Trump threatened to “deploy every tool in our arsenal to protect American families from continued abusive drug pricing practices” if companies refuse to comply.

“This case underscores the limited role of the courts in overseeing the IDR process. In addition to declining to micromanage the implementation of the NSA, other courts have held that providers have no private right of action to enforce IDR awards.”

“The problem is the TPAs, claims data, and intermediaries gumming up the reimbursement to extract their bounty. It’s such a waste of money.”

By Steve Ditto

Everyone’s a “Transparent PBM” Until It’s Audit Time. Marketing says “transparent.” Reality says… prove it.

“Something has to be done here to take out these people that are just trying to make money,” Schinecker said, in reference to pharmacy benefit managers (PBMs). “It can’t be that 50% of profits go then to intermediaries that take zero risk.”

What If Your Miracle Drug Came with a Payroll Stub?

By Craig Gottwals

I’ve recently waded deeper into the GLP-1 weight loss craze; not because I’m prepping for beach season, but because two things crossed my desk that pleaded to be connected.

By Michael S. Tesoriero

The average stop-loss coverage premium increase is 9.7 percent for the 221 health plans in Segal’s 2025 national medical stop-loss dataset.

By: Madeline Ashley

The Justice Department has launched a civil antitrust investigation into New York City-based NewYork-Presbyterian regarding concerns over health insurer contracts that could have raised healthcare costs and lessened competition, The New York Times reported July 28.

We’re excited to introduce a new option in Curative’s plan lineup: the EPO Value Plan — designed for cost-conscious groups looking to offer a lower monthly premium while still giving members access to $0 care.

ICHRA Salesman Reacts…...”ICHRA is only as strong as the ACA market beneath it.”

SOURCE: Venteur – July 27, 2025

A few weeks ago, a report sent shockwaves through the individual health insurance market: the Wakely National Risk Adjustment Reporting (WNRAR) study. Since its release, Centene has withdrawn its earnings guidance and watched its stock fall nearly 40 percent. Oscar, Molina, and Elevance have all posted concerning Q2 earnings. Bloomberg has described the situation as a possible health insurer meltdown.

By Kimerly Carleson on Linkedin

The Medicaid-insurer money machine is breaking down fast. In just one year look at these numbers:
Centene- -57%
UnitedHealth- -56%
Molina- -48%
Humana- crashing toward $300/share

Dear George, I have a meeting with my CFO this morning. He expects an update on our September 2025 renewal in preparation for next week’s meeting with our BUCA Broker representing __________________ (Pick One: Marsh, Willis, Gallagher, Higgenbotham, other)

Gill and his colleague Rohan Ingrole did what no sane person had ever tried before: they flossed a mouse.

In 2 years, you could be working for AI Or, an AI could be working for you. Here’s how you can future-proof your career and stay ahead of the curve:

The best leaders are those nobody wants to promote.

He failed West Point. Twice. He was nearly court-martialed… twice. But when World War II ignited, America needed a fighter—not a bureaucrat.

By Russel Pekala

It’s hard to find a good explanation of ICHRAs that is neither sales slop nor regulatory jargon. I aim to change that, and hopefully in doing so explain why ICHRAs do not really solve any of the issues with your health plan or our societal failure to make health insurance work.

Mexican dogs can teach Trump a thing or two about the “Art of the Deal.

What’s all this nonsense about saving plan sponsors a whole lot of money by solving health care?

By Shrey Ansh on Linkedin

HOLY SH*T… These AI Sales Agents does everything 🤯 These are the exact systems agencies charge $12K for each build.

How will AI transform healthcare?

“Google receives approximately 1 billion health-related searches daily, with about 1% of all searches being symptom-related, equating to roughly 10 million searches per day specifically about personal medical conditions.”- Adam B. on Linkedin

“Why should health insurance companies negotiate lower prices with hospitals when, thanks to the federal government mandate known as the Minimum Loss Ratio, both get paid more through higher prices? There must be another reason”– Bill Rusteberg

“Now, we have a 4th-party payment system. Insurers and hospitals fix prices at about three to five times actual costs, and then the oligopoly (four national carriers) shadow price each other to feed these perverted prices to employers.”

MyHealthGuide Source: Scripta Insights, 7/15/2025

Scripta’s Rx Navigator, a price transparency tool, provides visibility into drug costs, enabling employers to lower costs, reduce legal exposure and enhance fiduciary oversight.

By Alden Bianchi

Yesterday, I claimed that “voluntary benefits have gone mainstream [ ] despite that some folks are not happy about it.

By Chris Deacon

It’s official: “The Great American Healthcare Heist” is available for pre-order, including bulk pre-orders for teams, clients, or events.

This book pulls no punches. It’s part confidential dossier, part public reckoning—the kind of inside account that is meant to rewire how you see the entire system. After this, those pharma ads, multi-million dollar sports sponsorships by non-profit healthcare systems, and billion-dollar care campuses will hit differently.

