
PBMs: The “Tapeworm” Revealed
How is it that the process of distributing a drug and tracking who buys it sucks up much more of the value chain than actually making it?

PBMs: The “Tapeworm” Revealed
How is it that the process of distributing a drug and tracking who buys it sucks up much more of the value chain than actually making it?
By Bill Rusteberg
In 1982, after nine years of corporate servitude, I left the inner sanctums of a large health insurance company and the comfort of receiving a corporate paycheck every two weeks whether I earned it or not.
Continue reading Feeding Brokers At The Expense of Starving Ones

By Bill Rusteberg
“Playing” health insurance brokers is the easiest sale ever. I was reminded of that today when a company rep. said “Bill, I never call on a prospect directly, I always work through the broker on the case. It’s the easiest sale ever. I don’t have to cultivate a relationship with the client. That can take years. It’s already been done by the current broker.”

J. Patrick Rooney is considered by many to be the Father of Margin Based Pricing better known these days as Reference Based Pricing. Many believe his conclusion of what the “sweet spot” reference point should be still holds true today.

Associate Superintendent of Human Capital and Operations Anthony Sorola and Medical Plan Consultant Eric Smith listen as Director of Benefits & Risk Management Yolanda Gordon talks about the newly opened ECISD Wellness Center. (Ruth Campbell | Odessa American)
Continue reading West Texas School District Opens On-site Clinic
You Can Always Count On Aldeen’s Weekly Bathroom Read Series Which Has Never Missed A Deadline Even In The Hardest Of Times………We Can’t Wait For The Easter Edition…….
Continue reading Weekend bathroom read (Spring Break/Hangover Edition)

“For 2021, the NET prices for brand-name drugs dropped – for the FOURTH consecutive year…….” Lantus, an insulin drug, has fallen 62% since 2012 but costs for patients with health insurance who use Lantus have GONE UP by 60% over the same period.”

Global reinsurance giant Swiss Re has reportedly decided to cease taking on new business with clients in both Russia and Belarus amid the ongoing invasion of Ukraine, according to Reuters.

How will each regional service center identify and analyze three alternative health care options within their region?
Continue reading Texas Legislature Wants School Districts To Assess Health Coverage Options
A San Antonio brokerage firm touts their success in helping a San Antonio school district reduce their medical spend by 40% by implementing ……….Drum Roll Please………..A wellness plan. We find this hard to believe.
“Pssst Godfather….We Need To Get In The Drug Business!” We can make a lot of money in rebates…….I mean kickbacks. And we can open specialty pharmacies and skim off the float too and call it spread pricing or shrinkage……………We can call ourselves Pharmacy Benefit Managers……..Has a nice ring to it……………..We can make some really serious money Godfather!”

A hospital in Munich, Germany sent this letter where they announce that “from now on and until further notice, we will not treat Russian and Belarusian citizens.”
Continue reading German Hospital Refuses To Treat Russians or Belarusions

By Bill Rusteberg
White Flag plan sponsors are those employers who cower to the Great American Health Care Industrial complex, willingly prostrating themselves to continued abuse at the hands of hospital administrators, insurance companies and a host of third party intermediaries.
Continue reading White Flag Plan Sponsors Need An Intervention

Dear Valued Employees, we are pleased to announce we have added medical expenses to your company provided expense account effective immediately………..
Continue reading Good News! Your Company Expense Account Now Includes Medical Expenses!
Mark your calendar – Continue your education here…………………
Continue reading Advanced Health Care Studies 401 – New Group Requirements Under The CAA

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

With little formal training, a majority of health insurance brokers back in the day were simply spreadsheet artists………………………….
Continue reading Managing Risk vs Servicing Risk – The End of Status Quo Brokers?

By Marissa Plescia
Five medical bills have made headlines in the last few months, including a $13,000 one for a kidney donation and a $847 “facility fee” for a telehealth visit.
Self-funded plans need to check their administrative services agreements to see exactly how much responsibility they might bear for decision-making…. Who will make decisions and represent the plan when it comes to arbitration? Will it be Tom, Dick or Harry?
Continue reading NSA – Whose Responsibility? Who Makes The Decisions ?
“For 2022, many TPAs are subjecting NSA claims to their ‘shared savings’ and similar programs, which could result in unexpectedly large fees….

C2C Choice Rx provides patient concierge and advocacy services………….. With our patient assistance program, you will typically get your medication for free.
“I Call The Plan Fiduciary To The Stand!”
Whether they like it or not plan sponsors must now understand they are in the health insurance business……
Continue reading Why a ‘Tidal Wave’ of Fiduciary Lawsuits Are Coming Soon
Yale University reached a nearly $1.3 million settlement with workers who say a rule requiring them to participate in a wellness program or pay a fee violated federal disability bias and genetic information laws, Connecticut federal court records show.
Continue reading Yale Reaches $1.3 Million Deal in Wellness Plan Bias Suit
This report briefly summarizes each kind of HRA, highlighting key aspects regarding eligibility and insurance coverage requirements, contributions, distributions, and the treatment of unused balances for each arrangement. It also provides a side- by-side comparison table of the different kinds of HRAs.

