Risk Managers

Drugmakers pushed aggressive diabetes therapy. Patients paid the price.

Pharmaceutical giants launched years-long marketing campaigns for a treatment target they helped create, and as their sales of diabetes drugs soared, so did incidents of low blood sugar, a potentially deadly medication risk.

Are hospitals gaming the system at the expense of low income patients?

“The insurer may not base the reimbursement to the physician or provider on the insurer’s usual and customary rate; and shall reimburse the phnysician or provider at the physician’s or provider’s specialty rate in accordance with the physician’s or provider’s expertise, experience and rate history.”

“It is the intent of the legislation that the premiums for TRS-Care and TRS ActiveCare be calculated and adjusted taking into consideration the money appropriated ($286,337,761) under this section.”

Some make getting aid hard, delay checking eligibility and press for payments that aren’t refunded…….

“This is going to be the solution that frees you from the dysfunctional medical system…….People have been led to believe that healthcare is so expensive that they can’t afford it without insurance… we teach you how to go without insurance and yet not be financially at risk. We call it assurance, vs. insurance.”

I was a 19-year-old machine gunner at the Battle of the Bulge in World War II. And I didn’t talk about my Army service for more than 65 years after that.

Ed Snowden releases a new cache of emails purloined while working for the CIA. One explosive email exposes a sinister conspiracy to upend American commerce.

The next biennial Texas legislative session begins January 10, 2023 and it’s going to be a doozy, action packed with a significant number of bills to be introduced related to insurance matters.

Johnny Dollar was every insurance executive’s dream, an investigator who found the bad guy, or girl, and kept the insurance company from paying out a bunch of money on a bogus claim. People offered him a cut of the money and women offered him even more but Johnny couldn’t be persuaded to throw away his integrity for a bribe.

It takes hospitals months and months to get paid for services. It involves pre-certification, claims filing, handling claim disputes, chasing patient share and a whole lot of other nonsense. After reading the article below timing couldn’t be better to suggest to hospitals there is a better way.

PBMs are one of the seven parts of the prescription medication ecosystem………………

By David Contorno on Linkedin (Posted Saturday, 13 November 2022

Our 13 year old daughter, Hannah Contorno, who many of you met at our inaugural You Powered Synpoisum, was diagnosed with a rare blood disorder this week called Acute Immune thrombocytopenia (ITP).

“Employer-purchasers need to let go of their “devil you know” mindset and stop buying into the narrative that employees can’t handle change. Although there may be risks in taking action, they are far less than the risks of comfortable inaction that have enabled a vast transfer of wealth from working Americans to the medical industrial complex.” – Neil Quinn

By Bill Rusteberg

If you’re active in vying for public sector business we extend our deepest sympathies. It’s a tough world out there dealing with politicians and bureaucrats.

Hospital spend equals 40% of a plan’s spend. Professional spend equals about 20%. That leaves 40% left over. Guess which beast feasts on the remaining 40%?

Interesting numbers happen when a plan excludes specialty drugs……………Then factor RFP & CPO…

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.

“We then compared that uninsured person to us – what we’re paying – and in many cases what we found is we’re paying more than an uninsured person.”

“Full disclosure of direct and indirect compensation triggers the business equivalent of finding out one’s spouse cheated on them.”

Employers Don’t Pay – You Do

Employers don’t pay a dime towards employee health insurance. Employees pay the full boat but don’t realize it. Try explaining that to the police and fireman union during the next negotiation cycle.

A HSA is by far the best tax advantaged investment ever devised by mankind. Contributions are tax exempt. Withdrawals before age 65 for qualified medical expenses are tax exempt. Withdrawals at age 65 and used for any reason are tax exempt.

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?”

(This article first appeared on this blog March 7th, 2021. It was written at the suggestion of the President of a local County Medical Society representing over 4,000 physicians in Texas. His intention was to recommend it be published in their monthly newsletter. It never was.)

Walgreens-backed VillageMD announces $8.9 billion deal

by Bloomberg 08 Nov 2022

by Michelle F. Davis

VillageMD, the primary-care provider controlled by Walgreens Boots Alliance Inc., has agreed to acquire Summit Health-CityMD in an $8.9 billion deal that shows the drugstore operator expand deeper into health-care services to reduce its reliance on retail.