“It is now overwhelmingly apparent that PBMs are operating the biggest shell game in modern history, and we are all paying for it.” – Antonio Ciaccia, 3Axis Advisors

Jul 22, 2025

Arthur J. Gallagher & Co. confirmed on Tuesday that Shannon Gunderman will succeed Dorothy Gjerdrum as head of its public sector and K-12 education practice, effective January 1.

Ms. Gjerdrum will retire at the end of the year after 26 years with Gallagher. She was one of the 2014 Business Insurance Women to Watch.

Mr. Gunderman, based in Bellingham, Washington, will be managing director of the U.S. public sector and K-12 education practice.

Mr. Gunderman is currently executive director of the public sector and K-12 education practice. He joined Gallagher in 2021 and before that was administrative services director for Yuma County, Arizona, where he managed the county’s property, liability, unemployment and workers compensation programs.

SOURCE: Business Insurance

By Julie Wasserman

Spinal Fusion anyone? If you’re in Texas you’re in for a wild ride trying to figure out what the cost is going to be. While you’re checking out the chart below, I DO have some thoughts…SHOCKING!

By Steve Ditto on Linkedin

What the heck is going on in Iowa? They finally pass a PBM reform bill—and a business group is suing to stop it? Someone’s been drinking the ethanol again.

By Steve Ditto on Linkedin

You didn’t pay for them—but you might still be liable for them.

“The best work comes out of great relationships. Honesty, respect and gratitude are the keys to a great relationship and therefore we have an interest in treating each other with these values at all times.”

We’re proud to announce that Kirk Cole, a highly respected leader in Texas public health policy, has joined GovExperts. With decades of service at the Texas Department of State Health Services (DSHS)—including as Chief Deputy Commissioner — Kirk brings unparalleled insight into the public health landscape across the state.

Someone has to talk about it………..

Posted by Greg Gottwal on Linkedin

At their July 8, 2025 board meeting DART awarded two insurance contracts totaling $14,389,242 for retiree health insurance and group term life insurance.

Ukrainian doctor drives a child’s heart through Russian attack to perform a life-saving transplant

By Lisa Collins

The Only Reason Employers Offer Health Insurance Is to Attract and Retain Employees

HUGE NEWS!  The Patients Patient’s Deserve Price Tags Act just dropped — and it’s the most aggressive, pro-transparency healthcare legislation we’ve seen in years.

Here’s what’s inside:

“The market is rapidly changing with new players coming in led by young techy types starting TPA operations incorporating the latest AI based technology. How are you keeping up with this? I asked

By Justin Leader

With the enhanced ACA subsidies set to expire and insurers filing for 15–20%+ premium increases in 2026, many are bracing for what could be a massive affordability shock for middle-class families, especially those who have relied on expanded subsidies since 2021.

“Cost of Obamacare is expected to soar” headlines the reporter. Not true. Other than the usual annual rate increases we’ve experienced every year for the past 40, the cost hasn’t increased at all. In fact the opposite is true…………for the first time in living memory the cost has decreased.

“Monte’s Ancestor? The ability to predict future trends before others do is a common trait of futurists. Monte Jennings insists the future is now and he’s here to lead it” – Molly Mulebriar

We are beginning to see pharmaceutical manufacturers breaking away from supply chain middlemen (PBMs) saving consumers imbedded commissions (rebates) for savings of 40% and more. For example Novo Nordisk Direct and Lilly Direct offer certain GLP-1 drugs for $500 or less, a more than 50% price drop.

New data from the Oregon Health Authority shows that commercial health insurance payments to hospitals have continued to climb, while prices for similar procedures varied widely across hospitals.AP file photo

Oregon Health Authority committee floats cap on commercial health insurance payments to hospitals

A cash-based health plan with a RBP wrap does not require a traditional TPA nor does the plan require stop loss insurance. In lieu of stop loss insurance a risk transfer mechanism is triggered when the plan aggregate limit is breached.

Will George Replace Insurance Brokers & Consultants Too?

Connect with colleagues from across the state and gain insights from industry experts! at South Padre Island Convention Center.

“Before we go further Mr. Prospect, let’s determine if you are a half pregnant flower lover with a passion for tulips or a cliff diver looking for adventure.”

The next time you hand over your Rx card and pay your $10 copay do you really care what the price is? Do you really want to know who gets paid what? That’s the beauty of todays managed care world. Middlemen are earning billions.

This illustration is on a 465 life case that has been on a Reference Based Pricing plan for over a decade. They have never had a rate increase.

The illustration breaks down the various cost components.

In this instance the plan is a Cash Pay Centric Plan with a Reference Based Pricing wrap.

Plan contributions are a sum of all costs distributed across participation tiers.

Plan contributions shown include a margin over expected claims. A plan sponsor may decided to fund less than the suggested funding rates especially if there are adequate booked reserves from the prior year.

