebody, you may offer them something that they hadn't thought of before and a different kind of viewpoint and analysis so that they can have both as opposed to all of a sudden they're paying less percentage and then they're kind of in a spiral. And that's what I've seen a lot of my colleagues get into. It's sort of this downward spiral year after year that they're trying to figure out, okay, how can I lower this crazily growing rate? And it ends up kind of eating away at the participation because of how they do it, and certainly it eats away at their retention.

Todd Lewis (00:53:21):

Yeah.

Ivo Ivanov (00:53:23):

So I'm trying to understand it. Is it correct to say that ECR plans, they help by offering more affordable, more portable tax advantage benefits that adapt workers' life not the other way around?

Todd Lewis (00:53:45):

I wouldn't go so far as to say that in all cases they offer more affordable benefits. What they do offer is choice. And so the affordability of those benefits are still going to be determined partially on the employer group's investment and subsidizing that plan. The healthcare.gov, the exchange plans, they're subject to the same inflation that the commercial insurance side is.

(00:54:19):

They're subject to the same claims volatility. And so you're still going to see increases even on the healthcare exchange. Let's talk the state of Kansas here. You see carriers coming in and out of the exchange, they'll stay in for a couple of years, you see them drop out, they'll come back in, but they're subject to the same volatility of claims that a commercial insurance. But what the ICHRA will do for a population, especially the population that those listening to this pod caregiving organizations, it offers them choice. So instead of just taking one of the two options or three options on a group plan, you're going to have 27 different options on the healthcare exchange. You can choose the carrier based on network penetration. And so again, the importance of having a third party that's working with the employer group to help provide that concierge level of support, and there's a lot of 'em out there.

(00:55:32):

There's Fabi, there's gravy, there's sizzle, there's quite a few out there. IMA works pretty close with brave and they've been a fantastic partner of ours really providing high level concierge service to that single mom with four kids who is trying to decide what kind of plan on the exchange she needs to choose. Oftentimes, if we talk about the population that you're hiring in this industry, most I would say, and this is based on my time working, not only working in hr, not only in child welfare, but also in senior living and pediatric private duty nursing in my career, the majority of folks are living in high deprivation areas. So if you look at research social determinants of health, you know that their social risk factors are higher. If you look at IMA’s book of business across the entire country, we see about a 5% higher rate of hypertension.

(00:56:40):

We see roughly 2.6% higher rate of diabetes and a 1.4% higher rate of depression. So then you translate those to healthcare claims and you're talking on an average plan with a hundred employees, you're talking about an extra quarter million dollars in healthcare spend per year. When if we can provide an option for them to choose a plan that fits into their budget rather than having them stretch and decide between feeding their kids, paying their rent, staying in that cycle of poverty rather than having the opportunity to jump up out of it, if we can offer them something that lets them choose, then we have a better opportunity to bring some of those claims down. So it's not the silver bullet. There are a lot of bullets out there, figuratively speaking, that we can use to attack the problem of our insurance costs going up in the caregiving industry. But this is one of them that allows choice and can allow someone to make an option, choose a healthcare option that fits into their budget rather than trying to ram our options.

Dr. Mike Strouse (00:58:01):

And in a minute, a little bit later, I want to talk about some other things other than ICHRA. But before we even get there, I do want to just point out a simple thing is most people group plans, they don't offer a bronze plan that doesn't comply as an example, but bronze plan obviously are less costly and people that are looking for the coverage for the catastrophic, or I've seen some really good plans for people don't have a lot of money where they pay some preventative of stuff and then they pay for catastrophic Stuff

(00:58:36):

More at the bronze level. One of the things that ICHRA does, let's say maybe good life would say, Hey, I'm going to pay so much a month for you. You pick whatever plan you want. And that was based upon really paying 75% or 80% or 90% of a silver plan as an Example.

(00:59:01):

Let's say I paid 90% of a silver plan costs and I'm just saying, I'm giving you this money.

(00:59:07):

And then they go and they say, well, you know what? I want a bronze plan, and that covers a hundred percent of a bronze plan. It might even cover 120% of a bronze plan. And then another thing we didn't say is an ICHRA can cover health premium. It can also cover medical expenses or both categories. So if somebody had a little bit of money left over, they can pay for some of the ongoing medical costs that are not covered by the or not covered by the plan. So when you're making those hard choices, as an hourly person of, I can't afford a platinum plan by any nation and I can't even afford a regular plan, but maybe I'd rather have a bronze plan than

(00:59:55):

