“On January 18, 2022, State Farm sent an email recruiting its agents for a “unique project”. Consumers’ Research obtained a copy of that email, and we knew we had a duty to alert the public.”
Meet the Vitori Victory© Guarantee, the first of its kind. This health plan savings guarantee will reimburse you up to $1,000,000 if we don’t hit your savings target.*
“How Sweet It Is…………………….!
Pharmacists and wholesalers can import drugs from Canada but only as part of state programs ……………meanwhile, back at the ranch, everyday Americans are importing Canadian drugs for personal use often facilitated by plan sponsors under the personal use doctrine achieving significant savings. An 800 life San Antonio employer ran 12 months of paid drug spend through CANARX and found they could have saved over $800,000………A county government employee health plan has saved millions by importing Canadian drugs for personal use of their plan members since 2004…………….
The most effective way to address the NSA legislation, particularly elements of the IDR process, is to adopt a “pure” RBP plan.
Health Insurance Carrier Stock Performance Has Been Amazing!
The cost for Latuda oral tablet 40 mg is around $1,503 for a supply of 30 tablets according to drugs.com. That’s $50 per pill.
In 2019, C2CRx member companies spent 47% PMPM less than the Industry National Average; Since drugs represent 20 to 30% of a plans costs, this represents 10 to 12%
The evolution of specialty drug risk transfer gains speed as more employer sponsored health plans face crippling and unsustainable costs for drugs that shouldn’t cost that much………………and don’t in other countries.
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.
Employer: “Specialty Drugs Aren’t Covered!”
The best way to avoid risk is to eliminate it. That’s what more employers are doing these days with high-cost specialty drugs……………
A Kraut’s Dilemma in Combat
By Col. E. Rusteberg
At the time of the Battle of the Bulge in WWII, my unit was in charge of the defense of a small village in Alsace.
“Median prescription drug manufacturer pre-rebate costs per covered life increased by 54.5% for individual plans, 24% for small group plans, and 7.6% for large group plans annually……”
Truth, fiction and word smithing intertwined requires expert unpacking for the benefit of clueless laypersons. With that in mind, the following applies.
Cost Containment Strategies Haven’t Changed In 18 Years
This 2004 report by the State of Texas outlines strategies employed towards controlling rising medical costs that haven’t changed since. The solution? Reduce benefits and cost shift to plan members.
Back in the day insurance companies required 75% participation of eligible employees to achieve an acceptable spread of risk. Now we see carriers requiring much lower participation requirements. What happened?
“Good news!” says the PBM representative, “Your generic spend equals 90% of total drugs dispensed, Good Job!”
“Wow!” says the CFO, “That’s awesome……. members are getting the cheaper generic drugs! We must be saving a ton of money!”
“Yes indeed, we’re saving you money by charging more!” purrs the rep.
In reading today’s financial news I noticed an article about John Ruiz, a Cuban immigrant made good. He made his billions in the health care industry by recovering health claim dollars on a commission basis for his clients. (See article below)
This is an action for restraint of trade, unlawful monopolization, and unfair methods of competition seeking classwide damages and injunctive and equitable relief under the Sherman Act, 15 U.S.C. §§ 1 et seq., and Wisconsin’s antitrust laws, Wis. Stat. §§ 133.01 et seq
“Who Me? I didn’t count those bills!
“In the first two months of 2022, the NSA prevented more than 2,000,000 potential surprise medical bills across all commercially insured patients………….”
A surprising number of new businesses were started during the pandemic, from online ventures to side-hustles-turned-full-time and more. These new businesses need liability insurance coverage, and Hiscox can provide it.
By Molly Mulebriar
“Daddy, what do you do for a living?” asks the son. “I destroy relationships” says the daddy.
By Bill Rusteberg
Imagine a group health plan option costing around $400 per month for single coverage and about $1,000 for full family coverage with no financial barriers to healthcare. No deductibles, no co-pays, no co-insurance and no balance billing.
HOSPITAL: Our chargemaster says you owe us $229,112.13!
PATIENT: But you told me I owed only $1,300! What’s a chargemaster?
