While chasing a squirrel in the woods, beloved pet dog tore the anterior cruciate ligament in her left knee. Turns out she had better insurance than her master………………………………

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       Dale Folwell

“For years, the plan has paid medical claims after the fact without knowing the contracted fee. It is unacceptable, unsustainable and indefensible. We aim to change that.”

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Now we know where Texas lost it’s cojones (Has Texas Lost It’s Cajones?)………..in North Carolina. Mr. Folwell, please bring them back! The upcoming Texas  biennial session needs them…..

“I’m calling for the United States Department of Justice and the North Carolina Department of Justice, on behalf of the State Health Plan, to recover the potentially hundreds of millions overcharged to consumers by hospital management from this illegal activity.” – Dale Folwell

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This excellent White Paper examines some of the implications for health care financing and delivery were the U.S. government to supplant employers as the financer of medical care for most workers and their families…………………….

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Dave Chase

When patients choose a hospital or other provider, they don’t really know what they’re getting………..The reality is that status quo health benefits are a horrible value proposition for employers and individuals……………

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Call it a warning shot: last week an Indian patent court shocked the $600 billion global pharmaceutical business by ordering Bayer, the German health care giant, to allow a tiny Indian generic drug company to sell cheap copies of the blockbuster cancer drug Nexavar – even though everyone agrees that the drug is protected by a patent…………………..

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David Belk, M.D.

The question I’m addressing today is: How much help can you expect to get from your Part D plan when you use it to buy prescription drugs?

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t’s history repeating itself.  Been there done that…………………..

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Milliman White Paper Shows How Self-funding Gives Employers More Control Over Medical Insurance Programs

MyHealthGuide Source: Jennifer Janvrin, CEBS, 11/2018, Milliman White Paper (full text)

Editor’s Note (Ernie Clevenger): This excellent White Paper by Milliman provides key values of self-funded and statistical tables to illustrate risk and risk management.

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Healthcare is Cuba’s most lucrative export. The “More Doctors” aid programme operates in 67 countries, and makes the island $11bn a year…………………..

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You won’t see recognizable logos or insurance company names on their health insurance I.D. cards. You may wonder “what kind of insurance is this?”

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The three priorities in order of importance in practicing medicine: (1) Don’t get sued, (2) Make Money and (3) Take Care of Patients…………………………..

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Judiciary says it’s unconstitutional, so legislators  have developed a cure of their own………….

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“To gain control over the ever-increasing cost of employee health insurance, more and more employers are discontinuing their fully insured coverage and switching to self-funded models.”

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In the five decades after the passage of America’s two largest health care entitlements, that sector has become a maw, eating everything in its path. Health spending has reshaped the nation’s job market, its household finances, and its public budgeting…………………..

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“The greed of the prescription drug industry is literally killing Americans and it has got to stop…..”

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Once enrolled on the TRS ActiveCare health plan, school districts are forever prohibited from leaving. There are no exceptions permitted. Or are there?

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Michael Meloch, President of TPAC Underwriters, comes up with a new term for Reference Based Pricing in a Phia Group podcast…………………………..

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Blue Cross Blue Shield plans have collected billions of dollars in profit in the first six months of this year………………………….Premiums have vastly outpaced the claims that the health insurers had to pay out to hospitals and doctors……………..

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   “Drug Costs Are Too Damn High”

As long as consumers purchase drugs with other people’s money big pharma knows consumer (market) blow back from pricing increases will be minimal……..

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Allied National’s Funding Advantage contract returns unused claim fund dollars to employers who have favorable claims experience!

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Making $2 million on an 8,000 life Texas school district is really easy. I know because it’s been done, even as we speak…………………..

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INSIDE AWP: THE ARBITRARY PRICING BENCHMARK USED TO PAY FOR PRESCRIPTION DRUGS

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What’s ironic about this story, is this is exactly how we’d do it if our dog needed knee surgery…….

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“The only party not taken into consideration is the employer who is on the hook for the vast majority of the cost of drugs that will be sold through this channel……………….”

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“It doesn’t matter who the governor is, or who controls the legislature. It’s not political. It’s mathematical.”

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“Aetna pays its ‘medical directors’ bonuses for increasing the company’s profits by denying claims…….”

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Government continues to interfere in citizen’s sex lives……………………..

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Firestone deference – Many ERISA plans use plan document language stipulating the plan administrator has the authority to interpret plan terms and resolve any ambiguities. The United States Supreme Court has held that when a plan contains this language, courts must show deference to the administrators and review their decisions under an arbitrary and capricious standard…………….

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………………and clients aren’t doing anything about it

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Business strategy is to focus on four pillars of growth: the Canadian home insurance and wealth market, US group benefits, global asset management, and distribution excellence in higher growth markets in Asia…………………………

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Drugs excluded includes brand-name drugs for which less expensive brand or generic alternatives are available in the market…………………………………..

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Grand Rounds is focused on reducing high cost claimants and improving patient outcomes and we have tangible evidence to prove it……………………

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He’ll give you time if you’re big or small
All in line for this court is neat
Peace brother, here comes the Judge 
Here comes the Judge…………………………………….

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With a Democratic House, a Republican Senate, and President Trump in the White House, get ready for two years of maneuvering but little progress on health care…………..

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The savings are anywhere between 38% to 75% well may save the state millions each year……..

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Proposed changes would have increased CPT 99213 by 30%……………..Primary Care Physicians lose out on pay raise. 

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How do you know if your surgeon is the best of the best or the worst of the worst? Unfortunately most patients play Russian Roulette when it comes to picking one………………….the results can be hazardous  to your health…………..

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More doctors in Texas plan to make the switch to primary care out of frustration with the current healthcare system…………………………….

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“Employers are cutting out insurers completely and contracting directly with providers and/or creating near-site or on-site health clinics for primary care……………….More traditional cost management techniques are simply running out of gas. Employees, who have borne half of recent-year cost increases, simply can’t afford anymore,”

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San Patricio County is seeking competitive specific stop loss proposals for a January 1, 2019 effective date. This 400 life case has been on Reference Based Pricing for the past ten years and does not access any managed care networks.

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