No plan, that's a choice you can have with an IRA that might not be afforded to the group plan. So again, you need help on all of this. And the one thing I would also say is, and by the way, IRAs have gone up in the last, I think it was since COVID, they've gone up over 400% in popularity, really have targeted working class. You see them more in religious organizations and not-for-profits. You see it really going up in there. And so that's kind of the niche of that you've seen. But at the end of the day, the goal is just trying to investigate all of these kinds of things to see what might work best. And for all my colleagues that are struggling out there that are trying to choose between offering kind of diminishing everybody's premium, there may be a way to do it. And the other thing I'm going to tell you is that you mentioned it a concierge,

(01:01:06):

You can't do this on your own, really. You have to have a concierge help you with this. And there are great pretty good, you have good partners, but we work through you to look at these NS and then you connected it with the partners and you've got other ones than just Acra, which is super important when you pick an insurance company is to, I always say, I think you'd see in not-for-profit, there's a tendency to pick insurance companies based upon who's on your board or those sorts of things. And you've got to look at it carefully and pick a great company that can offer you this kind of analysis and support, those sort of things. And I think that's important. But we as a company, in fact, we wrote some grants and we're really into non-traditional benefits beyond health coverage. And I can even say beyond 4 0 1 Ks because is people pick 4 0 1 Ks in safe harbors primarily because it's, I mean, hourly people do it as much because it's just free money. But if I went to my employees and said, Hey, would you rather have me match a 401k or would we rather me match your student loan or would you rather me match

(01:02:32):

Housing subsidy, which we actually do by the way, to live close to our home so that we can have people work close to those sorts of things. And that's a topic for another day. But the reason I brought that up is that of course, the 401k safe harbor, you have to match that first. That has to be their first choice. But if they choose to not do that, you don't have to take that money away from them. You could offer it for something else. And you got to be innovative with the money that you have, and you got to try and give people what they need to make ends meet. And that's the real golden handcuff if you can.

Todd Lewis (01:03:16):

Yeah, and I love that you just said that, Mike. And if I could just share a quick anecdote from my years on the client side. So before I came to IMA six years ago, I spent the first 20 years of my career, as we've talked about in caregiving organizations, behavioral health, residential treatment, healthcare back in 2013 or 14 IMA was everything comes back around. But IMA was my consultant, my employee benefits consultant, they started having conversations with me and I was in hr and I was of that mindset. And I don't think it's isolated to HR because I think whether it's CFOs, CEOs, leaders and organizations, we care very much about our people, but sometimes that means that we make assumptions about what they want and need, and we begin choosing things based on what we believe they want and need, not necessarily what they want and need. And so

Dr. Mike Strouse (01:04:26):

No true awards were ever said.

Todd Lewis (01:04:28):

That's right. So 20 13, 20 14 IMA comes to me and says, Hey, we'd like to propose that we launch this initiative. We want to start with your organization, the Wichita Market, to launch this in all of our markets. And we want, essentially, we want to listen to the voice of the employee and we will do the legwork and we will ask your employees what they value about your benefits, your compensation, and there are multiple other buckets. But that benefits piece was so interesting because I was very proud at that time. I was the leader of the HR team, was running part of the operations portfolio of that company too, and very proud of the benefits program we had put together. But what we found, so we said yes to that, we said, yeah, we absolutely, let's ask. Let's say, hey, we're going to throw out the playbook and we are going to ask you what you value, ask you what you need. And what we found was so interesting, we found that to the tune of six figures, we were subsidizing benefits that our employees really didn't value. I mean, they enrolled in it because there was no barrier to enroll because we were subsidizing almost the whole thing. So of course they just checked the box

Dr. Mike Strouse (01:05:51):

Free money too. I mean,

Todd Lewis (01:05:53):

Right. When asked about it, they're like, yeah, well, I probably wouldn't enroll in it if it wasn't so cheap. What I'd really love is this, well, guess what? That was 75% cheaper or less expensive to subsidize and invest in that something our employees really wanted than it was to do what we were doing. But it took us admitting that we might not know what our employees want and need to find that out. And so as the HR leader, I was able to return a ton of money back to the ownership group. We were able to reinvest that back into a growing company, and we were able to give our employees something that they really truly wanted and they valued and it created stickiness. We all know that in senior living, I think I read, it's been a few years, the Annie EKC foundation did some research on turnover in senior living and found that average in assisted living was about 125%. And then there are other studies that say that the direct and indirect cost of turnover is somewhere between 0.75 to a hundred percent of the cost, the annual compensation for that employee. So

(01:07:18):

