Underwriter Opines on Reference Based Pricing

December 30th, 2018

By David Stanard   VP, Underwriting Manager at Excess Risk Reinsurance Posted on Linkedin

As an underwriter, I’m always surprised by the examples given when discussing RBP. They always seem to omit the fact that RBP has almost NO impact on an employers drug spend. In today’s market, that’s 30-40% of your cost.

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Reference-Based Pricing: a Welcome Disruption

December 30th, 2018

Disruptors Change History in Boston – “Tea Anyone?”

These plans are a game-changer in our industry, and a much-needed disruption to the status quo……………

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WELLNESS PROGRAMS – The Good, The Bad, and The Just Plain Silly

December 29th, 2018

 

 

 

The good news is that the wellness industry is finally coming around (kicking and screaming at times) to the realization that their programs are not a health care cost savings strategy………………..

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Employer Based Food Insurance

December 29th, 2018

The government bestowed a big tax break on employer-purchased food plans a few generations ago……..

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High RBP Fees Offsets Plan Savings

December 28th, 2018

“By the time you add third party intermediary fees of $1 million and consider the additional balance billing liability to plan participants, Cost Plus Insurance may not make much sense to those in the domino parlor.”

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Protection Money In Healthcare

December 25th, 2018

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 or audit, violates fiduciary duties and is contrary to traditional American business practices.“

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Merry Xmas Mulebriar!

December 24th, 2018

Mulbriar receives unsolicited Christmas gift revealing best kept secrets of out-of-network reimbursement strategies among the BUCA’s…………………..

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Doctors Strike

December 20th, 2018

 

 

TPA / RBP Vendor Compares Fees To Competition

December 20th, 2018

Commission driven broker / consultants push certain products over others. Here’s an example…….

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Managing Risk vs Servicing Risk – The End of Status Quo Brokers?

December 19th, 2018

With little formal training, a majority of health insurance brokers back in the day were simply spreadsheet artists………………………….

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Insulin’s Inventor Sold the Patent for $1

December 18th, 2018

Insulin’s Inventor Sold the Patent for $1. Then Drug Companies Got Hold of It

Never underestimate the greed of a pharmaceutical company.

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A $5,571 Bill For Sitting In A Waiting Room

December 18th, 2018

More evidence the American healthcare delivery system is in melt down………………Continued destruction of the American middle class…………….

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Is 150% of Medicare The RBR Sweet Spot?

December 17th, 2018

 

On average, commercial rates were 89 percent higher than Medicare rates……………….That means 5-% of commercial rates are less than 89% of Medicare………………..

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Uh Huh, Right………………………

December 17th, 2018

John Roberts – ObamaCare Savior

The Individual Mandate no longer ‘triggers a tax’ beginning in 2019……………………..

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Tyrone Is At It Again Godfather!

December 17th, 2018

I came across the single best explanation of AWP or Average Wholesale Price and I want to share it with you.

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Telemedicine Back In The Day

December 17th, 2018

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Blue Cross Faces Antitrust Claims

December 15th, 2018

 John Sherman

Blue Cross Blue Shield faces allegations of anti-competitive behavior that violates the Sherman Antitrust Act of 1890………………………………….

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McAllen Independent School District Seeks Insurance Consultant

December 14th, 2018

McAllen Logo 2C BlackFFCC00

McAllen Independent School District (the “District”) invites your submittal on:

                     Insurance &Employee Benefits Consulting Services 

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Free Market Fails, Government Steps In…………….

December 14th, 2018

Is government mandated price controls the answer to rising health care costs……………?

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Why Does 100 Year Old Life Saving Drug Cost So Much?

December 14th, 2018

For a product that’s nearly 100 years old prices are too high, forcing diabetes patients to ration their drugs and sacrifice their health for financial reasons………only hree drugmakers control all of the U.S. insulin supply……………..list prices for one type of insulin grew 600% over 14 years…………

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ERISA Class-Action Litigation over Fees in Health and Welfare Plans

December 13th, 2018

A potential mine field for health-plan fiduciaries involves failure to ensure that plan participants pay only ‘reasonable’ fees for services, including co-insurance and deductibles…………..

