tag:blogger.com,1999:blog-37614700268160626852024-03-14T01:59:23.600-07:00Benefit RevolutionFree Market Solutions for Employee Benefits and Human ResourcesCraighttp://www.blogger.com/profile/14913599100409003265noreply@blogger.comBlogger1619125tag:blogger.com,1999:blog-3761470026816062685.post-69695547450799703602024-01-02T09:48:00.000-08:002024-01-02T09:48:00.018-08:00How Big Pharma and Insurance Work, From Insider Brigham Buhler<p> </p><div style="text-align: center;"><iframe allow="autoplay; clipboard-write; encrypted-media; fullscreen; picture-in-picture" allowfullscreen="" frameborder="0" height="351" loading="lazy" src="https://open.spotify.com/embed/episode/4mCXtp4ylKsOX5fHx6Qzd9/video?utm_source=generator" style="border-radius: 12px;" width="624"></iframe></div><div style="text-align: center;"> </div>Craighttp://www.blogger.com/profile/14913599100409003265noreply@blogger.comtag:blogger.com,1999:blog-3761470026816062685.post-34019035133142607072023-12-20T15:33:00.000-08:002023-12-20T15:40:05.660-08:00On Armstrong and Getty for a Couple Hours This Morning<p>7 AM Hour - <a href="https://open.spotify.com/episode/0afqI3SSblwXO5ZRWVqYs0?si=RHTZC5GISoSNYhINcoSTPA" target="_blank">Just a Wee Bit Less Dynamic</a>: features our guest, Craig, the Obamacare Guru, who joins Jack to discuss...</p><p></p><ul style="text-align: left;"><li>The escalation of Christmas...</li><li>The Trump/Colorado ruling...</li><li>Jack's confrontation conundrum...</li><li>Immigration...</li><li>Those magical family moments! </li></ul><p></p><iframe allow="autoplay" frameborder="0" height="200" src="https://www.iheart.com/podcast/64-armstrong-getty-on-demand-20474616/episode/just-a-wee-bit-less-dynamic-136913051/?position=9&embed=true" width="100%"></iframe><div><br /></div><div><br /></div><div>8 AM Hour - <a href="https://open.spotify.com/episode/4sKGtu1X4s57FAemnOufBI?si=MGkJr6lVSG-oWq8cd8FqaA" target="_blank">Just Eat Your Cotton Candy!</a> features Craig, the Obamacare Expert, who joins Jack to discuss...</div><div><br /></div><div><ul style="text-align: left;"><li>The Trump/Colorado decision...</li><li>Weight Loss Drugs...</li><li>The Ukraine/Russia War.</li></ul></div><div>Plus...</div><div><ul style="text-align: left;"><li>Expert military analyst Mike Lyons joins the show to talk about the Israel/Hamas war.</li></ul></div><div><br /></div>
<iframe allow="autoplay" frameborder="0" height="200" src="https://www.iheart.com/podcast/64-armstrong-getty-on-demand-20474616/episode/just-eat-your-cotton-candy-136919266/?position=1&embed=true" width="100%"></iframe><div> </div>Craighttp://www.blogger.com/profile/14913599100409003265noreply@blogger.comtag:blogger.com,1999:blog-3761470026816062685.post-14294077421712034972023-09-15T15:05:00.003-07:002023-09-15T15:05:36.460-07:00Healthcare's Final Frontier: Navigating the Wild West of RBP with Industry Renegades<h3 style="text-align: left;"><a href="https://gottwals.substack.com/p/healthcares-final-frontier-navigating#details" target="_blank">Omar Arif of ClaimDOC & Scott Schnaidt of HST on All Things RBP</a></h3><div><br /></div><h3 style="text-align: left;"><div class="separator" style="clear: both; text-align: left;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiMNkshVy6YMSVPBAw7ukrKQd7EVUVNIZL7U-AgluaGrPWA0vrofhKGhtOz27AFAIIRhoqwiFhlG5XJawvNyIwNhAe9tCLVuQNKoIM3G92_CobstzMOqsfnzmxBSidUrdMKf_01QM7CgyHrwSFLo1WAzn8KAWsj2zWG3t3E5_7OmiQfAdCDHMtB-mRfXTc/s1456/Omar%20and%20Scott.webp" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="664" data-original-width="1456" height="292" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiMNkshVy6YMSVPBAw7ukrKQd7EVUVNIZL7U-AgluaGrPWA0vrofhKGhtOz27AFAIIRhoqwiFhlG5XJawvNyIwNhAe9tCLVuQNKoIM3G92_CobstzMOqsfnzmxBSidUrdMKf_01QM7CgyHrwSFLo1WAzn8KAWsj2zWG3t3E5_7OmiQfAdCDHMtB-mRfXTc/w640-h292/Omar%20and%20Scott.webp" width="640" /></a></div></h3><div><br /></div><div><a href="https://gottwals.substack.com/p/healthcares-final-frontier-navigating#details" target="_blank">Link to audio</a>. </div><div><br /></div>Ever imagine healthcare could feel like the Wild West? Welcome to the untamed lands of Reference-Based Pricing (RBP), the sizzling frontier where a select few employers unleash radical savings while giving the traditional PPO system a stiff arm.<br /><br />Unveil a world where only 3-4% of employers dare to tread, but where jaw-dropping 30-40% savings rain like gold and concierge-level service is the sheriff in town.<br /><br />Curious about RBP's magic? This isn't just healthcare. It's "Health-FAIR!" Here, employers "price-match" medical costs against benchmark prices, slicing their claims in half compared to big insurers. <br /><br />Projections say employer healthcare costs will shoot up another 7-9% in 2024. Yet Medicare Part D Premiums are projected to decrease by 1.8%. All major insurers participate in both markets. The lesson? Employers with private insurance are subsidizing Medicare. But hold your horses. With RBP, brace yourself for a 0-2% trend that turns the tables on traditional care.<br /><br />Jump into this roller-coaster ride of a podcast with your guide through this maze, joined by two titans of the trade—Omar Arif of ClaimDOC & Scott Schnaidt of HST. They've both cracked the code, each in their unique ways, and the results? Nothing short of spellbinding.<br /><br />🎯 What's on Tap:<br /><ul style="text-align: left;"><li>The gears and levers behind RBP</li><li>Navigating the legal minefields</li><li>Secrets from Third-Party Administrators (TPAs)</li><li>RBP's performance across the geographical board</li><li>The art of handling balance bill claims</li><li>Litigation: When & How Often</li><li>Co-fiduciaries: The real deal or just smoke and mirrors?</li><li>Show Me the Money: Their pay structure dissected</li><li>Year-end Report Cards: The Good, the Bad, and the Profitable</li></ul>And just when you think it couldn’t get any cooler—did one of these guys actually play pro baseball in a global tourney, while the other rocked the stage with NIRVANA? 🎸⚾<br /><br />Lock in your earbuds. Prepare for a mind-bending journey. You’re entering "The Repricers"—Healthcare’s Final Frontier! 🌌🛸<div><br /></div><br />Craighttp://www.blogger.com/profile/14913599100409003265noreply@blogger.comtag:blogger.com,1999:blog-3761470026816062685.post-1142179993645586432023-09-02T08:42:00.001-07:002023-09-02T08:42:21.090-07:00The U.S. Will Finally Start Negotiating Drug Prices with Armstrong and Getty<p>I spent one morning this week chatting with <a href="https://www.armstrongandgetty.com/featured/armstrong-and-getty/content/2023-08-30-health-care-is-the-number-1-lobby-in-the-us-craig-gottwals-talks-to-ag/" target="_blank">Armstrong and Getty</a> regarding the news that the federal government will finally begin negotiating the price of drugs. 10 of them. Two and a half years from now. </p><p>Well, it's a start...</p><iframe allow="autoplay; clipboard-write" frameborder="0" height="180" src="https://omny.fm/shows/armstrong-getty-extra-large-interviews/health-care-is-the-number-1-lobby-in-the-us-craig/embed" title="Health Care Is The Number 1 Lobby In The US: Craig Gottwals Talks To A&G" width="100%"></iframe>Craighttp://www.blogger.com/profile/14913599100409003265noreply@blogger.comtag:blogger.com,1999:blog-3761470026816062685.post-62205774277427724172023-08-08T18:08:00.000-07:002023-08-08T18:08:23.843-07:00It's A Government Healthcare Complex: Craig Gottwals Talks To A&G<p>Your health insurance costs and premiums have skyrocketed compared to the rate of inflation since Obamacare passed. Meanwhile, insurance carrier stock prices have grown by 1900% in the same timeframe.</p><p>"They're making unimaginable amounts of money... off of you." -Joe Getty</p><p>Craig Gottwals, aka "Craig the Healthcare Guru,” talks about that and more in a new episode of A&G's Extra Large Podcast.</p><p>Listen to the Armstrong & Getty Extra Large Podcasts featuring Craig.</p><p>Originally posted <a href="https://www.armstrongandgetty.com/featured/armstrong-and-getty/content/2023-" target="_blank">here</a>. </p><p><iframe allow="autoplay" frameborder="0" height="300" src="https://www.iheart.com/podcast/64-armstrong-getty-extra-large-30400323/episode/its-a-government-healthcare-complex-craig-120656642/?embed=true" width="100%"></iframe></p><p><br /></p>Craighttp://www.blogger.com/profile/14913599100409003265noreply@blogger.comtag:blogger.com,1999:blog-3761470026816062685.post-48184816158711423502023-07-15T07:03:00.000-07:002023-07-15T07:03:09.819-07:00Required Leave for Any Reason, Ozempic, and Coverage for Gender Affirming Care<p><b><span style="color: #005d98; font-family: sans-serif; font-size: 15px;">Tools & Webinars:</span></b></p>
<ul>
<li><a href="https://click.icptrack.com/icp/rclick.php?cid=712030&mid=376385&destination=https%3A%2F%2Fwww.mcgriff.com%2Fresources%2Fwhite-papers%2F2023-national-benefit-trends-survey-result.html&cfid=4005&vh=5c179158d81cf059a02799436f0d3eff82a10c1bacf11a00a3b7b814f8af22fc" style="color: #298ccd;" target="_blank">McGriff's 2023 Benefits Survey Results</a></li>
<li>
<a href="https://click.icptrack.com/icp/rclick.php?cid=712030&mid=376385&destination=https%3A%2F%2Fwww.flipsnack.com%2FAE7A8FCC5A8%2Fmcgriff-2023-q2-pharmacy-insights-newsletter%2Ffull-view.html&cfid=4005&vh=abbe312e7712b979fdfd79570d1c4c2dab12413eee6fd00e209f2cd4a798142f" style="color: #298ccd;" target="_blank">McGriff's Quarterly Pharmacy Newsletter</a>: covering Diabetes, obesity, and new weight loss drugs. </li>
<li><a href="https://click.icptrack.com/icp/rclick.php?cid=712030&mid=376385&destination=https%3A%2F%2Ftruistevents.webex.com%2Fwebappng%2Fsites%2Ftruistevents%2Fmeeting%2Fregister%2F1f81235b1ab2454989fcc8e63d9bd5e4%3Fticket%3D4832534b00000006cb047c2e5fe7de9ebc93b1f4f3f93d837e2af328734014b1db74dd7244ccbeed%26timestamp%3D1688920332987%26RGID%3Drb22e0b7a7bfcc40929d5eedbc882d4d4&cfid=4005&vh=dedfcebcc320a50977237a3182bdfaff548dd434f893a1785e03d591293f10bf" style="color: #298ccd;" target="_blank">Trending Topics in Retirement Webinar on July 27th</a></li>
<li><a href="https://click.icptrack.com/icp/rclick.php?cid=712030&mid=376385&destination=https%3A%2F%2Fwww.flipsnack.com%2FAE7A8FCC5A8%2Fjuly-it-benefits-you-2023-1m01q2lpma%2Ffull-view.html&cfid=4005&vh=34b38a0d23534b46011f756105f158f6f6ab128bfa2c5c8669e52a797e0284a7" style="color: #298ccd;" target="_blank">In case you missed it, the July It Benefits You Newsletter</a></li>
<li>
<a href="https://click.icptrack.com/icp/rclick.php?cid=712030&mid=376385&destination=https%3A%2F%2Fregister.gotowebinar.com%2Fregister%2F5908374597690494048&cfid=4005&vh=38774eb0d6ba9f92f8c9113e581d995bdf4d1e9c7791e7cc805ad14916a88f59" style="color: #298ccd;" target="_blank">Our Monthly Mineral Demonstration</a>
- robust web-based resource with live advisors, reliable content, and
interactive technology solutions that provide an end-to-end People Risk
Management solution</li>
</ul>
<h3 style="color: #005d98; font-family: sans-serif; font-size: 15px; margin-bottom: 0px; margin-top: 10px;"><br /></h3>
<h3 style="color: #005d98; font-family: sans-serif; font-size: 15px; margin-bottom: 0px; margin-top: 10px;">Compliance News:</h3>
<p style="margin-bottom: 0px; margin-top: 16px;"><a href="https://click.icptrack.com/icp/rclick.php?cid=712030&mid=376385&destination=https%3A%2F%2Fwww.benefitspro.com%2F2023%2F07%2F06%2Fneed-to-get-plan-b-or-an-hiv-test-online-facebook-may-know-about-it%2F&cfid=4005&vh=9a0ac8a8b1678ead9a2980529f2b72a006041d9ce7805273f9457f68679a3e85" style="color: #298ccd;" target="_blank">Pharmacies are Sharing Sensitive Health Data with Facebook</a>
- "Looking for an at-home HIV or Plan B test on CVS’ website is not as
private an experience as one might think, and CVS is not the only