You think about what you're spending to turn people over more than one time a year at 125%. And if you can create some stickiness by saying, look, I value your opinion. I value your opinion so much, I'm going to ask you about it and I'm going to act on it and I'm going to invest in benefits. Sometimes non-traditional benefits based on what you value and want. I think to me, that's as close to a silver bullet in this industry is anything, Mike is listen to your people. They will tell you what they value, they will tell you what will keep them engaged and working for your organization. But you have to listen to that

Dr. Mike Strouse (01:08:01):

At Good Life. We have an annual assessment we do with our hourly and other folks, and we have kind of a running list of possibilities. And as we discover new ones, we add to the list. And what we do is we say, which ones do you value most? We try to get some feedback from them of what ones they value most. Now I'll tell you something, we thought we knew everything and we didn't. I mean, there were things that we thought they valued a lot and that was a reason why they stayed here. But it turned out not to be the things, and there were other things that were, and so

(01:08:43):

We're evolving. And also you learn that not everybody wants the same thing. And so that's cool too. And so one of the reasons that I brought that up is remember when you were saying on this ICHRA, you need a navigator or a concierge, whatever you want to call it. We just received a grant to hire navigators at good Life. Because when you get into the world of individualized benefit structures, I'm not beyond group plans and beyond all of the traditional plans, but non-traditional sorts of things, you need somebody that can help do that. And when you get to the point where the people that we serve are eligible for many of the same benefits of the people that help them, I mean it's really, but how do you access 'em down to food pantry access and down to housing subsidies and all kinds of stuff that they just are mystify most People.

(01:09:52):

But you need to offer help for accessing those things. You need to ask them for sure on that. And one other thing, anybody wants to write in and ask for it, and we have a way to do that on the website, but we actually, good life was asked to conduct a survey of a state that we worked with. I can't remember if it was Utah, Arizona, Megan did this, Megan Todd did this. But basically we worked with over a sample of over 500 providers and employees and things in the hourly world. And they came back with what they wanted. And it was really insightful. And it was sort of the beginning of trying to leave it a broader list of what our industry is like needing. And the other thing we work really hard on is you mentioned the cost of turnover. And it is so incredibly devastating on, I mean, cost in terms of human care, number one,

(01:11:04):

And go past that. Then just the cost to an agency to this high number of different people involved in care. As a behavioral scientist, I can tell you the one metric that is the most damaging to care is too high. A number of people involved in the care, the more people involved in care that goes up, the quality of care goes down. So that's mostly our space. We look at all these different ways to do it. Certainly benefits and non-traditional benefits is one, but schedules, attractiveness, schedules, pay strategies we use live in, live by, live near strategies, which are many non-taxable ways to pay people. I call it, it's a series of inches.

(01:12:02):

There's a few silver bullets to be honest with you, but outside of the few silver bullets, and to me the silver bullets are shared living is a really cool method to leverage pay for people. That's other episodes that we have. Divo, we worked with last episode with Lewis, another Lewis on that, Walton on Shared Living, but live, live by live near strategies in general allows some non-taxable advantages. Todd, our professional neighbors tenure or seven years, our shared living 10 years higher than that, we've had 3% turnover in that since 1999. We have. So there's ways that you can, the three day work week has just been a real with premium pay, which is another thing, but it's a real way to really improve your workforce exponentially and help the capacity of providers. So there's all kinds of ways, but they're all Pieces.

(01:13:15):

And I think my hope for everybody is, that's why we always call this the never ending journey for the good life is because you are never done. I mean, there's always more that you can do. And I think what you were saying about asking people what they want changes, it changes from individuals.

(01:13:40):

We're in the world of group and individual benefits. I mean, I think if you're really trying to make this work and those benefits are what you think of as traditional benefits, but they're also things of very non-traditional benefits. And one of the things I keep bragging on IMA about it is they get involved in things that don't necessarily even have a benefit for them, but they know it benefits your customer and the client. That's pretty cool. And that's one of the things that attracts me to you guys is that, and you seem to have a lot of people who are committed on, and you know guys play a big piece of that, but you also have a lot of partners that do. I mean, you get down to prescription buying stuff. How crazy that is where they're talking about now how much more are we paying in the United States, for example, for drugs versus other places. And there's ways that prescription folks that you partner with manage that I, there's just so many ways, and it takes a lot of effort to piece all that together.

Todd Lewis (01:14:58):

But it has to start, for us, it has to start with what is the organization trying to accomplish? The strategy is about what you're trying to accomplish. And so often in caregiving organizations, whether for profit or nonprofit, it is not just about, Hey, I've got to offer a plan because I'm mandated to offer a plan. There's truly altruism in taking care of people, helping them thrive, helping them on the quest for the good life. However you want to phrase that In caregiving organizations, not only are you caring for that inpatient, but you're caring for the people in the middle. You're caring for people who care for people. And so developing a strategy that optimizes their choices allows them to choose something that's within their budget. In this conversation, it's centered around ICHRA, which allows for all kinds of choice, but whether it's ICHRA, direct primary care, international, drug sourcing, whatever the tool, whatever the vehicle for healthcare delivery, it's about offering choice to take care of people.

