Jeff Evans, CRM, ACSF Passionate Risk/Insurance Educator-Coach-Author on LinkedIn: Three Healthcare Challenges Overcome by Virtual Specialty Care — And Why… (2024)

Great review of how the Big Pharmacy Benefit Managers manipulate employers and employees for profit over health. Employers have been hood-winked by obfuscation and deception.One of the biggest con jobs is "rebates". Really? How is overpaying for something just to get a portion of the overpayment back a good thing?Think about it like this: - Brand name drug "A" treats XYZ ailment, costs $10,000/month and pays a rebate of $3,000/per fill (30 day qty.). - Alternative therapeutic equivalent drug "B" with equal or higher efficacy costs $4,000/month but pays no rebate. - Employer lets PBM keep drug "A" on formulary over drug "B" for rebates. - Net Annual Cost of Drug "A" is $84,000 ($120,000 - $36,000 in rebates) - Net Annual Cost of drug "B" is $48,000 (no rebates) - Opportunity Cost: -$36,000 or +$36,000? - "But we got a $36,000 rebate . . ." - No, you overpaid by $72,000 to get a $36,000 rebate (your money back) and gave your PBM a $36,000 contribution to their profits instead of yours. The other games played on employers are just as bad.

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Here's a great post from Dean Jargo. He is absolutely right. The Big Health Insurance companies allow an astonishing amount of claims to be paid fraudulently, adding to their profits at the expense of employees and their health plan members. It is critical that employers put a stop to this abuse for both them and their employees. For employers, this is not only an issue of managing cost, but their fiduciary obligation to manage plan assets. Yes, employers are fiduciarily liable for this fraudulent abuse of plan assets and overcharging to employees/plan members.

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TO COVER OR NOT TO COVER - THAT IS THE QUESTIONHere's a great post from Mark Messick on employer approaches to their healthcare benefits. Do employers try to cover everything or limit the coverage to the more essential services?It depends on the goals of the employer. If they cover everything, more than likely the plan's cost will increase steadily, or possibly rapidly, to the point it is unaffordable. If an employer limits it to the essentials, it may not be competitive enough to attract and retain employees.With fully insured plans employers are buying an "off-the-shelf" or "pre-canned plan". It has fixed options with no ability to manage the performance of the plan. They get a fixed cost for 12 months, but then hope for the best at renewal.Self-funding used strategically allows employers to offer the best of both worlds. They can offer more options and can design their plan to meet the needs of their specific population of employees. They can implement the appropriate cost containment strategies for their plan and have access to data to manage the plan wisely and efficiently on an on-going basis, adjusting the benefits as necessary. The can also implement new strategies or replace specific service providers or point solutions as necessary or become available to the market.If an employer wants to offer an employee health plan but does not want to be involved other than offering it and paying part fo the premiums, then a fully insured option may fit. As long as they don't mind having no control over the increasing premiums and variability of renewals, i.e. - close your eyes and hope for the best.Self-funding with one of the Big Health Insurance carriers, or BUCAs, is a step in the right direction, employers can save money, but are still subject to the profit seeking business practices and the whims of the Big Health Insurance carriers. There are more limited plan options and typically little or no options for any other service providers or point solutions than those owned by the carrier they go with.If an employer is truly interested in being more strategic and managing the cost of their health plan, self-funding with an independent TPA and the guidance of an experienced advisor can pay dividends. It can enable them to flatten renewals and apply the savings to other areas of their business.It comes down to how the employer looks at their employee benefits plan, as an "Albatross or Asset".

This is an interesting article discussing inefficiency in our current healthcare system. This is also a contributor to the high cost of healthcare.The fact that there are more administrative personnel than healthcare professionals in our current system should be concerning to all. "Research has shown that there aretwice as manyadministrative staff as there are clinicians working in U.S. healthcare. There areover 22 millionhealthcare providers in the United States."Also, consider that many of those additional positions are senior executives with littel or no medical training or experience, but paid substantial salaries, many higher than the highest paid healthcare providers delivering care.A great example of the inefficiencies is still completing paper forms and submitting them via fax versus completing electronically and uploading or emailing them. Two administrators for every one healthcare provider? Really? That's a lot of overhead.

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Mark Cunn=ban's response to getting into the pharmacy space is great! "It's the easiest industry I've been in to disrupt," Mr. Cuban said.Why is it so easy to disrupt? Because it's so complicated, unnecessarily, and som any intermediaries have their fingers in the pie that when you introduce a simple, affordable, easy-to-use competitor it takes off. People know what the prices are and it's very transparent.Go figure, who'd have thunk someting so simple would take off compared to the vague, opaque, confusing version?

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HOSPITAL PRICING EXPLAINEDHere's a great peice from William Rusteberg explaining hosptial pricing. They scream, "We're not making money, we're not making money?" But somehow they keep building, running expensive TV adds, not meeting their charity care obligations, paying hospital executives BIG $$$, . . . oh, and saying how their committed to their patients.Their commitment to their patients seem like its more towarda squezzing as much money out of them as possible insteadof delivering the highest quality care, at an affordable price, which in turn would help amke sure peopole receive the care they need. (just my 2¢)

SABOTAGING PATIENT-CENTRIC HEALTHCARE REFORMGreat Post from Dutch Rojas. He hits the nail on the head!

Interesting article with great points about hosptial billing. Employers and their employees need to understand what's happening to them.

Here's another great post form Chris Deacon. She's exactly right! The next time you hear a hospital system executive talk about expanding to "better serve the community . . ." That's right, as long as it contributes to increased profits by expanding access to the services that make them the most money, not necessarily the services the community might need.