Must Reference Based Pricing Vendors Be Licensed?

June 21st, 2018

Hospitals and their attorneys are getting creative. One issue of particular interest outlined in the article is apparently a new line of attack……………………..

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We’re not good golfers…………………

June 21st, 2018

This is one of the best insurance agency websites I have seen in a long time. They memorialize their philosophy in a compelling manner………………………….

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Embodiment of Corruption: Your Health Insurance Network

June 21st, 2018

Secret network pricing helps render patients defenseless against price gouging. It’s as absurd as grocers being permitted to keep the price of milk secret……………..

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Government Control of Health Care Loosened in Bold Move

June 21st, 2018

Move keeps the government officials from using its power and influence to direct the practice of medicine……………………….

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Why Do Prescription Prices Vary By Up to 1,300%

June 21st, 2018

Learn how a recent study found that prices for 5 commonly prescribed prescription drugs varied but up to 1,300% based on where the drugs were purchased.

Montana Experiences “Holy Cow” Moment

June 21st, 2018

Montana’s high-stakes game of chicken designed to change how the state did business with its 60 hospitals, which accounted for 43 percent of employee health care costs, turning the normal purchasing process on its head……………………..

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Sana

June 21st, 2018

Are you looking for new commission and bonus opportunities: Join us for a catered lunch at one of our local Texas events to learn how Sana is changing health insurance. Plus meet the founders.

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Reference-Based Pricing Litigation: Brick By Brick

June 21st, 2018

NOTE: The author of this article is unknown. If any of our readers recognize who the author is please email RiskManager@RiskManagers.us so we can give proper credit.

Whether you believe modern Reference-Based Pricing models are presently being built, remodeled, or dismantled “brick by brick” truly depends on your perspective. Either way, this is an interesting time to review the recent challenges, results, and future risk created by this important approach to health care reimbursement, which has saved employers millions of dollars and sparked fierce conversations about reasonable value across the nation.

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Renting Medicare’s Provider Network

June 20th, 2018

 democratrepublican

An idea with bi-partisan support?

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Association Health Plans Go Into Effect

June 20th, 2018

This expansion of health care choices returns certain risk manager tools stolen by the government with the passage of the Affordable Care Act (ACA):

☐ Allows plans to exclude coverage for maternity care, prescription drugs, mental-health services and other ‘essential health benefits’ the ACA requires of coverage

☐ Plans will have more freedom to charge different prices depending on customers’ ages, genders and locations — something ACA coverage cannot do.

☐ The regulations erase a requirement that any association must already have existed for a purpose unrelated to health insurance.

☐ These plans will also be able to reduce administrative costs and strengthen negotiating power with providers from larger risk pools and greater economies of scale….

☐ Moves health-insurance regulation from the state level to the federal level.

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Peeling Back The Health Care Onion

June 19th, 2018

“Colorado hospitals statewide are paid an average of 290% of Medicare for inpatient services and 520% of Medicare for outpatient services…………………”

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Unwieldy Health Costs Often Stand Between Teachers And Fatter Paychecks

June 19th, 2018

In an era of $100,000-a-year drugs and government budget cuts, school districts are struggling to find the money to keep up their end of the bargain (providing benefits), forced to take away from classroom funding and even modest, cost-of-living raises. Many cash-strapped school boards, cities and legislatures view health care benefits as an unpredictable budget-buster.

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Don’t Hire An Actuary Because You May Get Really Bad News

June 19th, 2018

As a benefits consultant, if you not employing a licensed actuary providing these services your competition will……………………………..

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McAllen Independent School District Seeks Reference Based Pricing Vendor

June 18th, 2018
The McAllen Independent School District in deep South Texas is seeking competitive proposals for Reference Based Pricing plan administrator. Sources say the district is facing increasing health care costs and seeks to adopt a Reference Based Pricing plan option to offer in addition to their current PPO plan.

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Why You Will Never Win

June 18th, 2018

This was sent to several of us this afternoon from the one and only, Carl Schuessler, health care disruptor extraordinaire.

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Introductions Are Worth Big Bucks In The Insurance Industry

June 14th, 2018

Earning commissions forever by simply making an introduction beats working for a living………….

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Owe Medical Bills? Don’t Pay Promptly, Pay Late & Join The 50% Club

June 13th, 2018

Members of the 50% Club subscribe to the Upside Down Economics of Health Care. They understand those who pay on time are screwing themselves and those that don’t are rewarded…………….