pharmacy sharing this kind of sensitive health data, according to a KFF
Health News investigation. We found trackers collecting browsing- and
purchase-related data on websites of 12 of the U.S.’ biggest drugstores,
including grocery store chains with pharmacies, and sharing the
sensitive information with companies like Meta (formerly Facebook);
Google, through its advertising and analytics products; and Microsoft,
through its search engine, Bing."</p>
<p style="margin-bottom: 0px; margin-top: 16px;"><a href="https://click.icptrack.com/icp/rclick.php?cid=712030&mid=376385&destination=https%3A%2F%2Fportal.careplusbenefits.com%2FLinkClick.aspx%3Ffileticket%3DAjfySMwi0Dw%253d%26portalid%3D142%26timestamp%3D1687989742590&cfid=4005&vh=6320681f84626b7ebd17c180a13b48d7d56d284f2019b24573287ce50a0dc1c8" style="color: #298ccd;" target="_blank">The IRS recently issued Notice 2023-37</a>
to update its guidance for high deductible health plans (HDHPs) on
expenses related to COVID-19 testing and treatment. The notice also
clarifies whether certain items and services are treated as preventive
care under the tax rules for HDHPs, and confirms that for plan years
ending after Dec. 31, 2024, an HDHP is not permitted to provide benefits
for COVID-19 testing and treatment without a deductible. </p>
<p style="margin-bottom: 0px; margin-top: 16px;"><a href="https://click.icptrack.com/icp/rclick.php?cid=712030&mid=376385&destination=https%3A%2F%2Fwww.benefitslawadvisor.com%2F2023%2F06%2Farticles%2Faffordable-care-act%2Fopen-issue-employer-sponsored-health-plans-and-coverage-of-gender-affirming-care%2F&cfid=4005&vh=5045b8ca84ab7aed4387969583078d0ed681efc1d0978bc92876d0f5d74c7069" style="color: #298ccd;" target="_blank">Open Issue: Employer-Sponsored Health Plans and Coverage of Gender-Affirming Care</a></p>
<p class="paragraph-spacing-none" style="margin-bottom: 0px; margin-top: 0px;"><em>June 28, 2023 – Jackson Lewis P.C.</em></p>
<p class="paragraph-spacing-none" style="margin-bottom: 0px; margin-top: 0px;">Whether
an employer-sponsored health plan must cover gender-affirming care is
often dependent on whether the employer’s health plan is fully-insured
or self-insured; fully-insured plans must provide gender-affirming care
to the extent required by applicable state and federal law, while the
law on categorical exclusions for gender-affirming care in self-insured
plans continues to develop. </p>
<p class="paragraph-spacing-none" style="margin-bottom: 0px; margin-top: 0px;"><br /></p>
<p class="paragraph-spacing-none" style="margin-bottom: 0px; margin-top: 0px;"><a href="https://click.icptrack.com/icp/rclick.php?cid=712030&mid=376385&destination=https%3A%2F%2Fwww.hrmorning.com%2Farticles%2Ftalk-about-fmla-leave-headache-this-one-migraine%2F&cfid=4005&vh=a8f9060acca6224591ce7d105bc7ee29506c34d4643490c17dc0c456100b6a12" style="color: #298ccd;" target="_blank">Talk about an FMLA leave headache! This one was a migraine</a></p>
<p class="paragraph-spacing-none" style="margin-bottom: 0px; margin-top: 0px;"><em>June 27, 2023 – HR Morning</em></p>
<p class="paragraph-spacing-none" style="margin-bottom: 0px; margin-top: 0px;">A
federal appeals court rejected claims filed by terminated employees who
sought FMLA leave along with many others, ruling that the employer had
good reason to believe the employees acted dishonestly and sought leave
for an improper purpose. Employers can also take away from this article a
few tips to curb FMLA leave abuse. </p>
<p class="paragraph-spacing-none" style="margin-bottom: 0px; margin-top: 0px;"><br /></p>
<p class="paragraph-spacing-none" style="margin-bottom: 0px; margin-top: 0px;"><a href="https://click.icptrack.com/icp/rclick.php?cid=712030&mid=376385&destination=https%3A%2F%2Fwww.littler.com%2Fpublication-press%2Fpublication%2Fjuly-new-january-pace-new-state-laws-heats%3Futm_source%3Dvuture%26utm_medium%3Demail%26utm_campaign%3Dnews%2520%2526%2520analysis%2520june%25202023&cfid=4005&vh=0dd1dd1f13f691fb62a4001f3885937d7aaed1e0165e410c0be1a6698dcb4152" style="color: #298ccd;" target="_blank">July Is the New January: The Pace of New State Laws Heats Up</a></p>
<p class="paragraph-spacing-none" style="margin-bottom: 0px; margin-top: 0px;"><em>June 26, 2023 – Littler Mendelson P.C</em>.</p>
<p class="paragraph-spacing-none" style="margin-bottom: 0px; margin-top: 0px;">This
article offers insight into an array of labor and employment laws and
ordinances from across the country, state by state, that take effect
mid-year and will implicate employers’ compliance obligations. </p>
<p class="paragraph-spacing-none" style="margin-bottom: 0px; margin-top: 0px;"><br /></p>
<p class="paragraph-spacing-none" style="margin-bottom: 0px; margin-top: 0px;"><a href="https://click.icptrack.com/icp/rclick.php?cid=712030&mid=376385&destination=https%3A%2F%2Fwww.lexisnexis.com%2Fcommunity%2Finsights%2Flegal%2Fcapitol-journal%2Fb%2Fstate-net%2Fposts%2Fpaid-leave-continues-to-be-big-issue-for-state-lawmakers-post-pandemic&cfid=4005&vh=e14579129e2e26212a365128191c69df5dd98627e272b0905b74e7c16bdf62e8" style="color: #298ccd;" target="_blank">New Trend in State Laws, Paid Leave for Any Reason </a>-
"In May 2019, Maine became the first state in the nation to require
private employers to provide paid leave for any reason when Gov. Janet
Mills (D) signed LD 369. Nevada followed a month later, in June 2019,
when then-Gov. Steve Sisolak (D) signed SB 312, which also granted paid
leave for any reason. Illinois is poised to join their ranks on January
1, 2024. In March 2023, Gov. J.B. Pritzker (D) signed SB 208, which says
that beginning on January 1, 2024, private employers must offer their
workers five days paid time off for any reason after they’ve completed a
90-day probation period."</p>
<ul><li>In Nevada, for example, Employers may limit the use of paid
leave to 40 total hours per benefit year and may prevent an employee
from using any accrued paid leave until the employee reaches their 90th
day of employment. Employers may also set minimum increments of paid
leave which an employee may elect to use, so long as that limit does not
exceed 4 hours.</li></ul>
<h3 style="color: #005d98; font-family: sans-serif; font-size: 15px; margin-bottom: 0px; margin-top: 10px;"><br /></h3>
<h3 style="color: #005d98; font-family: sans-serif; font-size: 15px; margin-bottom: 0px; margin-top: 10px;">Benefits News:</h3>
<p style="margin-bottom: 0px; margin-top: 16px;"><a href="https://click.icptrack.com/icp/rclick.php?cid=712030&mid=376385&destination=https%3A%2F%2Ffinance.yahoo.com%2Fnews%2Fa-relief-for-retirees-expected-health-care-costs-didnt-increase-this-year-173036127.html&cfid=4005&vh=dc256adb62b25f276ac0cdd4a130e49c9553f19de7c6cdcc1b40efde3b721556" style="color: #298ccd;" target="_blank">A Couple Retiring in 2023 Needs $315,000 in Retirement Savings Just to Cover Medical Expenses in Addition to Medicare</a>
- "The after-tax cost for medical expenses throughout retirement for a
single, 65-year-old retiree held steady at $157,500 ($315,000 for the
average retired couple at the same age), according to the new 2023
Retiree Health Care Cost Estimate, which tracks retiree healthcare
expenses annually."</p>
<p style="margin-bottom: 0px; margin-top: 16px;"><a href="https://click.icptrack.com/icp/rclick.php?cid=712030&mid=376385&destination=https%3A%2F%2Fwww.fiercehealthcare.com%2Fpayers%2Funitedhealth-extends-its-hot-streak-most-profitable-payer-q1&cfid=4005&vh=5825d1e01b7b544d54ebcdc1bf4fb50c6341000f9fe676804c63e977d455660a" style="color: #298ccd;" target="_blank">Renewals Not Looking Good for UHC Clients</a>:
"UnitedHealth Group extended its streak as the most profitable company
among major national insurers in the first quarter of 2023, reporting
$5.6 billion in earnings. By comparison, fellow healthcare giant CVS
Health reported the second-highest profit in the quarter at $2.1
billion, less than half of UnitedHealth's haul. CVS' profit also
declined year over year, as it posted nearly $2.4 billion in the first
quarter of 2022. UnitedHealth also takes the top spot on revenue for the
quarter, reporting $91.3 billion. That's up from $80.1 billion in the
prior-year quarter. CVS again lands at No. 2 on revenue, posting $85.3
billion."</p>
<p style="margin-bottom: 0px; margin-top: 16px;"><a href="https://click.icptrack.com/icp/rclick.php?cid=712030&mid=376385&destination=https%3A%2F%2Fcaliforniahealthline.org%2Fnews%2Farticle%2Fprimary-care-health-system-changes-pcp%2F&cfid=4005&vh=dc860534c1fba043276df07d86d4985f3e2a69e5d2c5a1a55e62fa85d4e8d08b" style="color: #298ccd;" target="_blank">Will the Doctor See You Now? The Health System's Changing Landscape</a>
- "About 48% of primary care physicians currently work in practices
they do not own. Two-thirds of those doctors don’t work for other
physicians but are employed by private equity investors or other
corporate entities, according to data in the “Primary Care Chartbook,”
which is collected and published by the Graham Center.... it now takes
an average of 21 days just to get in to see a doctor of family medicine,
defined as a subgroup of primary care, which includes general
internists and pediatricians. Those physicians are many patients’ first
stop for health care."</p>
<p style="margin-bottom: 0px; margin-top: 16px;"><br /></p>
<h3 style="color: #005d98; font-family: sans-serif; font-size: 15px; margin-bottom: 0px; margin-top: 10px;">Health and Wellness:</h3>
<p style="margin-bottom: 0px; margin-top: 16px;"><a href="https://click.icptrack.com/icp/rclick.php?cid=712030&mid=376385&destination=https%3A%2F%2Fyoutu.be%2FYx-PCEcG8xw&cfid=4005&vh=2055af1dba9f28d08c337fcd97be760a275c25add7c2d9f8b53c5bb7e12ea95c" style="color: #298ccd;" target="_blank">Watch The Truth About Weight Loss Drug Ozempic with Dr. Peter Attia</a> - a one-minute short.</p>
<p style="margin-bottom: 0px; margin-top: 16px;"><a href="https://click.icptrack.com/icp/rclick.php?cid=712030&mid=376385&destination=https%3A%2F%2Fen.wikipedia.org%2Fwiki%2FList_of_largest_pharmaceutical_settlements&cfid=4005&vh=32dd8223cf6725bc7123f5449f7fc68ed323d4821d71b2fd6619ef0315dfed99" style="color: #298ccd;" target="_blank">Trusting
The Science: The following is a list of the 20 largest settlements
reached between the United States Department of Justice and
pharmaceutical companies from 1991 to 2012</a> - Pfizer claims the
largest criminal fine in U.S. history, while GlaxoSmithKline holds the
largest pharma-fine in history when combining civil and criminal
penalties.</p>
<p style="margin-bottom: 0px; margin-top: 16px;"><a href="https://click.icptrack.com/icp/rclick.php?cid=712030&mid=376385&destination=https%3A%2F%2Fdoctortro.com%2Fwhat-you-need-to-know-about-ozempic-mounjaro%2F&cfid=4005&vh=776712107b8a3759b57b90aa3e7469dd210df192c4a7f8028d0d19b986d307b7" style="color: #298ccd;" target="_blank">What you need to know about Ozempic & Mounjaro</a>
- "But I want all my patients and the public to know that the appetite
and weight loss effects do not last forever. Effects on hunger, cravings
control, sweet cravings, mood & fullness are TEMPORARY and return
to baseline between years 1 & 2. This was shown in surveys taken
from patients using the medication over the long term."</p>
<p style="margin-bottom: 0px; margin-top: 16px;"><a href="https://click.icptrack.com/icp/rclick.php?cid=712030&mid=376385&destination=https%3A%2F%2Fstudyfinds.org%2Fis-anyone-perfectly-healthy%2F&cfid=4005&vh=0f11bd93e74002015974763846ef096a1e6aa41bfb3a9dda03036d0ad600bf69" style="color: #298ccd;" target="_blank">Just 3% of adults show no major health risk factors linked to death</a>
- "Overall, most of us have something wrong with us, and we’re more
likely to have a lifestyle health-risk factor now than in the ’80s and
that’s actually associated with even greater mortality risk now than
