Healthcare Stole the American Dream – Here’s How We Take it Back

December 9th, 2017

Dave Chase explains how healthcare has stolen the American Dream……………..

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The Mystery World Of PBM’s & The Black Box

December 9th, 2017

The price you pay is all a black box………………………..

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The Decline of Employer-Sponsored Health Insurance

December 9th, 2017

Working families across the country are spending more of their income on insurance that doesn’t protect them as much as it used to………………….

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December 9th, 2017

“If one has a brain and a backbone, they can achieve amazing things in health benefits. “ – Dave Chase

Socialism Spawns Medical Flea Markets

December 8th, 2017

Peddlers offer everything from antibiotics to contraceptives laid out among the traditional fruits and vegetables…………

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Remember This?

December 7th, 2017

December 6th, 2017

Flu Season To Be Historic?

December 6th, 2017

America is set to endure one of the most perilous flu seasons in years – with doctors warning it could be similar to the deadly 2014 outbreak. 

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DELUCA v. BLUE CROSS BLUE SHIELD OF MICH. – Plan Sponsors Beware!

December 6th, 2017

Plan sponsors and their administrators are increasingly at risk of legal exposure for breach of fiduciary duties. This lawsuit is an early example. Experts in our industry suggest more to come, rivaling the potential to earn more in legal fees that will make the famous Tobacco Settlement look like peanuts.

The weapon of choice of plaintiff’s attorneys is:

Section 502(a) (2) of ERISA authorizes a beneficiary to bring an action against a fiduciary who has violated Section 409. Massachusetts Mutual Life Ins. Co. v. Russell, 473 U.S. 134 , 140, 105 S.Ct. 3085, 3089, 87 L.Ed.2d 96 (1985). The Supreme Court explained in Russell that “[a] fair contextual reading of the statute makes it abundantly clear that its draftsmen were primarily concerned with the possible misuse of plan assets, and with remedies that would protect the entire plan, rather than with the rights of an individual beneficiary.”

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Just A Guess But…………………………..

December 5th, 2017

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Welfare Causes Workers To Work Less

December 4th, 2017

The tragic truth of where our country is heading can be found in the article that follows. A growing welfare state is effectively eroding the American work ethic. In this article, a working American earning a good income decided to work less in order to receive welfare funded health insurance……………

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Renting Medicare’s Provider Network

December 3rd, 2017

 democratrepublican

An idea with bi-partisan support?

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Health Plan Industry’s Worst Nightmare: Employers Realizing They Are Actually The Insurance Company

December 3rd, 2017

Dave Chase

Any company over 100 employees or so is an insurance company in all but name. The wise ones are already self-insured……

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December 2nd, 2017

Established in 1959, this TPA is one of the largest, privately-held insurance services organizations in the country…..

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Ever Hear of a 51 Year Waiting Period For Medical Coverage?

December 2nd, 2017

Ever hear of a longer waiting period than 90 days? Paying for coverage for 51 years before coverage took effect brings cause for reflection…………….

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PHI Data Breach Warrior in Hot Water – Big Government Over Reach?

December 2nd, 2017

Justin Shafer & Family

“A friend of mine was released from unlawful confinement today. I’m a happy man” – Darrell Pruitt

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Ternian Develops PPO Network in Mexico

November 28th, 2017

Helping members in border states maximize their benefits: Ternian develops new PPO network of providers in Mexico
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Indians Are Restless – “We’re Not Paying This!”

November 28th, 2017

We’ve heard of shareholders’ lawsuits – it’s high time Plan members hold decision-making entities responsible through Plan member lawsuits……………….

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The Cost of Health Insurance Would Drop With This Legislation

November 28th, 2017

One reason health insurance companies are so strong and controlling is that they are exempt from antitrust regulations, allowing them to conspire on premium pricing…………………

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Insurica

November 28th, 2017

Placing nearly $1 billion in annual premiums for our clients, INSURICA is among the 50 largest insurance brokers in the United States and is currently the 27th largest privately-held independent agency in the country.

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Get It Done With A Freelancer Like RiskManagers.us

November 28th, 2017

Grow your business with the top freelancing website.

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ERISA Experts Provides Plan Sponsor Support

November 28th, 2017

The Employee Retirement Income Security Act (ERISA) of 1974 establishes minimum standards for retirement, health, and other welfare benefit plans, including life insurance, disability insurance, and apprenticeship plans.

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3000 Insurance Group Specializes In Association Sponsored Insurance Plans

November 28th, 2017

Oklahoma insurance agency specializes in association sponsored insurance programs since 1955………..

