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DeKalb County hears stark insurance data as self‑funded plan shows big claims and pharmacy spend
Summary
Apex Insurance presented county health‑plan data showing large individual claimants and near‑$1M pharmacy spend; staff recommended a pharmacy RFP, wellness initiatives and further budgeting to manage projected claim increases for the self‑funded plan.
County officials on Aug. 12 were presented with financial results and trend lines showing a substantial rise in health‑plan claims since DeKalb moved to a self‑funded arrangement.
An Apex Insurance representative told commissioners the county’s combined annualized premium facing them in a fully insured scenario had been roughly $2.86 million when the consultant began work in 2023. Under the county’s current self‑funded model, the consultant said expected claims, stop‑loss reimbursements and some large individual claimants mean the plan’s worst‑case exposure is substantially higher this year.
Apex highlighted that pharmacy paid totals approached $1 million and that several very high‑cost members (one claimant exceeded $480,000 in paid claims) were driving spikes in spend. The consultant recommended immediately running a standalone pharmacy RFP to carve out and better control pharmacy benefit management and to pursue tighter contract terms that pass rebates and negotiated discounts back to the county.
The presenter also urged continued investment in wellness and preventive programs, including required biometric screenings for the next plan year, as a long‑term cost‑management tactic. Commissioners said they were concerned about a potential renewal that could reach multiple millions and asked the consultant to provide more clinical detail and options for comparing fully insured versus self‑funded renewal scenarios.
What happens next: staff and the consultant will report back with a more detailed clinical financial analysis, pursue a pharmacy RFP and provide options for budgeting the coming plan year, including potential reserve and ARPA allocations for the self‑insurance fund.