before."</p>
<p style="margin-bottom: 0px; margin-top: 16px;"><a href="https://click.icptrack.com/icp/rclick.php?cid=712030&mid=376385&destination=https%3A%2F%2Fwww.bloomberg.com%2Fnews%2Farticles%2F2023-07-10%2Fnovo-weight-loss-drugs-probed-by-eu-over-report-of-suicide-risks%3FleadSource%3Duverify%2520wall&cfid=4005&vh=b833728cf3b67f470408fe975830d8531fc5b0223642c3c8260ec62c1cc88fa3" style="color: #298ccd;" target="_blank">Ozempic, Weight-Loss Drugs Probed Over Reports of Suicidal Thoughts</a>
- "Novo Nordisk A/S’s weight-loss medications are under investigation
by the European Union’s drugs regulator after a small number of reports
of suicidal risks were referred to the watchdog. The European Medicines
Agency is looking at adverse events noted by the Icelandic Medicines
Agency, including two cases of suicidal thoughts linked to the drugs
Saxenda and Ozempic, the EMA said in a statement Monday." </p>
<p style="margin-bottom: 0px; margin-top: 16px;"><br /></p>Craighttp://www.blogger.com/profile/14913599100409003265noreply@blogger.comtag:blogger.com,1999:blog-3761470026816062685.post-6628974122466624862023-06-19T08:52:00.011-07:002023-06-24T15:06:55.501-07:00This Week In Red Pilled Healthcare News<ul style="text-align: left;"><li><a href="https://aequumhealth.com/blog/healthcare-inflation-unusually-trails-general-inflation-squeezing-financially-fragile-employees-from-both-sides/">Because Healthcare Inflation Unusually Trails General Inflation, 2024 Looks Grim for Traditional Health Plans</a><div class="separator" style="clear: both; text-align: center;"><a href="https://aequumhealth.com/blog/healthcare-inflation-unusually-trails-general-inflation-squeezing-financially-fragile-employees-from-both-sides/"></a><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjOP_CqnJpWzBM31H4ODnbVOSFCxAM_hmcYexn9DRzGUaTjehz1LAxRBIqouZYTP6k152SKSyMZwMX67PLyKwF6Oz4LmoUgkxU2tW2F9BrU5fFsY0N_I3QIQd5_8m__3-E9v3rjEBbX4iTCp3l_XcQcEHeGAFrOqWgfLcOecNEdRMPe5TlktlwrcQYx4cw/s1024/Red%20Pilled.png" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" data-original-height="1024" data-original-width="1024" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjOP_CqnJpWzBM31H4ODnbVOSFCxAM_hmcYexn9DRzGUaTjehz1LAxRBIqouZYTP6k152SKSyMZwMX67PLyKwF6Oz4LmoUgkxU2tW2F9BrU5fFsY0N_I3QIQd5_8m__3-E9v3rjEBbX4iTCp3l_XcQcEHeGAFrOqWgfLcOecNEdRMPe5TlktlwrcQYx4cw/w320-h320/Red%20Pilled.png" width="320" /></a></div></li></ul><ul style="text-align: left;"><li>Not worried about the fiduciary obligation to keep costs as low as reasonable? <a href="https://www.napa-net.org/news-info/daily-news/schlichter-exclusive-does-new-wave-fiduciary-litigation-loom">This firm looks for employers</a> to sue on this very topic: "His law firm, Schlichter Bogard, LLC., recently posted advertisements looking for employees and potential plaintiffs at Target, State Farm, Nordstrom, and Pet Smart. They seek “current employees who have participated in the company’s healthcare plan.”</li></ul><ul style="text-align: left;"><li><a href="https://www.cnbc.com/2023/06/14/health-stocks-slide-after-unitedhealth-warns-of-higher-medical-costs.html">UnitedHealthcare Is Prepping Everyone - Costs Are Going Up More Than in Recent Years in 2024</a></li></ul><ul style="text-align: left;"><li>What should be the first step in the management and oversight of any health plan? Well, as Dr. John Abramson of Harvard Medical School writes, "<a href="https://www.jabfm.org/content/jabfp/18/5/414.full.pdf">The first step is to give up the illusion that the primary purpose of modern medical research is to improve Americans’ health most effectively and efficiently. In our opinion, the primary purpose of commercially funded clinical research is to maximize financial return on investment, not health</a>."</li></ul><br />Craighttp://www.blogger.com/profile/14913599100409003265noreply@blogger.comtag:blogger.com,1999:blog-3761470026816062685.post-49609775557242341522023-05-22T07:55:00.000-07:002023-05-22T07:55:15.356-07:00 HR’s Porta-Potty Predicament: California Compliance Chaos<h3 style="text-align: left;">From Armchair Lawyer to Bathroom Auditor. A Peculiar Friday at the Office</h3><p>In the late afternoon on Friday, at the brim of the weekend, my phone shrieked with a call of urgency. It was from a client named Nancy, who, with an audible eye-roll, launched into an account of her current predicament. Here's a condensed retelling of our dialogue.</p><p>“Craig, we have a pressing compliance concern that needs an immediate solution. Regrettably, it's not tied to benefits, but I’m betting you might be of assistance.”</p><p>“Consider it done, Nancy. I'm all ears.” ...</p><p>The full story is on my <a href="https://gottwals.substack.com/p/hrs-porta-potty-predicament-california" target="_blank">Substack</a>. </p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjN__q8RvVPZ3Lwq7e6sVsj-NtmpBs7LiMb5rNR-OCl2IU_IiP32gxwJzmyNokmEm4TKTrwvIFDWoltRuvqI6VLvqb_5kU8PXXHkh3F_93zVGEyWd1YaRg3YHu3A7oeRpdJFxiq9NWjighrtliIgA2WRzm8ubQ0aAUAUHzmTvNsDBSmVByUp47G8dCr/s1061/CA%20Porta%20Potty.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="905" data-original-width="1061" height="546" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjN__q8RvVPZ3Lwq7e6sVsj-NtmpBs7LiMb5rNR-OCl2IU_IiP32gxwJzmyNokmEm4TKTrwvIFDWoltRuvqI6VLvqb_5kU8PXXHkh3F_93zVGEyWd1YaRg3YHu3A7oeRpdJFxiq9NWjighrtliIgA2WRzm8ubQ0aAUAUHzmTvNsDBSmVByUp47G8dCr/w640-h546/CA%20Porta%20Potty.jpg" width="640" /></a></div><br /><p><br /></p>Craighttp://www.blogger.com/profile/14913599100409003265noreply@blogger.comtag:blogger.com,1999:blog-3761470026816062685.post-91891804533562885902023-05-12T07:00:00.000-07:002023-05-12T07:00:07.459-07:00One In Three Dollars You Spend on Healthcare is Squandered on Waste, Fraud or Abuse<p><b><span style="color: #0b5394; font-size: medium;">Employers: It Does Not Have To Be This Way</span></b></p><p>This story with a voiceover is posted on my <a href="https://gottwals.substack.com/p/one-in-three-dollars-you-spend-on" target="_blank">Substack</a>. </p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgU8fYEeXWZDomG6wGDhOIJAF2LxF2m0i6Np-UQO3apH-BYr7M-gEGhoCD7ggY8lS0aoUVrFysWlYg-OBf7ql_t-eirUurJkbgCPYnV90ihSb6eGmYyusfMGr5d44dFhNEpbHpxielVmqFgyjVHbOU0pR2JHMxAJYYP4q5hffVY5L25mPCgARFEhm9L/s1024/Medical%20Fraud.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1024" data-original-width="1024" height="640" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgU8fYEeXWZDomG6wGDhOIJAF2LxF2m0i6Np-UQO3apH-BYr7M-gEGhoCD7ggY8lS0aoUVrFysWlYg-OBf7ql_t-eirUurJkbgCPYnV90ihSb6eGmYyusfMGr5d44dFhNEpbHpxielVmqFgyjVHbOU0pR2JHMxAJYYP4q5hffVY5L25mPCgARFEhm9L/w640-h640/Medical%20Fraud.jpg" width="640" /></a></div><br /><p><br /></p>Craighttp://www.blogger.com/profile/14913599100409003265noreply@blogger.comtag:blogger.com,1999:blog-3761470026816062685.post-3848128792349723422023-05-06T14:49:00.019-07:002023-05-07T13:06:20.646-07:00Employers Needlessly Overpay 224% for Healthcare<p class="MsoNormal" style="line-height: normal; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto;">This week in the government-healthcare complex's
gluttonous plundering of U.S. business, we saw that: <o:p></o:p></p><ul type="disc">
<li class="MsoNormal" style="line-height: normal; mso-list: l0 level1 lfo1; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list .5in;"><a href="https://www.healthcarefinancenews.com/news/cigna-logs-13b-profit-q1-promises-transparency-around-pbms" target="_blank"><span style="color: #0070c0; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-fareast-font-family: "Times New Roman"; mso-font-kerning: 0pt; mso-ligatures: none;">Cigna posted $1.3 billion in Q1 profit</span></a><span style="color: #0070c0; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-fareast-font-family: "Times New Roman"; mso-font-kerning: 0pt; mso-ligatures: none;"> </span>on the heels of learning
that <a href="https://www.propublica.org/article/cigna-pxdx-medical-health-insurance-rejection-claims" target="_blank"><span style="color: #0070c0; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-fareast-font-family: "Times New Roman"; mso-font-kerning: 0pt; mso-ligatures: none;">Cigna saves millions by having its doctors reject
claims without reading them</span></a>; and <o:p></o:p></li>
<li class="MsoNormal" style="line-height: normal; mso-list: l0 level1 lfo1; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list .5in;"><a href="https://www.healthcarefinancenews.com/news/envision-healthcare-receives-912m-judgment-against-unitedhealthcare" target="_blank"><span style="color: #0070c0; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-fareast-font-family: "Times New Roman"; mso-font-kerning: 0pt; mso-ligatures: none;">UnitedHealthcare lost a 91 million dollar suit for
chronic underpayment and unjust claim denials</span></a>. <o:p></o:p></li>
</ul><p class="MsoNormal" style="line-height: normal; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto;">I read stories like this every week and become
increasingly enraged at the cruel injustice of it. </p><p class="MsoNormal" style="line-height: normal; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto;"><span style="color: #005c98; font-size: medium; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-fareast-font-family: "Times New Roman"; mso-font-kerning: 0pt; mso-ligatures: none;"><b>We Already Have a Socialized
System</b></span><span style="color: #005c98; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-fareast-font-family: "Times New Roman"; mso-font-kerning: 0pt; mso-ligatures: none;"><o:p></o:p></span></p><p class="MsoNormal" style="line-height: normal; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto;">The latest studies on the topic show that the American
taxpayer funds <a href="https://www.healthcaredive.com/news/taxpayers-cover-71-of-health-costs-in-california/425635/#:~:text=This%20year%2C%2071%25%20(%24260.9,followed%20by%20Medicare%20at%2020%25." target="_blank"><span style="color: #0070c0; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-fareast-font-family: "Times New Roman"; mso-font-kerning: 0pt; mso-ligatures: none;">71% of all healthcare</span></a> in blue states like California. That leaves 29% of healthcare costs funded by
folks paying their own way to <a href="https://www.rand.org/pubs/research_reports/RRA1144-1.html" target="_blank">pay 224%</a> of what the healthcare industry's
largest customer (the federal government, primarily via Medicare and Medicaid)
pays for the same procedures at the same facilities. Still think that the healthcare you receive
at work is not taxed? <o:p></o:p></p><p class="MsoNormal" style="line-height: normal; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto;">The rampant fraud riddling American healthcare boggles my mind. No, I'm not talking about the
fact that one of every three dollars spent in the Medicare and Medicaid system
is squandered on waste, fraud, or abuse <b>(1)</b>. Nor am I lamenting how America's largest
purely socialized system, the Veteran's Administration, is so indifferent to
our veteran's needs that <a href="https://www.washingtonpost.com/politics/whistleblower-says-va-ordered-fake-appointments-to-cut-waiting-list/2019/06/26/97e50648-9856-11e9-a027-c571fd3d394d_story.html" target="_blank"><span style="color: #0070c0; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-fareast-font-family: "Times New Roman"; mso-font-kerning: 0pt; mso-ligatures: none;">it creates fake appointments at nonexistent clinics</span></a><span style="color: #0070c0; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-fareast-font-family: "Times New Roman"; mso-font-kerning: 0pt; mso-ligatures: none;"> </span>so it can show auditors that the wait times and abject
patient neglect are not as they indeed are.
