PPOs and the $444 Box of Kleenex

May 16th, 2019

Healthcare providers set astronomical, arbitrary prices, and employers and insurers have few options. But a solution is emerging. 

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Texas School District Challenges TRS ActiveCare Plan Mandates

May 15th, 2019

Tired of waiting for the Texas legislature to act in addressing crippling health care costs affecting hundreds of thousands of Texas educators, the Raymondville Independent School District in deep South Texas has decided to act.

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More TRS ActiveCare Angst Among School Administrators

May 13th, 2019

Local school districts voice concern over rising costs for health coverage

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Another State Adopts Reference Based Pricing

May 13th, 2019

“To attract providers, Washington lawmakers chose a relatively high figure to start: The plan caps payouts at 160 per cent of federal Medicare rates……..”

Plan is expected to be competitive “in part to savings from a cap on rates paid to providers……………..”

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TRS Strategy To Control Health Care Costs Screws Plan Members

May 12th, 2019

The following article reports that “TRS trustees noted the only tools available to them to address rising costs each year are to”:

  1. increase premiums
  2. lower benefits
  3. or a combination of both

Really?

Meanwhile, smart plan sponsors have solved the rising cost of health care in Texas and it ain’t by increasing premiums and lowering benefits. Rather, it’s by lowering costs and improving benefits at the same time……sounds crazy doesn’t it?

(The Texas legislature’s answer to addressing rising health care costs is House Bill 3987, that if passed, will authorize a committee to study the issue and report back in two years. But some Texas school districts are not waiting……..)

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Let The Sun Shine In…………………..

May 11th, 2019

Health Plans Should Prepare For Plan Fallout Of HHS Rule Requiring Manufacturers Disclose Drug Prices

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El Paso ISD To Adopt Exemption To TRS ActiveCare Requirement

May 11th, 2019

The El Paso Independent School District is set to adopt an exemption to Texas Education Code 22.004(i), which prohibits a District that has implemented employee group health coverage pursuant to Chapter 1579 of the Insurance Code (TRS ActiveCare) from providing any kind of alternative group health coverage at their May 14 board meeting.

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Too Damn HIgh!

May 11th, 2019

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Fearless Agitator Rattles Cages For Fun

May 10th, 2019

The Real David in David & Goliath 

By David Contorno

Employers…..contrary to what you think, health insurance carriers make MORE revenue and profit as your health care costs go up. It’s federal law.

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Protection Money Scheme Dominates HealthCare

May 8th, 2019

Pssst…Godfather, Mulebriar Is At It Again!

“Paying protection money (PPO access fees) for the promise of no balance billing against egregious, arbitrary sticker pricing that have no relationship to costs whatsoever, and agreeing to provider reimbursement levels based upon secretive contracts you cannot see nor audit, violates fiduciary duties and is contrary to basic, common American business practices. “

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The Fallacy of PPO Re-Pricing Exercise

May 8th, 2019

Each time I see a Request for Proposals put out by insurance consultants requiring a PPO Re-Pricing Exercise in an effort to determine which network has the best discounts the temptation to reach out to Jose Cuervo is tough to ignore. 

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Who’s The Dick That’s Going To Explain Our Healthcare Tragedy?

May 7th, 2019

If you’re an insurance company, the simplest way to make more money, is to PAY MORE for medical services. In fact, provider negotiations should go like this:

Doctor: I want $100 for this procedure.

Insurance Company: No, we won’t pay you a penny less than $250. 

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Hospitals Are Committing Financial Suicide But Don’t Know It

May 6th, 2019

Hospitals have overplayed their hand. Galeforce blowback has arrived.

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Size Means Nothing in Health Care Financing – Common Sense Does

May 5th, 2019

This is what a +400,000 life group plan offering status quo healthcare strategies gets you these days…………

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Reference Based Pricing Blitzkreig

May 3rd, 2019

“For-profit hospitals charge 700% more than Medicare prices, while non-profit hospitals charge 550% more. Traditional PPO plans offering a 50% discount may end up paying 300% more than the Medicare price”.  In Texas where Reference Based Pricing strategies have been around since 2007, plan sponsors are paying between 120% to 150% of Medicare…………………….The Reference Based Pricing Blitzkreig is gaining market share quickly……………

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Astute Purchasing Agent Nails It

May 3rd, 2019

A long time friend who has spent almost all of his working life in the pubic purchasing arena in Texas has a perspective that many of us in the insurance community have failed to acknowledge. 

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Grandpaw-hood At Risk?

May 2nd, 2019

 “Please don’t leave us Grandpaw!!!”