• Ozempic 1 mg pen: ~$419 in Canada
• Wegovy 2.4 mg: ~$499 in Canada 
• Mounjaro 15 mg: ~$680
• Rybelsus 14 mg: ~$295 

We talk about $10/month plus the cost of the risk, but what does that really mean?

By Monte K. Jennings – Jul 14, 2025

Introduction

Today we are going to talk about risk. First we will define risk, then we will walk through an example of how we calculate risk in layman’s terms, and finally we will discuss what the risk means to you, your family, your wallet, and most importantly your insurance premium. We will also discuss why these things are so difficult to calculate.

Constriction looms for a key segment of healthcare coverage

In anticipation of substantial enrollment declines, Affordable Care Act marketplace plans are pushing large increases in premiums for next year.

“Hidden fees are eating away at your health plan—just as they once ate away at retirement savings plans. But with the right tools, oversight and processes, you can uncover mismanagement, improper practices or unethical conduct—and reclaim control of your plan spend.”

“Within three to five years, we’ll see AGI systems as smart as the best humans. And in six years, artificial superintelligence smarter than all of us combined. T

SOURCE: Out Fox Health

Give your members a better experience at a lower cost with Outfox Health.
Now that’s smart………

“How much do you charge for the operating room? I asked.

Joe Sixpack wanted to know where he could get the best cash price for a MRI. His employer’s group health plan pays the lowest cash price for any given service in full so Joe was pretty much incentivized to find the lowest cost.

“The largest recommended increase is in the Local Government (SHBP-LG) plan, where AON has called for a 36.5 percent increase in premiums. In the School Employees’ Health Benefits Program (SEHBP), AON has recommended a 29.7 percent increase. And in the State Health Benefits Program (SHBP-State), the recommended increase is 21.0 percent.”

By Dr. Elisabeth Potter, MD

I’m sharing an actual recent peer-to-peer call that shows what physicians and patients face when trying to get a surgery approved. This call felt as absurd as it sounds.

The peer-to-peer call was to advocate for surgery to prevent and treat lymphedema for a patient with breast cancer. Her risk is high and we can perform a surgery to lower it.

“Pharmaceutical companies and chain hospitals are key healthcare corporations within the Medical Industrial complex.”

Pete Tessier knows Insurance. As the host of the Insurance Podcast, he speaks to Insurance professionals about the challenges in the business. But let’s face it – no one really thinks about Insurance unless they work in it.

*Image created based upon real text messages between PBM and Consultant*

By Chris Deacon

At a recent event, I mentioned something in passing: “You know, the price vendors have to pay just to get on the spreadsheet.”

By Sidney Haitoff on Linkedin

As access barriers are torn down by new payment models, modern admin infrastructure, and AI, we’ll see a new class of healthcare navigator emerge. These sherpas will help curate optimal pathways, manage alerts and alarms, translate new data models, and coordinate collaboration across service sites and delivery channels, and triage issues.

Start an ICHRA and add Choice Benefits

It’s time to turbocharge your employee benefits plan and change how you shop and administer employee benefits. 

By Chris Deacon

You can’t be bound by a contract you’ve never seen. Unless, apparently, you’re a self-funded employer.

“For county employees, navigating healthcare can often feel like another job—long waits, rushed appointments, and unclear bills. But with this new Advanced Primary Care model, employees enjoy easy, on-site access to care, at times that work with their schedules, and a location that is convenient for them. No complicated scheduling systems or insurance red tape—just care when they need it.”

The Streisand Effect

Brokerage Firm Earns $7 Per Script. At a statistical average of 1.2 scripts per member per month (not per employee), that can add up to a butt load of money………..

“For the time being, Ascension-Seton remains non-participating in our traditional network because it charges substantially higher than market rates to provide care for Curative members.” – John Bock, Vice President of Sales

ZorroRX is a health benefits program designed to make healthcare more accessible and affordable for patients while reducing costs for employers. We partner with hospital pharmacies to offer $0 copays on medications, free telehealth visits with specialized pharmacists, and dedicated concierge support.

You just got a balance bill from a hospital. “You owe us $30,000 because your insurance company underpaid us!” was the note on the bill. “Pay up or we’ll send you to collections and you will forever be labeled as a DEADBEAT!”

Study indicates that replacing group health plans with individual plans will benefit workers…………

SOURCE: Fox Business (READ THE LAST TWO PARAGRAPHS)

CVS Caremark, one of the three major pharmacy benefit managers (PBM) in the U.S., stopped coverage for Eli Lilly’s popular weight-loss drug Zepbound, blaming drugs like it for driving up overall plan costs. 

KSAT anchor goes viral for ‘speaking the truth’ about Texas leaders

KSAT12 anchor Stephania Jimenez has gone viral after “speaking the truth” about Texas leaders and their response to the deadly flooding that has killed over 80 people in the state over the Fourth of July weekend.