Archive for the ‘Uncategorized’ Category

I Don’t Care

Monday, October 22nd, 2018

“Why aren’t you gonna pay for my prescription! My doctor ordered it!!!!”

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Balance Billing Is A Plan Sponsor’s Best Friend

Sunday, October 21st, 2018

“Balance billing only occurs when purchasing  goods or services without asking  the price.”

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Uproar at Purdue

Thursday, October 18th, 2018

Employees upset with cost containment move by University officials………….“How long can we continue to offer health care coverage when we’re experiencing 20 percent to 30 percent increases on a regular basis?”

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KISS – Keep It Simple Surgery

Thursday, October 18th, 2018

The KISx Card was created as a solution for self-funded employers to tackle egregious surgical pricing while bringing simplicity to the employee experience……………….

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Blue Cross Blue Shield IL Sued for Fraud, Robbing Chicago Taxpayers

Wednesday, October 17th, 2018

Working The Spread is nothing new. Seems quite common. The article below is about a lawsuit in which spread pricing is alleged.

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Email Solicitation – To Good To Be True? You Decide

Wednesday, October 17th, 2018

We get unsolicited emails every day like the one below. This one touts a plan we have never heard of before, offering what appears to be “to good to be true” pricing. We thought we would share this for our three readers…………………….

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Paying for Coverage Without Any

Wednesday, October 17th, 2018

“What are you talking about! That’s insane” cried the HR lady. …….”I thought you needed to know” I replied.

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Chinese Government Demanding Big Discounts from Drugmakers

Monday, October 15th, 2018

The power of large numbers, 1.379 billion Chinese, brings big benefits when negotiating with drug manufacturers…………………………….

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Many Agents and Brokers Are Still Uncertain About “REFERENCE BASED PRICING”

Friday, October 12th, 2018

Breaking The Status Quo

Allied National employer groups are proving beyond the shadow of a doubt that the Freedom Plan (our reference based pricing reimbursement) is a better, lower cost, solution than traditional PPO networks.

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South Texas Health Cooperative

Friday, October 12th, 2018

Rest Easy In Our Pool

Taming Health Care Alligators Since 1998

The South Texas Health Cooperative (STHC) provides affordable health insurance to member school districts since 1998. Through careful risk management strategies, the STHC risk pool has achieved lower and stable costs while improving benefits at the same time.

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Wow! What a Difference!

Friday, October 12th, 2018
Earlier this year I moved a client from a BUCA PBM to an independent PBM. No benefit or formulary changes were made. Now that I have mature credible claim data on the move from the BUCA PBM to an independent PBM, I find Rx claims have reduced 30.1%.

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Big News! FTC to Probe Hospital Contracts

Thursday, October 11th, 2018

 

This may become the tipping point in health care reform. “The Senate Judiciary Committee chairman questions contract terms between insurers and hospital systems…………..contracts between insurers and hospital systems are limiting competition and pushing up health-care costs……………..”

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Gag Clauses Now Illegal

Thursday, October 11th, 2018

In an effort to increase drug price transparency, President Donald Trump signed two bills into law that ban insurers from writing gag clauses into their contracts with pharmacists………………

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Texas Spanks Humana – Who’s Gonna Pay For It?

Thursday, October 11th, 2018

Now let me get this straight. Humana tries and fails to negotiate a reasonable rate with enough in-network providers and is punished for it. Well, the solution is to get rid of the network and treat all providers as out-of-network. That’s what Reference Based Pricing plans do.……………..BTW guess where Humana is going to get the $700,000………………………..

– Bill Rusteberg

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Hospital Profits High In Indianapolis

Thursday, October 11th, 2018

Hospitals in central Indiana enjoy a higher profit margin than those elsewhere because they overcharge insurers…………………..

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UMMC / BCBS Squabble

Thursday, October 11th, 2018

The following article (Posted on Linkedin by Carl Schuessler) brings to mind deeper issues than the “surface” issues most consumers reading this will take away. The article hints of a gold mine of information leading to more questions than answers.