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As Health Care Changes, Insurers, Hospitals and Pharmacies Team UP

November 27th, 2017

Now that federal officials have quashed the mega-mergers proposed by the biggest insurers and blocked a deal between two large community pharmacy chains, established players in the health care industry are venturing beyond their traditional lines of business……………

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CEO: You Run a Health Care Business Whether You Like It or Not

November 26th, 2017

WHO, ME?

Warren Buffett said it all: “GM is a health and benefits company with an auto company attached.” In fact, it spends more on health care than steel, just as Starbucks spends more on health care than coffee beans………….

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Destroying Evidence – A Time Tested Strategy

November 26th, 2017

Sutter Health intentionally destroyed 192 boxes of documents that employers and labor unions were seeking in a lawsuit that accuses the giant Northern California health system of abusing its market power and charging inflated prices, according to a state judge……

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Rx Savings Solutions

November 26th, 2017

For the more than 1 million members with access to the Rx Savings Solutions desktop and mobile app, saving money on a medication can sometimes require a new prescription from their prescriber. They can now request and initiate this switch in a matter of seconds…………………

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A Thanksgiving Message From Brian Klepper

November 22nd, 2017
Here’s wishing all my colleagues on this listserv a very happy Thanksgiving, with deep gratitude for your energetic and thoughtful participation in discussions about how to leverage high performance health care in ways that positively change our health system.
Kaiser Health News ran this lovely article about setting aside some time tomorrow to talk about everyone’s end-of-life wishes. I lost my precious wife Elaine 3 years ago today, but because we were fastidious about specifying how we wanted it to go, it was as smooth and satisfying an experience as possible. We never know what awaits us, and I can’t begin to express how important this is.
One more thing. In honor of Elaine’s memory, here’s a wonderfully sweet piece she wrote on end-of-life for TedMed.
Have a great weekend – Brian

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State Gifts Workers Who Have Sex – Xmas Every Day Makes For Happy Employees

November 22nd, 2017

Thanks To Santa having sex is less financially stressful now……….

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Does BCBS Manage Claims or Do They Just Pay Them?

November 19th, 2017

One of my arguments about Blue Cross is that they do not manage claims, they just pay them…..

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PPO “Discounts” Off Billed Charges Mean Nothing

November 19th, 2017

 

A fascinating study by Alan T. Sorensen in 2003 on PPO discount patterns is an instructive read. The State of Connecticut’s data of the state’s hospital industry provided Sorensen a rare opportunity to study payer-level differences in negotiated discounts for hospital services and gives the reader insight into certain myths the managed care industry (including carriers, TPAs, agents and brokers) have successfully foisted upon clueless consumers for the past 35 years.

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83% Of Business Leaders Think Their Insurance Agents Suck!

November 19th, 2017

Benefits represent a company’s second largest expenditure, yet only 17 percent of business leaders think their programs are being managed effectively…………..

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How One Insurer Makes A Fortune By Reducing Healthcare Costs

November 18th, 2017

“The best way to lower health care costs is to lower health care costs”……………”Healthcare costs are directly related to what we agree to pay for healthcare”…………………..”The secret to lowering health care costs is to find providers willing to take less and discarding providers who want more – it’s called Free Market”…………. “If you want to cut your health care costs by 50% and more, without sacrificing quality or level of benefits, you can…………………”

The following article proves all of the above:

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Request For Proposals – Non-Disclosure Statement

November 17th, 2017

By Bill Rusteberg

Acting as a fee based insurance consultant in managing a formal, public Request For Proposal process requires adherence to certain guidelines memorialized in statutes pertaining to political subdivisions.

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HOLY BENEFIT MANAGEMENT, BATMAN!

November 15th, 2017
 
Employers are unhappy with their PBM relationships. Only one-third of employers rated their PBM as “very trustworthy.”

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TRS Care Marketing Opportunity for Insurance Agents

November 14th, 2017

As expected, there are many people leaving TRS and trying to secure a new health and drug plan in 2018……

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DOL Gives Kiss of Death in “Healthcare Madoff” Scheme

November 13th, 2017

By Mark Flores

The Complaint also alleges multiple violations of ERISA including, using plan assets to pay excessive fees and expenses, assessing undisclosed fees to the contribution amounts, failing or refusing to pay approximately $16 million for member’s medical claims, then transferring unpaid monies to offshore bank accounts in Bermuda.

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Veterans Day 2017

November 10th, 2017

 rusreberg

Lt. Col. E. Rusteberg – West Point 1934 – Two Silver Stars, One Bronze Star, Presidential Unit Citation (Battle of Hatten), Purple Heart. American hero.

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How Reinsurers Help Hedge Funds Shelter Taxes

November 10th, 2017

Zero tax rate attracts money offshore………………………..

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The Smart Plan

November 10th, 2017

QUESTION: What’s the opposite of “Smart?”

