Reference Based Pricing California Style

June 24th, 2019
California Assembly Bill No. 72  – OUT OF NETWORK REIMBURSEMENT

Texas School District Chaffs Under Government Health Plan

June 23rd, 2019

House Bill 3987 was filed this session to create a committee to review health benefits from TRS, but the bill did not move past the House Pensions, Investments & Services Committee.

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Second Texas School District Challenges TRS ActiveCare Mandate

June 22nd, 2019

The El Paso Independent School District (EPISD) is the second Texas public school district ( See Texas School District Challenges TRS ActiveCare Plan Mandates) to challenge TRS ActiveCare by offering district employees a choice between the state sponsored program and a commercial health plan alternative.

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President Trump to Issue Executive Order on Health Care Price Transparency

June 22nd, 2019

HOSPITAL ADMINISTRATORS REACTS

Hospitals and insurers say they are against the idea of transparency. Sunshine adverse, these pasty faced third party intermediaries say transparent pricing will lead to increased costs. That must mean the cost of goods and services in this country can be reduced by adopting health care pricing strategies of Don’t Ask And We Won’t Tell!

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Gateway to Health Care: The Clerk In The Cubicle

June 22nd, 2019

The way out of this mess is for Americans to remove themselves from the health insurance market altogether—or to participate in other forms of health insurance such as health sharing ministries and short-term insurance plans. Individuals can actually pay a doctor, hospital, or outpatient center for a service performed without filing claims or getting pre-approval from a clerk in a cubicle.

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It’s Xmas In Texas – State Passes “No Credit Ding Law”

June 21st, 2019

Major boon to Reference Based Pricing plans…………………..

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Will Senator Ted Cruz Come To The Rescue?

June 20th, 2019

Frustrated by a lack of response to our previous inquiries among numerous sources we approached (including several well known benefit experts) in seeking a definitive answer to a burning ACA question we have, it was decided by staff to attempt one last hopeful effort in peeling back the regulatory onion in search of the truth. Will Ted and his staff come to the rescue?

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Little Ole Gran Ma From Little Ole Montana Teaches The Big Boys A Lesson or Two

June 20th, 2019

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Direct Hospital Contracting

June 20th, 2019
“Only about 3 percent of self-insured companies nationally have some form of direct contracts with providers, said the National Business Group on Health.

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Game of Chicken – North Carolina Style

June 19th, 2019

Hundreds of millions of dollars and medical care for more than half a million people are at stake in what amounts to a game of chicken over a cut in how much the largest health insurance plan in North Carolina pays for care.

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Senators Avoid Agent Comp Topic at Health Cost Bill Hearing

June 19th, 2019

A major new health care and health insurance cost control bill still includes a long agent and broker compensation provision — but senators don’t seem to be eager to talk about it.

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Why Can’t I Get A Total Price On My Healthcare Procedure Before I Go?

June 18th, 2019

Thomas Farmer

“It looks like we are entering the “shipping & handling” awareness phase of healthcare costs.”

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Was J Patrick Rooney Right?

June 17th, 2019

Purveyors of Reference Based Pricing strategies can’t seem to agree on what the reference benchmark should be. Thirteen years ago J. Patrick Rooney (1927-2008) said it was 125% of Medicare. Was he right?

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Dendy Opines on North Carolina RBP Fiasco

June 17th, 2019

The state of North Carolina has received considerable push back from the medical community in their efforts to reign in rising health care costs for public employees. Scheduled to implement Reference Based Pricing strategies beginning January 1, 2020, the state’s medical industry (primarily hospitals) have pushed back so hard there is now doubt the plan will ever take effect. 

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 John W. Sbrocco

June 14th, 2019
John W. Sbrocco, CSFS
Healthcare Consultant helping self-funded employers evacuate & reduce medical claims.

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Sharing Plans Gaining Market Traction

June 14th, 2019

Sharing plans are not new. They have been around for years. While not insurance, these programs can offer affordable access to health care.

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Hungry? Free Lunch in San Antonio June 19!

June 13th, 2019

HealthComp Hosts “Lunch & Learn” with H-E-B and Baptist Integrated Health Partners in San Antonio

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Will Judge Demand Marriage Annulment?

June 12th, 2019

Some marriages are just not meant to be…………………..

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Medicare-For-All Gaining Support Among Businesses?

June 10th, 2019

“Businesses are really angry about the system, and there is a lot of frustration with its rising costs and dysfunction………”

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The Best Discounts In Health Care Are Not Through Your Health Insurance Company

June 8th, 2019

 

 “How Much Did You Say That Xray’s Gonna Cost?

