Allison De Paoli grew up around employee benefits. Her father and stepmother built a consulting firm some 40 years ago, and after graduating from college she joined them in Florida, learning self-funded plan design when premiums were still manageable and the system had not yet grown into the complexity it carries today. She eventually moved to Texas, spent years in another part of the benefits world, and then found herself increasingly frustrated.
“Why is this happening? You would just do it this way, and this problem would be solved,” she recalls thinking. The answer she gave herself was straightforward. “Go fix it yourself.”
Altiqe was founded 14 years ago and pivoted fully into the health insurance space in 2018. Today the firm works with employers across the country, and its results are concrete. One client with approximately 800 employees has not increased its healthcare budget in four years, while actually expanding what the plan covers. This year that client is running at 83 percent of budget. “We fix it one employer at a time,” De Paoli says. “Is it perfect? No. But can we make real impacts? Yes.”
De Paoli’s central argument is one the industry tends to overlook. No matter how well designed a benefits solution is, a person still has to change their behavior to access it.
“So many advisors leave that out,” she says. “We are going to put this solution in and it can do this, and we are going to put that solution in and it can do that. Great. How are you going to get the humans to do that? You either have to design solutions that the human does not need to change their behavior to access, or you need to create a plan to help the member adjust. One or the other, or your solutions will fail.”
She is equally direct about patient agency, something she believes the system gradually erodes. She encourages plan members to slow down before making medical decisions and to seek a second opinion if something does not feel right. “Any high-quality doctor will welcome that,” she says. “If you do not want to do it, do not do it. The consequences are yours, whatever they are. But that is your choice.”
A recent workplace health case highlights one employee spent months worrying after being referred to a medical specialist following a routine health assessment. By the time the appointment arrived, the specialist was able to reassure them that there was no immediate concern and recommended follow-up tests simply as a precaution and to establish a baseline for future care. Looking back, the prolonged anxiety was driven more by uncertainty than by the medical findings themselves. The experience highlights the value of asking questions and understanding the purpose of referrals from the beginning.
When De Paoli takes on a new employer client, she pulls whatever claims data is available. Beyond that, stop-loss carriers and reinsurance companies have access to tools that draw on prescription history and, through credit card purchasing data, lifestyle patterns. The purpose is to build a more accurate risk profile for the group.
Workforce demographics can provide useful insights into potential healthcare and wellbeing needs. For instance, an organization with a large proportion of employees at a similar life stage may experience higher demand for certain types of healthcare services than one with a different age or demographic profile. When combined with claims data and other health indicators, these trends can help organizations better understand potential risks and support needs within their workforce. In regions where specific health conditions are more prevalent, such as diabetes and metabolic syndrome in South Texas, this information can further refine the overall picture.
Importantly, the detail does not flow to the employer. “We get the result, but not the raw data,” she says. Individual clinical notes may be reviewed in limited circumstances, such as assessing the risk around a chronic condition, but only at the advisor level. She acknowledges the privacy concern directly. “The intent is not malevolent. The intent is to try to help people get what they need. But privacy is a valid concern.”
One data point that does reach employers clearly these days: the most requested employee benefit in the United States right now is pet insurance. De Paoli notes it without judgment. The workforce is changing, the definition of family has changed, and benefits packages that do not reflect that are already out of step.
Precision diagnostics are increasingly available, and De Paoli is working to build them directly into the prior authorization process. The principle is simple: test before you treat.
Drugs in the United States are typically FDA approved if they work for roughly a third of the population with the condition they are designed to treat. For a drug like Humira, which acts on one of several biological pathways involved in autoimmune disease, that means two thirds of patients prescribed it may see no benefit at all.
“If you have nine Humira patients, Humira will work on three. On the other six, you are tossing $60,000 out the year apiece,” she says. “But it is not in the PBM’s interest to stop prescribing those drugs.” Her response is to work with pharmacy benefit managers that operate on a transparent, fiduciary model, ones whose revenue does not depend on maintaining prescription volume.