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Everyone Is Paying For Mary’s Deductible Because Mary Isn’t

June 12th, 2018

Lucky Mary is even more lucky now that her employer decided enough was enough…………………….

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Saving Rural Hospitals By Gaming The System?

June 11th, 2018

GAMING THE SYSTEM: Remote billing by rural hospitals is becoming a strategy to remain solvent? Medicare and commercial insurers tend to pay more for tests to sustain endangered rural hospitals compared with urban hospitals and especially outpatient labs………………………………

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Medicare For All & Reference Based Pricing

June 11th, 2018

Since Medicare For All is only a few elections away some employers are asking “Why wait? Let’s do it!

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Schools Buying Insurance Against Mass Shootings On The Rise

June 10th, 2018

McGowan Cos., the largest underwriter of “active shooter” coverage, said they’re having a tough time keeping up with hundreds of inquiries from schools and other customers……………….

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PUNISHMENT LETTER 226-J

June 9th, 2018

The government of the United States has sent out 30,000 punishment letters to employers who have failed to comply with the ever so popular AFFORDABLE HEALTH CARE ACT…………………………..

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Justice Dept. Says Crucial Provisions of Obamacare Are Unconstitutional

June 8th, 2018

Is it a tax if it raises no revenue………………………………….?

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Single Payer System Is One Election Away

June 8th, 2018

The Elephant In The Room is stirring, anxiously awaiting the fall mating season……………………….

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Accidents Of History Created U.S. Health System

June 7th, 2018

How did Americans end up with a system in which employers pay for our health insurance? After all, they don’t pay for our groceries or our gas……………

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Welcome To The ATM World of Pharmacy

June 7th, 2018

Pharmacist-supported self-service kiosk pharmacies ………………….

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Christian Healthcare Ministries – Alternative To Traditional Health Insurance

June 7th, 2018

Christian Healthcare Ministries, one of several “health sharing ministries” whose members pool their resources to pay for one another’s health care expenses and has not had a rate increase in ten years……………………

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Co-Pay Tactic by Benefit Managers Credited with Cutting Prescription Drug Prices

June 6th, 2018

“It’s a constant cat and mouse game,” said Express Scripts Chief Medical Officer Steve Miller………………..

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Will California Criminalize PPOs?

June 6th, 2018

California would use Medicare rates as a floor for determining base amounts for providers and Medicare Advantage rates to set payments to health plans. Providers and health plans would be allowed to appeal for a higher amount based upon outstanding factors.

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Wellness Programs Don’t Work

June 5th, 2018

On its surface, who can argue with the concept of workplace wellness? How could there be anything wrong with corporations helping their employees reduce their risk of disease while saving money in the process?

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Renowned Texas Heart Transplant Program Suspends Operations

June 5th, 2018

Over 30% of patients who received heart transplants at St. Luke’s since the start of 2018 have died…………………………

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Drugmakers Blamed For Blocking Generics Have Jacked Up Prices And Cost U.S. Billions

June 4th, 2018

By Sydney Lupkin MAY 23, 2018

The Trump administration is shaming brand-name drug makers who refuse to sell samples so generics can be made from their products.

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Sex Sells – Winning Sales Quota by Banging Doctors?

June 1st, 2018

In 2012, Insys hired a new sales executive: Sunrise Lee, a Florida escort service manager and former strip club dancer with no academic degree, according to Guzman’s complaint. Burlakoff allegedly defended the decision, claiming, “Doctors really enjoyed spending time with her and found Sunrise to be a great listener.” He added, “She’s more of a closer.”

The regional sales manager reported that the new employee was “dumb as rocks, but that she was sleeping with another doctor and getting a lot of prescriptions out of him.” Read the rest of this entry »

The Hidden Monopolies That Raise Drug Prices

May 31st, 2018

“PBMs don’t stop at legal money-making schemes……….. undisclosed rebates, artificial price inflations, kickbacks, steering, and other deceptive practices.”

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Why Did It Take So Long To Realize PPO’s Suck?

May 31st, 2018

Agents, brokers and consultants, once so welded to the status quo, are now some of the most vocal and ardent supporters of the movement away from PPOs……………

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A Health Plan Veteran Is Tired of Provider Networks

May 31st, 2018

“The health care game is rigged,…………………“That’s why we don’t play by their rules — and neither should you.”