I'm also not referring to how and why you overpay for prescriptions by
at least <a href="https://www.pbs.org/newshour/health/why-a-patient-paid-a-285-copay-for-a-40-drug" target="_blank"><span style="color: #0070c0; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-fareast-font-family: "Times New Roman"; mso-font-kerning: 0pt; mso-ligatures: none;">25%</span></a> to 50%. Pharmacy
benefits are a treasure trove of corrupt pricing, hidden rebates, and shell
games that would expand this post beyond a reasonable length <b>(2)</b>. <o:p></o:p></p><p class="MsoNormal" style="line-height: normal; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto;">Instead, I'm talking about the gargantuan tax every
employer and employee <b>(3)</b> pays for the "privilege"
of buying commercial health insurance through the workplace. Because Medicare and Medicaid pay
facilities <b>(4)</b> so <a href="https://www.kff.org/report-section/understanding-medicaid-hospital-payments-and-the-impact-of-recent-policy-changes-appendix/view/print/" target="_blank"><span style="color: #0070c0; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-fareast-font-family: "Times New Roman"; mso-font-kerning: 0pt; mso-ligatures: none;">meagerly</span> </a>for services, hospitals respond by listing retail
or chargemaster prices that are three, four, five, or even ten times as high
for the same procedures at the same facilities.
<o:p></o:p></p><p>
</p><p class="MsoNormal" style="line-height: normal; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto;">Below is a 2016 summary of cost data on Medicaid (for low-income) showing that, on average, Medicaid may not even cover the actual cost of
providing services. Generally, Medicare (for the elderly) pays a little better than this in most states. <o:p></o:p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj8pV8ijIIefX13rj0t8hMTm9wz3gznthwSfBgUb8ynUG5jpqrJyTH6jjFGy1yGebOWi1HHQhKyZH_oB30Ggu-oilX7SvvN-RaKYaWnRfrdTJaSWwh7ifsg4BYTOG4YmIb-_JzX0FrkwT7SjHY9s0Pbiuyg6iWOgBCyvntIvZ2h38ak_Etaczobj4ba/s979/Medicaid%20Cost%20Sample.png" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="731" data-original-width="979" height="478" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj8pV8ijIIefX13rj0t8hMTm9wz3gznthwSfBgUb8ynUG5jpqrJyTH6jjFGy1yGebOWi1HHQhKyZH_oB30Ggu-oilX7SvvN-RaKYaWnRfrdTJaSWwh7ifsg4BYTOG4YmIb-_JzX0FrkwT7SjHY9s0Pbiuyg6iWOgBCyvntIvZ2h38ak_Etaczobj4ba/w640-h478/Medicaid%20Cost%20Sample.png" width="640" /></a></div><span style="color: #444444;"><div style="text-align: left;"><span style="text-align: center;"><span style="font-size: 10pt;"> <u>Source</u></span></span><span style="font-size: 10pt; text-align: center;">: Understanding Medicaid Hospital Payments and the Impact
of Recent Policy Changes, </span><a href="https://www.kff.org/report-section/understanding-medicaid-hospital-payments-and-the-impact-of-recent-policy-changes-appendix/view/print/" style="text-align: center;" target="_blank"><span style="color: #0070c0; font-size: 10pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-fareast-font-family: "Times New Roman"; mso-font-kerning: 0pt; mso-ligatures: none;">KFF</span></a><span style="font-size: 10pt; text-align: center;">, 2016. </span> </div></span><p class="MsoNormal" style="line-height: normal; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto;">Your health insurer then negotiates a 50% discount on
that completely phony "price" the facility claims through its
chargemaster in the hopes that employers and employees will be mollified by the
seemingly considerable discount they receive for the privilege of having a
private plan. In the end, private payers
pay a national average of 224% of Medicare and as high as 600% of a hospital's
cost in a state like California. <o:p></o:p></p><p>
</p><p class="MsoNormal" style="line-height: normal; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto;">Does your business get to mark up its products by
600%? <o:p></o:p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjUZZetxtcw-90lv0NAEp6BqleQwIU4eB6mTpnRa8i5mk5piSdGmDZseCUJc4qPoQkMi9ZX_h1WZfFmDMRHmpoWBoPktT3zPCw4nFVOZ1vEfdi61oG-ALvR2OPdc9RRRfA7sovpXaP2j8E1jWPC3sVzpXLaaItQQ5HPrCt_joldV2WTFIAxuefxlgh4/s1672/Hospital%20Plunder.png" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1044" data-original-width="1672" height="400" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjUZZetxtcw-90lv0NAEp6BqleQwIU4eB6mTpnRa8i5mk5piSdGmDZseCUJc4qPoQkMi9ZX_h1WZfFmDMRHmpoWBoPktT3zPCw4nFVOZ1vEfdi61oG-ALvR2OPdc9RRRfA7sovpXaP2j8E1jWPC3sVzpXLaaItQQ5HPrCt_joldV2WTFIAxuefxlgh4/w640-h400/Hospital%20Plunder.png" width="640" /></a></div><p class="MsoNormal" style="line-height: normal; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto;">Additionally, those with self-funded plans know that
you are also paying $20 per employee per month for that privilege of getting a
50% discount on a claim that's been fraudulently priced at 500% of Medicare. It is what <span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-fareast-font-family: "Times New Roman"; mso-font-kerning: 0pt; mso-ligatures: none;"><a href="https://www.forbes.com/sites/davechase/?sh=f3fdcf51f378" target="_blank">Dave Chase</a></span>, writing at Forbes, hypothesized might be "<a href="https://www.forbes.com/sites/davechase/2016/09/05/have-ppo-networks-perpetrated-the-greatest-heist-in-american-history/?sh=a1ed1ec33300" target="_blank"><span style="color: #0070c0; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-fareast-font-family: "Times New Roman"; mso-font-kerning: 0pt; mso-ligatures: none;">The Greatest Heist In American History</span></a>." <o:p></o:p></p>
<p class="MsoNormal" style="line-height: normal; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto;"><o:p></o:p></p><p>Obamacare was going to fix this, right? Remember
when President Obama stood in front of cameras and told us, tens of times, that
<a href="https://youtu.be/_o65vMUk5so" target="_blank">the cost of healthcare was going to godown by $2,500 per family</a>? </p>
<div style="text-align: center;"><iframe allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/_o65vMUk5so" title="YouTube video player" width="560"></iframe></div><p class="MsoNormal" style="line-height: normal; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto;">Here is what that government promise of a $2,500 reduction in family premiums looks like in real life. It is the orange line below. See the massive drop in 2010 and the continued drop over time? Neither do I. </p><p class="MsoNormal" style="line-height: normal; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto;"><o:p></o:p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi1EwyG_MyebiWhql-Gtu_oiLl0Lruo_LAU1YM_lusPNaJdmdAPo0aAZhCt8diw5xynDNGaVZ5sp7sXotqWgqR-Q_016UkiPSNJlqm19i2XECU_FILmvuod551POo6NV0t7nPPwQzEw5ASDIXYaD5eF6yIizUQW4xl1XLpdJtebHx9scFoKj6M5rzUE/s1612/Premium.png" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="940" data-original-width="1612" height="374" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi1EwyG_MyebiWhql-Gtu_oiLl0Lruo_LAU1YM_lusPNaJdmdAPo0aAZhCt8diw5xynDNGaVZ5sp7sXotqWgqR-Q_016UkiPSNJlqm19i2XECU_FILmvuod551POo6NV0t7nPPwQzEw5ASDIXYaD5eF6yIizUQW4xl1XLpdJtebHx9scFoKj6M5rzUE/w640-h374/Premium.png" width="640" /></a></div><p align="center" class="MsoNormal" style="line-height: normal; margin-bottom: 0in; text-align: center;"><u><span style="color: #666666; font-size: 10pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-fareast-font-family: "Times New Roman"; mso-font-kerning: 0pt; mso-ligatures: none;">Source</span></u><span style="color: #666666; font-size: 10pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-fareast-font-family: "Times New Roman"; mso-font-kerning: 0pt; mso-ligatures: none;">: KFF Employer Health Benefits </span><span style="color: #666666;"><span style="font-size: 10pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-fareast-font-family: "Times New Roman"; mso-font-kerning: 0pt; mso-ligatures: none;">Survey, 2018-2022</span><span style="font-size: 10pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-fareast-font-family: "Times New Roman"; mso-font-kerning: 0pt; mso-ligatures: none;">.</span></span><span style="font-size: 10pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-fareast-font-family: "Times New Roman"; mso-font-kerning: 0pt; mso-ligatures: none;"><o:p></o:p></span></p><p>But certainly, our fearless government leaders finally reined in the obscene carrier profits in order to protect the little guy with the passage of ObamaCare, right? Not so much. </p><p></p><ul style="text-align: left;"><li>Since 2009 the S&P 500 is up 422%. </li><li>In that same time, five of the largest health insurer stock prices are up an average of 1,921%.</li></ul><p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgS_8c5bk0XZFUz8vZ6TYe0DMm9nEbWq_6SZZZSqAmAnhvbtq7rgaltp5iOq7-IL4qPZeDscxZZKjQ6CF6p0YH1CGN182FgqdSLMLoa2XQSY4p1L4SdsbLiG2iIkshKqMVapiKldq0Rk2JjYgc-YFv28G_3ddZwJ0n0Nn3ynwoXt5UI-Fo-oXoIP0Wg/s2102/Stocks.png" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1083" data-original-width="2102" height="330" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgS_8c5bk0XZFUz8vZ6TYe0DMm9nEbWq_6SZZZSqAmAnhvbtq7rgaltp5iOq7-IL4qPZeDscxZZKjQ6CF6p0YH1CGN182FgqdSLMLoa2XQSY4p1L4SdsbLiG2iIkshKqMVapiKldq0Rk2JjYgc-YFv28G_3ddZwJ0n0Nn3ynwoXt5UI-Fo-oXoIP0Wg/w640-h330/Stocks.png" width="640" /></a></div><p class="MsoNormal" style="line-height: normal; margin-bottom: 0in; text-align: center;"><u><span style="color: #444444; font-size: 10pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-fareast-font-family: "Times New Roman"; mso-font-kerning: 0pt; mso-ligatures: none;">Source</span></u><span style="color: #444444; font-size: 10pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-fareast-font-family: "Times New Roman"; mso-font-kerning: 0pt; mso-ligatures: none;">: Yahoo Finance. </span><span style="font-size: 10pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-fareast-font-family: "Times New Roman"; mso-font-kerning: 0pt; mso-ligatures: none;"><o:p></o:p></span></p><p>Okay, enough of this. I cannot stomach another fact in this vein. </p><p><span style="color: #005c98; font-size: medium; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-fareast-font-family: "Times New Roman"; mso-font-kerning: 0pt; mso-ligatures: none;"><b>Employers, There is
Another Way </b></span></p><p class="MsoNormal" style="line-height: normal; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto;"><b><span style="color: #666666; font-size: 12pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-fareast-font-family: "Times New Roman"; mso-font-kerning: 0pt; mso-ligatures: none;">Three Steps to a 40%
Cost Reduction - A HealthCost Revolution</span></b><o:p></o:p></p><p class="MsoNormal" style="line-height: normal; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto;"><b><u><span style="color: #3d85c6; font-size: 12pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-fareast-font-family: "Times New Roman"; mso-font-kerning: 0pt; mso-ligatures: none;">Step 1</span></u></b><b><span style="color: #3d85c6; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-fareast-font-family: "Times New Roman"; mso-font-kerning: 0pt; mso-ligatures: none;">:</span></b> if you are too small to engage in any form of self-funding
or partial self-funding, buy as little insurance as possible. The more premium you pay, the more you are
pilfered. You have to get out of that
game. Purchase the highest-priced
deductible plan your insurer offers, then self-fund the amount under that
deductible with a Health Savings Account (HSA) or Health Reimbursement Account
(HRA). If you have less than about 250
employees, depending on your cash flow, industry, and geographic locations,
this might be the best you can do. <o:p></o:p></p><p class="MsoNormal" style="line-height: normal; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto;"><b><u><span style="color: #3d85c6; font-size: 12pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-fareast-font-family: "Times New Roman"; mso-font-kerning: 0pt; mso-ligatures: none;">Step 2</span></u></b><span style="color: #3d85c6; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-fareast-font-family: "Times New Roman"; mso-font-kerning: 0pt; mso-ligatures: none;">:</span> If you have more than about 250 employees, you
should evaluate whether you can opt out of this fraud entirely, say goodbye to
your insurers, and move to a reference-based pricing (RBP) system whereby you
pay some reasonable margin over the Medicare price. For example, you might pay 120% to 140% of
Medicare. It fundamentally works, is
legally quite creative and astute, and will provide your employees with better
benefits, lower costs, and more freedom.