Hey Grandpaw, I’m thinking of giving my children (your grandchildren) a few free gifts this year but I may decide later to take them back. But………. I’m worried the government will require you to disown us under penalty of sanctions!

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Shoddy Health Care, Missed Diagnosis, Unnecessary Treatment……….

April 30th, 2019

Diagnosed with the “Big C?” At least 10% beat it because they didn’t have cancer in the first place……...

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Judge Recuses Self Over Views On Insurer’s ‘Barbaric’ Policy

April 30th, 2019

UHC Company Executives?

A Florida federal judge stepped down Monday from a proposed class action claiming UnitedHealthcare improperly classified a certain cancer treatment as experimental to avoid providing coverage, saying his personal opinion prevented him from ruling fairly on what he called “immoral and barbaric” actions.

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Is Your Employer Worksite Medical Clinic a Group Health Plan?

April 29th, 2019

“An employer maintaining a workplace clinic (or considering one) needs to understand the group health plan compliance risks and the general risks associated with doing so and take reasonable steps to mitigate those risks.

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Medicare For All Already Exists

April 29th, 2019

We have Medicare for all already………………………………………..

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States Look To Medicare-Based Reference Pricing Strategies

April 25th, 2019

Meanwhile, back at the ranch, the Texas legislature kicks the can down the road……………..again.

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The Future of Personalized Medicine is Here

April 25th, 2019

One simple test, we can improve quality of life and save healthcare resources……………..

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Power Struggle in Dallas

April 25th, 2019

Blue Cross Blue Shield of Texas removes 14 DFW hospital emergency rooms with out-of-network docs from network………………….

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A New Kind of Pharmacy

April 25th, 2019

Blue Cross To Offer $10 Co-pay Food Plan

April 25th, 2019

Will food program drive down health care costs in Chicago and Dallas?  A portion of your BCBS premium dollars will be allocated to find out……………

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Need Surgery? Go On-Line and Book It

April 24th, 2019

Imagine if you need some sort of surgical procedure like a knee replacement. Simply go on-line and book it. Your employer has arranged to pay the providers you select  prior to services rendered, including all or a part of your share of the cost. It’s that easy.

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Texas House Bill 3933 – A Panacea for Reference Based Pricing Plans?

April 23rd, 2019
The Texas legislature is considering numerous bills of interest to those of us engaged with health care delivery in this state. HB 3933 is one, that if passed, will have a considerable impact upon the health care community.

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Webb County Seeks P&C Insurance Consultant

April 23rd, 2019

RFQ 2019-0006 Package for a Consultant for Health Insurance for Webb County can be obtained from our EBid site located at:  https://webbcountyebid.ionwave.net/CurrentSourcingEvents.aspx

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PBM’s

April 23rd, 2019

Going Broke? Never Mind, Just Print More Money

April 22nd, 2019

Trustees project Medicare trust fund will be depleted in seven years………..So let’s do Medicare For All and see if we can go broke faster……………………………Never mind. Sam, fire up the ole printing press will ya………..we’ed be needing some money to pay for all this.

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Disruptive Digital Business Models For Health Insurers

April 22nd, 2019

“The main impact of digital business models is on company evaluation, which reflects the hype that some companies have created in the investor community. Companies like Oscar, Clover Health, and Bright Health are valued at over $1 billion USD each after only a few years of operation.”

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Texas Considers Balance Billing Legislation For Self-Funded Plans

April 21st, 2019

At first glance Texas Senate Bill 1530 looks appealing. Balance billing protection for self-funded health & welfare plans would be a welcomed gift from government, especially among purveyors of Reference Based Pricing plans. 

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33% of U.S. Workforce Using Prescription Pain Medications

April 18th, 2019

      Morning Shift Arriving At Work

One in three workers reported using prescription pain relievers — the majority under treatment of a physician………………………

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The Antithesis of Managed Care

April 18th, 2019

Insurer Paid +300% of Medicare But The Discount Was Really Good

April 18th, 2019

In the article by Marshall Allen that follows patient questions why Aetna paid  a grossly inflated rate of more than 300% of Medicare for his in-network claim. Well, that’s not the way Aetna or any other managed care company wants you to look at it. Instead they want you to focus on “discounts.” Managed care companies like Aetna reinforce that focus by sending patients EOB’s highlighting those amazing and magnificent discounts applied against billed charges. Could it be you may be looking at a 50% discount off double the price?