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Sales Bonus or Bribe?

December 13th, 2018

“The employer has no one — not the carrier, the broker, the third party administrator, the pharmacy benefit manager, the hospital or the doctor — sitting on their side of the table, with a shared incentive to lower healthcare cost.”

– Nelson Griswold, president of Bottom Line Solutions in Nashville, Tenn.

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I Own You – Do What I Say or I’ll Break Your Legs!

December 12th, 2018

Pssst, Godfather, Bill Is Attempting To Move Our Business!

“Tell Bill I’ll make him an offer he can’t refuse………………………………………”

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Rebates!

December 11th, 2018

Rebate programs do not save employers money…………………………..

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Handling Health Claims: Traditional Carriers vs TPAs

December 11th, 2018

“For the lion’s share of claims, the TPA is still leasing a large carrier network in order to secure the negotiated discounts with doctors and hospitals. But … there are some services for which the carrier’s network rates are egregiously high — and for those services the TPA will simply apply Medicare reimbursement levels instead….”

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Sierra-Berkshire Associates

December 11th, 2018

Affordable Care Act Increases Need for Actuarial Services……………

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What Is AWP?

December 11th, 2018

It is an elevated drug price that is rarely what is actually paid……………So why use it?

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Rare View Behind The Curtain

December 11th, 2018

Drug prices are difficult to determine for patients. Drug wholesalers, distributors, healthcare providers, pharmacy benefit managers and pharmacists keep prices hidden from the public. Until now…………………………..

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That’s Not What We Were Told!

December 10th, 2018

Hermann Ebinghaus

How effective are employee health insurance benefit meetings? Or are they a waste of time?

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Texas: Short Term Medical Plans Under Attack

December 9th, 2018

In January, the 86th Texas Legislature will convene in Austin. Hopefully, they will address expanding health coverage in Texas, prohibit short-term coverage from discriminating based on health status, and limit the maximum time an individual may be enrolled to less than 364 days………….

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Deep South Texas Faces Unique Health Care Challenges

December 9th, 2018

25% of the population in deep South Texas receive free health care. Known as The Valley, the region has unique health care and economic challenges including a high diabetes rate, high poverty rate, and heavy dependence upon government and health care jobs…………………

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Tyler Man Connected To PBM Kickback Scheme

December 8th, 2018

Tom Slack, of Tyler, received more than $1.5 million in illegal kickbacks………………

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Texas Insurance Consultant Forfeits License

December 8th, 2018

Convicted Texas insurance consultant William Haff forfeits insurance licenses……………accepted bribes to steer public school business to insurance broker………………

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Health Care Sharing Memberships Top 1 Million

December 8th, 2018

A million Americans — a number that is growing — have rejected medical insurance for membership in one of the 104 known and active Health Care Sharing Ministries in North America…………………………….

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Decades Old BCBS Love Hate Relationship Continues……….

December 8th, 2018

Hospital administrators throughout Texas say the insurance company is using “strong-arm” tactics to push unfavorable contracts……………

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Guaranteed Cost Stop Loss Insurance

December 8th, 2018

Guaranteed cost stop loss insurance for today’s environment……….

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RxReins

December 8th, 2018

Bringing financial stability. Ensuring peace of mind.

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Plan Sponsors At Risk For High Fees – Breach of Fiduciary Oversight

December 8th, 2018

 

“Health-plan participants could conceivably choose to challenge health-plan fees with general fiduciary-breach claims. In fact, it is reasonable to expect that such claims will be made against other health-plan sponsors, given that plaintiffs’ firms have begun to solicit potential class representatives and request health-plan fee information from employers.”

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Communist China Adopts Free Market Medical Costs Strategy

December 7th, 2018

China embraces competitive bidding instead of price fixing?………….A free market approach in a communist country?…………………….Mao Zendong must be rolling over in his grave these days……………..Meanwhile back in the United States Cloned Zendong’s move forward pushing their Cultural Revolution with fervor……………..