Dr. Mike Strouse (01:16:16):

One pitch I'm going to make just generally to the listeners, because some of them are managed care organizations and managed care organizations are literally the majority of how services are now managed now are moving towards, which is another insurance company, but for the management of public benefits and long-term services. And Kansas, the state that we are in was the very first state in the country that pivoted to managed care for long-term services.

(01:16:53):

And we sort of knew it was going to happen and everybody's so uncertain about all of these kinds of moves, but we decided to do everything we could to work with them and develop relationships. And it really paid off for us because we have good working relationships. In fact, we work with managed care companies all over the country now in multiple states and not from a service provision, but what we learn is they contract with states, they compete to get contracts, and one part of their competition is what I call added value services. So the truth is managed care in the state, and we all have one thing in common. We need a caregiving workforce. And in order to deliver a care cost effectively, if we can't get that, we can't accomplish our goal for our customer. And we're all kind of lined up at least on that one goal.

(01:17:56):

And I can tell you that we work pretty closely on how we could help, even when they are making applications and states on how we can help be added value for helping them understand and helping them actually deliver possible advantages for caregivers. Because again, that would be attractive to a state. Anybody who can do that, it is attractive. And I will just say I have seen some states, maybe it was because of COVID funding, but it kind of caught on where they're really working hard as a state to help providers help the people who provide care and how they can improve that stability of the workforce. And the idea of investing in navigators who can help providers access these non-traditional benefits for their employees.

(01:18:58):

I think if you have an HR director and a program, which everybody does, you should be having a navigator in there as of equal importance. And I can see down the road how navigators could be a third party service that kind of plugs into agencies may be offered by insurance companies or offered by brokers as added value, those kinds of things because, and you kind of do that, but that's a service that for the working class, for example, we have most of our folks that are in shared living who have kids, they are eligible for public funding, for the insurance for their kids, for example, things like that.

Todd Lewis (01:19:47):

Some you would, I think a lot of leaders in this space believe that, oh, well, if they make 15 to 17 to $18 an hour, they know what's available to them. And that's just not true. And so you may have people on your payroll that are paying for a family plan, that single mom of four kids that I mentioned earlier, paying for a family plan, basically 50 to 60% of their paycheck every two weeks or every week, whatever the payroll is when they have their kids, are eligible for CanCare, which is the state assistance, the medical insurance in the state of Kansas. But she doesn't know that. And so yeah, I love the idea of a navigator because it can educate your workforce and hey, let's find the most cost effective coverage for you. And it doesn't have to just be this or just be this. Maybe it's a combination of these things. Let me hold your hand and let me help you navigate this really complex world of both state and private insurance.

Ivo Ivanov (01:21:00):

Yeah. Todd, what position did you play in football?

Todd Lewis (01:21:04):

I was a defensive end,

Ivo Ivanov (01:21:07):

So

Todd Lewis (01:21:07):

I was a little too slow to play linebacker and a little bit too short to play defensive end at the D one level. So I played at a small private college here in Kansas.

Ivo Ivanov (01:21:16):

It's a very hard position to play, very hard, very demanding, taxing on your body.

Dr. Mike Strouse (01:21:21):

I played a little too, and my job was to run away from you. That's right. As fast as I could. I didn't like you at all. Used me harm at that moment.

Ivo Ivanov (01:21:38):

Guys, at this point with 400% growth of vira, this is not just a policy, this is a movement. I had no idea that the growth was so rapid in such a short timeframe, and this might be the next big evolution in how we take care of our caregivers. And I don't know if you remember Mike and Todd doesn't know that, but Mike, years and years ago, before this benefit structure went mainstream, started offering stipends to the workforce, empowering them to shop the A, a marketplace for insurance, and this often qualifying for additional income based subsidies. So you really foresaw this movement long time ago, Mike,

Dr. Mike Strouse (01:22:37):

But there wasn't really a methodology out there to really do it. But I wanted the movement, I wanted it, and I wanted it as a way to bifurcate the workforce when, because it was a method to do that. That's what I always called it, and it'll tell you how crazily I wanted it. I explored for years creating what was called A PEO, but most people when they use a PEO, it's a leasing company

(01:23:07):