Instead “Name your own price for health care services” (reference-based pricing strategy), along with rigorous auditing of facility claims.” 

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What is Trump Going To Do To PBM’s on Friday?

May 30th, 2018

President Trump Beating Up On PBMs In Oval Office?

“This system is completely broken … It is layered and layered with conflicts of interest. I don’t care who the PBM is.

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Risk Tolerance & Reference Based Pricing Strategies

May 29th, 2018

The problem I see with most health insurance consultants is almost all pre-determine a client’s tolerance for risk before determining where the risk tolerance actually lies.

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The Rising Cost of Cost Containment

May 29th, 2018

“Reference Based Reimbursement, while not perfect, provides a clear and distinct effort to bring attention to the actual cost of healthcare goods and services.” – Scott Haas

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Blue Cross Gets It Right

May 29th, 2018

If it’s not an emergency, Blue Cross Blue Shield won’t pay……………

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Economies of Scale In Health Care?

May 29th, 2018

In health care size make no difference……or does it?

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Memorial Day 2018

May 25th, 2018

 rusreberg

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

The battalion began the battle of Hatten with 33 officers and 748 en- listed men. Fifty-two hours later it had an effective strength of 11 officers and 253 enlisted men. All others were either killed, wounded or missing in action.

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Court Case Shows How Health Insurers Screw You

May 24th, 2018

The insurer claimed—I’m not making this up—that its customers bore some of the financial responsibility for being ripped off because they weren’t paying close enough attention to what BCBSM was doing………………..

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Texas Ruling on $11,00 ER Bill May Have Long-Lasting Effects

May 24th, 2018

The health care industry is closely watching a recent decision by the Texas Supreme Court that some say could have broader implications on how hospitals and health insurers negotiate their rates………………..

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New Resource For Texas Political Subdivisions

May 23rd, 2018

TAGCO RiskManagers, LLC (TAGCO) was formed by industry insiders as a resource for political subdivisions seeking solutions to rising healthcare costs…………………………

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May 23rd, 2018

We have the expertise, experience and bulldog tenacity to do the job and do it right……………………….

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Insurance For Pandemic Losses

May 22nd, 2018

Marsh has launched a new insurance product to provide financial protection to US-based businesses and their global operations affected by an infectious disease outbreak.

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The Phenomenon of Balance Billing Under PPACA

May 22nd, 2018

tomdick1

“Balance billing is representative of the last throes of a failed health care delivery system.”

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Games Brokers Play – A True Story

May 22nd, 2018

“Those who have data win. Those who have good data win a lot. Those who have real time data win all the time” – John W. Richards Jr, M.D.

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What Barbershops Can Teach About Delivering Health Care

May 22nd, 2018

Health care reimbursement in the United States usually focuses on the clinical encounter, at a physician office or hospital. This reflects a belief that care is best offered there, even when evidence says otherwise………………

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California Pushes To Give Illegals Full Health Care Benefits

May 22nd, 2018

“We are trying to address the fact that, whether you like it or not, our undocumented community needs the care, and we are paying for it anyway………………..California needs to be a laboratory for social change by taking the lead on progressive causes.”

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Anti-Assignment Clauses Are Enforceable

May 21st, 2018

The US Court of Appeals for the Third Circuit has held that anti-assignment clauses in health plans governed by the Employee Retirement Income Security Act of 1974 (ERISA) generally are enforceable.

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Texas Healthcare Costs

May 21st, 2018

Article referred by David Wendel

The Texas Department of Insurance (TDI) has a new  website that provides cost information on more than 200 of the most common medical procedures, including many tests, surgeries and office visits.

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How Do You Measure Savings?

May 19th, 2018

Question: How do we know we are doing better (saving money) this year than last year?

Answer: What was this year is last year plus or minus this year’s change.

Question: Then if change is the only constant why do we need to measure it? You don’t know if something is better if you didn’t know how to measure what it was before.

AUTHOR UNKNOWN

Slippery Slope Insurance Consulting?

May 19th, 2018

By Molly Mulebriar

The City of New Braunfels RFP recently hired an insurance consultant to assist the city in a competitive RFP process for their employee health & welfare plan. Or did they hire two?