<o:p></o:p></p><p class="MsoNormal" style="line-height: normal; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto;">Is the first step intimidating, potentially rocky, and
one that requires plenty of education? <b>Yes</b>. But making this move will reduce the cost of
your health plan by<b> 20% to 40%. </b><o:p></o:p></p><p class="MsoNormal" style="line-height: normal; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto;">I wrote about how this will be the only mechanism that
has a meaningful chance of saving private healthcare in America back in 2020
here: <span style="color: #0070c0;"><a href="https://www.benefitspro.com/2020/04/06/america-will-dramatically-change-the-way-it-provides-health-care-by-2030-412-96023/" target="_blank"><span style="color: #0070c0; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-fareast-font-family: "Times New Roman"; mso-font-kerning: 0pt; mso-ligatures: none;">America will dramatically change the way it provides health care by 2030</span></a></span><span style="color: #0070c0; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-fareast-font-family: "Times New Roman"; mso-font-kerning: 0pt; mso-ligatures: none;"><o:p></o:p></span></p><p class="MsoNormal" style="line-height: normal; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto;">I recently wrote about the financial imperative of
evaluating this process now, here: <span style="color: #0070c0;"><a href="https://www.benefitspro.com/2023/04/11/the-fiduciary-imperative-of-reference-based-pricing-a-legal-and-financial-analysis/" target="_blank"><span style="color: #0070c0; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-fareast-font-family: "Times New Roman"; mso-font-kerning: 0pt; mso-ligatures: none;">The fiduciary imperative of reference-based pricing: A legal and financial
analysis</span></a></span><u><span style="color: #0070c0; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-fareast-font-family: "Times New Roman"; mso-font-kerning: 0pt; mso-ligatures: none;">.</span></u><span style="color: #0070c0; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-fareast-font-family: "Times New Roman"; mso-font-kerning: 0pt; mso-ligatures: none;"><o:p></o:p></span></p><p>
</p><p class="MsoNormal" style="line-height: normal; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto;">And I was
recently interviewed on <span style="color: #0070c0;"><a href="https://www.armstrongandgetty.com/featured/armstrong-and-getty/content/2022-09-21-lowering-the-healthcare-gap-craig-gottwals-talks-to-armstrong-getty/" target="_blank"><span style="color: #0070c0; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-fareast-font-family: "Times New Roman"; mso-font-kerning: 0pt; mso-ligatures: none;">the Armstrong and Getty Radio program, discussing this here</span></a></span>. <o:p></o:p></p><p><iframe allow="autoplay" frameborder="0" height="200" src="https://www.iheart.com/podcast/64-armstrong-getty-extra-large-30400323/episode/lowering-the-healthcare-gap-craig-gottwals-102309571/?embed=true" width="100%"></iframe></p><div><p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><b><u><span style="color: #3d85c6; font-size: 12pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-fareast-font-family: "Times New Roman"; mso-font-kerning: 0pt; mso-ligatures: none;">Step 3</span></u></b><span style="color: #666666; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-fareast-font-family: "Times New Roman"; mso-font-kerning: 0pt; mso-ligatures: none;">: </span>In
conjunction with your move to a self-funded RBP platform, you then must also
take control of your pharmacy coverage via a direct contract with a pharmacy
benefit manager (PBM) or one of the newer consortiums that aggregate numerous
employers under one set of contract terms to maximize the pharmacy discounts
and rebates for you, <i>not</i> an insurer.
This move alone reduces your pharmacy bill by 25% to 50%. <o:p></o:p></p></div><div><span style="color: #666666;"><br /></span></div><div><span style="color: #0b5394; font-size: medium;"><b>An Inconvenient Truth</b></span></div><div style="text-align: left;"><br /></div><div style="text-align: left;">Or
should I say a "problematic" reality in the parlance of one of
today's most overused buzzwords? Okay, I'm making myself nauseous again. </div><div>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;">If
your broker is not talking to you about what I call the <b>HealthCost
Revolution</b> of: <o:p></o:p></p></div><div><ol style="text-align: left;"><li>Getting off of first-dollar insurance plans (i.e. moving to HRAs or HSAs); </li><li>Evaluating RBP; and </li><li>Getting your Rx out of the carrier world and into a direct PBM contract...</li></ol><div><p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;">You
need to fire them. Period. Hard stop. </p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;">I've
been an attorney for 23 years and a full-time insurance broker for 21. The required education and licensing for
brokers are hysterically ludicrous. In
most states, it takes a one-week course and a junior-high education to become a
licensed broker. Carrier influence
dominates that process as agents-to-be are taught that they have an equal
obligation to their carrier and policyholder.
Future agents are trained that this is some sort of collaborative cuddle
fest in which carriers, employers, and employees all sit around campfires,
roast marshmallows, hold hands and sing Kumbaya. </p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;">Oof. I need to step away for a bit. Why do I insist on making myself so
sick? </p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;">I
recently created this meme for my team members after a carrier emailed us,
explaining that the carrier did not expect me or my team to market my
employer's policy this year, as asking for quotes every year is not the
"best way to proceed." </p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;">Ha!
Best for whom? <o:p></o:p></p></div></div><div><br /></div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjPkK8SavLU6WgsKP9o4fdLnChsHJxeXGu6JLXAnK8YA7P74NIm5-K2ghpWwAubF0f4LmdDLwMh1hfYlxAh2YLR1hSiFTpcW7LjpuGuAOUqCPEjtN2HPpm-bbwg9lFOcrOdecBQ2MVKFfixv4lCB7IFXemk-wnb-sZkV9ZajW-CaG7Dg06CHsjjtilj/s1120/Me.jpg" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1120" data-original-width="899" height="400" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjPkK8SavLU6WgsKP9o4fdLnChsHJxeXGu6JLXAnK8YA7P74NIm5-K2ghpWwAubF0f4LmdDLwMh1hfYlxAh2YLR1hSiFTpcW7LjpuGuAOUqCPEjtN2HPpm-bbwg9lFOcrOdecBQ2MVKFfixv4lCB7IFXemk-wnb-sZkV9ZajW-CaG7Dg06CHsjjtilj/w321-h400/Me.jpg" width="321" /></a></div><br /><div><p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;">Yes,
they are that brazen. They do not partner
with you and are not your friends. Their
job is to maximize revenue, and that means maximizing your premium.</p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;">Here
is the reality. Every one of those three
steps in the HealthCost Revolution reduces premiums and adds heaping piles of
work to your broker's plate. The broker will
be giving themselves a pay cut while requiring much more work and expertise. In fact, probably only about 5% to 10% of
brokers in the West are qualified to install and manage a self-funded plan, as
HMOs have been so dominant in the West that few brokers have had the
opportunity to learn what they need to effectively manage this process. </p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;">I can
hear some of you out there saying, "That's why we don't pay our broker a
commission; she is on a fee basis." </p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;">To
this, I respond, okay, great. At best,
you've capped their pay and will be asking them to do much more work to install
this protocol. Most likely, you are
paying your broker a fee and allowing your carriers to also collect the
commission that <i>should</i> be going to your broker. Yep, Obamacare created that double-dip trap as
well. I wrote how and why that happened
years ago <span style="color: #0070c0;"><a href="https://www.thinkadvisor.com/2015/02/24/view-why-broker-health-plan-fee-agreements-no-longer-work-2/" target="_blank"><span style="color: #0070c0; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-fareast-font-family: "Times New Roman"; mso-font-kerning: 0pt; mso-ligatures: none;">here</span></a></span><span style="color: #0070c0; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-fareast-font-family: "Times New Roman"; mso-font-kerning: 0pt; mso-ligatures: none;">.</span> </p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;">As a
lawyer, my training is to protect my client (policyholder) in <i>all</i> cases. I scoff at the "equal duty to carrier
and employer drivel" and act solely as my employer's advocate. Asking a broker to be the prosecutor, public
defender, and judge in one proceeding is a bad joke. </p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;">Our
healthcare system is a convoluted, byzantine myriad of corruption. I cannot stand by and refrain from screaming
from the rooftop. Don't get me wrong. There are plenty of fantastic people in the
healthcare system. In fact, I know that
the vast majority of them are there for the right reasons. They want to help people.</p>
<p align="center" class="MsoNormal" style="line-height: normal; margin-bottom: 0in; text-align: center;"><b><span style="color: #0070c0; font-size: 14pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-fareast-font-family: "Times New Roman"; mso-font-kerning: 0pt; mso-ligatures: none;">But even good people
cannot save a corrupt system.</span></b></p>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;">That's
right; it’s corrupt. I used to say it
was broken, but it is not. It is
designed this way. We didn't end up here
by accident. If you doubt me, let me
repeat: <o:p></o:p></p>
<ul type="disc">
<li class="MsoNormal" style="line-height: normal; mso-list: l0 level1 lfo1; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list .5in;">Since 2009 the S&P 500 is up 422%. <o:p></o:p></li>
<li class="MsoNormal" style="line-height: normal; mso-list: l0 level1 lfo1; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list .5in;">In that same time, five of the largest health insurer stock prices
are up an average of 1,921%. <o:p></o:p></li>
</ul>
<p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;">The healthcare
industry represents the largest employer and the largest lobbyist in the United
States, spending <a href="https://www.hfma.org/healthcare-news-of-note-the-healthcare-sectors-lobbying-expenditures-exceeded-700-million-in-2020/#:~:text=Education%20%26%20Events%20Overview-,Healthcare%20News%20of%20Note%3A%20The%20healthcare%20sector's%20lobbying,exceeded%20%24700%20million%20in%202020" target="_blank"><span style="color: #0070c0; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-fareast-font-family: "Times New Roman"; mso-font-kerning: 0pt; mso-ligatures: none;">$700 million</span></a> lobbying
legislators and regulators every year. It
makes up <a href="https://www.statista.com/statistics/184968/us-health-expenditure-as-percent-of-gdp-since-1960/" target="_blank"><span style="color: #0070c0; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-fareast-font-family: "Times New Roman"; mso-font-kerning: 0pt; mso-ligatures: none;">18.2% of the U.S. economy</span></a>. At its highest levels, it is loaded with the shrewdest
operators you can imagine. It uses
artificial intelligence and massive data analytic tools to vacuum up every
