Archive for September, 2013

Is Your Service Provider Consistent?

Sunday, September 29th, 2013

goofyBy William Rusteberg

Do you remember that kid  Dennis in sixth grade who nobody believed? “Hey guys, my parents took me to Disney World over the weekend! See my new lunch pail…….it’s got Mickey Mouse and Donald Duck on the front and Goofy on the back!”

Mixing truth (the lunch pail was real) with variance of the truth (lying) is an effective way to sway, impress, convince, mollify, and control those who one intends to “take to the cleaners.” At least that may be true in the short term when sales are made and consequences are of little concern.

How many of you have run into Dennis in the business world? Ok, that’s what I thought. Yes, it appears that Dennis survived elementary school, even progressing through high school and, believe it or not, college.

He is now your service provider and you like his stories, all of them. You like them so much you have built up an unusually  high level of trust. You rely on his expertise to guide you in business decisions. After all, you know how to run your business, you are an expert at manufacturing widgets. But, for example,  you don’t know much about insurance. Dennis seems to know his stuff. He is the expert! He has become an invaluable resource for you.

Thus, Dennis has achieved his goal of control through skills honed in elementary school.

Over time you notice subtle nuances in things Dennis is telling you. “My company must charge you in this manner because if we both are sued by XYZ Company  we have to demonstrate there is no conflict of interest. We can’t charge you any other way as it would put you and I at risk.”

A year later, upon renewal of Dennis’s contract, he says “We are changing the contract and will be charging you on a new basis (the lunch pail is real) …… here is the contract to be signed (the lie).

How does one defend against the Dennis’s of the world? Hiring a class of sixth graders to ferret out the truth could work………………….



Hope & Change…………….Or Is It Change & Hope?

Friday, September 27th, 2013


By William Rusteberg

Have you ever wondered what is in the contract you signed during that moment of insanity when, flush with subjective buying emotions fueled by looming deadlines and a multitude of vendors painting pictures on demand, you penned your legal rights or lack thereof to the last page without reading the preceding pages and the addendums you initialed?

Most don’t read their contracts until there is a dispute, such as when you are notified that the other party is going to charge you for something you don’t remember agreeing to pay.  “Look at your contract, it’s all in there!” replies Dynamic Bob, your account representative who answers your email, “Page 22, paragraph 4, Section A-5 reads “Not withstanding your understanding, you agree to pay and to be bound to additional charges as we may deem necessary in rendering certain unspecified, and heretofore uncontemplated services and/or products designed to enhance the value and long term effects of this mutually agreed and binding contract, not withstanding any attempts to bypass this agreement by pleading ignorance or lack of mental capacity.”

Of course, this is far fetched. Or is it?

What could be worse than this Alice In Wonderland Tale would be a unilateral decision upon the part of the vendor to charge their client a fee or a cost to do or deliver something of value that is not stipulated at all within the contract between to the two parties. Without asking their client’s approval or even presenting an amendment to the original contract for consideration  of the party to be charged compounds the hustle. At least that would be a plausible observation one would think.

How does one “sell” fees or costs to be charged that are not contractually agreed to between the two parties, without mutual agreement?

Hope and change  on the part of the messenger come to mind. Or should it be “Change and Hope.”







Health Care Costs Are A Direct Function Of What We Agree To Pay…………….

Thursday, September 26th, 2013


“…. it’s actually a good thing that insurers are forcing hospitals and doctors to compete on price. Indeed, these “narrow networks” may be one of Obamacare’s best features.”


Another Hidden Gem In ObamaCare Discovered – Section 1331 Plans

Tuesday, September 24th, 2013


The Centers for Medicare & Medicaid Services (CMS) has drafted regulations for a program that could help some states crowd commercial insurers out of directly serving the health coverage market for the working poor. CMS is getting ready to publish the “Basic Health Program” (BHP) draft regulations Wednesday in the Federal Register.


OBA – VPA – EBC Annoucement to Brokers

Tuesday, September 24th, 2013


Ogden Benefits Administration (OBA), Employee Benefit Concepts (EBC), and Variable Protection Administrators (VPA) have strived to always provide our brokers cutting edge ideas and services. To mitigate the rapid increase in health insurance premiums,  we have had to be creative in order to stay ahead of the hospitals, pharmaceutical companies, and other providers. With the passage of the Affordable Care Act (ACA),  all aspects of health insurance and the deliverance of benefits have changed.


