Within any given industrial sector, certain individuals stand out as having played key roles in that industry’s development and growth. These are the people who have spearheaded major initiatives, devised innovative ways to streamline operations and pushed for new products and services when others in the field were content with the status quo or unsure of how to resolve certain issues. When looking at Puerto Rico’s health insurance sector, Carlos García Flores stands out as one of those individuals and today is one of the most sought-after experts in the market. “I’ve been in the health insurance business all my professional life and it is very satisfying to represent the interests of those who really appreciate and value my knowledge, credibility and dedication,” he said.
A Long-term Commitment
Not long after he started working at Cruz Azul in the early 1980s, Carlos was put to work on a massive advertising project, given his prior experience in the media industry. However, as the company made a number of management changes, he was asked to wear several hats and was put in charge of marketing, sales, provider relations, regional offices, group service, advertising and public relations. “At 29, this was a major challenge for me but I agreed to accept it,” he said. However, the more involved he became with each of these areas, the more he realized the local health insurance industry needed some major improvements. “The industry was being developed from a poorly managed physician-ruled environment, where most of those involved came from a technical rather than a business-oriented background,” he said. “As a result, employer groups weren’t getting the kind of sound advice they needed to become more efficient [health insurance] buyers.”
This led him to start his own consulting business in 1988 to help large employers, including government agencies, select the right plans for their needs. “I served this niche for 10 years but there were a number of roadblocks,” he said. For example, he explained that each time government leadership changed hands, the government agencies he was serving would cancel their contracts and he would have to more or less negotiate all over again. “The other issue had to do with employers and their agents,” he said, “although many companies were using agents and brokers who were technically behind on everything going on in the marketplace, there was a bond of loyalty between them that went back many years.” Given these scenarios, Carlos determined he could better serve the health insurance market by going wholesale.
Carlos García Flores Health Insurance General Agency
Serving insurance producers (formerly known as brokers), authorized representatives(formerly known as agents) and consultants, the Carlos García Flores Health Insurance General Agency is the only general agency on the island that is exclusively devoted to health insurance. Given its focus on this specialized niche, the agency has become a major source of health insurance expertise for producers, authorized representatives, consultants andinsurance companies alike. “We specialize in health insurance and all that it entails,” said Carlos. “We have a very close relationship with every health insurance company on the island and any time one of them comes up with something new, they call us.”
He explained that while the producers and authorized representatives know their clients’ needs and the budgets they have to work with, they rely on his agency to go to the insurance companies, shop around, get quotes and put together the most comprehensive plans available. “Because we have practically everything that is in the market, we are in a position to help them sort out what their client really needs,” he said. “We can either put together a package from what is already being offered by the insurance companies or we can write some specs and request quotes for custom-made products.” He also pointed out that while his agency is aware of all the products available on the local market, he refuses to carry those that contain exclusions, which may leave the patient’s health condition unattended for financial reasons. “If it comes from us, it comes with a guarantee,” he said, “we make sure everything we sell is comprehensive and works. Even though we deal at the wholesale level, our goal is still the satisfaction of the individual insured person.”
Adding Value
Serving as the much-needed link between health insurance companies and the firms and individuals who work directly with the employers, the Carlos García Flores Health Insurance General Agency is highly valued by both sides. “For the producers and authorized representatives, we get involved in the cases as much as they want,” said García Flores. He explained that because many authorized representatives and producers are involved in selling other kinds of insurance, such as property, casualty and life, they aren’t as up to speed on all the intricacies involved in purchasing the right health insurance plans for a given employer. “It is very important how the financial arrangement is set up and producers and authorized agents need to be careful when buying for their clients because some [insurance] carriers have risk pools and some don’t,” he said and explained that with this kindof pool, the good (healthy) employer groups subsidize the not-so-good ones. For example, if a client has employees whose dependents have a lot of health problems, the treatment costs could outweigh the premiums if they go with a nonpool insured product. As a result, the insurance company could eventually drop that client and not renew the policy. “If the representatives and producers don’t know how to go about it, they can come to us and we’ll help them obtain the kind of insurance they need,” said Carlos. In addition to going to the insurance companies and obtaining proposals for wholesale clients, Carlos and his team can also do all the analysis as well. “We will even prepare and give presentations to the employers if necessary,” he added.
He also explained that because he receives payment from the insurance companies there is no charge to the producers, authorized representatives or consultants for this kind of service. “We have the resources to go every step of the way with them if that is what they need,” he said. “If they go directly to the insurance company, they will pay the same.” He added that everyone who comes to his agency, no matter what the level of experience or size, receives the same quality service.
And while producers, consultants and authorized representatives look to Carlos for his agency’s extensive knowledge of health insurance plans and coverage, the insurance companies on the other hand rely on its client-related expertise. “The insurance companies know our value because we know the groups and the market we serve,” he said. “They don’t see us as an expense but as an added value to their marketing effort.” He pointed out that any time a local insurance company wants to do something new in the area of health care they call him for advice. “Whatever they come up with, they go through here,” he said. “I learn firsthand when the products are in the planning stage and no insurance company will take the risk of putting a product on the market without calling me and finding out if there is a market for it.”
Setting Standards
As the major consultant for large government accounts, which include the Puerto Rico Electric Power Authority (Prepa) and the student health benefits program at the University of Puerto Rico, the Carlos García Flores Health Insurance General Agency has been known for setting standards as well. “If anything new arises and there is not a policy out there to handle it, they come to us,” he said. He also pointed out that given the nature of the health care business, where the doctor is primarily responsible for generating costs by prescribing tests, drugs, lab work, extra visits, etc., insurance companies need to have good cost containment measures in place to determine if someone is abusing the system. “We personally review and measure every group every three months,” he said. “If we suspect that someone is abusing the system, we refer them to the insurance company’s case management group. If there is a small group that has a lot of sick people, we’ll put it in a risk pool.” On the insured or client’s side, his agency can also analyze how their experience is going and advise the necessary parties on what to expect at the time the plan comes up for renewal.
As a member of the Puerto Rico Association of General Agents, he was also a member of the committee that created Puerto Rico’s first HMO, as well as part of the team that brought the first Prescription Benefits Manager (PBM) to the island. As the cost of healthcare continues to rise, he is adamant when it comes to setting standards related to much-needed lifestyle changes. “The driver behind health care costs is lifestyles,” he said. “If we can get people to exercise more, change their eating habits and stop smoking, health care costs won’t rise as drastically and employers will be able to stay within their budgets while providing their workers with the best coverage possible.”