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We All Have Health Care Stockholm Syndrome

Monday, October 8th, 2018

“The Stockholm syndrome we have been suffering under is starting to break……………

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Another State Adopts Reference Based Pricing Strategies

Friday, October 5th, 2018

First it was Montana, a smallish state somewhere up north of us, who adopted Reference Based Pricing for their state health plan (Montana Adopts Reference Based Pricing Strategies). The little lady up north has big brass cojones! (Tough Negotiator Saves State Millions In Health Care).

Next there is California which is currently considering similar efforts. (California Assembly Bill 3087 Would Control Prices in the Commercial Market).

Now there is yet another state adopting Reference Based Pricing for their state employee plan. They must have heard about the little lady in Montana.

I thought Texas would lead the country on this. After all, several of us have been making noises in Austin over the past two years. Has Texas Lost It’s Cojones?.

– Bill Rusteberg

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Deductibles Hit $2,000 As Employers Intensify Cost Shift

Friday, October 5th, 2018

“Annual deductibles for Americans with employer-based health coverage are hurtling toward $2,000 on average, according to new studies analyzing employee medical benefits.”

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New England Journal of Medicine Slams Wellness Programs

Thursday, October 4th, 2018

“Outcomes-based wellness programs don’t work, so why do them?  There is no upside and therefore no argument in favor of poisoning the doctor-patient relationship. “

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Employer-Provided Health Insurance Approaches $20,000 a Year

Thursday, October 4th, 2018

Rising prices “chiefly tied to rising prices paid for health services.” Yet health care costs have remained essentially static for the past ten years. It’s the prices that have increased, not the cost of health care. – Bill Rusteberg

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San Antonio Emergency Room Raises Concerns

Thursday, October 4th, 2018
San Antonio’s newest Emergency Room service sparks interest among residents and government officials.  The Emergency Room “is not even open for business but is already causing controversy.”

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Tough Negotiator Saves State Millions In Health Care

Tuesday, October 2nd, 2018

 Marilyn Bartlett

Marilyn Bartlett took a deep breath, drew herself up to her full 5 feet and a smidge, and told the assembled handful of Montana officials that she had a radical strategy to bail out the state’s foundering benefit plan for its 30,000 employees and their families………………..

Will Texas be next?

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An Electrical Physical? How Much Is That?

Monday, October 1st, 2018

“No, I am not doing an electrical physical, I’m here for a cold and I don’t need that test!” ……“But sir, your Blue Cross will cover it” came her soothing reply.

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Who Are A Status Quo Health Insurance Salesman’s Two Best Friends?

Sunday, September 30th, 2018

If you are a status quo broker your two best friends are………………….

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Important Decision For Reference Based Pricing Lawsuit?

Saturday, September 29th, 2018

This is a suit where the hospital alleged numerous claims against the RBP vendor and the RBP vendor responded with a motion to dismiss………………………..
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Dr. Hodad

Friday, September 28th, 2018

Every medical community has a Dr. Hodad (Hands of Death & Destruction). Peers never talk about Dr. Hodad for fear of lawsuits…………………………………………..

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Generic Substitute for $94,000 Drug To Be Released Jan. 2019

Friday, September 28th, 2018

Harvoni drug cost in the US for a three month, 84 tablet course of therapy, is $94,500. The same drug if purchased in India for example costs $900 for 3 months 84 tablet course………………

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HealthSmart Reference Based Pricing Strategies

Thursday, September 27th, 2018

Our solution pays pre-negotiated rates to hospitals and facilities at various rates of Medicare pricing…..

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The End of The Health Insurance Carrier

Wednesday, September 26th, 2018

Health insurance carriers face slow but steady disintermediation by innovative next generation benefits advisers who are using alternative funding to take control of employer health plans and reduce costs………..the beginning of the end of these dinosaurs

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Anti-Deductible Health Insurance Plans

Tuesday, September 25th, 2018

The movement away from deductibles illustrates a growing sentiment that exposing patients to more out-of-pocket healthcare costs doesn’t solve the cost conundrum and could harm patients’ health…….

