Growing up in a family of health care entrepreneurs, Mark Gaunya grew frustrated observing the way the American health care system kept patients disengaged from the cost and quality of their own care. So in 2000, when he had the opportunity to join a firm that was promoting the notion of consumer-driven health care long before health reimbursement arrangements or health savings accounts came into practice, he was all game.

However, it took a little more convincing to bring the other players onboard with the concept. "So many brokers and employers would say, 'You want me to do what? You want me to implement a high-deductible health plan and put after-tax money in a regular bank account? That's going to increase costs by 7%. Why would I do that?'" Gaunya recalls.

Once he explained the behavior change that comes with using your own money for health care expenses, Gaunya helped build the plan from zero to about 60,000 members in four years. "It was quite a fun experience to go through," he says.

It was also one that would set the path for accomplishing his life-long goal of becoming an author.

In November 2009, Gaunya and business partner Jennifer Borislow published Bend the Healthcare Trend: How Consumer-Driven Health & Wellness Plans Lower Insurance Costs to further spread the word on the benefits of CDHPs.

Tag team

Soon after graduating college in 1982, Borislow founded Borislow Insurance in Methuen, Mass. Shifting from an original focus on financial services to employee benefits, Borislow has taken the business from one employee to 26, thanks in large part to her partnership with Gaunya.

"The grand slam of my career was about five years ago when Mark and I came together as business partners," she says. "We came from two different tracks. I came from the home-grown, self side, always been in sales, never had the experience on the big company side or any of the internal forces that happen behind the scenes. Our two experiences together make us a powerful combination."

The two first crossed paths a couple of years earlier when Borislow went to Chicago as part of a broker advisory council to evaluate Gaunya's CDHP insurance company, Destiny Health.

When Destiny Health, which has since been sold, entered into an alliance with a Boston HMO, Gaunya jumped at the chance to move back to New England, where he'd lived and attended school. The pair became fast friends and it wasn't long before Borislow convinced Gaunya to join Borislow Insurance.

As director of finance for New Hampton School, Jill Duncan began working with Borislow Insurance about six years ago. She's particularly impressed with Borislow's foresight to see developments in the industry, as well as her decision to bring in Gaunya. "They're a great tag team and they've continued to be able to stay on top of the industry," says Duncan.

New Hampton School is part of a health trust of 15 New Hampshire schools that work with Borislow and bid annually to carriers that service the entire state. When Borislow first introduced the concept of CDHPs to the group a few years ago, "a lot of us said, 'How are we ever going to get our employees to buy into that?' But we did, through their help," says Duncan.

With Borislow Insurance "holding their hand," the trust went to an all-CDH plan two years ago. "It's gone really well. People are getting more involved in their health care. They're more aware that it does cost something when you go to the doctor's and it isn't $10," says Duncan. "That there are options out there, that you can shop, you can ask your doctor questions. You can seek alternatives."

Borislow helped New Hampton School create a plan design where they pay for the first half of employees' deductible, and if they don't spend it all, the remaining dollars carry over into the next plan year. "Initially I did not think I wanted to contribute the first half of the deductible. I wanted the employees to own that, but they convinced me that that wasn't the right decision, and they were right," says Duncan. Our employees "were actually more concerned about it so that they didn't have to get into their own pocket."

With years of creating unique plans for Borislow Insurance clients like Duncan, as well as the knowledge base they built through Gaunya's CDHP experience on the carrier side, Borislow and Gaunya decided to take on the task of writing Bend the Healthcare Trend about a year and a half ago.

To keep their practice running smoothly and client needs taken care of, at first Borislow and Gaunya decided to work with a ghostwriting company to get the book done. They gave the company all of their PowerPoint presentations and other literature they'd produced for clients on CDHPs, but something was off. "The voice didn't sound right, so we quickly readjusted our strategy," says Gaunya.

Instead, Borislow and Gaunya decided to write the whole thing themselves, setting a goal of writing one chapter a month. Gaunya would write the content while Borislow would edit and contribute client success stories. As they were busy with clients, staff and associations during the day - Gaunya is currently president of the Massachusetts Association of Health Underwriters and Borislow will take the reigns as president of the Million Dollar Round Table in 2012 - all of the writing took place nights and weekends.

Through marathon phone sessions that lasted long after their spouses and children had gone to sleep, "we spent an enormous amount of hours just making sure that it delivered the message that we were trying to communicate, and importantly, that it was done in a professional way," says Borislow.

"We were able to drive each other," she adds. "When he'd get really busy I'd bring us on track, when I'd get really busy he'd bring us on track. So it didn't get out of control because we were a great check and balance for each other."

The CDHP experience

Bend the Healthcare Trend is built around three principles: transparency, responsibility and opportunity, says Gaunya. Specifically, transparency of cost and quality, responsibility through living a healthy lifestyle and making informed health care purchasing decisions, and opportunity to physically and financially improve. "It explains it in layman's terms and it starts with principles, then mechanics: How's the plan designed? How do you effectively create one? Then it talks about how you implement it, communicate it, educate people on it and how you monitor the performance," says Gaunya.

The book is aimed at employers. While Gaunya says "individuals can take away information from it as well," he and Borislow approached it from the purchaser's perspective because of the importance of keeping the C-suite engaged. "They have to be," Gaunya says, "Because ultimately change like this can only be effectively implemented when it's top town. When we've had success is when we've got the leadership team of a particular organization engaged in what we're trying to achieve."