New proposals for universal health care in Oregon and Washington

ROGER COLLIER 

NOVEMBER 6, 2022 

Once again, it’s time to consider universal health care. What are the implications? Could it happen?

Status quo health care pricing through managed care contracts hasn’t worked out very well. Reference Based Pricing is an alternative, transitory strategy that has worked. But there is something better……….

If Rx standalone Stop Loss premium = 2-3% of overall Rx spend and the savings on medical stop loss premium is 5%-10% when carving out the Rx program, what is the net difference?

ReviveHealth and PCI Direct Care have partnered in a collaborative effort to bring a differentiated and competitive solution providing affordable and easy access to primary health care and prescription drugs for members located in the Lower Rio Grande Valley in deep South Texas.

Insurance companies have traditionally required a minimum percentage of employees to enroll in coverage. Participation requirements helps insurance companies avoid adverse selection. Minimum participation requirements have traditionally been 75%.

“The Medicare payment schedule released today puts Congress on notice that a nearly 4.5% across-the-board reduction in payment rates is an ominous reality unless lawmakers act before Jan. 1”

The independent thought leaders at Catalyst for Payment Reform (CPR) have recognized Vitori Health as a Market-Shaping Enterprise (MSE) that’s helping to reshape the dysfunctional incentives that influence today’s healthcare market.

By Bill Rusteberg

Five years ago a San Antonio plan sponsor had enough. Self-insured with a BUCA wasn’t working out too well. Three years in a row annual rate increase of 20% and more each year was unsustainable. Drug costs were going through the roof. Something had to be done.

Lucky Mary. She has a $1,500 deductible through her employers health plan but everyone else is paying for it because she’s not…………….

“If you could pay $25,000 for a car or $75,000 and the only difference was the overhead of the dealership, why would you pay $75,000?”

For the first time in more than a decade, your Medicare Part B payments will be going down in 2023.

When the dust settles 18 months from now Blue Cross of Montana is gonna look like Superman to Montana legislators by saving millions of dollars on the state’s Reference Based Pricing employee health plan.

Article Referred By Bob Calvisi

Kalsariya had no way of knowing then that she was embarking on a crusade that would take over a year, send their bill to debt collections, lead her to complain to the Illinois attorney general, and discover that the hospital charged nearly $7,000 for a procedure that was never performed.

Blue Cross of Montana throws in the towel and joins the Reference Based Pricing movement at the expense of their provider partners…………………

If TRS ActiveCare would adopt this strategy there would be no commercial vendor able to compete competitively. The only difference would be in fixed expenses which TRS ActiveCare would win hands down. Commercial vendors have enormous expenses TRS ActiveCare doesn’t.

If you can’t beat them, join them. A stirring giant ends hibernation in Montana………….

Price maker vs. price taker- Montana tweaks its RBR model

Doug Aldeen ERISA Healthcare Attorney and General Counsel

“…Montana is positioning itself to tweak its model, just as more states and employers, seeking to cut costs, consider adopting it. That has health economists and those working to lower hospital prices elsewhere wondering whether the state is once again moving ahead of the curve — or setting itself up for a setback.”

Aldeen’s Sunday Morning Bathroom Read exposes BCBS Admin. Agreement with the State of Montana. BCBS was recently awarded a contract to administer the state’s Reference Based Pricing plan.

Dr. Peter McCullough, one of the most respected doctors in the world, has been a beacon of light throughout this pandemic. His reward for speaking the truth? He’s being stripped of his credentials.

These four models should be fairly easy for Americans to understand because we have elements of all of them in our fragmented national health care apparatus…..

When it comes to solutions for the healthcare system, Americans are more divided. Younger Americans, those between 18 and 49, are more likely than adults older than 50 to believe it is the federal government’s responsibility to make sure all Americans have healthcare coverage. Overall, two-thirds of adults believe this, up from 57% in 2019 and 62% in 2017.

According the the American Hospital Association, “Only employer-based plans regulated under ERISA may use reference-based pricing as a comprehensive payment strategy.“

SOURCE: SOLVING THE HIGH COST OF HEALTHCARE WITH OTHER PEOPLE’S MONEY

The overarching goal of Obamacare was to expand access to health insurance, and to make it affordable.

“We’re leaving TRS ActiveCare and you’re not welcome back for five years!” says Little Rabbit Independent School District.

