“In response to the continued relentless rise in health care costs, Insurers are taking a long, hard look at the value PPOs deliver versus their ability to contain medical costs.“

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

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By Bill Rusteberg

A random sampling of hospital / facility claims incurred in the Lower Rio Grande Valley, Texas (The Valley) illustrates the crazy world of health care pricing strategies.

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“The penalties for this type of fraud should be severe. All benefits leaders and their consultants should be overhauling how they manage care and cost, or risk the consequences. It’s particularly notable that the Department of Labor is now arguing that fiduciary dereliction in health benefits is rampant.” – Brian Klepper

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As health care costs escalate, Cost Plus / Reference Based Pricing plans gain traction within the employer community…………….

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Hospital systems are beginning to screen patients in high-deductible plans for their propensity to pay. And for those who can, they are developing systems to collect in advance of care.

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More and more employers are eliminating specialty drug coverage entirely. They really have no choice.

Imagine a small employer group of 250 employees assuming outright the risk of $1 million for Smoker Smith who now has lung cancer and is taking one of the new specialty drugs costing $85,000 per month. There is no way for the employer to continue his group medical plan. 

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Mike Dendy, MBA, MHA

“OPEC laughed at the US and the rest of the world when we complained that $120 per barrel oil was choking the life out of business and the public in general around the world.  Rather, they built ski mountains in their deserts out of the rest of the world’s money and threatened to drive oil prices even higher. ”  

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(May 17, 2016)—HealthSmart announced today that Mark Stadler has been named CEO of BridgeHealth, effective June 1, 2016. Mark joined HealthSmart in September 2011 and has been the leader in our commitment to price transparency and empowering our members to become savvy healthcare shoppers.

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 David Belk, M.D.

Hello. It’s time for another chapter on the many ways in which our health care system is a total mess.

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In an Oct. 5 report, The Wall Street Journal noted that prices for the 30 best-selling drugs last year had gone up an average of 76 percent since 2010 – eight times faster than general inflation.

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Some plan sponsors hire a third party administrator to manage costs. Others hire third party administrators to process claims.

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“All we’re asking is for the federal government to do what they promised” – David Holmberg.

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Need a low cost Windows solution for creating and managing Medicare and other RBRVS based fee schedules?  Try RBRVS EZ-Fees…….

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Blue Cross mobile enrollment office – when gas was 17 cents, and health insurance was affordable

In a deep dark recess of today’s Federal Register, large corporations just quietly received permission to “play doctor” with their employees.

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“Those who say Cash Pay Plans are pie-in-the-sky dreams are mistaken. If man can fly then so can Cash Pay Plans.”

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“In the world of group health insurance, in order to reach the best financial outcome, you often have to depart from the realm of logic, reason and actuarial principles.”

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Will Religious Institutions Be Required To Fund Against Their Will?

By Jeff Overley

Law360, New York (May 16, 2016, 10:35 AM ET) — The U.S. Supreme Court on Monday sent a long-running battle over the Affordable Care Act’s contraception mandate back to lower courts, directing the Obama administration and religious nonprofits to work out a compromise.

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Is HealthSmart TPA for sale? Word on the street says it is so.

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Hidalgo County health officials breathed a sigh of relief after the federal government last week extended the state’s 1115 Waiver program that provides hundreds of millions of dollars for health care services throughout the county.

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“Multi-Tiered provider networks will work best if an employer creates their own proprietary network on a direct basis rather than rely on third party intermediaries. Here is how it would work: Area providers are invited to enter into direct agreements with ABC Fence Company. They are given three choices: Tier 1 – 100% of Medicare, Tier 2. 125& of Medicare and Tier 3. 150% of Medicare. Plan participants who use Tier 1 providers pay less out-of-pocket than if they had used Tier 2 providers. Using Tier 3 providers would take economic courage.”  – Homer G. Farnsworth, M.D.

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Companies are charging copays that exceed the customers’ costs for their drug. Pharmacists call it a clawback – the company is essentially clawing back money from you and, our source tells us, you probably don’t even realize it’s happening. “They have no idea,” the pharmacist says.

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Medsavers Pharmacy is a family owned and operated pharmacy in Austin, Texas founded in 2005 on the principle: “we don’t deal with insurance companies.”

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Quality improvement, revenue growth, and business transformation for providers, health systems, employers, and payers transitioning to value-based care.

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As Medicare and private insurers continue to struggle with implementing accountable care organization- and population-linked payments, an increasing amount of attention is being paid to a less expansive but almost as complex method of shifting risk to hospitals and physicians: paying a fixed price for an episode of care, or bundling.

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Continental Benefits is one of the fastest growing TPA’s in the United States. Founded in 2013 this national TPA is committed to reducing health care costs 25% and more. And they are doing just that.

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New CEO takes charge………….Maxor to exit correctional pharmacy services?

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“The timing of DeVeydt’s resignation may “generate uncertainty among investors until fully understood”

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Why should you pay more to go to The Valley than the knuckle head sitting next to you?

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“Spurred by competitive demands for more agile organizations, the world of work is pivoting to a blended workforce………..nearly 40 percent of top performing firms already have more than 30 percent of their labor force composed of contract/freelance workers.”

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“The leadership of Botetourt County has, like many municipalities, been searching for innovative ways to reduce their health costs without increasing deductibles and co-pays to the members….”

Botetourt County, Virginia and San Patricio County, Texas have something in common – the political will to seek innovative strategies to rein in ever increasing, tax payer supported, health care costs for their employees. Challenging the status quo within their respective local health care community takes a rare political courage to prevail – Bill Rusteberg

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