Right now she is building a catalog with one of her PBMs of which precision diagnostic tests are worth paying for and why, with the goal of embedding the testing requirement into prior authorization so the right drug is confirmed before the prescription is written.
The stakes are equally significant in mental health, though here the issue is less about cost and more about human impact. Every SSRI and psychiatric medication takes approximately 12 weeks to determine whether it is effective. If the first drug fails, the process starts again. Three more months. Then possibly a third option, or a combination.
“The cost of those drugs is nothing. I mean, it is $20, $30, $50. But the human toll can be significant,” De Paoli says. “And that human toll impacts an employer, because it manifests as absenteeism, presenteeism, and behavioral issues on the job.”
She describes a friend whose child was on a combination of medications that were not working. For months, nothing changed. Finally, a physician ran a genetic diagnostic test, identified which drugs were appropriate, and the child’s condition improved substantially. “They got the child on the right medications and the child is doing remarkably well. But that was not a dollar cost. That was a human cost.”
De Paoli has a plain-English explanation for how drug pricing in the U.S. becomes so disconnected from what drugs actually cost to produce and distribute.
The structure began sensibly enough. As prescriptions became a larger part of medical care, pharmacy benefit managers emerged to sit between employers and pharmacy networks, facilitating transactions and ensuring that employer plans paid their share. Members went to a participating pharmacy, paid their copay, and the system worked.
“What has happened over time is that PBMs have created more and more layers in between,” she explains. Employers can obtain a list showing what they will be charged for a given medication, along with an associated discount. What that list does not show is what the pharmacy is actually being paid. The PBM sets one price for the employer and a lower price for the pharmacy. The difference between those two figures is the spread. Spread pricing.
Her counter-measure is auditing. In a transparent PBM contract, she can show a client precisely what the pharmacy received and what the plan paid, and the same drug can cost $20 at one pharmacy, $40 at another, and $200 at a third. Knowing that, she can guide members to the lower-cost option.
“For drugs, you want to pay the lowest net cost,” she says. “Not the biggest discount, not the biggest rebate. Lowest net cost.”
The consolidation reshaping the industry is, for De Paoli, best understood through one transaction. “CVS bought Aetna, not the other way around. And I think that is a very clear indication of who has the money.”
UnitedHealth Group’s Optum, Blue Cross, and Cigna all own their own PBMs. When a large carrier controls the insurance, the pharmacy benefit management, and increasingly the care delivery layer as well, revenue generated at every stage flows upward to the parent. The employer plan at the base of that structure is, in effect, funding profit at each level.
De Paoli also points to what has happened at the advisory level. Many smaller, independent benefit firms have been acquired and rolled up into larger houses. “When that happens, you are no longer paying the broker or the advisor. You are paying this large entity. The advisor gets some of that, the team gets a small portion, and the rest goes to debt service and profit for the investors.” Employers, particularly mid-sized ones, are often left receiving less specialized service while paying for a structure built around investor returns.
The expected medical trend for 2027 sits at approximately 9 percent. For employers who are fully insured, or in an ASO arrangement, meaning self-funded but administered through a large carrier, actual renewal increases are likely to land significantly higher, perhaps 15 to 25 percent, once the carrier’s margin is factored in.
De Paoli breaks healthcare spending into three buckets to show where the leverage actually lies.
The first is stop-loss premium, the true insurance element, where a carrier steps in when a single claimant’s costs exceed a defined threshold. Even fully insured carriers layer reinsurance above reinsurance; they do not absorb all the risk themselves.
The second is administrative costs: the TPA fee for processing claims, network access fees, medical management fees, and PBM costs. “At their heart, big insurance companies are just TPAs,” she says.
The third, and most actionable, is the claims bucket. “What many advisors will tell you is that a claim is a claim is a claim. It is not. You want to pay the right price for care.”