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Vermont To Permit Drug Imports From Canada

May 19th, 2018

Vermont initiative creates a wholesale importation program to purchase high-cost drugs in Canada, where they often sell for less…………………Will retail Rx outlets then advertise and export these cheaper drugs from Vermont to the rest of the county? Could be a fantastic Rx mail-order business domiciled in Vermont…………….

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Turning Bronze Into Gold

May 18th, 2018

Turning Bronze Plans into Gold Plans at Bronze Plan costs is a common but unspoken strategy……………

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Physician Strikes It Rich in Health Care Arena

May 17th, 2018

A Texas doctor used his million-dollar private jet or drove in his Maserati, which were both emblazoned with his initials “ZQ” between his offices in the Rio Grande Valley and San Antonio…………he purchased private jets, luxury vehicles, clothing from high-end retailers such as Louis Vuitton and exclusive real estate located throughout the United States and Mexico………..all garnered through his successful clinic operation in deep South Texas………………

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Medicare + Fee Schedules

May 15th, 2018

NATIONAL ASSOCIATION OF PREFERRED PROVIDERS (NAPP) Fee Schedule:

☑ Medicare plus 25% or 80% of billed charges, whichever is less.

THREE RIVERS PROVIDER NETWORK (TRPN) – PPO Fee Schedule:

125% of the existing Medical fee schedule as total reimbursement for covered services less applicable co-payments, co-insurance or deductibles.

IMAGINE A ONE  OR TWO PAGE HOSPITAL CONTRACT INCORPORATING THESE FEE SCHEDULES…………………….

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Refried Beans

May 15th, 2018

In a previous RFP for Section 125 Administration & Products, a bid was awarded in March 03-18-S40-229. Now we see the City of McAllen is re-bidding again. What happened?

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Pointing Fingers

May 14th, 2018

Republicans and Democrats blame each other for the great American health care failure. But isn’t it true that once government gets involved in anything costs go up? For example, food costs are higher because of the food stamp industry wherein recipients really don’t care what the cost of food is since its free. And how about college tuition? With rampant student loans students (and their parents) don’t feel the financial pain……………until much later. Isn’t the same true for the high cost of health care?

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OUT OF THE LAW FIRM, INTO THE ADVISORY WORLD

May 14th, 2018

“I’d like to call the employee benefits “advisory” space another one of the most respectable professions in existence, but I can’t. Advisory is in quotes because that’s not really what it is. Many employee benefits consultants are brokers, a line of work that differs sharply from what it means to be a true advisor.”

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Providers Fight Back

May 13th, 2018
With the “death stars” of Amazon/Berkshire Hathaway/JP Morgan, CVS/Aetna and United/Optum moving quickly to disrupt the provider space, it is now more important than ever for providers to have effective tools to fight back………………………..

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Troubled School District Seeks Insurance Consultant………….Again

May 12th, 2018

The Donna Independent School District in deep South Texas has had plenty of bad press during the past several years – board members sent to prison, hiring of convicted felons, lawsuits and counter lawsuits, sanctions by the Texas Education Agency, and now TEA oversight (Texas Border School Scandal Highlights Culture of Corruption – Breitbart).

Now we learn the DISD is again seeking yet another insurance consultant. This will make the sixth “insurance consultant” / brokers utilized by the district in less than three years………………..

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Son’s Death Sparks Outrage

May 12th, 2018

He lasted 27 days without insurance…………………….

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Litigation Risks: The Dark Side of Reference-Based Pricing (RBP)

May 10th, 2018

RBP can save a self-funded plan a lot of money and create immense opportunity to permanently improve the benefits for employees in that plan; however, RBP can also create an environment for conflict, individual tragedy for plan members, and protracted litigation…………….

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Plan Sponsors Gamble Even Though Odds Are Against Them

May 7th, 2018

The 60 Minutes story (www.cbsnews.com/video/the-problem-with-prescription-drug-prices/) aired last night illustrates the continuing gamble most plans sponsors take in not addressing high cost specialty drugs. There is not a group in this country that offers ACA complaint health care benefits for their employees that is not at risk of bankruptcy, yet they continue to gamble they will beat the odds.

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Fake News Story Revised – The Power of The Press

May 7th, 2018

Last week a story ran in the Victoria Advocate (Victoria, Texas) that told the sad story of mean insurance companies bankrupting a new start up business whose goal was to service the dire health care needs of locals. See Mean Insurance Companies Bankrupt Free Standing ER.

