St. Charles schools review first full year of self‑insured health plan as high‑cost claimants drive costs

Samantha Beerus, the district’s insurance technician, told the St. Charles Parish Public Schools board that the district became self‑insured for medical coverage on May 1, 2024, and that the first full plan year’s data are guiding next steps to control costs.

At a detailed presentation led by benefits broker USI and claims administrator UMR, staff said high‑cost claimants — defined in their reporting as members with $50,000 or more in combined medical and pharmacy charges — represented about 3% of the covered population but drove roughly 37.8% of plan spending, or about $11.4 million for the year ending April 30, 2025. USI representatives said the district will target those members with case management and other clinical programs to curb future costs.

Why it matters: With medical and pharmacy combined per‑member costs above the peer norm, the board heard that reducing avoidable high‑cost episodes is the most direct lever the district has to lower net spend. USI and UMR also recommended care‑management expansion and member education to shift nonurgent care away from higher‑cost settings.

USI and UMR outlined the programs the plan already offers: utilization management (prior authorization), complex‑condition case management, ongoing‑condition disease management, maternity programs and digital tools such as a telehealth service. Presenters said engagement rates are strong in some areas — about 58% for complex condition care and roughly 36% for ongoing‑condition care — and the district will use those programs to try to limit conversions to high‑cost status.

Pharmacy and rebates: The vendors reported plan pharmacy spend of approximately $10.37 million for the 12‑month reporting period. Before rebates, pharmacy plan‑paid per‑member‑per‑month was $224.54; the pharmaceutical rebates the plan received during the year offset roughly 32% of that cost, lowering net pharmacy PMPM to about $150.14 and producing roughly $3.1 million in rebates over the period.

Avoidable ER use and network questions: USI highlighted that emergency‑room visits were about 17% higher than the UMR norm and flagged potentially avoidable ER diagnoses (back pain, upper respiratory infections, some infections) that typically cost the plan an average of $1,588 more than an urgent care visit. Board members pressed for facility‑level breakouts — especially to distinguish freestanding emergency facilities from urgent care centers — and for comparisons with prior carrier years so the board can tell what changed after the 2024 vendor transition. Staff agreed to provide facility‑level and multi‑year comparisons and to include recommendations on possible benefit design changes for the February renewal discussions.

Claims audit and reporting timeline: Beerus told the board that BMI will perform a stratified random audit of 250 medical claims; staff said preliminary vendor agreements are complete, data requests are under way and the audit is estimated to take five to seven months with results reported to the board (staff estimated an April 2026 completion).

LCMC negotiations noted during presentation: The vendors also briefed the board on active contract negotiations with LCMC Health (a major local hospital system). USI said both parties were still negotiating and that LCMC’s most recent proposal would materially raise market reimbursement levels; the vendors warned that a settlement at the level proposed could meaningfully raise costs for self‑funded customers. Staff told the board they would notify impacted members and that targeted letters were being mailed to members who recently used an LCMC facility.

What’s next: USI/UMR will return with financial results for the plan year, the facility‑level ER/urgent‑care breakdown and recommendations related to benefit design (including whether to adjust emergency benefit differentials). The district will run the BMI audit and report the findings to the board when complete.

At the meeting’s close on this topic, the board instructed staff to bring comparative historical metrics and to present formal recommendations at upcoming renewal and budget meetings.