Benefits Accountability Matrix (BAM)

The BAM is a one page worksheet with four boxes: what the benefits program is for, what you do on a schedule to serve it, what is in the way, and everything else you are paying for. Rate each obstacle on impact and effort, and the four corners tell you where the year should go.

Health benefit programs are a hairy problem. They are the kind of problem where everyone wants to see improvement and improvement is difficult to measure. The employer sits between overall inflation and a set of incentives that generally push cost down onto employees.

The BAM is the tool I have developed to have an honest, upfront conversation with your internal stakeholders, with your executive team, and with your outside consultants or the health plan itself.

The goal is simple. A one page worksheet that lets you take an honest look at four areas.

What goes in each of the four boxes?

01 Purpose. Two lines. Why the program exists, in one sentence, and then the test you would use to know whether it is working. The test is the line that matters, because a purpose cannot be checked against anything and a test can.

02 Cadence. What you do on a schedule to serve that purpose, who owns each line, and how you will know it worked. An activity with no measure is a habit, and a measure with no owner is a report.

03 Drag. What is actually in the way. Rate each one twice, on impact and on effort. The two ratings together decide where the year should go, and they will not always agree with where it has been going.

04 Additional efforts. Everything else you are paying for. What it costs a year, whether anyone measured what it moved, and whether it is worth continuing.

What is the worksheet meant to do?

Overall, the BAM is built to save time, effort, energy, and arguments.

Generally, when I sit with a committee, most of the argument happens in the lower half of the sheet, and the work that stands the best chance of moving the number rarely gets the same hour on the calendar. Filling this in tends to do two things at once. It gets the low effort, high impact items done, because once they are written into a corner with a name against them they are hard to leave alone. And it makes room for a real conversation about the high effort, high impact ones, which are generally the items that need executive air cover rather than another meeting.

In the sheets I have seen filled in, wellness programs, education campaigns and virtual care are the items that most often land in the lower half. That is not an argument against any of them, and your own ratings may put them somewhere else. It does mean they should not be standing in for the work, and it means the people making the decision get better context for what they are funding and why.

Why is box 04 the one that matters?

The sheet works or fails on box 04. Most benefit programs carry a few things that were bought before anyone named the problem they were meant to solve, and nobody can say whether they worked, because there was never a stated thing they were supposed to move. Writing those down in front of the people who approved them is the hard part of this, and it is generally where the useful conversation starts.

One note that belongs on that box. Ask whether the savings figure you were shown is measured against billed charges or against what the plan actually paid. Those are not the same quantity, and only the second one is your money.

Download the worksheet

Two pages. The front is a worked example, a made up 900 person self funded manufacturer filled in the way a real one would be, with a thought box of scenarios to draw from. The back is blank and meant to be written on.

How do you fill it in?

Page one. Read the worked example first. It is there so nobody has to guess what a good answer looks like.

Page two. Fill in the worksheet with the people who actually decide. One name per line, and a measure on every line.

Ninety days. Come back to it against the same four boxes. Filled in once and filed it does not do much, and the value generally shows up on the second or third pass, when you can see what moved and what did not.

Why is re-marketing the network in the stop focusing corner?

The "stop focusing" corner on the worked example is filled in with the annual network discount re-marketing, and that is not an arbitrary choice. The reason sits in what a network discount actually buys, which works through why hospital identity explains far more of what a plan pays than the insurer does. Before you put it in your own bottom left corner, run what your hospitals actually get paid against your own market and see whether the same holds where you are.

Fringe Theory is independent and unaffiliated. Views expressed are my own and do not represent those of my employer. Nothing here is legal, tax, medical, or investment advice.