Mike Dendy, AMPS CEO interviewed on Bloomberg Radio, “Taking Stock” to discuss the problem and solution to rising healthcare costs in the US. Click on the icon below to listen to the full interview.
Archive for August, 2014
By William Rusteberg
What constitutes minimum compliance under the Rx minimal essential benefit mandate? Minimum requirements are set by each state. In Texas the minimum benchmark is the BCBS Best Choice PPO – RS26 plan.
According to 45 CFR 156.122, to offer essential health benefits, health plans must cover at least the greater of (1). one drug in every USP therapeutic category and class or (2) the same number of drugs in each USP category and class in the state’s benchmark plan.
Does your current Rx plan comply or does it over-comply, i.e., more expensive than it is mandated to be? For example, if your current plan covers 20 different medications for a given category when only 10 is the required minimum mandated number, you may want to remove 10 of the more expensive medications from that class.
With drug costs accounting for as much as 25% of a plan sponsor’s spend, it may make sense to develop a Minimum Compliant Rx Plan utilizing the least expensive drugs in each therapeutic category and class. Minimum compliance benefits for Texas can be found here – texas-ehb-benchmark-plan (pharmacy is the last five pages).
It may make even more sense to subject Rx benefits to a deductible and eliminate co-pays. Consumers would be required to pay cash up front for drugs at the point of sale before filing a claim like in the old days. The shoe box effect, along with the behavioral effect of “skin in the game” at the point of sale should reduce claims even further. Of course our PBM friends won’t like this idea. Neither will HR directors.
When people talk about expensive drugs, they usually are referring to drugs like Lipitor for high cholesterol ($1,500 a year), Zyprexa for schizophrenia ($7,000 a year) or Avastin for cancer ($50,000 a year). But none of these medicines come close to making Forbes’ exclusive survey of the most expensive medicines on the planet.
September 2, 2014 Agenda Item: Recommend awarding CSP #15-033 Third Party Administrative (TPA) Services for the Self-Funded Group Health Plan to BlueCross BlueShield of Texas, Stop Loss to Voya Financial, Basic Life and AD&D Insurance to Aetna Life Insurance for a three (3) year term with an option to renew for two (2) additional one (1) year terms.
Editor’s Note: Though this is agenda item calls for approval of BCBS, Don Pedro says “Something tells me, based on ant activity this afternoon, a storm is brewing.” And out he went.
Bush regards health care from the perspective of a successful entrepreneur, and sees the health care industry as “the new oil”—a vast landscape of opportunity with untapped potential. All the waste and inefficiency—estimated by the Institute of Medicine to account for one-third of the spending—are gushers waiting to be discovered.
Go to www.CostPlusInsurance.com for powerful ideas & common sense solutions
Excellent video by Cost Plus Advisors
Excerpt of Article Written by Amy Monahan and Daniel Schwarcz, Associate Professors of Law – University of Minnesota Law School
“Exchange dumping is a risk transfer mechanism whereby plan sponsors may induce high-risk plan participants to opt out of employer-sponsored coverage in favor of insurance available on the individual market. ”
“The risk of employer dumping of high-risk employees is hardly exotic. In fact, dumping of high-risk policyholders is merely a subset of the larger insurer practice of risk classification.” Do lasers come to mind?
“If properly designed, such an employer dumping strategy can promote the interests of both employers and employees by shifting health care expenses on to the public at large. ”
“The ACA leaves self-insured employer plans virtually unregulated allowing employers a tremendous amount of freedom in designing the terms of their plans. Such employers are consequently free to design plans that appeal to relatively young and healthy employees but are unattractive to high-risk employees. Strategies include exclusion from coverage of certain high-cost conditions such as AIDS, diabetes and hemophilia. Neither ACA nor other existing sources of law substantially restrict the ability of self-insured plans to engage in indirect risk classification through design of plan benefits. ”
RiskManagers.us offers solutions for self-funded plan sponsors who seek innovative risk transfer alternatives. For more information visit www.RiskTransfer.us or write RiskManager@RiskManagers.us
Growing up in Kansas, Payne remembers trying on her mother’s clothes and dressing as a girl every year for Halloween. She dreamt of having another life after this one, as a girl
“Abortion is a basic health care service … the (State ) Constitution prohibits health plans from discriminating against women who choose to terminate a pregnancy. Thus, all health plans must treat maternity services and legal abortion neutrally.”
All benefits subject to the deductible with the exception of preventive benefits and Rx benefits
By James Aldridge
San Antonio Business Journal
A new survey by the Texas Alliance for Patient Access shows that Texas ranked second nationally behind California in physician recruitment.
The report, titled “The Truth about Texas’ Medical Lawsuit Reforms,” attributes the growth to the passage of medical liability tort reform measures in 2003. Officials say since then, Texas has more doctors than ever treating patients.
