Cost containment. Direct contracts and smarter pricing.

Your plan's cost comes down to how often claims happen and how much each one costs. Ethos Benefits evaluates and implements strategies that change both: reference-based pricing, direct contracts with providers, direct primary care, specialty drug programs and international pharmacy, each with service level agreements and results measured against your data.

Request a Strategic Analysis Kalos Services: $13.5M in claims savings

What you get.

Most cost containment is sold as a product with a savings promise. The real question is whether it changes the frequency or severity of your plan's claims, and whether the contract lets you measure it.

Reference-based pricingClaims paid as a set percentage of Medicare rates rather than a network discount, with member support for any billing disputes.
Direct contractsAgreements negotiated directly with hospitals, surgery centers, imaging centers and other providers for set prices and quality standards.
Direct primary carePrimary care offered through a direct arrangement, so employees have easy access to a doctor and fewer avoidable emergency visits.
Pharmacy programsSpecialty drug programs, manufacturer assistance and international sourcing where appropriate, run through your PBM strategy.
Service level agreementsEvery program contracted with measurable standards and performance guarantees, scored under vendor management.
Measured resultsEach program’s claimed savings checked against your plan’s own claims data.

Two levers: frequency and severity.

Frequency: how often claims happen. Direct primary care, care navigation and plan design reduce avoidable claims.
Severity: how much each claim costs. Reference-based pricing, direct contracts and pharmacy programs reduce what the plan pays per claim.

What it did for Kalos.

Kalos Services, an HVAC and construction company in Central Florida, moved from a fully insured plan to a self-funded plan with reference-based pricing, direct primary care and a fiduciary PBM. Kalos reported $13.5 million in claims savings since October 2022, 34% fewer emergency room visits with direct primary care, and a 70% reduction in pharmacy cost per member.

Figures as published in the Kalos Services case study, with Kalos’s permission.

Every program, under contract.

Each program is selected through Ethos Fiduciary Procurement, contracted with service level agreements, and measured under vendor management. Programs that don’t deliver are replaced.

Part of your Fiduciary Framework™.

Every Ethos service reports to your benefits committee. The work is reviewed at your quarterly committee meeting, each decision is recorded with the reasoning behind it, and the record lives in your Ethos Fiduciary OS. That is what lets your committee show the plan was run prudently.

See the Fiduciary Framework™ · How fiduciary governance works

Questions employers ask about this.

What is reference-based pricing?

Reference-based pricing pays providers a set percentage of what Medicare pays for the same service, instead of a negotiated network discount. It can lower claim costs sharply, but it needs strong member advocacy for the cases where a provider bills the difference.

Does reference-based pricing work for a fully insured plan?

Generally no. Reference-based pricing is used by self-funded and some level-funded plans, because the plan decides how claims are priced.

How do you decide which programs to use?

From the data. Claims analytics shows where cost is concentrated, and each program is chosen for the claims it addresses and contracted with guarantees.

See what your plan is really costing you.

A Strategic Analysis starts with your plan documents and your broker agreement, then shows you what your plan costs, where the risk sits, and what a committee would decide with the full picture.

Request a Strategic Analysis Call (407) 803-4710