conceivable detail about every one of us, as I recently wrote about here: <a href="https://www.benefitspro.com/2023/04/19/weaponizing-hipaa-privacy/" target="_blank">WeaponizingHIPAA privacy</a>. </p><p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;">Furthermore, it is important to note that officials responsible for managing federal agencies tasked with supervising the United States healthcare system frequently transition from their governmental positions to leading roles in the very corporations they once regulated. The term for this phenomenon is "<a href="https://www.opensecrets.org/revolving/" target="_blank">revolving door</a>," which refers to the movement of government officials between public sector roles and private sector positions, often within industries they previously regulated. This repugnant twist enables them to capitalize on their expertise, influence peddling, and skillfully manipulate the governance system for the benefit of their new employers. Recently, The Survival Podcast highlighted this phenomenon through a <a href="https://twitter.com/TheSurvivalPodc/status/1655209426393939968" target="_blank">thought-provoking illustration</a>. Employing humor as a coping mechanism for such prevalent absurdity is essential; without the ability to find levity in these situations, I’d struggle to maintain my sanity.</p><p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><br /></p><table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto;"><tbody><tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiIYE-N6xSQkLLoU0ncjEnCX0_NjuecazXARogwLpFp0tiZ_t_Wz1S3MKJ2mDfHevBLj-mqMHH5KOXfwnBkuILq0GKi2eK-Urs8kSeJC78jenD4OsZ9ObrzJmcUM3IosLYeQf5BVFcSs-WzRtxiMwUVAltUSOzCV1TdQNj-j2KjwQZ8if1D0n5jNk3v/s504/Science.jpg" style="margin-left: auto; margin-right: auto;"><img border="0" data-original-height="504" data-original-width="500" height="640" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiIYE-N6xSQkLLoU0ncjEnCX0_NjuecazXARogwLpFp0tiZ_t_Wz1S3MKJ2mDfHevBLj-mqMHH5KOXfwnBkuILq0GKi2eK-Urs8kSeJC78jenD4OsZ9ObrzJmcUM3IosLYeQf5BVFcSs-WzRtxiMwUVAltUSOzCV1TdQNj-j2KjwQZ8if1D0n5jNk3v/w634-h640/Science.jpg" width="634" /></a></td></tr><tr><td class="tr-caption"><span style="color: #666666;">A light-hearted look at the most recent Revolving Door “swingers.” For a sobering look at the hundreds of these taking place in D.C. visit </span><a href="https://www.opensecrets.org/revolving/" target="_blank">Open Secrets</a>.</td></tr></tbody></table><p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;">In summary, it is crucial to understand that health insurers do not serve as your friends or allies. When Chief Financial Officers delegate the responsibility of managing health insurance expenses—which frequently rank as the second or third largest cost for employers—to Human Resources departments, they are neglecting their fiduciary duty to minimize costs in a reasonable manner. Human Resources professionals typically lack the legal expertise of attorneys and the financial acumen of finance executives, which further underscores the importance of involving the appropriate personnel in managing these critical expenses.</p><p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;">It is imperative that American businesses take decisive action to reduce healthcare costs by utilizing the innovative tools at their disposal and engaging the most competent consultants or brokers to aid them in this process. Failure to do so could result in the collapse of the employer-based healthcare system, leading to the implementation of a minimal, Medicaid-for-all arrangement. Under such a system, individuals with the means would acquire supplementary coverage, while those without would face extended wait times for necessary care and elective procedures. This will, in turn, prompt the departure of more top-tier providers from the system <b>(5)</b>.</p><p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;">It is essential to emphasize that this scenario envisions Medicaid for all, rather than Medicare. Despite the government's willingness to employ quantitative easing measures, injecting trillions of dollars into the economy at a moment's notice, Medicare remains prohibitively expensive—even for a nation with a $32 trillion debt and no hesitation to take on more.</p><p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;">Concluding on a lighthearted note, I would like to share two more memes. As the adage suggests, "A picture is worth a thousand words," so allow me to present an additional 2,000 words of insight.</p></div><div><span><br /></span></div><div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiT0WkHMMZK2sj7hh2kCIE0tv03t1ywWA4s9lndoUiK8LSz-BU_NQo0GGlvj3Aw6d4dYn0QK-JGNLqVYVlqS3S7CzpKzC-vvYtV1hAO1ANG2SIQyfDMwDr2wGXyjJ-EqcOZoMbQbDaIv6XqbNygVnJ1MZCjX5WxkeLbQ9-Y4S-AUEUPMS3QHnZo5cPY/s2001/Promised%20v.%20Got%203.jpg" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1123" data-original-width="2001" height="360" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiT0WkHMMZK2sj7hh2kCIE0tv03t1ywWA4s9lndoUiK8LSz-BU_NQo0GGlvj3Aw6d4dYn0QK-JGNLqVYVlqS3S7CzpKzC-vvYtV1hAO1ANG2SIQyfDMwDr2wGXyjJ-EqcOZoMbQbDaIv6XqbNygVnJ1MZCjX5WxkeLbQ9-Y4S-AUEUPMS3QHnZo5cPY/w640-h360/Promised%20v.%20Got%203.jpg" width="640" /></a></div><br /><table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto;"><tbody><tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiEY9wmQh-s3F-hFSisZkP6iPQs2mkGSquBJzJgszLBC4e2lFkdF8Khtsk4j2ZMC0XUo3yIRfWz3iMtpngSjAGbQ8WueVKotRVeCehsFb3DMBe1mDwQCJDCLT_HsdEwJdl0G68E47kkg4DM6t9iuqTF8465yDFtro7Gmd2wqqQCqt9c9nLMHDRJGaax/s1964/PPO%20v.%20RBP%20Pitt.jpg" style="margin-left: auto; margin-right: auto;"><img border="0" data-original-height="1094" data-original-width="1964" height="357" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiEY9wmQh-s3F-hFSisZkP6iPQs2mkGSquBJzJgszLBC4e2lFkdF8Khtsk4j2ZMC0XUo3yIRfWz3iMtpngSjAGbQ8WueVKotRVeCehsFb3DMBe1mDwQCJDCLT_HsdEwJdl0G68E47kkg4DM6t9iuqTF8465yDFtro7Gmd2wqqQCqt9c9nLMHDRJGaax/w640-h357/PPO%20v.%20RBP%20Pitt.jpg" width="640" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;"><span style="color: #666666;">It's time to tighten up your health plan. </span></td></tr></tbody></table></div><div><span style="color: #666666;"> </span></div><span style="color: #666666;"><div style="text-align: center;"><b>________________________________________________________________________</b></div>
</span><p></p><p class="MsoNormal" style="line-height: normal; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto;"><b><u><span style="color: #0b5394; font-size: 14pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-fareast-font-family: "Times New Roman"; mso-font-kerning: 0pt; mso-ligatures: none;">Footnotes</span></u></b><b><span style="color: #0b5394; font-size: 14pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-fareast-font-family: "Times New Roman"; mso-font-kerning: 0pt; mso-ligatures: none;">: </span></b><span style="font-size: 12pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-fareast-font-family: "Times New Roman"; mso-font-kerning: 0pt; mso-ligatures: none;"><o:p></o:p></span></p><p class="MsoNormal" style="line-height: normal; margin-bottom: 12pt;"><b><span style="font-size: 10pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-fareast-font-family: "Times New Roman"; mso-font-kerning: 0pt; mso-ligatures: none;">(1)</span></b><span style="font-size: 10pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-fareast-font-family: "Times New Roman"; mso-font-kerning: 0pt; mso-ligatures: none;"> Malcolm K.
Sparrow, a professor at the Kennedy School of Government at Harvard
University whose book License to Steal is a classic in the field, thinks that Medicare’s
fraud-related losses may run “as high as 30 to 35 percent” of its budget. From Chapter 12 in </span><a href="https://www.amazon.com/Overcharged-Americans-Much-Health-Care/dp/1944424768/ref=sr_1_1?crid=EWL62RT9KWF2&keywords=overcharged&qid=1683414024&sprefix=overcharged%2Caps%2C151&sr=8-1" target="_blank"><span style="color: blue; font-size: 10pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-fareast-font-family: "Times New Roman"; mso-font-kerning: 0pt; mso-ligatures: none;">Overcharged: Why Americans Pay Too Much For Health Care</span></a><span style="font-size: 10pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-fareast-font-family: "Times New Roman"; mso-font-kerning: 0pt; mso-ligatures: none;">, by David A. Hyman and Charles
Silver. <o:p></o:p></span></p><p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><b><span style="font-size: 10pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-fareast-font-family: "Times New Roman"; mso-font-kerning: 0pt; mso-ligatures: none;">(2)</span></b><span style="font-size: 10pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-fareast-font-family: "Times New Roman"; mso-font-kerning: 0pt; mso-ligatures: none;"> The following is an excerpt from the same book. It is an anecdotal example of just how
corrupt our prescription rules and practices are: </span></p><p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span style="font-size: xx-small; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-fareast-font-family: "Times New Roman"; mso-font-kerning: 0pt; mso-ligatures: none;"><br /></span></p><p class="MsoNormal" style="line-height: normal; margin-bottom: 5.0pt; margin-left: .5in; margin-right: 0in; margin-top: 0in; margin: 0in 0in 5pt 0.5in;"><span style="color: #444444; font-size: 10pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-fareast-font-family: "Times New Roman"; mso-font-kerning: 0pt; mso-ligatures: none;">Why do so many eye
doctors use pricier Lucentis when cheaper Avastin is available? You guessed it:
Medicare pays physicians a lot more for using Lucentis. A 2013 Washington Post article explained the
finances. </span><span style="font-size: 10pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-fareast-font-family: "Times New Roman"; mso-font-kerning: 0pt; mso-ligatures: none;"><o:p></o:p></span></p><p class="MsoNormal" style="line-height: normal; margin-bottom: 5.0pt; margin-left: .5in; margin-right: 0in; margin-top: 0in; margin: 0in 0in 5pt 0.5in;"><span style="color: #444444; font-size: 10pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-fareast-font-family: "Times New Roman"; mso-font-kerning: 0pt; mso-ligatures: none;">Under Medicare repayment
rules for drugs given by physicians, they are reimbursed for the average price
of the drug plus 6 percent. That means a
drug with a higher price may be easier to sell to doctors than a cheaper one. In addition, Genentech offers rebates to
doctors who use large volumes of the more expensive drug. </span><span style="font-size: 10pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-fareast-font-family: "Times New Roman"; mso-font-kerning: 0pt; mso-ligatures: none;"><o:p></o:p></span></p><p class="MsoNormal" style="line-height: normal; margin-bottom: 5.0pt; margin-left: .5in; margin-right: 0in; margin-top: 0in; margin: 0in 0in 5pt 0.5in;"><span style="color: #444444; font-size: 10pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-fareast-font-family: "Times New Roman"; mso-font-kerning: 0pt; mso-ligatures: none;">Got that? Medicare pays
doctors far more for administering Lucentis than Avastin to patients with wet
macular degeneration because Genentech charges more for the former than the
latter. Six percent of $2,300 is $138; 6
percent of $60 will barely buy you a white chocolate mocha at Starbucks. Genentech then sweetens the deal by giving
doctors who use large amounts of Lucentis discounts that the doctors get to
keep. It’s easy to see how Medicare put
taxpayers and seniors on the hook for $1.2 billion in payments for Lucentis in
2012. The hard part is explaining why
many doctors, to their credit, continue to use Avastin. The cost to taxpayers and elderly patients
could be much higher. </span><span style="font-size: 10pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-fareast-font-family: "Times New Roman"; mso-font-kerning: 0pt; mso-ligatures: none;"><o:p></o:p></span></p><p class="MsoNormal" style="line-height: normal; margin-bottom: 12pt;"><span style="font-size: 10pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-fareast-font-family: "Times New Roman"; mso-font-kerning: 0pt; mso-ligatures: none;"><b>(3)</b> I write "employer and employee" here to not confuse
folks needlessly while making a different point. But make no mistake; employees pay for every
nickel of this. We often fail to
acknowledge this reality because, on its face, an employer generally deducts
10% to 50% of our healthcare premium and then pays the rest of the bill to the
carrier monthly. However, every single
penny comes from an employee's compensation.