“That is the exact opposite of what we saw during the crisis years, when the state experienced a per-capita loss of patient care physicians,” said Dr. Howard Marcus, an Austin internist and chair of Texas Alliance for Patient Access in a release.
Since 2003, 80 percent of the state’s 22 trauma regions experienced a per-capita gain in physicians. Also, during that same period, 59 rural counties have added at least one emergency room physician, 32 rural counties have added an obstetrician, 24 rural counties have added a cardiologist and 17 counties have added an orthopedic surgeon.
One interesting aspect of the report shows that 40 rural counties that did not have a single ER doctor in 2003 now do.
“Rural Texans were losing physicians during the liability crisis years,” says Marcus. “Today, those numbers are on the upswing with more physicians per-capita serving rural Texas than ever.”
Blue Cross Blue Shield was awarded the group health insurance contract last night at the La Joya Independent School District.
2. Next, we require the newly uninsured to be re-insured.
3. To re-insure the newly uninsured, they are required to pay extra charges to be re-insured.
4. The extra charges are required so that the original insured, who became uninsured, and
then became re-insured, can pay enough extra so that the original uninsured can be insured, which will be free of charge to them.
The Brownsville Independent School District, the largest employer south of San Antonio, is in the process of selecting a record keeper (TPA) for the district’s self-funded employee health plan. Seven proposals were received and ranked. Instead of focusing on the top three contenders, the insurance committee decided to invite all vendors to give a 10 minute presentation as part of the evaluation process. Will 10 minutes make a difference?
“With the passage of the Affordable Care Act, transparency in medical pricing has gained added traction. Narrow networks, i.e, less expensive providers, is one trend, while the other is reference based pricing which is necessarily based on transparency. Health insurance has now become more of an individual responsibility and less of an employer’s moral responsibility. Consumers are beginning to recognize this. Once consumers have skin in the game, cost transparency becomes a market demand upon which medical care givers either do well or lose business.” – William Rusteberg
The Business Of Medical Practice: Transformational Health 2.0 Skills For Doctors by David E. Marcinko & Hope Hetico.
Page 33: “Similarly, RiskMangers.us is a specialty company in the benefits market that, while not an insurance company, works directly with health entities, medical providers, and businesses to identify and develop cost effective benefits packages, emphasizing transparency and faiirness in direct reimbursment compensation methods – William Rusteberg, 2010, Personal Communication –www.riskmanagers.us ”
Allied National is seizing advantages in Texas with their self-funded “Provider Freedom” plans. Provider Freedom plan sales represent 85% of new business sales for this Kansas based third party administrator. According to sources at Allied National, mid-market cities (Midland – Odessa – Longview) have been stronger markets than the metro-plexes, however traction is beginning to take hold in the larger metropolitan areas as well.
The Provider Freedom Plan is not a PPO program and is very similar to Cost Plus Insurance.
For more information, contact Dan Meylan, National Sales Director of Allied National @ email@example.com
We have been looking for a stop loss carrier that offers an old fashion participating contract for many months now. Well, we found one. Mystery Re has an experience refund calculation on their stop loss policies. Much like a participating contract without the downsides. Minimum premium is $500k. This carrier also has a “laser pool” for their groups.
A participating contract is better than using a captive – no management fees, no capitalization, etc.
Editor’s Note: Mystery Re is a pseudonym. Write RiskManager@RiskManagers.us for details.
“Percentage of savings fees is the greatest fraud foisted upon consumers since Vicor Lustig sold the Eiffel Tower in 1925. To earn 24% of an inflated, arbitrary number that no one ever pays is better than robbing a bank.” – William Rusteberg
The initiative, launched in January 2013, is one attempt under the Patient Protection and Affordable Care Act to test incentives for providers to more closely control costs.
The Local reports that Sergio Canavero, a neuroscientist, said it may be possible to merge bone marrow when fusing one person’s head with another’s spine. Writing for the journal Frontier Neurology, he said that operation could be made possible by using membrane-fusing substances called fusogens, injected between the two stumps.
Adam Russo of the Phia Group explains balance billing strategies
Editor’s Note: Excellent explanation of balance billing and Cost Plus Insurance through Caprock Health Plans. If you don’t have the time to view the entire video, fast forward to the 30:36 minute mark.
Living out in the country has challenges most city folk never experience. The first rule of country living is that “things” constantly break and need repair. Not a day or week goes by without some sort of catastrophe that must be addressed for life to get back to normal. It could be a well pump, fencing down, or a worn out hydraulic pump on a tractor.
Sure enough, just the other day the hydraulic pump on the tractor suffered a stroke. Living in the country, losing use of a tractor is a serious, serious development needing immediate attention.
Loading the tractor on the trailer, a quick trip 37 miles to the nearest Tractor Emergency Room in Victoria, Texas brought anticipated relief that all would be cured expeditiously. I felt we were in good hands, after all these guys are experts in their field. I trusted them.