“How Sweet It Is!”
Doctors say a young boy called Easton has made medical history by becoming the first person in the world to receive a combined heart and thymus transplant.

Dr. Joseph Fraiman: “Personally, I would like to apologize to the three other scientists sitting with me here on Zoom, the proponents of the Great Barrington Declaration…I’m sorry, because I believe now you guys were correct. And you were correct from the beginning.”

“Eighteen-year-old high school student Edger Mulili says he would not be alive today if his father had not contributed $5 a month to a government health insurance scheme.”
Continue reading National Hospital Insurance Fund (NHIF) Saves Edger’s Life

“Thank You Consolidated Appropriations Act, 2021!”
“The motherlode for the plaintiffs’ bar however is in the broker/consultant compensation disclosure rules. For starters, there is the obvious claim that the rule was not properly followed, thereby triggering a prohibited transaction. Equally obvious and even more worrisome, however, are claims that are right out of the 401(k) litigation playbook: the plan paid excessive fees and plan fiduciaries were not paying attention. Essentially, the statute’s focus on fee disclosure invites scrutiny of the underlying fees and the accompanying fiduciary engagement.”
Continue reading Lawyers, Spiders, Snakes and Other Scary Things

What if you could buy healthcare like you buy anything else? If you know you need a knee replacement, imagine going to a website, picking an operation, and seeing the price, just like you do on Amazon or McDonald’s……………………..
Continue reading Welcome Sir. Here’s Our Menu. May I Get Your Drink Order While You Decide?
Ever wonder why your provider asks if you have “other insurance……………”
Continue reading Insights on How Insurance Companies Handle Medical Claims

Thinking Outside The Box
“Hue builds health plans around the concept of advanced primary care as the center of all patient care coordination–a “healthcare quarterback.” Their highly scalable, value-based network approach enables providers to focus on practicing medicine how they see fit based on what their communities need, spending dramatically less time on billing and administrative services.”
Continue reading Replacing Traditional TPA’s With Next Generation Health Plans
This is another great video by Eric Bricker. But he may have missed one other important quality in banging a deal together for the home office……………….

Today, doctors and teachers are exiting entrenched institutions and building exciting, new models that offer greater freedom and flexibility for all.
Continue reading Bye-Bye Bureaucracy & Burnout: Teachers and Doctors Build New Alternatives

Dental assistant Atkins trained to calm uptight patients without slobbering………….
Continue reading Snuggle Ready Dogs Join Health Care Provider Community

The federal government pays the employer a set amount for each person in the plan……..
Continue reading Hallelujah! Group Retiree Health Plans Discover Found Money!

Sold policies to more than 400,000 individuals across America over the phone…..
Continue reading How Steven Dorfman & Friends Made A Fortune Dialing-For-Dollars

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“Sanctions also will affect the balance sheets of Russian insurers and their relationships with international partners,” added Todor Kitin, financial analyst. “The valuation of investments would be affected by a prolonged equity market downturn, any increase in the Russian Central Bank’s policy rate or a widening of credit spreads. On the other side of the balance sheet, higher-than-anticipated inflation would impact claims costs, with potential implications for the adequacy of reserves.”
Continue reading Ukraine Invasion to Likely Have ‘Substantial Impact’ on Insurance Industry
Single-payer proponents haven’t been able to broaden their movement beyond liberal activists or convince people that they should pay higher taxes in exchange for scrapping health care premiums, deductibles, and copays.
Continue reading Liberal Activists Fail To Revamp American Health Care

The Feds are about to set higher interest rates in March, or so those on the streets say. It is expected more hikes will follow each quarter of 2022. With the government printing presses working overtime, dumping more fake money into the economy, prices are going up everywhere and the feds are worried, or should be. The fake money supply has increased by more than 20% in the past year alone.
Continue reading How Will Rising Interest Rates Affect My Health Insurance Premiums?

Given the current litigation over the implementation of the No Surprises Act, I thought it worthy to highlight this “Bill of the Month” from NPR which highlights a “loophole” when a facility fails to provide the necessary documentation to support an ER claim.
Continue reading Aldeen’s Sunday Bathroom Edition, Winter Edition, Vol. 1, Article 3
Ever been told as a kid you couldn’t have something?
Continue reading World’s Most Aggressive Telemarketer Employs Ancient Sales Tactic

Business is about solving other people’s problems. Solving the high cost of healthcare giving employers a competitive advantage is ours.
“Providers could be more likely to use the federal IDR process to obtain higher out-of-network payments when doing so is not warranted. This could make the IDR process more likely to become inflationary, leading to higher health care costs and premiums.”