A little ole housewife with cash in her purse has more bargaining power than Blue Cross, United HealthCare and Aetna combined………………………

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San Antonio Flu Epidemic Season Is Winter, Spring, Summer & Autumn

June 7th, 2019

It pays to be sick in San Antonio and Dallas these days………………………

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Recent Trends in Stop Loss Claims

June 7th, 2019

SOURCE: Frenkel Benefits

“The largest single Sun Life claim was $7.5 million and the largest injectable drug claim was $1.8 million. Injectable drugs account for 9.2% of the total cost of large cost claims.

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Survey Reveals “Me Too” Brokers In The Majority

June 6th, 2019

“It’s evident that many brokers believe the (PPO) networks are not the long-term answer, but brokers and consultants continue to push business to the traditional model or utilize TPAs with carrier or independent networks because it’s the status quo, what we have always done.”

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One Election Away From Free Single Payer System

June 5th, 2019
Successful pandering to gain voters is best achieved by promising free stuff. Each national election we end up getting more free stuff. And we haven’t yet run out of other people’s money…..Hallelujah!

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If We Don’t Fix Health Care Big Government Will

June 5th, 2019

There has not been a competitive health care market for years. Managed care contracts have contributed to that. Some employers have fixed health care buy most haven’t. This blog has written about the former in the past so if you are a regular reader you know exactly what we are talking about.

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2020 HSA and ACA NGFP Limits

June 4th, 2019

Government control of health care (a precursor to a single payer system) continues to manifest itself with constant dictates from bureaucrats in Washington. . The newest and latest message from the swamp is “we’ve placed a new limit on what you can save tax free towards your personal healthcare……………….” Our in-box receives numerous daily updates like the one below:

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Health Care Financing 101

June 3rd, 2019

Massachusetts hospitals stash $1,600,000,000 in offshore accounts…………….

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MediBid is Pleased to Announce Its New Medicare Allowable Lookup

June 2nd, 2019

                  Ralph Weber 

Ralph says bundled health care pre-negotiated cash pricing comes in at an average of 108% of the Medicare rate.  That’s a very good number in case you’re wondering………………. 

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Trump Ready To Force Transparency In Healthcare Pricing With An Executive Order

May 30th, 2019

Transparency in health care pricing doesn’t make a whole lot of sense when it’s other people’s money paying for all of this. Who cares what the cost is when all you have to pay is a small co-pay, or some sort of deductible. Then, when you enter that Magical Kingdom called Maximum-Out-Of-Pocket Limit you tend to go crazy in getting more health care to (1) milk it for all it’s worth and (2) revenge against the evil insurance carrier that makes you pay so much in co-pays and deductibles while charging you an arm and a leg in insurance premiums.

Health care pricing transparency does makes sense when Reference Based Pricing strategies are employed. “My plan will pay you $500 for that procedure, so how much will you charge me? Oh, never mind, I think I can find someone else that will do it for $500………………………

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California – Free Health Insurance For Planet Inhabitants

May 30th, 2019

If you live anywhere on this planet and need free health insurance that covers pre-existing conditions without any waiting period what so ever, come quickly to California now! No passport needed nor pesky immigration hurdles to jump through. Just cross the border at any point of your choosing, turn yourself in and get a free airplane or bus ticket to the Golden State.

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Hospitals Foster Lonely Hearts Club Memberships

May 29th, 2019

“If you are isolated and lonely, but you have someone that you remember, like nurse April, nurse Tina, or nurse John, and they’re like, ‘Hey, how are you doing?’ And you’re greeted with warmth and love, well yeah, I’m gonna come back”………………Three (lonely) patients visited the hospital 500 times in one year………………..

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The Cost of Convenience

May 27th, 2019

“More employers are seeing the value of adding a little bit of inconvenience to their health plans these days.

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Hospitals Dismiss Significance Of Chargemaster Prices?

May 27th, 2019

Victor Lustig

“Percentage of savings fees is the greatest fraud foisted upon consumers since Victor 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.”

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Are Carriers and PPO Networks Slowly Becoming Obsolete?

May 26th, 2019
PPO networks do not offer the savings they were designed for when first introduced to the market over 25 years ago………..The days of the PPO and HMO networks are slowly becoming as obsolete as the rotary phone, because the current system is just not working…………….Reference Based Pricing is going to become the new norm, providing competition in the marketplace and controlling costs……...

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McAllen ISD Invites 212 Vendors To Submit Bids – Chaos & Madness

May 25th, 2019

Insurance Brokers Fight For Markets

We received notice / invitation to bid from the McAllen Independent School District along with 211 other vendors shown as email recipients. The brokers among them will be stumbling all over themselves to get quotes from the same four or five markets……………………This is exactly why smart brokers stay away from public RFP’s…………….

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Blue Cross Joins The Doctors Practice Party

May 25th, 2019

“In 2018, Blue Cross members seen at South Florida Sanitas clinics—which opened in late 2015—had 32 percent fewer inpatient admissions, 34 percent fewer outpatient visits and 20 percent fewer emergency room visits compared with members who went to nonaffiliated clinics.”