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Wallet Biopsy Determines Prognosis

December 7th, 2018

Patients must be first class fund raisers – their lives depend on it…………………………

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Here’s To The Crazy Ones……………….

December 6th, 2018

“Here’s to the crazy ones. Misfits, rebels, troublemakers. They are not fond of rules. They have no respect for the status quo. They change things…………………….”

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Turd Polish Season

December 6th, 2018

Most traditional benefits brokers are wrapping up Turd Polish season (aka Open Enrollment). You know, that process of trying to make the “pay more, get less” benefits discussion that happens every year.

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Get Your Healthcare Before It’s Too Late

December 6th, 2018

If you’re currently without healthcare for next year or are in search of a new program heading into 2019, you need to know that the deadline to purchase health insurance through the government Exchange is December 15.

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Pigs To The Rescue…………………

December 6th, 2018

Pig hearts could soon be tested in humans after scientists pass important milestone…………..

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Find Out If You Have Cancer in 10 Minutes

December 5th, 2018

Blood test to detect cancer within just 10 minutes developed by scientists

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Charge Master Rates & Magical Discounts

December 5th, 2018
A client on Reference Based Pricing experienced first hand the magic of Charge Master rates and magical discounts………………………….

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How to Bring the Big Health Insurers to Their Knees

December 4th, 2018

The American health care revolution is in full swing and growing………………….

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Missouri Chamber Health Plan Misses It’s Mark

December 4th, 2018

“When the data is hidden, you have no choice but to hope that the insurance company is managing your money appropriately.” – Adam Berkowitz

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Indemnity Insurance Plans Provide Best Coverage

December 4th, 2018

Plan liability is well defined and budgetable, patient liability is too…………….

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4 Reasons Reference Based Pricing Could Become The Norm

December 3rd, 2018

Reference based pricing isn’t new, nor is it unproven. The need to control still-growing health insurance costs will make more large employers sit up and take notice of the practice……………….

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The Wall Street Journal: Employers Change Tactics To Curb Health-Insurance Costs 

December 3rd, 2018


Company leaders are grappling with how to deal with the rising cost of health insurance in ways that get beyond the longtime strategy of simply passing on more of the burden to workers.

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Health Care Lobby VS Dale Folwell

December 2nd, 2018

“Lobbying? We’ve got 9 million taxpayers and 720,000 participants in this plan who understand that they aren’t consuming health care, it’s consuming them.” – Dale Folwell

Folwell’s plan is attracting national attention because of its far-reaching implications………………

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Montana Association of Counties Moves To Reference Based Pricing

December 1st, 2018

Why The Move to a Medicare Reference Based Pricing program?

The cost of medical services continue to rise at a rate far faster than inflation of other goods/services and faster than employees’ pay. Reference based pricing is the most effective tool we have to bend that cost curve. This change will mean less money going to health care expenses and more going into employees’ pockets. It also creates a system that is more fair, transparent, comparable and predictable than how hospitals charge us now.

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BCBS To Administer State’s Reference Based Pricing Plan

December 1st, 2018

If You Can’t Beat Them, Join Them…………………………BCBSNC embraces Reference Based Pricing in order to retain +700,000 employee lives in the great state of North Carolina……………..

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MY DOG HAS BETTER HEALTH INSURANCE THAN I DO!

November 30th, 2018

While chasing a squirrel in the woods, beloved pet dog tore the anterior cruciate ligament in her left knee. Turns out she had better insurance than her master………………………………

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State Health Plan Launches New Provider Reimbursement Effort

November 30th, 2018

       Dale Folwell

“For years, the plan has paid medical claims after the fact without knowing the contracted fee. It is unacceptable, unsustainable and indefensible. We aim to change that.”

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NC State Treasurer Displays Big Brass Cojones

November 29th, 2018

Now we know where Texas lost it’s cojones (Has Texas Lost It’s Cajones?)………..in North Carolina. Mr. Folwell, please bring them back! The upcoming Texas  biennial session needs them…..