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Health Insurance Hustle

April 18th, 2019

Behind the Scenes, Health Insurers Use Cash and Gifts to Sway Which Benefits Employers Choose

The insurance industry gives lucrative commissions and bonuses — from six-figure payouts to a chance to bat against Mariano Rivera — to the independent brokers who advise employers. Critics call the payments a “classic conflict of interest” that drive up costs.

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The Death of PPO’s

April 17th, 2019

PPO’s are a fraud and more are beginning to understand that. The only thing PPO’s can guarantee is the promise of no balance billing. That’s a powerful and effective coercive method used to foster obedience to status quo strategies of the past 35 years.  However, the truth is we are all running out of money to fuel the American Healthcare Monster. Breaking away from status quo solutions will soon become a national epidemic towards fundamental change bringing sanity to health care costs in this country – Bill Rusteberg.

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Reason & Logic Won’t Move TRS ActiveCare Trustees

April 16th, 2019
TRS ActiveCare Plan Manager Struggles To Save Program
“It’s impossible to prove something to someone whose salary depends on believing the opposite” – Upton Sinclair

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Another Win For The Oklahoma Medical Association

April 16th, 2019

We’re excited to have a contract for services with the Texas Free Market Surgery Center. Our Texas clients who join the Oklahoma State Medical Association (OSMA) health plan will now have access to bundled pricing in Austin, Texas.

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Fully Insured Dental Plan Request for Proposals

April 15th, 2019

McAllen Independent School District (the “District”) invites your submittal on: RFP No. 2018-200 – Fully Insured Dental Plan…………………….

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Adverse Selection Dooms TRS ActiveCare

April 15th, 2019

The TRS ActiveCare plan for Texas school districts is imploding. Many want out of the program…….

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Scientist Proves Employee Benefit Meetings Are A Waste of Time

April 13th, 2019

The Ebbinghaus Study is widely accepted as a definitive study in human intelligence. The study concluded that within 24 hours we will forget 75% and within 30 days we will forget 90%. The remaining 10% will remember only 5%.

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Why Do Some Fiduciary Violations Go Unpunished While Others Result in Jail

April 12th, 2019

“People are going to jail over ERISA fiduciary violations and the dollar amounts pale in comparison to what is being wasted on the employee health plan side of ERISA.”

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Is Medicare Supplemental Insurance Worth It?

April 12th, 2019

Dr. Dave opines again on Medicare supplemental insurance policies…………….

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RBP Market Growth Continues – Blue Cross Adopts No Network Model

April 11th, 2019

 

The North Carolina Blue Cross Blue Shield “My Choice” policies aim to change the way doctors and hospitals are paid by limiting reimbursement for services to 40% above what Medicare would pay. The plan has no network of doctors and hospitals…………………

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Hospital Insults Plan Sponsor – Wants 1,947% of Medicare

April 9th, 2019

Hospital demands almost 2,000% of Medicare to settle claim………………….

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Health Insurance Bankrupting Americans – Personal Debt Reaches New Highs

April 8th, 2019

A new survey from Gallup shows that Americans borrowed a staggering $88 billion in 2018 to pay for health-care costs that were not covered by their insurance plans………..….

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Cancer Cure?

April 8th, 2019

Activated immune cells travel throughout the body, killing tumors wherever they find them…………….

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Surprise Medical Bills – Two Texas Physicians Respond

April 8th, 2019

“Conditions and diseases of healthcare systems which are relevant to this discussion include: incentive malalignment syndrome, hypermetricosis, benefit managementosis, maladaptive dysdocumentosis and more.” – Texas Physician

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3 Ways Employees Can Reduce Prescription Costs

April 8th, 2019

Senator Cruz Proposes 4th Method To Reduce Drug Costs?

In an unprecedented move, Tx. Senator Ted Cruz introduces Senate Bill to free the worlds most successful drug importer. “Chapo has proven cheap and effective drug importation is possible! With his direct-to-source plus vast American distribution system, El Chapo, his organization has the where with all to help solve our broken health care delivery system. FREE CHAPO!

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InstaMed

April 7th, 2019
Creating electronic movement of healthcare data and money faster than a melting Raspa …………..

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Doctors Practices Leaving Charlotte Hospitals Catch The Eye Of Their Industry

April 7th, 2019

By Alex Olgin  Mar 25, 2019

For the more than 40 doctors at Lakeside Family Physicians and Huntersville OB/GYN, the move away from Novant Health is a return to how they used to practice medicine. Both groups were independent before joining with Novant about 15 years ago.

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Employers Get Choosier About Workers’ Doctors

April 6th, 2019

Many big companies are mining data from their own health plans and public records and working with consultants to compare physicians, searching for those with the best results and competitive costs.