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New Drug Will Bankrupt Your Plan by $2,100,000.00

May 25th, 2019

At $2.1 million, newly approved Novartis gene therapy will be world’s most expensive drug

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A Status Quo Broker’s Worst Nightmare Just Happened In D.C.

May 24th, 2019

Status Quo Health Insurance brokers are in for a lot of explaining to do. “Mr. Employer, I’m receiving $340,000 more than the $124,000 I’ve disclosed to you in the past. Plus, if I convince you to renew with your current carrier, I get an additional $25,000 renewal bonus! You OK with that? “

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Memorial Day 2019

May 23rd, 2019

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.

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Working Smart – It’s All About Destroying Relationships

May 23rd, 2019

By Charles Specht

I love this stuff! Targeting signed Broker of Record Letters makes so much more sense than blindly quoting policy renewals, throwing mud against the wall to see what sticks, and “hoping for the best.”

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Health Sharing Plans

May 23rd, 2019

By Bill Rusteberg

Health share plans are growing in popularity these days. Cost is significantly lower than insurance plans as you will see by clicking the link below. However beware these plans are not insurance and there is no guarantee claims will be paid/covered.

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Hidden Fees

May 21st, 2019

By Bill Rusteberg

Hidden fees in health care delivery earned by third party intermediaries can be significant.

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‘Sham’ Sharing Ministries Test Faith Of Patients And Insurance Regulators

May 21st, 2019

Texas insurance officials have scheduled a hearing to consider a similar order against Aliera, which has 100,000 members nationwide and reported revenue of $180 million in 2018, documents showed……

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Why Employers Are Getting Screwed In Health Care Pricing

May 21st, 2019

“As recently as 2000, private payers were paying only 10% more than Medicare. Since then, the gap has been growing by leaps and bounds.” That has since grown to 200-300% and as much as 400%……….

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PPOs and the $444 Box of Kleenex

May 16th, 2019

Healthcare providers set astronomical, arbitrary prices, and employers and insurers have few options. But a solution is emerging. 

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Texas School District Challenges TRS ActiveCare Plan Mandates

May 15th, 2019

Tired of waiting for the Texas legislature to act in addressing crippling health care costs affecting hundreds of thousands of Texas educators, the Raymondville Independent School District in deep South Texas has decided to act.

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More TRS ActiveCare Angst Among School Administrators

May 13th, 2019

Local school districts voice concern over rising costs for health coverage

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Another State Adopts Reference Based Pricing

May 13th, 2019

“To attract providers, Washington lawmakers chose a relatively high figure to start: The plan caps payouts at 160 per cent of federal Medicare rates……..”

Plan is expected to be competitive “in part to savings from a cap on rates paid to providers……………..”

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TRS Strategy To Control Health Care Costs Screws Plan Members

May 12th, 2019

The following article reports that “TRS trustees noted the only tools available to them to address rising costs each year are to”:

  1. increase premiums
  2. lower benefits
  3. or a combination of both

Really?

Meanwhile, smart plan sponsors have solved the rising cost of health care in Texas and it ain’t by increasing premiums and lowering benefits. Rather, it’s by lowering costs and improving benefits at the same time……sounds crazy doesn’t it?

(The Texas legislature’s answer to addressing rising health care costs is House Bill 3987, that if passed, will authorize a committee to study the issue and report back in two years. But some Texas school districts are not waiting……..)

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Let The Sun Shine In…………………..

May 11th, 2019

Health Plans Should Prepare For Plan Fallout Of HHS Rule Requiring Manufacturers Disclose Drug Prices

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El Paso ISD To Adopt Exemption To TRS ActiveCare Requirement

May 11th, 2019

The El Paso Independent School District is set to adopt an exemption to Texas Education Code 22.004(i), which prohibits a District that has implemented employee group health coverage pursuant to Chapter 1579 of the Insurance Code (TRS ActiveCare) from providing any kind of alternative group health coverage at their May 14 board meeting.

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Too Damn HIgh!

May 11th, 2019

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Fearless Agitator Rattles Cages For Fun

May 10th, 2019

The Real David in David & Goliath 

By David Contorno

Employers…..contrary to what you think, health insurance carriers make MORE revenue and profit as your health care costs go up. It’s federal law.

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Protection Money Scheme Dominates HealthCare

May 8th, 2019

Pssst…Godfather, Mulebriar Is At It Again!

“Paying protection money (PPO access fees) for the promise of no balance billing against egregious, arbitrary sticker pricing that have no relationship to costs whatsoever, and agreeing to provider reimbursement levels based upon secretive contracts you cannot see nor audit, violates fiduciary duties and is contrary to basic, common American business practices. “

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The Fallacy of PPO Re-Pricing Exercise

May 8th, 2019

Each time I see a Request for Proposals put out by insurance consultants requiring a PPO Re-Pricing Exercise in an effort to determine which network has the best discounts the temptation to reach out to Jose Cuervo is tough to ignore. 