Employees facing unaffordable premiums and out-of-pocket burdens may decide to self-select out of group coverage in favor of individual policies, Medicaid (if eligible), or no coverage (uninsured).

An attractive, low cost, capitated employer sponsored plan for $125 per employee per month covering primary care, ER visits, lab and radiology with no co-pays, deductibles with no restrictions on pre-existing conditions?

Johnny Agent calls on an employer asking permission to quote on their self-funded health insurance plan. “Sure, here’s our census data, claims information, benefits summary, and current premium” says the CFO.

The clinic is the medical school’s first in a planned network of DPC clinics…..Startup costs for the pilot clinic are funded by a $1 million gift from The Cullen Trust…….patients receive customized, comprehensive primary care services for a flat, affordable membership fee of $60 per month….

“Let’s take our medicine that costs $1.20 and sell it for $130! And let’s have government tell consumers it’s free! And while we’re at it, lets tell them two doses offers very limited protection, if any, so make sure you take more doses, it’s free. Otherwise you may die sooner than later……………..……..later is better. Death is bad, life is good.

See where we’ve been, how far we’ve come and how we lead change……..

“As a result of the expanded eligibility for federal tax credits, employer plans may see a decrease in enrollment of spouses and dependent children in their health plans….

Mixing Reference Based Pricing with direct agreements is like mixing oil and water……………..

WE DUG IN DEEPER………………..HERE’S WHAT WE FOUND.

Thousands of pages, hundreds of documents, reams of case law, and more hours than we cared to count later…Somewhere deep in the research, we found it……………..

“Hospital Assistance Program has provided proven results through their efforts since 1990. Their recovery rate is excellent. This program also offers solutions for the patient that helps ease their mind.”

AbbVie is committed to helping patients get the medicines they need. That’s why we offer patient assistance programs that provide free AbbVie medicines to qualifying patients. Our Patient Assistance Programs are intended for people that live in the United States, have limited or no health insurance coverage and demonstrate qualifying financial need. In 2020, we assisted nearly 155,000 people.

HRAs are doubling on average among all states, with significant growth across all industries, types of employers and employee groups. 92% of adoption is happening among companies with 20 or fewer employees…………………

What’s next, a Broccoli Breakfast mandate?

Power On Your Health Plan

Self-Funding Reimagined for Small Groups

The process of traditional self-funding is complex and overly complicated for everyone involved, costing both time and money. Health in Tech (HIT) is the industry-leading insurtech company that delivers disruptive innovation that reimagines self-funded health plans.

If you are a full-time state employee lucky enough not to be a public school district employee Texas taxpayers will contribute $7,471.20 per year towards the cost of your Blue Cross Blue Shield health insurance for the 2023 plan year. But if you are a Texas public school employee the state of Texas contributes only $900 towards the cost of your Blue Cross health insurance, a funding level which hasn’t changed in over 20 years.

The hospital price transparency rule, which took effect in January 2021, requires hospitals to publish machine-readable price lists and display rates for medical services in a format that allows consumers to comparison shop. Insurers are now required to disclose rates they negotiate with providers.

Senate Bill 1444 was enacted in the 2021 Texas legislative session that amends law relating to participation in the uniform group coverage program for school employees. Senate Bill 1444 mandates a study with assessments to be conducted on the health care needs and health coverage options available to employees of Texas public school districts including charter schools.

At least once a day, Nancy Rahnama’s clinical nutrition practice in Beverly Hills, Calif., gets a call from a patient looking for a diabetes drug that they’ve heard can help them lose weight fast.

Of the more than 100 million Americans living at or below 400 percent of the Federal Poverty Level (e.g., a family of four with a household income of $106,000 or less), many might not realize they may qualify for low or no-cost medical care. Most likely, their employer and health plan sponsor are unaware of this opportunity as well.

Student Accident insurance coverages available:

• Excess/secondary student accident insurance coverage
• Deductible and coinsurance options and sub-limits can be added on certain internal benefits, such as physical therapy, orthopedic devices, etc.
• Fully insured or self-funded options available

Those impacted by the family glitch will have important new options to consider when open enrollment for 2023 marketplace plans begins on November 1.

Historic Exodus From Group Health Plans

Free, or near free health insurance extended to millions of Americans by Biden administration with the elimination of the “Family Glitch” will forever change group health insurance.