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TASA Hints At Potential TRS ActiveCare Changes

Tuesday, September 25th, 2018

The 86th Texas Legislature will convene on Jan. 8, 2019. While TRS cannot speculate on specific outcomes, the Texas Legislature may make changes to the health care program. If there are changes, we will notify our members in writing.

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Turning Bronze Into Gold

Monday, September 24th, 2018

Turning Bronze Plans into Gold Plans at Bronze Plan costs is a common but unspoken strategy……………but who is benefiting from “beating the system?”

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Three Victoria City Employees Criticize Proposed Health Insurance Plan

Sunday, September 23rd, 2018

Employees’ medical claim expenditures have increased in recent years, causing the health fund to deplete so significantly that the proposed budget for the 2019 fiscal year allocates an additional $1 million for the health fund…………….

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You Can’t Fix What You Don’t See

Saturday, September 22nd, 2018

candle

“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!”

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Texas Association of School Administrators Advocates Alternatives To TRS ActiveCare

Friday, September 21st, 2018

TASA advocates for alternatives to TRS-ActiveCare that would provide additional options to districts while sustaining the current system for those districts that remain in the system…………..

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It Depends What The Meaning of The Word “Is” Is

Friday, September 21st, 2018

Leaked contract with Express Scripts, the nation’s largest PBM, gets crafty with its definition of “rebate.” The contract carves out so many exceptions to the “rebate” that the PBM itself ends up retaining most of the negotiated discounts for itself.

If PBMs drive up Rx costs, why use them? Why not deal directly with each pharmacy and cut the middle man out? A small Texas county is doing just that with significant savings……………..

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Selecting a Third Party Administrator

Thursday, September 20th, 2018

By William Rusteberg

With the growing suggestion that the BUCAs are inflexible third party administrators unwilling and unable to administer Reference Based Pricing plans and other strategies in the market today, more brokers are seeking new partnerships with independent third party administrators (TPA). An independent TPA can offer much more than a traditional carrier model.

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Senate Votes 98-2 to Ban Pharmacist Gag Clauses

Wednesday, September 19th, 2018

 

The Senate late Monday passed a bill that would put an end to gag clauses that bar pharmacists from telling consumers when it would cost less to pay cash for a prescription than to shell out the copayment under their health plan………………..

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Xerox, Eastman Kodak And Cost Plus Insurance

Tuesday, September 18th, 2018

trojan

“The challenge facing successful business ventures is to understand the necessity to continuously respond to market forces in a proactive manner since competition will certainly become a factor to consider at some point. To ignore this basic business premise by remaining complacent is business suicide.” – Bill Rusteberg

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Secret Hospital Deals That Squelch Competition

Tuesday, September 18th, 2018

Contracts with insurers allow hospitals to hide prices from consumers, add fees and discourage use of less-expensive rivals………………………. (more…)

My Discount Beats Your Discount!

Tuesday, September 18th, 2018
Plan sponsors are probably the most confused group of people in the history of mankind. Every health insurance salesman that comes in the door says the same thing, “My discounts are the best!”

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Selling Fear & Cost Plus Insurance

Tuesday, September 18th, 2018

The most powerful selling tool is fear. It motivates buyers to act quickly and decisively without basis of reasoned consideration. Depending on the level of fear a seasoned salesman can gin up during his close,  fees to be charged and eagerly paid by the victim are directly and proportionally related. Higher fear levels bring higher fees.

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How Hospital Reimbursement Does and Does Not Work

Thursday, September 6th, 2018

Hospitals create chargemaster prices by multiplying the cost they pay for a product by 300 to 1200%. Another little hospital secret is what is called an outlier payment…………………….

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Anthem To Offer New Association Health Plan in Las Vegas

Thursday, September 6th, 2018

The Las Vegas Metro Chamber of Commerce announced Wednesday that it is partnering with Anthem Blue Cross Blue Shield to offer health plans to its members under a new Trump Administration rule that makes it easier for small businesses to collectively purchase insurance…………….