For employees. Many people were using a PEO for small companies where they could take a small company and pool it with other small companies, and then they could go to market Todd for benefits on scale. Well, I was looking at it and trying to work to create a PEO for hourly people. It was possible to do in many states, and that would allow me to bifurcate the workforce and take these people to market to get a better rates and scale in a way that we could do it and get people as a not-for-profit to invest in that group. Because I found that there are foundation resources, there's all kinds of people who want to improve the lives of the working caregiving class. It is just that you got to put a spotlight on that and you got to wrap it up and give it to people in a way that they can invest in it. And so anyway, there's all different ways to try and do it. We just keep looking at different ways. And at the end of the day, that's why I say there's no one way. There's about 200 ways, and we've only figured out like 20 of them. The rest of 'em we're still looking for, which is the quest for the good life. It's that holy grail out there. Maybe we'll find something out there down the road that everybody universally wants, but so far it's not Beens been elusive to me.

Ivo Ivanov (01:24:40):

Todd, do you remember Kevin Costner's character in the Horse Whisperer, Tom Booker? You've seen this movie, right?

Todd Lewis (01:24:51):

Yeah. Yeah.

Ivo Ivanov (01:24:54):

Mike is a huge, huge horse guy, and I remember,

Todd Lewis (01:25:00):

So am I.

Ivo Ivanov (01:25:01):

Yes. And that's why I brought up this movie. So remember, he was trying to heal Grace and Pilgrim at the same time, basically. And the character Annie, she approached him to help Grace and Pilgrim, and she said, I've heard you help people with horse problems. And then he answered, truth is, I help horses with people problems.

Todd Lewis (01:25:31):

Yes,

Ivo Ivanov (01:25:32):

I love that quote from that movie, and you remind me of him a little bit because you try to take care of everyone and you are a defender on the football field, but you're also a defender in the caregiver field.

Todd Lewis (01:25:47):

Thank you for that.

Ivo Ivanov (01:25:49):

So

Todd Lewis (01:25:50):

I'll go with that character just answered the question I

Dr. Mike Strouse (01:25:54):

Was trying. Absolutely. Who could go wrong by picking him, right? Tom Booker. Yeah. What a great character. No, I'm talking about the guy that played.

Ivo Ivanov (01:26:05):

Yeah,

Dr. Mike Strouse (01:26:06):

Kevin, if you're ing out a movie character, I mean, I think that's almost trumps Harrison Ford, to be honest with you.

Ivo Ivanov (01:26:14):

Yes, that's right. So if there's one takeaway, I think it's this, health benefits are not just about coverage. They're about care. And when we invest in the wellbeing of our workforce, especially the DSPs who serve the most vulnerable people, we unlock, we unlock better health, stronger retention, higher quality outcomes for everyone. And what we've heard today from Dr. Mike Strauss and Todd Lewis is that it's real, it's scalable, and already making a difference. So there a path forward for systems that have struggled far too long with instability. So whether you're a provider, policymaker, or employee, now is the time.

Dr. Mike Strouse (01:27:08):

If anybody has any questions about the podcast or if they have questions for Todd, we have a way to get those to us and we'll get them to Todd. But what I always tell people is most people go to market in the fall or even September, October in that area. You go to the market for the next year. Don't wait to explore these things. I found that the most sane time to have these discussions is right now, even the spring or the summers, when you want to have these discussions because sometimes whether you're doing Acra or whether you're just trying to explore non-traditional benefits or whether you're just trying to think outside of the box, I like to work with people that not only do one thing with the group things, but can give me insight with the rest. And I've liked that with IMA for a long time, and you work in many states.

(01:28:13):

I know that, which helps our listeners, so send us questions. Also, Megan would be happy to send the results of that national survey of what employees want, which might be useful to somebody. And I'm going to use that a little teaser if you want to just send that for the question. And then Megan will send you that out there. And then we'll be at lots of conferences talking about all of these things in more detail. So keep up with the Quest for the GoodLife, these ideas, and start exploring them because I'm telling you, you got to do a lot of things, but you want to make sure you don't waste your time on the things that maybe aren't as fruitful, especially if there's research out there on the things that actually are fruitful for people. Lots of stuff out there, and especially in the area of tax savings. And there are taxes to be saved, whether they're for housing or for phones or for all kinds of stuff. So give it some thought.

Ivo Ivanov (01:29:24):

Don't hesitate to contact us. This was the podcast for The Good Life with Dr. Mike Strouse. As usual, this episode was produced by Megan Olafson. Our outstanding guest today was Todd Lewis, AKA. Kevin Costner, he's vice president of IMA in the great city of Wichita. I was your co-host. We'd call most Ivo Ivanov. We'd like to thank you for being with us and assure you that the quest for the good life, we return in exactly two weeks. This is it.