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A Million Views in 44 Days! ClearHealthCosts Price Transparency TED Talk Goes Viral

April 6th, 2019

Jeanne Pinder scores big with TED talk…………………….

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Status Quo Consultants vs New Age Consultants

April 4th, 2019

By Bill Rusteberg

Last year I had the privilege to make a presentation to the Board of Trustees of a Texas independent school district. The district’s self-funded health & welfare plan was in trouble and they wanted to hear how we have been able to keep costs static over time for other school districts we have been fortunate enough to manage over the past twenty years. Those districts have beaten medical trend while improving benefits at the same time and at half the cost.

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Outrage Over Rising Costs of 100 Year Old Drug

April 3rd, 2019

Insulin manufacturers and PBMs have faced mounting pressure amid outrage over the rising cost of insulin, a nearly century old lifesaving drug.

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Clarity Benefit Solutions – TPA for Tax Advantaged Plans

April 3rd, 2019

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Clarity Benefit Solutions is a broker-friendly benefits technology company and TPA for Tax-Advantaged Plans with 25+ years of industry experience.  Our easy-to-use programs and tools are designed to innovate, integrate, and automate – taking the frustration out of benefits with solutions that actually work.

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How Two Common Medications Became One $455 Million Specialty Pill

April 3rd, 2019

You can walk into your local drugstore and buy a month’s supply of Aleve and Nexium for about $40. For Vimovo, the pharmacy billed my insurance company $3,252.

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DOL “End Run” Ends In Defeat

April 3rd, 2019

Stringent government control of health care continues to defeat efforts of free market proponents……………….

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Texans Support Consumer Protection Laws Against Medical Price Gouging

April 2nd, 2019

Texas Free Standing Emergency Rooms (FSER) resemble urgent care centers, but on average, an FSER costs 10 times as much as an urgent care visit for the same condition……………..

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New PHI Procedure

April 2nd, 2019

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The Balance Billing Myth

March 31st, 2019

A seemingly valid concern about Reference Based Pricing strategies on the part of consumers is the possibility of balance billing leading to personal debt, lawsuits and ruined credit.

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The Evolution of Reference Based Pricing

March 31st, 2019

Change over time is a constant……………………………………

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Thurman James Chapman

March 31st, 2019

OCTOBER 13, 1925 – MARCH 27, 2019

Thurman James (T.J.) Chapman, age 93, of Austin, Texas passed away peacefully at his home on March 27, 2019 after a long illness.

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Donna Independent School District Seeks Insurance Consultant

March 30th, 2019

Donna Independent School District is accepting Insurance Consulting Services RFP #032219-487 at the office of the purchasing agent located at:

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Judge Strikes Down Trump Administration’s Health Care Plan

March 29th, 2019

The most powerful branch of government strikes down proposed rules for association health plans………….The Trump administration had rolled out the plans after President Trump signed an executive order directing Labor Secretary Alexander Acosta to consider allowing more small employers to form association health plans.

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WellCare bought by Centene

March 29th, 2019

WellCare Health Plans Inc. will be acquired by Centene Corp. in a $17.3 billion cash and stock deal.

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Slapped in North Carolina

March 29th, 2019

“Delay and Confuse” is one of the oldest tactics used by incumbents under attack. The North Carolina flirtation with Reference Based Pricing for their state employees is a classic example.

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$15,000,000,000.00

March 28th, 2019

$15 billion deal creates insurance powerhouse………………..

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Reference Based Pricing Model For Prescription Drugs

March 28th, 2019

Reference pricing divides drugs into therapeutic classes, which allow a payer to identify an average price to use as a reference point……………………

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ObamaCare On The Ropes Again – Investors Skittish

March 27th, 2019

Here we go again. Another challenge to the ACA. But this time investors are weighing the odds and taking their money elsewhere…………………..

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Litigation vs. Negotiation: How to successfully structure RBP

March 26th, 2019

As consultants we have options when it comes to vendors, and if you’re in this healthcare revolution, I urge you to choose your partners thoughtfully and more importantly, in alignment with the values you communicate as an adviser…………….

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Medical Providers Declare War In North Carolina

March 23rd, 2019

North Carolina may not embrace Reference Based Pricing strategies for the state employee plan after all. The North Carolina medical community has declared war. “Delay and Confuse”, a time tested tactic, is the weapon of choice……….

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Health Care Prices vs Health Care Costs

March 23rd, 2019

  Dave Chase

Hospitals have overplayed their hand just like Pharma. At a certain point, gluttony has blowback.

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