In 2019, C2CRx member companies spent 47% PMPM less than the Industry National Average; Since drugs represent 20 to 30% of a plans costs, this represents 10 to 12%
The evolution of specialty drug risk transfer gains speed as more employer sponsored health plans face crippling and unsustainable costs for drugs that shouldn’t cost that much………………and don’t in other countries.
Lt. Col. E. Rusteberg – West Point 1934 – Two Silver Stars, One Bronze Star, Presidential Unit Citation (Battle of Hatten), Purple Heart.
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.
“Median prescription drug manufacturer pre-rebate costs per covered life increased by 54.5% for individual plans, 24% for small group plans, and 7.6% for large group plans annually……”
Truth, fiction and word smithing intertwined requires expert unpacking for the benefit of clueless laypersons. With that in mind, the following applies.
Cost Containment Strategies Haven’t Changed In 18 Years
This 2004 report by the State of Texas outlines strategies employed towards controlling rising medical costs that haven’t changed since. The solution? Reduce benefits and cost shift to plan members.
Back in the day insurance companies required 75% participation of eligible employees to achieve an acceptable spread of risk. Now we see carriers requiring much lower participation requirements. What happened?
In reading today’s financial news I noticed an article about John Ruiz, a Cuban immigrant made good. He made his billions in the health care industry by recovering health claim dollars on a commission basis for his clients. (See article below)
This is an action for restraint of trade, unlawful monopolization, and unfair methods of competition seeking classwide damages and injunctive and equitable relief under the Sherman Act, 15 U.S.C. §§ 1 et seq., and Wisconsin’s antitrust laws, Wis. Stat. §§ 133.01 et seq
“In the first two months of 2022, the NSA prevented more than 2,000,000 potential surprise medical bills across all commercially insured patients………….”
A surprising number of new businesses were started during the pandemic, from online ventures to side-hustles-turned-full-time and more. These new businesses need liability insurance coverage, and Hiscox can provide it.
Imagine a group health plan option costing around $400 per month for single coverage and about $1,000 for full family coverage with no financial barriers to healthcare. No deductibles, no co-pays, no co-insurance and no balance billing.
HOSPITAL: Our chargemaster says you owe us $229,112.13!
PATIENT: But you told me I owed only $1,300! What’s a chargemaster?
HOSPITAL: We make up absurd pricing so we can “negotiate” discounts with insurance companies like Blue Cross, United and all the rest. You’re not an insurance company. Besides, what’s a few extra bucks! Pay up!
Under new government health care transparency rules health care consumers are now able to see prices before they buy instead of learning prices after they purchase services. What a novel idea!
How can consumers know for sure their claims are paid correctly? How can plan sponsors be sure too? How many take the time and effort necessary for proper plan oversight?
“Texas school districts can improve benefits and remove financial barriers to healthcare while reducing costs at the same time based on proven risk management strategies that have been successfully operating in school districts for years.” (more…)
Ms. French was sued by a hospital that had initially given her an estimate of $1,336.90 for a necessary back surgery only to later bill her $303,709.48, asserting that she had agreed to pay “all charges” billed by the hospital…………………..
Senate Bill 1444 allows TRS ActiveCare member school districts to exit the program for the first time in 20 years. This has unleashed a competitive market for Texas school districts with multiple vendors actively seeking district business.
The EPISD board of trustees received an update to their self-funded health plan on April 5, 2022. Projected cost to provide coverage averages $10,500 per year per employee participating in the program. There are about 6,000 employees on the health plan. 6,000 X $10,500 = $63,000,000
Most residents in South Texas qualify for free hospital care under Hospital Financial Assistance Programs (HFAP) promulgated under the Affordable Care Act.
A basic ACA compliant Minimum Essential Coverage (MEC) plan doesn’t do much for plan members. Rather, it is simply a strategy enabling employers to avoid certain punishing government mandates designed to force employers to the government’s will.
“What network do you belong to? asks the in-take clerk. “I’m on the Medicare network” replied the member. “That’s funny, there is no indication of that on your I.D. card” responds the now puzzled in-take clerk. “Well, our group plan is on the Medicare +20% network, it’s sometimes called a Reference Based Pricing plan. Since you take Medicare patients already, you’re really gonna like our plan!” says the member. “Cool” says the in-take clerk.
“When a business sends a bill, to you or to another business, you pretty much expect the bill to show the value of what they provided, and therefore what they expect to be paid. But an insurance company pays the hospital based on pre negotiated rates, no matter what the bill asks for……………”
Hospitals Look to Raise Treatment Costs as Nurses’ Salaries Increase – Health insurers and employers are pushing back against requests to increase hospital prices by as much as 15%….. (more…)
If open enrollment is held once a year to allow plan members to make changes, then in this case the cost for “enrollment services” is $72 per employee. An Open Enrollment period lasts 30 days so earning $300,000 in 30 days is $10,000 per day (with weekends off).
Amazing things happen when vendors compete for business. With the passage of SB1444 by the Texas legislature this past session, TRS ActiveCare member districts are allowed, for the first time in 20 years, to exit the program and seek competitive alternatives in the commercial market.
Borders are manmade lines. The Texas / Mexico border along the lower Rio Grande Valley segregates medical care givers into two different economic pods. Drug manufacturers serve both but with vastly different pricing models.
The future of health care reimbursement is cash paid at the point-of-service funded by employers insuring over 170,000,000 Americans through work-place employer sponsored health plans. Screw insurance companies and other blood sucking third party intermediaries. (more…)
Specialty carve-out programs (also known as alternative funding programs) exclude most or all specialty drugs from the plan’s formulary. A patient technically has no coverage for the specialty drug. A third-party carve-out vendor helps the patient apply for the patient assistance funds from the manufacturer’s charitable foundation.
For the first time in 20 years the TRS ActiveCare government health plan hasn’t raised rates or reduced benefits to plan members. The Texas legislature has dumped hundreds of millions in additional funding cloaked as “Covid Relief” to keep the program solvent………….This has little to do with regional rating or anything else about controlling health care costs, which it doesn’t. More money-out with more money-in simply means more money…………… not less.
Back in the day insurance companies required 75% participation of eligible employees to achieve an acceptable spread of risk. Now we see carriers requiring much lower participation requirements. What happened?
A surprising number of new businesses were started during the pandemic, from online ventures to side-hustles-turned-full-time and more. These new businesses need liability insurance coverage, and Hiscox can provide it.
The EPISD board of trustees received an update to their self-funded health plan on April 5, 2022. Projected cost to provide coverage averages $10,500 per year per employee participating in the program. There are about 6,000 employees on the health plan. 6,000 X $10,500 = $63,000,000
If open enrollment is held once a year to allow plan members to make changes, then in this case the cost for “enrollment services” is $72 per employee. An Open Enrollment period lasts 30 days so earning $300,000 in 30 days is $10,000 per day (with weekends off). 
Specialty carve-out programs (also known as alternative funding programs) exclude most or all specialty drugs from the plan’s formulary. A patient technically has no coverage for the specialty drug. A third-party carve-out vendor helps the patient apply for the patient assistance funds from the manufacturer’s charitable foundation.