If the employer were not forced to fund those dollars into healthcare,
that remuneration would be provided to employees in the form of pay, other
benefits, time off, or efficiencies resulting in job/employment growth, etc. This is covered expertly in Chapter 1 of
Marshall Allen's book, </span><a href="https://www.amazon.com/Never-Pay-First-Bill-Health-ebook/dp/B08PCMYZJN/ref=tmm_kin_swatch_0?_encoding=UTF8&qid=1683414101&sr=8-1" target="_blank"><span style="color: #0070c0; font-size: 10pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-fareast-font-family: "Times New Roman"; mso-font-kerning: 0pt; mso-ligatures: none;">Never Pay the First Bill</span></a><span style="font-size: 10pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-fareast-font-family: "Times New Roman"; mso-font-kerning: 0pt; mso-ligatures: none;">. <o:p></o:p></span></p><p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><b><span style="font-size: 10pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-fareast-font-family: "Times New Roman"; mso-font-kerning: 0pt; mso-ligatures: none;">(4)</span></b><span style="font-size: 10pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; mso-fareast-font-family: "Times New Roman"; mso-font-kerning: 0pt; mso-ligatures: none;"> The same phenomenon exists for providers
(doctors) as well as facilities, but the problem with providers is not nearly
as pronounced as it is with facilities. Roughly
80% of a plan's claims occur with providers, but 80% of costs are generated via
the high-cost services occurring in facilities (primarily hospitals). </span></p><p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><b><span style="font-size: 10pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;">(5)</span></b><span style="font-size: 10pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;">
America is projected to have a shortfall of </span><a href="https://www.aamc.org/news/us-physician-shortage-growing" target="_blank"><span style="font-size: 10pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;">139,000
physicians</span></a><span style="font-size: 10pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;"> by 2033, representing 13% of U.S. providers.</span></p><p class="MsoNormal" style="line-height: normal; margin-bottom: 0in;"><span style="font-size: 10pt; mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;"><br /></span></p>Craighttp://www.blogger.com/profile/14913599100409003265noreply@blogger.comtag:blogger.com,1999:blog-3761470026816062685.post-91043863107142764082023-05-02T09:47:00.002-07:002023-05-02T09:47:38.385-07:00Why Your Health Insurer Doesn’t Care About Your Big Bills (Yeah It's Obamacare)<p> <span style="font-family: inherit;">From Marshall Allen at <a href="https://www.propublica.org/article/why-your-health-insurer-does-not-care-about-your-big-bills" target="_blank">ProPublica</a>: </span></p><p style="background-color: white;"><span style="color: #222222; font-family: inherit;"></span></p><blockquote><p style="background-color: white;"><span style="color: #222222; font-family: inherit;">Turns out, insurers don’t have to decrease spending to make money. They just have to accurately predict how much the people they insure will cost. That way they can set premiums to cover those costs — adding about 20 percent for their administration and profit. If they’re right, they make money. If they’re wrong, they lose money. But, they aren’t too worried if they guess wrong. They can usually cover losses by raising rates the following year.</span></p><p style="background-color: white;"><span style="color: #222222; font-family: inherit;">Frank suspects he got dinged for costing Aetna too much with his surgery. The company raised the rates on his small group policy — the plan just includes him and his partner — by 18.75 percent the following year.</span></p><p style="background-color: white;"><span style="color: #222222; font-family: inherit;">The Affordable Care Act kept profit margins in check by requiring companies to use at least 80 percent of the premiums for medical care. That’s good in theory but it actually contributes to rising health care costs. If the insurance company has accurately built high costs into the premium, it can make more money. Here’s how: Let’s say administrative expenses eat up about 17 percent of each premium dollar and around 3 percent is profit. Making a 3 percent profit is better if the company spends more.</span></p><p style="background-color: white;"><span style="color: #222222; font-family: inherit;">It’s like if a mom told her son he could have 3 percent of a bowl of ice cream. A clever child would say, “Make it a bigger bowl.”</span></p><p style="background-color: white;"><span style="color: #222222; font-family: inherit;">Wonks call this a “perverse incentive.”</span></p><p style="background-color: white;"><span style="color: #222222; font-family: inherit;">“These insurers and providers have a symbiotic relationship,” said Wendell Potter, who left a career as a public relations executive in the insurance industry to become an author and patient advocate. “There’s not a great deal of incentive on the part of any players to bring the costs down.”</span></p></blockquote><p style="background-color: white;"><span style="color: #222222; font-family: inherit;"></span></p><p style="background-color: white;"><span style="color: #222222; font-family: inherit;"><br /></span></p>Craighttp://www.blogger.com/profile/14913599100409003265noreply@blogger.comtag:blogger.com,1999:blog-3761470026816062685.post-7939173579456752592023-04-19T18:00:00.007-07:002023-04-21T14:27:39.219-07:00Scouring your PHI from Everyone, Everywhere, All at Once<div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjKiu9aDieXP9vFcwTmSCBmTWYW0xa2pLKXkEG2eCCKIg3bckaegOlXksG8EZIpgFqcpGJBHj2xSVBDAcXtjq4H7vJlkiUJkUR7wOXAhvzwdPkQ-lzGdwVbAUsO3YrrZQ36-k6JKr1bXQD4izdEcqWBgspr_kY6pPeZdUedC3zyNOLUjtXnugcJelc0/s1460/All%20Over.png" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="939" data-original-width="1460" height="413" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjKiu9aDieXP9vFcwTmSCBmTWYW0xa2pLKXkEG2eCCKIg3bckaegOlXksG8EZIpgFqcpGJBHj2xSVBDAcXtjq4H7vJlkiUJkUR7wOXAhvzwdPkQ-lzGdwVbAUsO3YrrZQ36-k6JKr1bXQD4izdEcqWBgspr_kY6pPeZdUedC3zyNOLUjtXnugcJelc0/w640-h413/All%20Over.png" width="640" /></a></div><div><br /></div>My latest is now up over at <a href="https://www.benefitspro.com/2023/04/19/weaponizing-hipaa-privacy/" target="_blank">BenefitsPRO</a>: <br /><br /><blockquote style="border: none; margin: 0px 0px 0px 40px; padding: 0px; text-align: left;"> You come to work one day, and notice Susan is not there. Nobody knows what happened to her, and everyone appears oddly tight-lipped about her absence. Finally, you and your coworkers are told she has taken a leave of absence. No other details are given. Attorneys, corporate compliance officers, and human resource personnel have been properly coached as to the myriad of stringent health privacy rules in the workplace, and everyone is rightfully paranoid.</blockquote><br /><blockquote style="border: none; margin: 0px 0px 0px 40px; padding: 0px; text-align: left;">I am reminded of an eccentric law professor I had who relished saying, “No good deed goes unpunished,” whenever discussing the inevitable unintended consequences of legislation or contract terms.</blockquote><br /><blockquote style="border: none; margin: 0px 0px 0px 40px; padding: 0px; text-align: left;">But after <a href="https://www.benefitspro.com/2022/11/11/2022-erisa-welfare-plan-automatic-participant-disclosures/" target="_blank">22 years of HIPAA Privacy, </a>I am not even sure the main impetus behind its passage was ever a good deed – at least not for those who have weaponized its use against employers.</blockquote><blockquote style="border: none; margin: 0px 0px 0px 40px; padding: 0px;"><p style="text-align: left;">The Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule was designed to protect individuals’ medical records and other personal health information. However, the latest practices by health insurance carriers raise serious concerns about how they circumvent these rules to maximize premiums. ...</p></blockquote><div><a href="https://www.benefitspro.com/2023/04/19/weaponizing-hipaa-privacy/" target="_blank">Full story</a>. </div><div><br /></div><div>I spent some time with <a href="https://www.armstrongandgetty.com/" target="_blank">Armstrong and Getty</a> this morning, discussing this story and the hidden tax built into all of our employer plans due to Medicare and Medicaid's chronic inefficiency and underpayment.</div><div><br /></div><div><iframe allow="autoplay" frameborder="0" height="300" src="https://www.iheart.com/podcast/64-armstrong-getty-extra-large-30400323/episode/the-high-cost-of-a-good-113584528/?embed=true" width="100%"></iframe></div><div> </div>Craighttp://www.blogger.com/profile/14913599100409003265noreply@blogger.comtag:blogger.com,1999:blog-3761470026816062685.post-34928052838893785472023-04-13T16:15:00.001-07:002023-04-13T16:15:32.505-07:001 in 5 California Hospitals is in Danger of Closure<p><span style="font-family: inherit;"></span></p><div class="separator" style="clear: both; text-align: center;"><span style="font-family: inherit;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjG4PP7cq0_YjoPe8SUEGZljUUp80NzyAsR8FMthRpdhGJl7KOZkBSKJAEkNo-jow9BrJGzk_BMfBLnFGOySIsGVenJKOaEyfAt8gi8PMbOc4OjfVqT8s4t5Fa3a7g1It2nzCznqrmWbCE73_ZpobRAYHZf6TaXrQHMzU7FAAPuQ4AtcnfGR_20irEn/s1456/Closed%20Hospital.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="816" data-original-width="1456" height="358" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjG4PP7cq0_YjoPe8SUEGZljUUp80NzyAsR8FMthRpdhGJl7KOZkBSKJAEkNo-jow9BrJGzk_BMfBLnFGOySIsGVenJKOaEyfAt8gi8PMbOc4OjfVqT8s4t5Fa3a7g1It2nzCznqrmWbCE73_ZpobRAYHZf6TaXrQHMzU7FAAPuQ4AtcnfGR_20irEn/w640-h358/Closed%20Hospital.png" width="640" /></a></span></div><br /> California hospitals are <a href="https://www.fresnobee.com/news/local/article274242050.html?utm_campaign=CHL%3A%20Daily%20Edition&utm_medium=email&_hsmi=254185044&_hsenc=p2ANqtz-91en4L2LInhH1DcA4cA3XH6j9SSwjpbOFAG070e-wwaOfoNwV_7f7oVwr8J7KNibF06DfJx9uK3Zwjy1eklLVOcrFD7lHswHrVSNnGAJj5h28M-C4&utm_content=254185044&utm_source=hs_email" target="_blank">in serious trouble</a> due to:<br /><ul style="text-align: left;"><li>The misguided government prohibition against non-COVID care during the pandemic;</li><li>Overall inflation;</li><li>And chronic underpayment from Medicare and Medicaid (only covering about <a href="https://www.fresnobee.com/news/local/article274242050.html?utm_campaign=CHL%3A%20Daily%20Edition&utm_medium=email&_hsmi=254185044&_hsenc=p2ANqtz-91en4L2LInhH1DcA4cA3XH6j9SSwjpbOFAG070e-wwaOfoNwV_7f7oVwr8J7KNibF06DfJx9uK3Zwjy1eklLVOcrFD7lHswHrVSNnGAJj5h28M-C4&utm_content=254185044&utm_source=hs_email" target="_blank">75 cents on the dollar</a> of actual costs).</li></ul>The underpayment then forces employer plans to pay absurdly high prices (<a href="https://www.rand.org/pubs/research_reports/RRA1144-1.html" target="_blank">224% of Medicare</a> in last year's study) to make up for the fact that many hospitals can't survive on government reimbursements.