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Study Shows Hospitals Charge 479% of Their Cost For Drugs

Thursday, September 6th, 2018

Percentage of Charges Model – 50% Off Double The Price?

Hospitals are generally not paid 100% of billed charges; however, hospital outpatient
departments are routinely reimbursed as a percent of billed charges by commercial payers……

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Demand For Medical Debt Reduction Service At All Time High

Wednesday, September 5th, 2018

Medical debt is a problem for 39% of insured adults in this country. 1 in 8 of those are on the hook for $2,000 or more. For more than 20 years RiskManagers.us has assisted members by reducing medical debt. As more employers cost shift to their employees, demand for medical debt reduction services is at an all time high………………………………

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City Budget Hinges On Employee Health Insurance Price

Wednesday, September 5th, 2018

A Texas municipality, facing rising health insurance costs, puts annual budget on hold until employee health insurance costs are negotiated. Maintaining city services and the expense of rising health care costs at the same time is Mission Impossible. Will Tax Man come to the rescue………………………?

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MedZERO Launches in Salt Lake City in Partnership with Asserta Health

Tuesday, September 4th, 2018

Offers zero-interest funds for out-of-pocket medical expenses…………….

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Dialing For Dollars

Monday, September 3rd, 2018

They changed over my status to “self pay” which cut my $10,400 the bill by 55%…………..

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$76,000,000 Health Insurance Swindle

Friday, August 31st, 2018

A Con Victor Lustig Would  Have Approved

Lab billing jumped more than 22,000 percent from August 2017 to May 2018, from an average of $37,400 per month to about $8.5 million per month………………..

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San Patricio County Seeks Insurance Consultant

Thursday, August 30th, 2018

San Patricio County is seeking qualifications from licensed insurance consultants to assist the county with its self-funded employee health & welfare plan. Firms / individuals are invited to submit their qualifications for consideration in providing a proposal for this scope of work.

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A Hospital Giant Discovers That Collecting Debt Pays Better Than Curing Ills

Thursday, August 30th, 2018

Making Money Off Medical Debt

As Tenet and other hospital companies struggle to make money providing medical care, they are turning to the profitable and growing business of collecting debt…………….

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She Paid $3.47 for a Prescription Drug. The Retail Price Was 10,000% Higher

Thursday, August 30th, 2018

 The story underneath is more complicated,” often reflecting a “black-box negotiation process between drugmakers, insurers and the middlemen who haggle behind closed doors over how much money changes hands……………….

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Why Use PBM’s When It’s Cheaper Without Them?

Thursday, August 30th, 2018

Insurance copays are higher than the cost of the drug about 25 percent of the time, according to a study published in March by the University of Southern California’s Schaeffer Center for Health Policy and Economics…………..

Editor – The problem is pharmacists are under a PBM gag order and cannot advise patients when it’s cheaper to pay cash than to use their prescription drug card

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How I Made $1 Million In One Phone Call

Wednesday, August 29th, 2018

“How Sweet It Is……………….”

Making $1,000,000 has never been easier……………………..

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Texas Teacher Thought He Had Great Health Insurance

Tuesday, August 28th, 2018

This blog entry illustrates the crazy world of hospital pricing in this country. A Texas teacher insured through his employer by a major carrier thought he had good insurance. He doesn’t think so now.

See how Scott Bennett calculated the hospital’s actual cost associated with a billed charge of +$164,000 in five minutes (www.linkedin.com/feed/update/urn:li:activity:6440264900991426560

Then read the article below.
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Someone Moved The Cheese!

Tuesday, August 28th, 2018

Even as they look back on several years of steady growth and success, many owners of independent insurance agencies now find themselves at a crossroad where they are pressed to make critical strategic decisions about the future of their firms……………….