HOSPITAL: We make up absurd pricing so we can “negotiate” discounts with insurance companies like Blue Cross, United and all the rest. You’re not an insurance company. Besides, what’s a few extra bucks! Pay up!
PATIENT: What’s the 13 cents for?
By Bill Rusteberg
Under new government health care transparency rules health care consumers are now able to see prices before they buy instead of learning prices after they purchase services. What a novel idea!
“PBM’s will acquiesce almost any rebate guarantee as long as they are still allowed to procure generic meds via an AWP discount method.”
How can consumers know for sure their claims are paid correctly? How can plan sponsors be sure too? How many take the time and effort necessary for proper plan oversight?
TRS ActiveCare Official Reacts
“Texas school districts can improve benefits and remove financial barriers to healthcare while reducing costs at the same time based on proven risk management strategies that have been successfully operating in school districts for years.” Read the rest of this entry »
Want out of TRS ActiveCare immediately? There’s a provision in the Texas Administrative Code that can make that happen.
NOTICE TO ALL EMPLOYEES: Where you go for health care is your business. How it’s paid is ours.
Article Referred By Lisa Behnke, M.D.
Ms. French was sued by a hospital that had initially given her an estimate of $1,336.90 for a necessary back surgery only to later bill her $303,709.48, asserting that she had agreed to pay “all charges” billed by the hospital…………………..
After reviewing the claim and the provider attorney letter, USB felt the best next step was to engage an ERISA attorney.
Senate Bill 1444 allows TRS ActiveCare member school districts to exit the program for the first time in 20 years. This has unleashed a competitive market for Texas school districts with multiple vendors actively seeking district business.
If Roe v Wade is overturned, will this change faith-based employer’s view on staying grandfathered? Read the rest of this entry »
Most residents in South Texas qualify for free hospital care under Hospital Financial Assistance Programs (HFAP) promulgated under the Affordable Care Act.
A basic ACA compliant Minimum Essential Coverage (MEC) plan doesn’t do much for plan members. Rather, it is simply a strategy enabling employers to avoid certain punishing government mandates designed to force employers to the government’s will.
“What network do you belong to? asks the in-take clerk. “I’m on the Medicare network” replied the member. “That’s funny, there is no indication of that on your I.D. card” responds the now puzzled in-take clerk. “Well, our group plan is on the Medicare +20% network, it’s sometimes called a Reference Based Pricing plan. Since you take Medicare patients already, you’re really gonna like our plan!” says the member. “Cool” says the in-take clerk.
“You’d better believe the hospitals will go after you for every penny. Here’s a copy of a letter one of my patients brought me.”
SOURCE: Hospital Billing | True Cost of Healthcare
“When a business sends a bill, to you or to another business, you pretty much expect the bill to show the value of what they provided, and therefore what they expect to be paid. But an insurance company pays the hospital based on pre negotiated rates, no matter what the bill asks for……………”
Hospitals Look to Raise Treatment Costs as Nurses’ Salaries Increase – Health insurers and employers are pushing back against requests to increase hospital prices by as much as 15%….. Read the rest of this entry »
By Doug Aldeen – ERISA Healthcare Attorney and General Counsel
“Mama’s don’t let your sons grow up to be cowboys but a medical debt collector in the state of Texas is perfectly acceptable………”
Psst, Godfather! The Cat’s Outa The Bag!”
“You don’t want me to know your business because it won’t be good for you.”
Amazing things happen when vendors compete for business. With the passage of SB1444 by the Texas legislature this past session, TRS ActiveCare member districts are allowed, for the first time in 20 years, to exit the program and seek competitive alternatives in the commercial market.
Borders are manmade lines. The Texas / Mexico border along the lower Rio Grande Valley segregates medical care givers into two different economic pods. Drug manufacturers serve both but with vastly different pricing models.
The future of health care reimbursement is cash paid at the point-of-service funded by employers insuring over 170,000,000 Americans through work-place employer sponsored health plans. Screw insurance companies and other blood sucking third party intermediaries. Read the rest of this entry »
For the first time in 20 years the TRS ActiveCare government health plan hasn’t raised rates or reduced benefits to plan members. The Texas legislature has dumped hundreds of millions in additional funding cloaked as “Covid Relief” to keep the program solvent………….This has little to do with regional rating or anything else about controlling health care costs, which it doesn’t. More money-out with more money-in simply means more money…………… not less.