In a recent renewal her firm managed, the stop-loss premium increased by 2 percent. The administrative bucket did not increase at all. The claims bucket rose modestly, reflecting some ongoing health challenges in the workforce, but that cost is manageable when the right controls are in place: lowest net cost for drugs, imaging directed away from hospitals where possible, maintenance care made easy and inexpensive to access, and early intervention prioritized over reactive treatment.
Claims experience moves in cycles, and De Paoli thinks employers, and their advisors, should be clearer about communicating that reality. Over a roughly seven-year period, a self-funded employer should expect two strong years, three acceptable ones, one difficult year, and one genuinely bad one.
“But over seven years, you are ahead of where you would have been as a fully insured employer,” she says. “Because if you are fully insured, somebody else is absorbing all your risk, you are paying for the privilege, and you are subject to their profit model.”
Within a self-funded model, the single most powerful variable is provider quality. “A high-quality provider is the biggest predictor of a good outcome. So do whatever you can to get people to high-quality providers. When you do, you might pay $25,000 to $30,000 for a knee replacement instead of $60,000 to $70,000.”
She is equally direct about the downstream cost of unmanaged chronic disease. “Make maintenance medication free, so that people are taking their cholesterol medication, their high blood pressure medication, their diabetes medication. Because that cost is far less than a $40,000 unexpected emergency room visit.” The progression from unmanaged diabetes to ulcers, amputation, and long-term disability is not hypothetical. It happens, and it is preventable.
One of the quieter consequences of rising deductibles and stagnant wages is that employees simply stop seeking care they cannot afford. They do not announce it. They work through it, defer appointments, and hope the problem resolves. The employer notices eventually, through poorer performance, greater absenteeism, or a claim that arrives later at far greater cost.
“You have no idea how often that happens,” De Paoli says.
“Any wage increase is being clawed back by premium. Deductibles are increasing. Out-of-pocket maximums are increasing. Copays are increasing or being eliminated entirely. High-deductible health plans were supposed to incentivize people to be good shoppers. Except that being a good shopper is almost impossible for a regular everyday consumer.”
The answer, for the employers she works with, is to reduce the barriers to routine care. Make primary care easy. Make maintenance medication free. The investment in access pays back many times over when it prevents a condition from becoming a crisis.
The clearest example of De Paoli’s approach in action is an on-site clinic she helped establish for a client with approximately 800 employees. Every employee can access it at no charge, regardless of whether they are enrolled in the company health plan. Everything provided at the clinic is covered at 100 percent. If a specialist referral is needed, the employee uses their network as normal. But inside the clinic, there is no bill.
Maintenance medications, including generics, are covered at 100 percent. Lab panels that would typically cost around $100 are billed at wholesale plus a draw fee, bringing the cost down to $25 or $30. The clinic arranges imaging at cost and passes it directly to the employer. PRP therapy and sleep studies are also available. The member pays for none of it.
“People love free healthcare,” De Paoli says.
The cultural shift has been substantial. In the early months, the HR team walked employees across to the clinic to build participation. The habit took hold. Several months in, a pregnant employee, around six or seven months along, told a co-worker she thought she needed to see her obstetrician. The co-worker walked her directly to the clinic. The clinic physician assessed her and called her OB. Together they agreed on a treatment plan and sent her home rather than to hospital, which would have been the standard referral for her presentation. She rested for a couple of days and returned to work shortly after.
“That on-site clinic effectively eliminated a claim that would have been $15,000 to $18,000,” De Paoli says.
Even accounting for the cost of operating the clinic, the employer is significantly ahead financially. The most common request from the workforce is that spouses and dependents be allowed to access it too. Capacity is currently the main constraint.
Away from plan design and pharmacy audits, De Paoli keeps life relatively simple. She shares her home with a large Great Pyrenees, travels regularly, reads widely, exercises consistently, and spends time with friends in San Antonio. She is open about having navigated her own medical decisions over the years, including choosing what to accept and what to decline. It is not a detachment from the work. It is the foundation of it.