However, anxiety levels reached new highs when told “Sir, your hydraulic pump has reached room temperature (Translation: it’s dead!) with no chance of recovery. We can perform a transplant for $2,400 plus labor.”
“Wait!. That seems outrageous! Is that the best your can do?” I said. “Yes Sir, that is the best I can do, I know it’s an awful lot of money , but it is what it is. Parts are expensive!”
“Don’t operate yet. I want to make some calls! I will get back to you shortly. I don’t have Tractor Insurance, this is self-pay!”
I called the dealer near Austin where I bought the tractor several years ago – his price? A bargain at $1,800! “Let me think about this, a funeral may be cheaper!” I said.
I turned to my “Procurement Officer” in Dallas (Number one son-in-law) for help. This guy finds stuff at good prices all the time – every family needs a guy like this. Within a day he found a source for a new hydraulic pump for $1,200, or half of the price quoted by the Tractor Emergency Room doctor in Victoria, Texas and significantly less than the tractor birthing center near Austin.
“Bill, If you had Tractor Insurance with a $20 co-pay, I bet you would have told the Victoia Tractor Emergency Room personnel to go ahead and operate! Isn’t this a lot like medical costs and insurance you deal with all the time in your business?” asked my new parts broker. “Yes, and I am going to assign the Victoria Tractor Emergency Room as an out-of-network provider for my self-pay tractor insurance program!”
According to buzz within the brokerage community, to meet minimum actuarial value, using the government’s own actuarial calculator, you can eliminate in-patient hospital coverage and remain within the definition. MEC plans and now this. What other “gems” can be found in PPACA? Pelosi was dead on – “We have to pass the bill so that you can find out what’s in it!”
Kaiser Health News reported regulators are developing stricter standards to address the concerns of consumers who say that many health plans under the Affordable Care Act have unduly limited their choices of doctors and hospitals, leaving them with unexpected medical bills. Officials indicated the new standards would be similar to those used by the government to determine whether Medicare Advantage plans have enough doctors and hospitals in their networks. The Kaiser Family Foundation is a non-profit private operating foundation, based in Menlo Park, California, dedicated to producing and communicating the best possible information, research and analysis on health. Click here to learn more.
RISKMANAGERS.US SOLUTION: Discontinue using PPO networks and pay all medical care givers on a fair and transparent basis using Medicare pricing as the benchmark.
By HEATHER CATHLEEN COX
Earlier this summer, SBCISD advertised an open request for vendor proposals for the following services: Stop loss insurance; diabetic supplies, pharmacy benefits manager, third party administrative services for employee benefit plans; and cafeteria and voluntary plans.
August 5, 201
COLUMBUS, Ohio – Over the next five years, leaders of Ohio’s 10 largest school districts expect their costs for employee retirement and health insurance benefits to increase by an average of 29 percent.
Editor’s Note: Ohio school districts would be wise to visit with Julie Mueller again – Custom Design Benefits Develops TrueCost (Cost Plus) Health Plan True Cost Insurance Plan Pits Hospitals vs Employers
REQUEST FOR PROPOSAL
The County of Willacy is accepting proposals for their Employee Health, Dental and Vision benefit program. Proposals will be accepted for both a fully-insured and self-funded program. Specifications will be released on Monday, August 4, 2014 and may be obtained by contacting:
Office of the County Treasurer – Ruben Cavazos
546 W. Hidalgo, Raymondville, TX 78580
The County of Willacy reserves the right to reject any or all proposals or any portion thereof and to accept the proposal most advantageous to the County.
“We’ve identified a need to offer Medicare repricing services at rates that are cost effective, and enable Clients to budget expenses. Today our Clients can select from several Medicare pricing solutions, including a PEPM fee to reprice medical claims as either a PPO alternative or for out-of-network medical bills. This can be for repricing services only, or can include Patient Advocacy, including direct negotiations when appropriate. We see this as the next logical step in making this solution affordable for Clients who wish to be more aggressive in keeping costs down”, said Joshua Carder, President at UCS.
United Claim Solutions is an innovative Medical Cost Reduction and Claims Flow Management company providing cutting edge and customizable programs for payers, employers, labor organizations, reinsurers, and health plans. UCS offers end to end services including Bill Review, Out-of-Network Bill Repricing, Bill Edits, Medicare Plus Repricing, PPO Administration, Medical Management, Clearinghouse Services, Data Warehousing, OCR/Scanning, and Plan Modeling. We provide solutions for Group Health, Workers’ Compensation, and Auto Liability. Contact UCS if you are looking for:
• A partner that puts Service first
• Industry leading Savings on medical bills
• Flexible Solutions that reduce administrative costs
Humana (NYSE:HUM) could be on track to get a total of $575 million to $775 million in Patient Protection and Affordable Care Act (PPACA) three R’s money for all of 2014. Roughly three-quarters of the money could come from a temporary PPACA reinsurance program. Aetna may get $50 million and Assurant hopes to get $140 million from TaxpayerRe.