The Gap
Your clients spend $7,000–$500,000+ per member per year on specialty continuation therapies. PA governs initiation. PBMs manage formulary. Nobody governs whether ongoing therapy is still clinically appropriate. No artifact exists. No stop-loss carrier has ever seen documented continuation oversight at renewal.
60%
RIR: trajectory change identified
40%
DAR: confirmed appropriate
50%
GPR: signals persisted
$14.3M
Cross-cohort GSV (modeled)
~19:1
Modeled signal-to-cost ratio
What You Say at the Stop-Loss Table
"Our client conducted a structured continuation governance cycle on their specialty population, independently reviewed by credentialed external PharmDs under a published standard. Here is the Governance Certificate. It documents a 60% Reviewer Influence Rate, a 40% Documented Appropriateness Rate, and an immutable audit trail. No other plan sponsor you're underwriting can show you this."
A 1–2% stop-loss term improvement on a $3–4M premium = $30,000–$80,000/year. The governance cycle costs ~$180,000 at $6 PMPM for 10,000 members. If modeled signals convert to claims changes, one favorable renewal and governance pays for itself. Break-even RIR: ~3.1%. The methodology found 60%.
What Your Client Holds
Governance Artifact
Configuration fingerprint, measured RIR/DAR, outcome distribution, immutable audit trail. Sealed and versioned. Board-ready.
Governance Certificate
The credential your client hands the carrier at renewal. Documented continuation governance no other plan sponsor can produce.
How It Works
One de-identified claims CSV (4 fields). 90-day governance cycle. Qualified external PharmD/MD reviewers. Advisory-only, with no denials and no clinical authority. $4.50–$6.00 PMPM based on cohort size. Governance Certificate included. No IT integration. No software. Your client's effort: approximately 4 hours in week one, then zero until artifact delivery.
Two independent cohorts. 25,000-member commercial payer + 9,500-member self-funded employer. Four therapy categories. The governance shape converged across both independent cohorts. RIR 58–60%. DAR 40–42%.
joe.nalley@showyourwork.health
showyourwork.health
The gap nobody's named.
The artifact nobody else produces.
GSV (Governance Signal Value) reflects modeled trajectory changes based on measured outcome distributions, not confirmed claims reductions. Actual financial impact depends on clinical action taken on governance findings.