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Who’s The Dick That’s Going To Explain Our Healthcare Tragedy?

May 7th, 2019

If you’re an insurance company, the simplest way to make more money, is to PAY MORE for medical services. In fact, provider negotiations should go like this:

Doctor: I want $100 for this procedure.

Insurance Company: No, we won’t pay you a penny less than $250. 

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Hospitals Are Committing Financial Suicide But Don’t Know It

May 6th, 2019

Hospitals have overplayed their hand. Galeforce blowback has arrived.

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Size Means Nothing in Health Care Financing – Common Sense Does

May 5th, 2019

This is what a +400,000 life group plan offering status quo healthcare strategies gets you these days…………

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Reference Based Pricing Blitzkreig

May 3rd, 2019

“For-profit hospitals charge 700% more than Medicare prices, while non-profit hospitals charge 550% more. Traditional PPO plans offering a 50% discount may end up paying 300% more than the Medicare price”.  In Texas where Reference Based Pricing strategies have been around since 2007, plan sponsors are paying between 120% to 150% of Medicare…………………….The Reference Based Pricing Blitzkreig is gaining market share quickly……………

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Astute Purchasing Agent Nails It

May 3rd, 2019

A long time friend who has spent almost all of his working life in the pubic purchasing arena in Texas has a perspective that many of us in the insurance community have failed to acknowledge. 

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Grandpaw-hood At Risk?

May 2nd, 2019

 “Please don’t leave us Grandpaw!!!”

Hey Grandpaw, I’m thinking of giving my children (your grandchildren) a few free gifts this year but I may decide later to take them back. But………. I’m worried the government will require you to disown us under penalty of sanctions!

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Shoddy Health Care, Missed Diagnosis, Unnecessary Treatment……….

April 30th, 2019

Diagnosed with the “Big C?” At least 10% beat it because they didn’t have cancer in the first place……...

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Judge Recuses Self Over Views On Insurer’s ‘Barbaric’ Policy

April 30th, 2019

UHC Company Executives?

A Florida federal judge stepped down Monday from a proposed class action claiming UnitedHealthcare improperly classified a certain cancer treatment as experimental to avoid providing coverage, saying his personal opinion prevented him from ruling fairly on what he called “immoral and barbaric” actions.

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Is Your Employer Worksite Medical Clinic a Group Health Plan?

April 29th, 2019

“An employer maintaining a workplace clinic (or considering one) needs to understand the group health plan compliance risks and the general risks associated with doing so and take reasonable steps to mitigate those risks.

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Medicare For All Already Exists

April 29th, 2019

We have Medicare for all already………………………………………..

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States Look To Medicare-Based Reference Pricing Strategies

April 25th, 2019

Meanwhile, back at the ranch, the Texas legislature kicks the can down the road……………..again.

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The Future of Personalized Medicine is Here

April 25th, 2019

One simple test, we can improve quality of life and save healthcare resources……………..

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Power Struggle in Dallas

April 25th, 2019

Blue Cross Blue Shield of Texas removes 14 DFW hospital emergency rooms with out-of-network docs from network………………….

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A New Kind of Pharmacy

April 25th, 2019

Blue Cross To Offer $10 Co-pay Food Plan

April 25th, 2019

Will food program drive down health care costs in Chicago and Dallas?  A portion of your BCBS premium dollars will be allocated to find out……………

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Need Surgery? Go On-Line and Book It

April 24th, 2019

Imagine if you need some sort of surgical procedure like a knee replacement. Simply go on-line and book it. Your employer has arranged to pay the providers you select  prior to services rendered, including all or a part of your share of the cost. It’s that easy.

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Texas House Bill 3933 – A Panacea for Reference Based Pricing Plans?

April 23rd, 2019
The Texas legislature is considering numerous bills of interest to those of us engaged with health care delivery in this state. HB 3933 is one, that if passed, will have a considerable impact upon the health care community.

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Webb County Seeks P&C Insurance Consultant

April 23rd, 2019

RFQ 2019-0006 Package for a Consultant for Health Insurance for Webb County can be obtained from our EBid site located at:  https://webbcountyebid.ionwave.net/CurrentSourcingEvents.aspx

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PBM’s

April 23rd, 2019

Going Broke? Never Mind, Just Print More Money

April 22nd, 2019

Trustees project Medicare trust fund will be depleted in seven years………..So let’s do Medicare For All and see if we can go broke faster……………………………Never mind. Sam, fire up the ole printing press will ya………..we’ed be needing some money to pay for all this.

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