More than a plan design, the principles in the book represent "a whole culture shift," he adds. "You can change the culture of an organization to want to engage their employees, educate them and empower them ... so that people feel responsible for their participation in the health care equation."

Approximately one out of four of the more than 350 Borislow corporate clients are currently on a CDHP - and that number is growing. Roughly one-third of their block of business comes from independent private schools, and 50% of them are on CDHPs, according to Borislow. "We spend a great deal of time educating our clients. All of our clients are well aware of what CDHP is and what the opportunity is if you engage your employees," she says. "We're huge advocates for engagement, so we beat that drum pretty loudly."

Half of Borislow Insurance's clients are nonprofit organizations, the perfect audience to embrace a CDHP, says Borislow: "They're the ones that are most concerned about where their dollars are going. So they take the time to really understand and embrace the messages that we have to share with them."

The Maine Association of Independent Schools trust is certainly on board. The 19 private schools are "very happy" with Borislow Insurance, says Michael Komich, business manager at Cheverus High School. They began working with Borislow about six years ago and are in their fourth year of offering a CDHP to employees. As at New Hampton School, it is now the only health benefit option available, although employees can choose from an HSA or an HRA.

The transition has been "a pleasant surprise," thanks in part to Borislow Insurance, says Komich. "Their presentation skills in making what can be a very complex subject very basic helped us with the whole idea of trying to do this sooner rather than later," he says. "I think it was their presentation skills and explanation of this concept that made that easier for us to do."

Each of the 10 chapters in Borislow and Gaunya's approximately 125-page book contains a case study that focuses on engagement and awareness. "When you look at it, it's a practical guide to help people understand [CDHPs] because the media does a fantastic job of mischaracterizing these plans and making people afraid of them rather than educating about what they really are and what they're intended to do," says Gaunya.

Although a fellow consultant recently told them "this is the best business card you'll ever develop," Borislow and Gaunya didn't write the book to become a best seller. "We wrote it to first, share the knowledge we have, but second, to provide us with credibility because we do a lot of speaking on this both publically and with our clients," says Gaunya.

In the past, Gaunya was hesitant to share the success he's seen promoting CDHPs for the fear that his competition would take advantage of it. "But the reality is you can't hold onto something, you need to let it go and share that knowledge with as many people as you can if you really believe it can fundamentally change health care," he says. "I know that sounds grandiose, but I really do believe that."

"We also know it works. It's not like this is pipe dream and we think it will work. We have client story after client story, anecdote after anecdote to show how these plans really do change lives. Does it require more work? Yes. Does it require more responsibility? Absolutely. But isn't that a good thing?"

Influencing health reform

It's no coincidence that Bend the Healthcare Trend came out in the heat of the health care reform debate. When it comes to the legislative debate in Washington, "Jennifer says she's concerned and I'm consumed," says Gaunya. "I follow it daily because I want to stay on top of it."

With a background in economics, Gaunya is frustrated to hear suggestions that the government is going to reach a solution by focusing on the supply side of care without addressing the demand. "When you look at economics, you have a supply and you have a demand curve. You can't ultimately touch one and not touch the other," he says. "What's frustrating to me is all I've heard about is we need to restrict the supply. We need to cut out costs for Medicare; we need to change the way providers are paid; we need to hold insurance companies accountable. But absent from all that discussion is the end consumer's role."

Sure, people know they need to eat well and exercise, but Gaunya argues that a large factor in their not doing so is that the current health care structure has them disengaged from the true cost of care. "If you pay a copay you really have no idea how much that health care service costs," he says. "And over 25 years you get desensitized to the cost of health care. When you're desensitized you don't value it as much as any other type of service. So what CDHP is designed to do is to create that transparency, to engage people in their overall health and wellbeing and ask them to look at health care differently."

Soon after Bend the Healthcare Trend was published, Borislow and Gaunya sent a copy, along with a personal letter, to all 100 U.S. senators. "What's disappointing about that huge effort that we put together is only three senators acknowledged even receiving the book," says Borislow.

Among the 97 who didn't were their own Massachusetts senators. However, with the upset election of Scott Brown to fill Sen. Edward Kennedy's seat, the pair can be sure there's at least one person on Capitol Hill who has heard their consumer-driven message. Both Borislow and Gaunya have "a personal relationship" with Brown, having worked on his campaign and fundraised for him. "We provided him with a copy of the book, so I wouldn't be surprised if he starts using some of the material in the book to talk about a market-based solution to rising health care costs," says Gaunya.

According to Gaunya, the architecture of the Senate's health care reform bill is "almost identical" to the one passed in Massachusetts in 2006. While Massachusetts now has the lowest rate of uninsured citizens in the country, the state budget went from $1 billion to $1.7 billion in three years; "so it's done absolutely nothing to lower the cost of health care," he says.

In fact, the state has exacerbated the problem in several ways, says Gaunya, such as merging the small group market with the individual market, which "gave individuals a 20% to 25% break in their price, but it also pushed up small group rates 5% to 7% on top of trend." Other examples include having too low a penalty ($1,000) for not acquiring health insurance, and not requiring insurance policies to be in effect for at least a year to avoid people taking advantage of mandatory coverage laws and only purchasing insurance when they need it.

As reform evolves, Borislow and Gaunya hope more lawmakers will turn to the principles in their book and commit to a CDH approach. They see a lot of mischaracterization of CDHPs as people refer to them simply as high-deductible plans without emphasizing their lower premiums and tax-advantaged accounts. "Are there things on the supply side that should be addressed? Absolutely," says Gaunya. "But we need to include the consumer in this discussion and get them engaged in being part of the solution."