“I’m calling for the United States Department of Justice and the North Carolina Department of Justice, on behalf of the State Health Plan, to recover the potentially hundreds of millions overcharged to consumers by hospital management from this illegal activity.” – Dale Folwell

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Replacing Employer Sponsor Health Insurance With Government Run Insurance

November 28th, 2018

This excellent White Paper examines some of the implications for health care financing and delivery were the U.S. government to supplant employers as the financer of medical care for most workers and their families…………………….

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Wait, Expensive Hospitals Aren’t The Best Choice?

November 28th, 2018

Dave Chase

When patients choose a hospital or other provider, they don’t really know what they’re getting………..The reality is that status quo health benefits are a horrible value proposition for employers and individuals……………

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How To Charge $1.6 Million For a New Drug And Get Away With It

November 27th, 2018

Call it a warning shot: last week an Indian patent court shocked the $600 billion global pharmaceutical business by ordering Bayer, the German health care giant, to allow a tiny Indian generic drug company to sell cheap copies of the blockbuster cancer drug Nexavar – even though everyone agrees that the drug is protected by a patent…………………..

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Is Medicare Part D Worth It? Dr. Dave Explores…………………….

November 27th, 2018

David Belk, M.D.

The question I’m addressing today is: How much help can you expect to get from your Part D plan when you use it to buy prescription drugs?

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Nevada Wades Into National Debate About Association Health Plans

November 27th, 2018

t’s history repeating itself.  Been there done that…………………..

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Why Self-Funding is A Better Way To Finance Health Care

November 25th, 2018

Milliman White Paper Shows How Self-funding Gives Employers More Control Over Medical Insurance Programs

MyHealthGuide Source: Jennifer Janvrin, CEBS, 11/2018, Milliman White Paper (full text)

Editor’s Note (Ernie Clevenger): This excellent White Paper by Milliman provides key values of self-funded and statistical tables to illustrate risk and risk management.

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Brazil Replaces Leaving Cuban Doctors

November 24th, 2018

Healthcare is Cuba’s most lucrative export. The “More Doctors” aid programme operates in 67 countries, and makes the island $11bn a year…………………..

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The Payer You Never Heard Of

November 23rd, 2018

You won’t see recognizable logos or insurance company names on their health insurance I.D. cards. You may wonder “what kind of insurance is this?”

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ER Doctors: 3 Priorities for Self Preservation…………

November 22nd, 2018

The three priorities in order of importance in practicing medicine: (1) Don’t get sued, (2) Make Money and (3) Take Care of Patients…………………………..

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Jenny & The Mexicats

November 22nd, 2018

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Cuero, Texas Home of The Turkey Trot

November 22nd, 2018

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Austin, Texas Sick Pay Leave Unconstitutional

November 21st, 2018

Judiciary says it’s unconstitutional, so legislators  have developed a cure of their own………….

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More Employers Are Leaving Fully Insured Plans………………

November 21st, 2018

“To gain control over the ever-increasing cost of employee health insurance, more and more employers are discontinuing their fully insured coverage and switching to self-funded models.”

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Health Care Ate America

November 21st, 2018

In the five decades after the passage of America’s two largest health care entitlements, that sector has become a maw, eating everything in its path. Health spending has reshaped the nation’s job market, its household finances, and its public budgeting…………………..

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Ending American Greed?

November 21st, 2018

“The greed of the prescription drug industry is literally killing Americans and it has got to stop…..”

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Texas School District Seeks To Exit TRS ActiveCare

November 20th, 2018

Once enrolled on the TRS ActiveCare health plan, school districts are forever prohibited from leaving. There are no exceptions permitted. Or are there?

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BenefitMall

November 18th, 2018

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Merloch Coins New Term For Reference Based Pricing

November 18th, 2018

Michael Meloch, President of TPAC Underwriters, comes up with a new term for Reference Based Pricing in a Phia Group podcast…………………………..

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