Now the same newspaper, different reporter, spins the story in a different direction…………….

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Small-Business Health Plan Rule Under White House Review

May 5th, 2018

Bill would allow more small businesses, including self-employed individuals, to form health plans on the basis of industry or geography…………………

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POSCA℠

May 4th, 2018

POSCA℠  is a first in class method for processing health care claims…………………..

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Bill Ebaugh 1930 – 2018

May 3rd, 2018
William Lee "Bill" Ebaugh Obituary

William Lee “Bill” Ebaugh

I have met a lot of people in the insurance business over the years, but Bill Ebaugh stands out. His knowledge and connections within the insurance industry was amazing. He was a master salesman, story teller, and visionary. His life’s experiences were something out of a movie. He attracted the best in everyone he met.
One day he called me –  “Hey Bill, why don’t you do a write up on what your’e doing with political subdivisions. It needs to be published!” So with much prompting I did as he suggested.
A month later I received a call from Bill – “Bill (we are both named Bill), what are you doing on December 17th?”
“Why nothing Bill, whats up?” I replied.
“The State of Wyoming wants to see you on the 17th. You will be getting a call from the governor’s office setting up the trip at the state’s expense” he announced.
Yeah right I thought. “Bill I will wait for the call” I said and hung up the phone. I turned to my secretary and said “Bill is one hell of a joker!”
I was in Wyoming on December 17.
– Bill Rusteberg

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Mean Insurance Companies Bankrupt Free Standing ER

May 3rd, 2018

In today’s Victoria Advocate newspaper (Victoria, Texas) there appears an article about a free standing ER closing down because the have “been having problems with insurance companies.” Actually the problem is not with the insurance companies. Its with hospitals gaming the system. Consumers equate free standing ERs as urgent care centers paying for services with other peoples money. An “office visit” there can cost several thousands of dollars for something as simple as a cold, insect bite or sprained ankle. The cost is so high and the profits so great it takes only 6 or 7 customers a day to reap a profit.

Yet you read the story below and come away thinking the mean, uncaring insurance companies seeking to pay as little as possible are to blame. BTW – insurance policies under the ACA cover emergencies.

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The Elephant In The Room

May 2nd, 2018

Health care is the focus of a national debate that never seems to end. So called “experts” on health care delivery offer all kinds of suggestions and advice to solving the health care financing crisis in this country yet they won’t admit the journey towards solving the crisis will soon end.

In my circle, for example, the discussion centers around performance based medicine, reference based pricing strategies, point of service claim adjudication/payment, wellness programs, direct contracting, value based outcomes and more. But all secretly recognize there is an Elephant in The Room.

The Elephant in The Room is the inevitable coming of a single payer health care system to this country. It’s only a few elections away and we all know it. Americans are fed up with the high cost of health care. Many employers  are simply running out of money to pay for it. The American middle class who has been bearing the brunt of the cost is a vanishing, diminishing class. Hospitals and third party intermediaries continue to raise pricing, compounded year after year well beyond true inflationary pressures. Drug manufacturers are reaping record profits on drugs that sell as much as 80% – 90% less overseas.

The experts mentioned above have the answers to solving our health care crisis and the proof to go with it but few seem to be listening………….

– Bill Rusteberg

The following article is about that Elephant:

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Therapeutic Interchange

May 1st, 2018

The Academy of Managed Care Pharmacy (AMCP) supports the use of therapeutic interchange programs as a part of a comprehensive approach to quality, cost‐effective patient care. Therapeutic interchange is the practice of replacing, with the prescribing physician’s approval, a prescription medication originally prescribed for a patient with a chemically different medication. Medications used in therapeutic interchange programs are expected to produce similar levels of clinical effectiveness and sound medical outcomes, based on available scientific evidence.

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AVYM White Paper Spurs New Jersey Probe Into Health Insurance Contracts

May 1st, 2018

“Based on court cases (cited in the paper), it seems apparent TPAs can and do hide ‘undisclosed’ administrative compensation fees within medical claims payments. These undisclosed fees, which can account for 30 to 60 percent of a plan sponsor’s health claims expenditures, are usually siphoned into the TPA variance account through ‘retention reallocations’ and ‘cross plan overpayment’ offsets, among other techniques………………..

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