Description

America spends more on healthcare than any other nation. Yet it gets less in return. U.S. healthcare waste totals an estimated $1.6 trillion every year. That figure exceeds the GDP of more than 180 countries. This waste does not accumulate by accident. It is built into third-party contracts with employers, protected by opacity, and perpetuated by vendors with no financial incentive to fix it. Employers who self-insure their health plans sit at the center of this problem. They also hold the most direct authority to solve it.

Model Optimal Care is a practical, data-driven guide for benefits directors, HR executives, CFOs, TPAs, PBMs, brokers, and healthcare consultants who are ready to act. Jude Odu draws on 25 years of direct experience across payers, providers, and healthcare technology to give plan sponsors a structured framework for identifying waste, eliminating inefficiency, and achieving significant reductions in annual healthcare spend.

The book introduces Model Optimal Care, a brand-new framework Odu positions as the next step beyond Value-Based Care. It is a care delivery model that is individualized, technology-enabled, methodical, measurable, and results-driven. It rests on five core principles: Transparency, Accountability, Integration, Engagement, and Technology Enablement. Every strategy in this book flows from those five principles.

What You Will Learn

Part I covers non-technology strategies that any self-insured employer can implement immediately: educating and engaging employees to make cost-conscious decisions; redirecting non-emergent care away from the emergency room; structuring benefits to steer members toward high-value providers; and building onsite and near-site clinic programs that reduce total plan costs.

Part II covers the technology layer: how to use AI-powered claims auditing to identify overpayments and duplicate claims in near real-time; how to apply price transparency tools to audit payments and negotiate from a position of data strength; how to detect and recover dollars lost to fraud, waste, and abuse; how to optimize formularies and shift pharmacy spend toward fiduciary PBMs that operate on a transparent pricing model; and how to build a predictive analytics strategy that anticipates risk months before it becomes cost.

You will also find a detailed examination of your fiduciary obligations under ERISA and the CAA, and a blueprint for turning those compliance requirements into a strategic cost-containment advantage.

Inside This Book

• A complete implementation framework for each strategy, with measurable outcomes
• Field-tested logic and report specifications for medical and pharmacy savings analysis
• A 90-day AI implementation blueprint for employer-sponsored health plans
• Executive narrative templates for communicating findings and driving member behavior change
• Case studies documenting millions in identified overpayments and recovered losses
• A vendor accountability model for auditing third-party vendors such as TPAs, ASOs, and PBMs while holding them to performance guarantees
• Implementation checklists for benefits teams, brokers, and consultants ready to act on the data

 

Who This Book Is For

This book is written for anyone with fiduciary responsibility for an employer-sponsored health plan: benefits directors, HR executives, CFOs, self-insured employers, TPAs, ASOs, stop-loss carriers, PBMs, PEOs, benefits brokers, healthcare consultants, and policymakers working to reduce the cost burden of employer-sponsored coverage in the United States.

Jude Odu is the founder of Health Cost IQ, a healthcare analytics company where he served as President and Chief Product Officer. A healthcare technology veteran with more than 25 years of experience, he has worked across all the major sectors of the U.S. health system, from commercial payers to acute-care hospitals to enterprise healthcare software and academia. He has founded or led several healthcare technology companies over the years. Odu received the 2015 BizTech Award from Columbus Business First and holds a B.S. in Health Care Administration from Ursuline College and an M.S. in Health Science from The George Washington University.

Model Optimal Care is not merely a critique of a broken system. It is a detailed, evidence-based guide for those prepared to fix the part of it they control.