Drug pricing in this country is a scam but most plan sponsors are doing nothing about it. That makes them complicit.
Continue reading The Great American Rx Ripoff – But No One Seems To Care

Attention insurance agents! Quote, Bind and Enroll group health plans all by yourself while sitting at home in your pajamas……………………..
Murray was a most amazing character and ended up selling me life insurance….. at 27 years old!
Continue reading King Murray – The Most Outrageous Insurance Salesman Ever!
World’s most ethical company has an important position to be filled in San Antonio, Texas. It involves revenue cycle management of one of the world’s largest hospital chains.
Continue reading World’s Most Ethical Company Seeks Charge Master Specialist

Politicians like to talk about bringing the price of prescriptions down, but per usual, the true leaders in society actually do it………………..

Whether to continue with a status quo health care plan or move to something different, public school districts face social, political, and administrative considerations all of which play an important part in the decision-making process.
Continue reading School District Announces Willingness To Fight Healthcare Costs
ILLUSTRATION: JOSIE NORTON
They are popular with managers and some workers, but overall they achieve little…………
Continue reading The Problem With Employee Wellness Programs

Victor Lustig Would’ve Approved!
“None of us want to underfund a hospital that is providing legitimate services, but this borders on criminal.” – Michael Watson
Continue reading OMG! HCA Hospitals Billing At 1,000 – 1,500% of Medicare?

Continue reading Attention School Districts! Want Funds For An Onsite Clinic? ESSER To The Rescue

There’s Gold In Those Den Darn Hills Boys!
This opportunity is for you. Learn about comprehensive technology designed to improve your patient outcomes and increase your revenue. No new staff or new patients required — with typical clients seeing 11.2x ROI!
Continue reading $20k More Monthly Revenue, Better Patient Care……In Just 2 Weeks!

Employers are living a nightmare. The American middle class is too……………
Ever call your insurance company about a claim? Or, if a broker, have you ever responded to an advertisement for a neat, new insurance brokerage product?
Blue Cross contracted hospitals have historically found breaking up is hard to do. The standard BCBS hospital contract is an annuity – hospitals get paid even if they don’t see patients.
What if doctors ran health insurance companies and in a position to develop health benefits based on their training and experience? After all, the doctor knows best…..
Continue reading What If Doctors Ran Health Insurance Companies?

Welcome to the fourth LUMINARIES Briefing of 2022. I’m Janet Levaux, editor in chief of ThinkAdvisor, and I’m pleased to announce that nominations for our 2022 recognition program are now being accepted online through April 29, 2022.

Hospital consolidation has crushed everyone’s bank accounts and has led to the rise of anti-competitive contracts that force insurers and employers to accept take-it-or-leave-it terms.
Continue reading Patients Are Coming After Hospital Monopolies

In the last Texas legislative session SB1444 was passed requiring each regional service center to poll all districts within their service area to determine if TRS ActiveCare members are happy or unhappy with their crappy and expensive health insurance benefits.
Continue reading Texas Legislature Wants To Know If There Is Something Better Than TRS ActiveCare

“Insurers are facing an extreme escalation in inflationary pressures that increasingly strained rate adequacy last year……….”

UnitedHealth Group was the most profitable payer in 2021, bringing in more than double the profit of its next-closest competitor with $17.3 billion in earnings.

”Private investors, retailers and health insurers are pumping billions of dollars into primary-care ventures in a reversal that’s turned one of American medicine’s least-lucrative practice areas into a hot spot.”
Continue reading Wall Street Billions Chasing Primary Care Mother Load

Why do self-funded plans hide behind a logo? Employers who self-finance their employee benefit program almost always do. It’s a practiced deception designed to fool everyone.

“Is it acceptable that our biggest employer and charity — one that made $1 billion in profit last year — forces their own employees to choose between paying their medical bills and their rent or getting sued?”
Continue reading Aldeen’s Sunday Bathroom Edition – Winter Edition, Vol. 1, Article 2

Market Conditions You can expect to pay more for insurance again this year. We suggest that you consider budgeting for these increases:

A Florida appellate court ruled Feb. 4 that Physician Partners of America must pay its competitors for hiring their former employees while they were under noncompete contract provisions……………….
Continue reading ASC To Pay $3.3 Million For Stealing Employees

South Texas Insurance Legend & “Tripa Club” Founder
McAllen – Jesus (Jesse) S. Trevino, age 95, died on Friday, September 3rd, 2021 surrounded by his loving family at McAllen Heart Hospital.

It’s Time To Escape From Inside The Box (or are you a scaredy cat?)
Schenectady County is saving millions per year on their group prescription drug program……
Continue reading County Program Saves Big On Prescription Costs — With Help From Canada
Report: Excess Deaths Up 40 Percent Among Americans 18-49
Continue reading Americans 18-49 Are Turning Room Temperature At Alarming Rates
Selling is a profession to be learned. It takes skill, experience, and an understanding of human nature.
Continue reading What Do You Say When You Hear “I Will Get Back To You”


By Molly Mulebriar
Health insurance in this country no longer exists. It has become nothing more than a highly regulated entitlement, a government utility subjecting employers to punishing government mandates and sanctions if they don’t conform.