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Humana Profits Fall As Insurer Cuts 2,700 (Human) Jobs

November 9th, 2017

Humana said the company is cutting the jobs in part to invest in technology………….…………

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County Continues To See Drug Savings Through Canadian Rx Mail Order

November 8th, 2017

The county continued to save money this year under its Canadian prescription drug program, county officials said Friday……

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‘High-Performance’ Health Innovators Could Improve Outcomes, Lower Costs

November 7th, 2017

Consider what might happen if you could, say, guarantee a benefits manager a 25% reduction over current healthcare spend, with better outcomes. That would be an offer that she couldn’t refuse, especially if her CFO heard about it.

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Confessions of a Reformed Health Insurance Broker – From Innocence To Darkness

November 5th, 2017

Slowly we saw the rise of third party administrators, the evil purveyors of self-funded employee health & welfare plans…..

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WHY AN ‘OUTRAGEOUS’ $169,600 MEDICAL BILL ACTUALLY GOT PAID

November 5th, 2017

OUTRAGED CONSUMER

Would you pay $169,600 for a $3,000 – $4,000 procedure? Well, guess what, you have already – it’s embedded in your health insurance premiums…………………..

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Cost Plus Rx Model For Self-Funded Health Plans

November 3rd, 2017

We bring you a network of independent pharmacies with a simple and unique pharmacy payment model. Our cost plus model reimburses drug costs via the nationally published public NADAC list and a fixed drug dispensing fee. No more arcane acronyms like MAC, AWP, and WAC and no more lengthy contracts detailing complex generic and brand definitions.

Editor’s Note: If you are in the pharmacy business I would like to hear from you – any comments or suggestions you may have I will post in a follow-up blog posting………….Rx costs are out of control and the PBM world doesn’t seem to care. Perhaps PBM’s are the bad guys? If not, convince me please………………Write to RiskManager@RiskManagers.us

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Blue Cross Blue Shield of Arizona PPO Rental Network

November 2nd, 2017

Blue Cross Blue Shield of Arizona (BCBSAZ) provides large, self insured groups access to the BCBSAZ provider network……………..But how do they keep their PPO payment methodologies secret from the TPAs and more importantly, plan sponsors who pay the bills?

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The Deception Behind Those In-Network Health ‘Discounts’

November 1st, 2017

UnitedHealthcare  boasts that its PPO—a network of more than 780,000 professionals—cuts the cost of typical doctor visits by 52%, while saving 69% on MRIs. Pull back the curtain, and you’ll see these discounts are an accounting trick. To allow PPOs to advertise big discounts, providers simply inflate their billed charges on a whole range of services and treatments.

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Wellness Plans Face Scrutiny By DOL – Why Have One?

October 31st, 2017

Company Wellness Coordinators

Wellness plans don’t work. In theory they may, but in reality they don’t. Changing behavior is very hard to do, especially if it is societal and ancestral. 

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Free Health Insurance – Welfare (Subsidies) on Steroids

October 31st, 2017

The American Welfare State continues to grow. Proponents don’t call it welfare though. They call it “subsidies” instead. That’s a nicer, cleaner, less controversial term intended to calm frayed political nerves among those who work for a living and pay their own way. So when you read the following article, mentally substitute the term “subsidy” to “welfare.” 

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Prescription Care Management

October 31st, 2017

PCM saves 10-15% of total drug spend by utilizing therapeutic alternatives………….

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CVS-Aetna Deal Could Upend Future Role of PBMs

October 31st, 2017

“You are hearing the warning for the end of the road for the classic standalone” pharmacy benefit business…………………………”

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How Health Systems Are Like Newspapers

October 31st, 2017

“Hospitals are losing money on Medicare and Medicaid patients! They must charge commercial payers more to make up the difference!” is a much used argument to gouge consumers up to 1000 times more than what Medicare pays. Perhaps there are other contributing factors to hospital angst these days? 

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Why the Potential CVS Acquisition of Aetna is Brilliant………………

October 31st, 2017

The Law of Unintended Consequences……………Revenue enhancement through deception?

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TPA Caught “Working The Spread”

October 29th, 2017

The settlement resolves a lawsuit in which the DOL alleged that the TPA breached its fiduciary duties and committed prohibited transactions when it retained and did not disclose “network management fees” consisting of the difference between amounts charged to plans and amounts paid to health care providers……………..

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Firm Offers Direct Provider Contracting for Employers

October 28th, 2017

GM&A is a leader in direct contracting between employers and healthcare providers……

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Amazon Gains Pharmacy Licenses in Multiple States

October 27th, 2017

Throughout the past year, and without much fanfare, Amazon.com Inc. has gained approval to become a wholesale distributor from a number of state pharmaceutical boards, according to a review of public records.

