LaSalle County insurance committee hears warning on rising health costs; health-navigation app activation targeted

LaSalle County Insurance Committee members heard an update on the county employee health plan that flagged early-2025 large claims and rising pharmacy costs as the main drivers pushing plan spending above last year’s levels. Beth, a consultant with the Horton Group, presented the quarterly review and discussed pharmacy trends, digital navigation tool performance and next steps to improve member use of available resources.

The committee was told the insurance market remains volatile. "They're struggling to appropriately price the risk that's in the market," Beth said, citing nationwide carrier losses and volatile specialty-drug spending. She said some carriers initially quoted renewal increases in the 20%–30% range for fully insured groups this year, with expectations at the end of negotiations to land in the early- to mid-teens.

Why it matters: large, one-off medical and specialty pharmacy claims concentrate risk in a partially self-insured plan and can significantly raise employer outlays before reinsurance begins. Those dynamics influence the county’s renewal outlook and budgeting for benefits.

Key findings from the presentation

- Large claims and year-to-date spending: The plan ran “hot” in January but normalized across the first quarter. Beth reported four claims above $75,000 in the first three months of 2025, versus two in the same period of 2024. Employer responsibility on the large claims totaled $486,000 so far in 2025, compared with $247,000 in the first quarter of 2024.

- Overall spend and drivers: Total spend for the period is reported as 25.8% higher than the same period in 2024 (an increase cited as about $536,000). Claimants with more than $10,000 in expenses accounted for roughly $447,000 of the increase.

- Reinsurance and plan design: The county’s plan is partially self-insured and carries a specific deductible; Beth said reinsurance typically covers amounts above the plan’s stop-loss threshold and represents about 15%–20% of the plan’s total costs. Beth noted that once the plan’s specified large‑claim threshold is met, reinsurance pays amounts above that threshold for the rest of the policy year.

- Per-capita and enrollment: Per-capita cost cited in the presentation was about $26,000 in January and improved to $23,900 by the latest month in the quarter. Enrollment was steady: the plan covered about 437 employees and 863 total members (employees, spouses and dependents).

Pharmacy specifics and GLP-1 medications

Beth highlighted specialty pharmacy and new weight-loss/GLP-1 medicines as major cost pressures. The plan’s specialty pharmacy spend was reported at about 33.5% of total pharmacy dollars; in the quarter the plan had 45 specialty claimants accounting for roughly $117,000 in specialty pharmacy costs.

On GLP-1 drugs (sometimes referenced in the presentation by example names), Beth said the medications are expensive—often $1,000 to $1,300 per month—and are generally covered only when prescribed for an approved diagnosis such as type 2 diabetes rather than for weight loss alone. She told the committee that, based on current evidence, most self‑insured and fully insured groups are not covering GLP-1s for weight‑loss indications and that generic options will not be available until patents expire (noted in the presentation as 2032).

Digital navigation and HealthJoy

Committee discussion turned to HealthJoy, the county’s member navigation app. Beth reported a 39% activation rate and said the app produced roughly $11,908 in savings during the most recent quarter and about $77,000 in savings since the program began in 2024 through redirections of care, pharmacy solutions and other interventions. Usage metrics presented included 64 wallet-card views, three chat interactions and 17 “find care” searches in the quarter.

Committee members and staff discussed strategies to increase activation, especially among spouses and household health managers who make many care decisions. Beth and staff said they planned targeted outreach (mailers with QR codes, facility/department visits and focused communications) aimed at boosting adoption by midsummer so the committee can measure impact during the remainder of the year. Beth said the plan is considering possible add‑on programs (for example, diabetes and hypertension management integrations) and is awaiting pricing and clinical details for emerging vendor tools.

Other items raised

- J‑code medications (drugs billed under medical claims) were discussed; Beth explained the plan transitions administration to lower‑cost settings where clinically appropriate (for example, moving from outpatient infusion to office or home administration when safe and available).

- Preventive care frequency: Beth cited the Patient Protection and Affordable Care Act, noting preventive services for non‑grandfathered plans are covered without arbitrary visit limits and that providers follow clinical guidelines by age and gender.

Committee direction and next steps

Committee members asked for more forecasting at the June meeting (when additional months of data will be available) and signaled support for more active member outreach to increase HealthJoy activation. Beth and staff said they will return with more detailed renewal forecasts and proposed activation tactics.

Ending

The committee voted to accept and place the health insurance reports on file at the meeting and approved the monthly bills by roll call. The committee’s next meeting is scheduled for June 26 at 9:30 a.m. in the same room.