“Now you can earn $100 per enrolled employee for every NEW Small Group (5 to 50 employees) you enroll into our Anthem Balanced Funding (ABF) plans, through 6/1/22 effective dates. Thereʼs no cap on how much you can make.”
“Maine’s Democratic governor, Janet Mills, signed legislation directing the Maine Health Data Organization (MHDO) to report annually on the potential savings if certain drugs were subjected to a referenced rate, which is the lowest of the prices available among Canada’s four largest provinces and the wholesale acquisition cost, beginning January 1, 2023.” MORE >>
Watch a health insurance renewal presentation on a 450,000 life case unfold before your very own eyes! Will rates go up? Will benefits reduce? Or will something magical happen?
“Blue Cross Members Get a Network with 95% of Doctors and 96% of Hospitals in the U.S.”
“The most effective way to address the No Surprises Act (NSA) legislation, particularly elements of the Independent Dispute Resolution (IDR) process, may be to adopt a pure RBP plan that does not contract with providers……………….”
The open portions of the April 28, 2022, meeting are being broadcast over the Internet…….
Texas hospital officials expressed relief that the future of the waiver was no longer in question but continued to push for other programs to help pay for the care of Texas’ uninsured population — the largest in the nation.
By Doug Aldeen on Linkedin
In Alec Baldwin’s iconic role in the seminal 1992 movie, Glengarry Ross, he advised his underlings to “always be closing ” (“ABC”). In Colorado, for hospitals under HB 1285, “ABC” =always be compliant… .
Government To Remove ACA Handcuff?
The Telehealth Benefit Expansion for Workers Act would allow employers to offer standalone telehealth service programs……………
A reference based pricing plan having direct provider contracts is by definition a “network” plan. (See definition of “in-network” in Code of Federal Regulations, 147.210, XII) In that instance a plan sponsor must publicly display in-network information containing name, CPT code and negotiated rate and fee schedule rates.
“Coming soon to a television near you: Our own Doug Aldeen is featured in this upcoming series on medical debt by our news partner KXAN TV in Austin, Tex.” – Jeanne Pinder – Founder, CEO, clearhealthcosts.com
Car dealer’s approach to health insurance lifts employees and profits
As working Americans struggle to manage the rising cost of health care, one Lakeland car dealership has developed a new way of trying to close the door on higher costs.
“It’s easy to get Medicaid, for sure,” Dr. Lazzopina says. “But just because you have a card doesn’t mean you’re going to get an appointment, at least any time soon.”
Is government health plan financing simply a price fixing scheme having little to do with supply and demand resulting in constricted access to care in an otherwise (almost) free market system?
By Bill Rusteberg
Sometimes we read things and wonder “what the heck were they thinking when they wrote this? Is there something I’m missing here!”
John Kirke leads BevCap Management’s healthcare captive team, client services and growth strategies empowering clients to create value for their organization through healthcare benefits sponsored in stop loss captives.
A.J. Loiacono Doesn’t Mince Words
Trying to understand the mystery world of American drug pricing will drive one to the nut house faster than you can spell P-H-A-M-A-C-E-U-T-I-C-A-L-S.
By Bill Rusteberg
A patient in severe pain barges into the doctor’s office screaming “I need to see the doctor! I’m in pain, terrible pain! Please, tell the doctor I need help!”
The DPC Coalition and American Academy of Family Physicians spent two years in collaboration with Milliman and the Society of Actuaries on a comprehensive evaluation of Direct Primary Care (DPC) as a growing health care delivery and financing model.
By Bill Rusteberg
Years ago when I was a sales representative for a health insurance company a disgruntled plan member cornered me, screaming her claim was denied. “Our insurance sucks! I pay a lot of premium and I don’t get anything in return!” she screamed for all to hear.
Last fall the Texas legislature gifted the TRS ActiveCare health fund +$200,000,000 and called it “Covid Relief.”