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Texas Hospital Operating Income Soars 448%

Tuesday, August 28th, 2018

Hospital’s net patient service revenue was nearly flat year over year, but its premium revenue grew 13.5 percent to $1.3 billion………………

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Texas Farm Bureau Applauds Gilsbar

Tuesday, August 28th, 2018

 

Never in our history has the administration of the program been as flawless, smooth and efficient as it has been since Gilsbar has been our third party administrator. Gilsbar’s ‘can-do’ attitude and willingness to go the extra mile in support of the health program are welcome changes to our experience of past years.” – Texas Farm Bureau

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Monday, November 12, 2018

Saturday, August 25th, 2018

 

What will Texas do to reign in health care costs for the public good. We may soon find out………….

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New Case May Set Precedent For RBP Lawsuits

Saturday, August 25th, 2018

Lawsuit highlights one risk associated with reference-based pricing models: balance billing…..

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CapRisk Consulting Group

Saturday, August 25th, 2018

Actuarial and Business Consulting Services

CapRisk Consulting Group brings a practical means of problem solving to all of your actuarial risk and business insurance matters. CapRisk is an independent consulting firm offering a unique combination of actuarial and business consulting services, assisting clients with local, national, and international interests.

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Shared Savings Programs Require Closer Inspection

Friday, August 24th, 2018

Shared savings programs entitle the health plan to retain a percentage of any savings generated by their focused interventions in a given area……………..

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PBM’s Take Fees of 31% on Generic Drugs

Friday, August 24th, 2018

Ohio’s Pharmacy Benefit Managers (PBMs) charged the state a “spread” of more than 31 percent for generic drugs – nearly four times as much as the previously reported average spread across all drugs, according to a new report by Ohio Auditor of State Dave Yost…………….

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Will PBM’s Become Extinct?

Friday, August 24th, 2018

Will pharmacy benefit managers (PBM) could go the way of the travel agent? After all, PBM’s function the way travel agents used to and benefit from price inflation………………………

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Man Made Pandemic Threatens San Antonio Employers

Thursday, August 23rd, 2018

 

Feared government mandate may lead to massive pandemic in Central Texas…………………

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Ruben Edelstein

Thursday, August 23rd, 2018

Ruben Edelstein practiced managed care in his own way……………………….

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Health Insurance Costs Pushing School District Towards Fiscal Cliff

Thursday, August 23rd, 2018

Steady increases in health care costs is one of the main forces driving this school district towards the proverbial fiscal cliff. Two school years from now, the district projects it will be spending $450 million more than it takes in…………………….

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How RBP Plans Can Easily Contract With All Providers

Monday, August 20th, 2018
By Bill Rusteberg
Through an innovative plan design, Reference Based Pricing (RBP) plans seeking to contract with local providers can do so quite easily.  It’s turning lemons into lemonade and it’s called an APO (All Provider Organization).

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Is Low Bid Always The Best Bid?

Sunday, August 19th, 2018

The science of how to compete against “low bid” is a discipline learned by losing. Over time a seasoned salesman will learn how to beat the “low bid” and win more than he loses.(How To Win Against A Competitor’s Low-Ball Price Bid – Forbes)…………….In the article that follows the “high bidder” who lost to the “low bidder” is protesting. Is the $700,000,000 savings really true……………….? Common sense dictates otherwise.

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Dirtiest Industry Secrets Exposed By Retired Insurance Agent

Sunday, August 19th, 2018

This anonymous agent reveals the dirtiest secrets of his profession, and the rules for building your personal safety net

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Telemedicine + Teachers = A+ Combo?

Sunday, August 19th, 2018
Niche marketing is a smarter way to quicker sales………………….

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How Much Did You Pay For Your Banana?

Saturday, August 18th, 2018

Imagine a banana in a supermarket.  It costs $1 for those paying with Visa, $3 for those paying with MasterCard, and $32 for those paying with cash.  You can’t sign up for Visa until you’re 65, and you can only get a MasterCard if you have a nice employer or a decent income.  Worse, customers have no idea that such price discrepancy exists.  They don’t even know how much they’ll pay for the banana until long after they’ve eaten it…………………

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Friends With Benefits Episode #9

Friday, August 17th, 2018

Jeff Bernhard and David Contorno interview  William Rusteberg on Reference Based Pricing

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