Benefit Consulting Firms To Trump Carriers? What A Phenomenal Change!

Monday, September 23rd, 2013


“American companies are sending shockwaves through the healthcare industry by moving a rapidly growing number of employees onto privately run online exchanges for their medical coverage…..In a business already bracing for major change because of President Barack Obama’s healthcare reforms, the decisions are threatening to shift more power in the market to the benefit consulting firms opening many of the exchanges…….Health insurance companies and pharmacy benefit managers who have traditionally had a more direct relationship with the employers could lose out to the nascent marketplaces.”


Employer Sponsored Health Clinic? Why Not? You Are Paying For It Anyway

Saturday, September 21st, 2013


Many large self funded employers have, in the past,  considered establishing their own Employer Sponsored Health Clinic (ESHC) but have determined it did not fit their business model for a number of reasons.  However, with the advent of Obamacare and the pressures being applied to the health care delivery system, it might be time to revisit and reconsider.


Guess Who’s Coming For Dinner?

Saturday, September 21st, 2013

dinnerBy William Rusteberg

Today we find ourselves in a dynamic and somewhat unpredictable market, particularly the political dimensions as government interference in health care continues to evolve. However, we do know, to a large degree, how we will be affected and what we must do to survive in each of our individual and unique places in health care.

(more…) Participates In Health Care Symposium At Physician Hospital Association Meeting In New Orleans

Saturday, September 21st, 2013

pha was a co-guest speaker  and panelist at the Physician Hospital Association meeting in New Orleans on September 19. The topic of the discussion was “How to Contract Directly With The Self-Funded Community and Win Every Time.” William Rusteberg and Harvey Billig, M.D., conducted the session which included a brief 20 minute overview followed by a question and answer session with the attendees.


Mapping Local Health Care Prices – A Crowdsourcing Consortium

Saturday, September 21st, 2013


We are a group of public radio stations, collaborative news ventures and nonprofits partnering with each other and with our communities to create reported and crowdsourced regional databases of health-care prices.

The project will not only generate unprecedented transparency to help health-care consumers make smart decisions and journalists do brilliant stories, it will also create novel digital pathways so consumers can contribute their knowledge and experiences. Further, the regional databases have value on a national scale for comparison and in-depth analysis.

“Obamacare has taken the moral imperative away for employers to continue offering coverage……..”

Saturday, September 21st, 2013


“What the ACA has done is put all 300 million-plus Americans in the mode of thinking about health care,” said Jim Winkler, a chief innovation officer at Aon Plc. (AON) The London-based company runs the private exchange that will serve Walgreen’s employees……You’ve got CEOs reading articles and going to conferences, and that leads to a lot of discussions with Finance and HR about, ‘What are you going to do to solve our health-care cost problem?’”

“The companies realized they cannot continue to be a social insurance system for the American people,” he said by e-mail. Businesses, he said, have been “woken up by the ACA.”


Patient Care To The Rescue!

Tuesday, September 17th, 2013

Your clients need Patient Care in place for Open Enrollment!   Reduce frustration…….Reduce confusion…Increase engagement…Increase satisfaction…

 Our Advocates will:        Answer open enrollment questions…………….Help members compare plans………..Clarify questions about exchanges………..Review how to allocate FSA/HSA/HRA dollars

 Call Patient Care today.    Kati Adam…………………            414-274-3492


ObamaCare Will Question Your Sex Life – Will Wikileaks Get Your Records?

Monday, September 16th, 2013


‘Are you sexually active? If so, with one partner, multiple partners or same-sex partners?”

Be ready to answer those questions and more the next time you go to the doctor, whether it’s the dermatologist or the cardiologist and no matter if the questions are unrelated to why you’re seeking medical help. And you can thank the Obama health law.

(more…) Issues Business Statement

Saturday, September 14th, 2013 is a specialty company in the benefits market that, while not an insurance company, works directly with health entities, medical providers, and businesses to identify and develop cost effective benefit packages, emphasizing transparency and fairness in direct reimbursement compensation methods. Business Statement

The Government Attack On 64% Of Insured Americans – Will Self-Funding Survive?