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DisneyLand Buys Blue Cross & Blue Shield

October 27th, 2017

In an unprecedented move, the Blue Cross & Blue Shield Association announced this morning Disneyland has concluded talks with all BCBS plans in the United States and has reached a definitive agreement to purchase the Blues for $4.3 trillion. A spokesman for the BCBS Association has scheduled a press conference this afternoon to provide details.

In tandem with this blockbuster announcement was breaking news out of Chicago………

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PPO’s Are Dying

October 24th, 2017

PPOs are Dying – Why Pay for One?…………….Do you pay for a grocery store network…………?

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Working The Spread

October 23rd, 2017

The Weslaco ISD lawsuit against Aetna is a fascinating read. The pleadings provide clues for those who are curious about various revenue streams found (or not found) within some administrative contracts for third party administration of group medical plans.

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Getting Screwed

October 23rd, 2017

When it comes to hospital bills, you don’t get the itemized version of the bill, so you often have no idea what you are actually paying for………. Read the rest of this entry »

EDMUNDO O. RAMIREZ  – 1952-2017

October 21st, 2017

Edmundo was a fighter. He fought hard for his clients and protected those he loved. He lived life on his own terms, and he died on his own terms. This rock solid, self-made man will be missed by many. 

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Slapped In Texas

October 20th, 2017

TPA Loses Lawsuit Against Private Citizen

“The Texas Legislature unanimously adopted one of the strongest Anti-SLAPP statutes in the nation and showed their continued support of the First Amendment.  On June 17, 2011, the Texas Citizens Participation Act (the “Texas Anti-SLAPP statute”) was signed into law by Gov. Rick Perry.”

“The statue allows a judge to dismiss frivolous lawsuits filed against one who speaks out about a “matter of public concern” within the first 60 days.  “Matter of public concern” is defined expansively in the statute.” (slappedintexas.com/primer/)

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Pile Makes Incredible Offer

October 19th, 2017

“I’ll Make You An Offer You Can’t Refuse”

Can anybody use 5% of their healthcare spend back?? Give me a call so I can show you why there is 5% there and how we will find and recover it for you.

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Direct Pay (Cash Pay) Strategies Make Sense

October 19th, 2017

By Bill Rusteberg

Direct Pay strategies, which I call Cash Pay strategies, has had a positive impact on a 400 life case we manage.

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Open Enrollment as Turd Polishing Season is Over

October 18th, 2017

For 20+ years, Open Enrollment has meant explaining to employees how they’re going to pay more and get less when it comes to health benefits……………………..

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TPA Promotes Reference Based Pricing Model – Guarantees No Balance Billing

October 18th, 2017

A TPA specializing in self-funding for small group plans of 100 employee lives or less offers a unique Reference Based Pricing model that includes the promise of no balance billing.

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Opioid Crisis Fueled By Drug Industry and Congress

October 16th, 2017

Whistleblower Joe Rannazzisi says drug distributors pumped opioids into U.S. communities — knowing that people were dying — and says industry lobbyists and Congress derailed the DEA’s efforts to stop it

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Insurance Consultants Are Biased

October 16th, 2017

mulebriar

“The last category of independent insurance consultants are those that are never comfortable outside their insulated environment. They like the warm and fuzzy feeling of staying at home in a loving environment with Mommy.”

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Largest Employer South of San Antonio Seeks Insurance Consultant

October 15th, 2017

Brownsville Independent School District, the largest employer south of San Antonio, Texas is seeking an insurance consultant for the district’s self-funded employee health & welfare plan.

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Selecting a Third Party Administrator

October 12th, 2017

By William Rusteberg

Selection of a third party administrator (TPA) is crucial to the success of a self-funded plan. Criteria usually revolve around several factors including compatibility. Corporate philosophies of the employer and TPA should harmonize.

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The Cost of Convenience

October 12th, 2017

ppoo

“More employers are seeing the value of adding a little bit of inconvenience to their health plans these days.

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Express Scripts to acquire EviCore Healthcare for $3.6

October 10th, 2017

Pharmacy benefit manger Express Scripts will acquire medical benefits management company eviCore Healthcare for $3.6 billion, which will give the company an entry point into a growing market, the company announced Tuesday in a securities filing.

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Dendy Opines

October 10th, 2017

When people or companies live off of opacity, there is a problem as one never knows if they are being treated fairly or not” – Mike Dendy

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How One Of America’s Most Innovative Benefits Leaders Reduces Clients’ Healthcare Spending 20%

October 9th, 2017

David Conterno

When the industry goes to higher deductibles, we remove them. When the industry goes to narrow networks, we remove networks. When the industry goes to narrow formularies, we expand them. When the industry invests in specialty care and surgical centers, we invest in primary care. When the industry looks to bring in more insurance products, we bring in less. Instead of increasing obstacles to getting any and all care, we need to be removing all obstacles to getting the right care.”

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