Friday, September 13th, 2013


The Affordable Care Act is supposed to be a paradise for the middle class, but now that Americans are starting to eat from the tree of knowledge, the liberal deities are trying to force them to stay inside the garden. Witness their crackdown on the booming ObamaCare alternative known as self-insurance.

No Employer Punishment Says Big Government Bosses – See, We Really Are Nice To Work With!

Friday, September 13th, 2013


Employers will not be fined by federal regulators if they fail to distribute to employees health care reform law model notices about the availability of public health insurance exchanges.

Using a question-and-answer format, the U.S. Department of Labor said Wednesday that while employers should provide such notices to employees by Oct. 1, “there is no fine or penalty under the law for failing to provide the notice.”

While the Patient Protection and Affordable Care Act is clear that penalties cannot be imposed, “Internet-based rumors have circulated recently that employers could face penalties of up to $100 per day for failing to distribute the notice,” Lockton Cos. L.L.C.’s health reform advisory practice said in a bulletin.

In May, federal regulators released model notices that employers can provide to employees to satisfy the exchange notification requirement.

TelaDoc Acquires Consult A Doctor

Thursday, September 12th, 2013


8 days ago – Venture-backed telehealth provider Teladoc Inc. has acquired Consult A Doctor, a Miami telehealth company which also is backed by venture investors.     Terms of the acquisition weren’t disclosed in a news release….

Teladoc Investors:

American Indians & Alaska Natives Pay Medicare Like Rates For Health Care

Sunday, September 8th, 2013


“……….The Medicare-like payment rate will constitute payment in full to Medicare-participating hospitals that deliver services to American Indians and Alaska Natives referred through IHS-funded programs……………”

Minimum Essential Coverage Plans (Skinny Plans) Mean Big Bucks To TPA’s

Saturday, September 7th, 2013


By William Rusteberg

Minimum Essential Coverage plans (MEC) have spawned due to a loop hole in PPACA that allows self-funded plans to offer preventive care benefits as the sole minimal essential coverage, thus avoiding a $2,000 punishment tax on each full time employee (minus the first 30).  This tax dodge provides welcomed relief to some employers, especially those whose workforce are in such industries as construction, fast food, and hospitality services.

TPA’s and a few carriers were quick to seize this new marketing opportunity. One carrier is selling a self-funded MEC plan with a fully-insured attachment with a monthly cost of $100 per insured. The MEC provides preventive care only, and is insured through an aggregate stop loss policy. No commissions are paid on the MEC but are paid on the fully-insured component attached to the plan. Commissions are 30%, which equates, on average, to approximately $20 pepm. That is a very attractive commission to the selling agent.

TPA’s are loading up on fees to be charged through MEC’s too. We looked at one recently, and were amazed that anyone would buy it. The TPA administration fee to process preventive care claims  is $25 pepm. Added to that were additional fees, such as $5.60 for a limited Rx benefit plus an additional $2.35 per prescription administration fee, $2.34 for telephonic access to a doctor, COBRA and HIPPA fee of $2.20 and, best of all, a $12.00 ACA Compliance Fee. All fees total more than $46.00 pepm. That’s higher than administering a full blown traditional health plan!

A plan sponsor willing to pay these exorbitant fees must be focusing on the tax savings as justification, while overlooking their fiduciary duties.


Brownsville Independent School District Sues HealthSmart…………….Again

Friday, September 6th, 2013

appleBrownsville Independent School District in deep South Texas has decided to reinstitute their lawsuit against HealthSmart. The district sued HealthSmart in 2010 ( ) but later dropped it after the election of a new majority on the school board. Now, with another subsequent school board election, with yet again another new board majority, the current Board of Trustees has decided to sue……………..again.

Second bite of the apple?

Editor’s Note: Elections have consequences.

New Models Of Payment: Cutting Out The Insurer, Or Can I Have A Lower Price For That?

Thursday, September 5th, 2013


This is the third part in our series of new models of payment in the health-care marketplace, touching employers and individuals. The first part is here, and the second part is here.

* * * * *

By Jeanne Pinder

We’ve been writing about new models of payment for health care by employers. So individuals might ask: How does this affect me?

As employers are starting to turn away from insurance companies and contract directly with providers, individuals are, too.


MediSave Accounts In Singapore

Thursday, September 5th, 2013


“Singapore does not have a free market for health care. What it does have is an alternative to the European/American welfare state, in which private saving and private insurance do what employers and governments do in other countries.”


Wide Price Variations Underscores Hospital Market

Thursday, September 5th, 2013

hosoitalbillWithin individual communities, prices vary widely, even after accounting for differences in the complexity of services provided. The highest-priced hospital typically is paid 60 percent more for the same inpatient services than the lowest-priced hospital. The price gap within markets is even greater for hospital outpatient services, with the highest-priced hospital typically paid nearly double the lowest-priced hospital, according to the study.”


Value Based Insurance

Thursday, September 5th, 2013

walmart“These large firms have shopped around and compared the value of all national medical centers, choosing to send their employees to those able to provide the best care at the lowest cost and setting an example for other self-insured companies to follow in their footsteps……………..Bundled payment systems facilitate transparent and simplified reimbursement structures, eliminating the risk inherent to procedures with high cost variability and reducing administrative costs………”


The Truth About Medicare Supplemental Insurance

Thursday, September 5th, 2013


The Creative Destruction Of Medicine

Thursday, September 5th, 2013


This is an amazing 8 minute video of a monumental change in our health care delivery system –

Leadership Forum Featuring Steven Brill

Wednesday, September 4th, 2013


The IMA Foundation, in partnership with The Colorado Health Foundation, sponsored a Leadership Forum in Denver, Colorado this morning. Featured guest speaker was Steven Brill, author of Time magazine’s special edition “Bitter Pill: Why Medical Bills Are Killing Us.”

Mr. Brill spoke for about 45 minutes describing his determined mission to “follow the money” in our health care delivery system. He opined that the current national debate on health care is about WHO SHOULD PAY, not WHY WE PAY SO MUCH.  He said that the market movement towards transparency is a good thing, but not enough. He advised the audience that the great American experiment in free market health care has failed, and a new approach has to be taken – Price Controls and perhaps the expansion of Medicare, which he said, is more efficient that the private payer system.

The IMA Financial Group specializes in risk management, insurance and employee benefits with nearly 500 employees in seven markets across the nation. Website:

It’s Called Capitalism: Doctor Owned Hospitals Thrive In Texas Despite Government Ban

Sunday, September 1st, 2013


Physician-owned hospitals in North Texas are finding ways to expand despite being banned from accepting Medicare and Medicaid patients. They are catering to and cashing in on a narrow patient market.


You Can’t Fix What You Don’t See

Sunday, September 1st, 2013


By William Rusteberg

Has your company tried, over and over again, to solve ever increasing health care costs?  “Yes, of course we have, but nothing seems to work!” is a common answer. “We bid out our employee health insurance every year through multiple brokers, we reduce benefits to offset rate increases, and we even light a candle 24 hours before year-end renewal!”

Unfortunately we are all in the same boat. We are told that ever increasing health care costs are driven by a multitude of things such as advanced technology, aging population, cost shifting from government payers, etc. All true, but deceptive.

The truth seems elusive at times. Yet the dominant underlying factor for ever increasing health care costs is rooted in partnerships formed between providers and third party intermediaries designed to maximize revenue streams through secretive contracts, and side agreements that you never see.  Costs are a function of what you agree to pay. Unfortunately most plan sponsors have no idea what rates have been negotiated for them through managed care contracts, yet they blindly pay anyway and wonder why their costs go up double digits every year.

The problem is apparent: You can’t fix what you don’t see…………..

Usually, when told you can’t see a contract you are probably paying more than you should. The first step a plan sponsor should take is to find out what terms and conditions are common to most managed care contracts. Now better informed, they will begin to understand one of the primary factors driving health care costs and will be in a position to take corrective action. They will have become empowered with knowledge the health care industry doesn’t want them to know and for the first time, will be in a position of strength in dealing with their broker, TPA, insurance company and the provider community. Thus, the greatest fear of those who now  control health care costs will have been realized.

Once a plan sponsor better understands how health care financing is structured in this country they  will be in a position to fix what they see.   The results may be dramatic.  Lighting candles could well become a fading memory.