<br /><br />When Medicaid (Medi-CAL) first passed, it was designed to cover the lowest 2% of wage earners. It now makes up <a href="https://www.fresnobee.com/news/local/article274242050.html?utm_campaign=CHL%3A%20Daily%20Edition&utm_medium=email&_hsmi=254185044&_hsenc=p2ANqtz-91en4L2LInhH1DcA4cA3XH6j9SSwjpbOFAG070e-wwaOfoNwV_7f7oVwr8J7KNibF06DfJx9uK3Zwjy1eklLVOcrFD7lHswHrVSNnGAJj5h28M-C4&utm_content=254185044&utm_source=hs_email" target="_blank">80% of patient volume</a> at many of these rural hospitals, and about four in ten Californians are born into it. That's what you call mission creep at its finest.<br /><br />As Patty Maysent, the CEO of UC San Diego Health, <a href="https://www.fresnobee.com/news/local/article274242050.html?utm_campaign=CHL%3A%20Daily%20Edition&utm_medium=email&_hsmi=254185044&_hsenc=p2ANqtz-91en4L2LInhH1DcA4cA3XH6j9SSwjpbOFAG070e-wwaOfoNwV_7f7oVwr8J7KNibF06DfJx9uK3Zwjy1eklLVOcrFD7lHswHrVSNnGAJj5h28M-C4&utm_content=254185044&utm_source=hs_email" target="_blank">explains</a>, "[t]here are hospitals all around the state ... that are two, three or four months away from running out of cash."<br /><br />There are answers! Employers need not suffer through this. I've written about this extensively. Here are a couple of good starting points:<br /><ol style="text-align: left;"><li><a href="https://www.benefitspro.com/2023/04/11/the-fiduciary-imperative-of-reference-based-pricing-a-legal-and-financial-analysis/" target="_blank">The fiduciary imperative of reference-based pricing: A legal and financial analysis</a>; and</li><li><a href="https://www.benefitspro.com/2020/04/06/america-will-dramatically-change-the-way-it-provides-health-care-by-2030-412-96023/" target="_blank">America will dramatically change the way it provides health care by 2030</a></li></ol><div><br /></div><p></p><p></p>Craighttp://www.blogger.com/profile/14913599100409003265noreply@blogger.comtag:blogger.com,1999:blog-3761470026816062685.post-33692679737499709362023-04-12T10:24:00.004-07:002023-04-12T10:25:29.605-07:00The Fiduciary Imperative of Reference-Based Pricing: A Legal and Financial Analysis<p><i>This is my latest; it can be read in full over at <a href="https://www.benefitspro.com/2023/04/11/the-fiduciary-imperative-of-reference-based-pricing-a-legal-and-financial-analysis/" target="_blank"><b>BeneftsPRO</b></a>. </i></p><p><b><span style="color: #3d85c6; font-size: medium;">Abstract</span></b>: This article examines the fiduciary obligation of CFOs, VPs of HR, and other health and welfare plan fiduciaries under the Employee Retirement Income Security Act (ERISA) to evaluate Reference-Based Pricing (RBP) in the context of their health insurance plans. The article argues that, given the federal government's endorsement of RBP and its proven efficacy in reducing employer costs and expanding participant options, it is now virtually impossible for a plan fiduciary to lawfully discharge their duties in accordance with ERISA without at least considering the implementation of RBP.</p><p><b><span style="color: #0b5394; font-size: medium;">Introduction</span></b></p><p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgf8LITpgKThktJs8MWS1wL6uCEbNMRfs8ZBm5VHyNYMtaxO61_MORrL17SV4Mo-YToTcIIOhx1M4Pw_4KSrWwQsrLxN58uFI6xBLopMVk4hm2vc7NCWm92T_iYwwM0kozwyXBqUhUJkDxf31kl_Kx7cSnZouszg5liIY9D_xpN_V5BpeZ4vgL38sSH/s1024/Image%202.png" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" data-original-height="1024" data-original-width="1024" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgf8LITpgKThktJs8MWS1wL6uCEbNMRfs8ZBm5VHyNYMtaxO61_MORrL17SV4Mo-YToTcIIOhx1M4Pw_4KSrWwQsrLxN58uFI6xBLopMVk4hm2vc7NCWm92T_iYwwM0kozwyXBqUhUJkDxf31kl_Kx7cSnZouszg5liIY9D_xpN_V5BpeZ4vgL38sSH/s320/Image%202.png" width="320" /></a></div>The landscape of American healthcare has undergone significant transformations in the past decade, with the emergence of numerous innovations and cost-saving measures. The most impactful development is the rise of Reference-Based Pricing (RBP), a pricing model proving to be a game-changer for employer-sponsored health insurance plans. This article argues that, given the demonstrated benefits of RBP, CFOs, VPs of HR, and other plan fiduciaries under ERISA are now under a fiduciary obligation to evaluate the potential incorporation of RBP into their health insurance plans – at least with respect to employers that are large enough to consider particularly self-funding their health plans. <br /><p></p><p><b><span style="color: #0b5394; font-size: medium;">I. Fiduciary Obligations Under ERISA</span></b></p><p>ERISA imposes a fiduciary duty on plan administrators to act solely in the interest of plan participants and beneficiaries and for the exclusive purpose of providing benefits and defraying reasonable expenses of administering the plan. To fulfill this duty, fiduciaries must adhere to certain principles, including prudence, diversification, and adherence to plan documents.</p><p>The duty of prudence requires fiduciaries to act with the care, skill, prudence, and diligence that a prudent person would use in a similar situation. This duty is not merely a passive obligation; rather, it compels fiduciaries to actively engage in the management and oversight of plan assets, constantly seeking opportunities to enhance the value and cost-effectiveness of the plan.</p><p>Donovan v. Bierwirth, 680 F.2d 263, 271 (2d Cir. 1982) emphasizes the importance of fiduciaries acting with prudence and diligence in managing ERISA plans:</p><p></p><blockquote>In every case charging breach of ERISA fiduciary duty, ... the central inquiry is whether the fiduciary has acted 'with the care, skill, prudence, and diligence under the circumstances then prevailing that a prudent man acting in a like capacity and familiar with such matters would use in the conduct of an enterprise of a like character and with like aims.'</blockquote><p></p><div>... Full story at <a href="https://www.benefitspro.com/2023/04/11/the-fiduciary-imperative-of-reference-based-pricing-a-legal-and-financial-analysis/" target="_blank">BenefitsPRO</a>. </div><div><br /></div>Craighttp://www.blogger.com/profile/14913599100409003265noreply@blogger.comtag:blogger.com,1999:blog-3761470026816062685.post-63891056686414499062023-04-09T06:23:00.002-07:002023-04-09T06:23:37.232-07:00Social Security will be Unable to Pay Full Benefits a Year Earlier Than Expected<h2 style="text-align: left;"><span style="color: #3d85c6;">Implications/Opportunities for Employers:</span></h2><p></p><ol style="text-align: left;"><li><u>Attract and retain talent through enhanced retirement benefits</u>: As concerns about Social Security's long-term sustainability grow, employers can differentiate themselves by offering attractive retirement plans, such as 401(k) matching or pension plans. This can help them attract and retain top talent who are looking for financial security in their retirement.</li><li><u>Encourage longer careers and phased retirement</u>: Employers can capitalize on the potential need for older workers to continue working by offering flexible work arrangements, such as part-time or remote work, to keep experienced employees engaged and productive. This can help employers maintain a skilled workforce and benefit from the knowledge and expertise of older employees.</li><li><u>Financial education and planning</u>: Employers can provide resources, seminars, or workshops on financial planning and retirement savings to help employees better prepare for their financial future. This can lead to increased employee satisfaction and loyalty, as employees appreciate the support in navigating a potentially uncertain financial landscape.</li><li><u>Promote a culture of saving and financial wellness</u>: Employers can encourage employees to save and invest for their retirement by offering financial wellness programs and incentives for participating in retirement savings plans. This can help create a financially savvy workforce that is better prepared for the future.</li><li><u>Collaborate with policymakers:</u> Employers, as significant stakeholders in the retirement landscape, can use their influence to advocate for policy changes and reforms that address the Social Security funding crisis. This can help protect both their employees' interests and their own long-term business interests. </li></ol>Full <a href="https://www.marketwatch.com/story/social-security-is-now-projected-to-be-unable-to-pay-full-benefits-a-year-earlier-than-expected-3fd83b63" target="_blank">story</a>.<div><br /><div>Related story: <a href="https://www.cato.org/blog/medicare-social-security-are-responsible-95-percent-us-unfunded-obligations" target="_blank">Medicare and Social Security Are Responsible for 95 Percent of U.S. Unfunded Obligations</a></div><div><br /></div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjAFCsiBbWNwCqRcRFhT2DcYEZSJzSOIlJurpYz5NMxDRi74j_9KdOjBbduoMRPtLp8e0xL1QFH-Gg6A7hs5EYOMua0nMyIKsQbK46aopmaGdumSYEdu0msX4cWythOHTvbAhV30NkgoX4DKFsf02lJSzpgH7ebsGfY8eJIiRA0L7chHKEA3Sxg_0Rg/s888/Screenshot%202023-04-09%206.22.23%20AM.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="632" data-original-width="888" height="456" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjAFCsiBbWNwCqRcRFhT2DcYEZSJzSOIlJurpYz5NMxDRi74j_9KdOjBbduoMRPtLp8e0xL1QFH-Gg6A7hs5EYOMua0nMyIKsQbK46aopmaGdumSYEdu0msX4cWythOHTvbAhV30NkgoX4DKFsf02lJSzpgH7ebsGfY8eJIiRA0L7chHKEA3Sxg_0Rg/w640-h456/Screenshot%202023-04-09%206.22.23%20AM.png" width="640" /></a></div><div><br /></div></div>Craighttp://www.blogger.com/profile/14913599100409003265noreply@blogger.comtag:blogger.com,1999:blog-3761470026816062685.post-299957298407943492023-04-09T06:16:00.001-07:002023-04-09T07:14:24.952-07:00Are Employers Selecting Affordable Healthcare Benefits?<p>Healthcare costs in the US continue to rise, with employers paying over $13,800 per employee for healthcare in 2023. McKinsey predicts that healthcare spending could take up as much as 75% of discretionary income for those making less than 200% of the federal poverty level. 66% of employees say the cost of receiving care through their current health plan is too expensive, and over half feel that their care is more expensive than expected in the last year.</p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg0p8XoE5g61cFIJVH8ui4-HMAIFRjMxT0Qg2OQeMNvwnncFcBfX9b6QXqy4IWCywFpigDXAwedKSWV_vkdUq1zQNwtHMU23EVGTQ2qY5kuwO860Gz-Z_8goWNiSZtdjQLTuI7cMTNgf28XaF4_MvOeNWhBe8gfKfyb8RbQXqcGIirxmGLrfDtw5R4v/s1599/tempFileForShare_20230409-071232.jpg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" data-original-height="1596" data-original-width="1599" height="319" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg0p8XoE5g61cFIJVH8ui4-HMAIFRjMxT0Qg2OQeMNvwnncFcBfX9b6QXqy4IWCywFpigDXAwedKSWV_vkdUq1zQNwtHMU23EVGTQ2qY5kuwO860Gz-Z_8goWNiSZtdjQLTuI7cMTNgf28XaF4_MvOeNWhBe8gfKfyb8RbQXqcGIirxmGLrfDtw5R4v/s320/tempFileForShare_20230409-071232.jpg" width="320" /></a></div><p></p><p>Arizent's research shows that 70% of employers believe they offer the best possible benefits, but 68% feel that their benefit design is limited by their budget. Employers who describe themselves as innovative are more likely to offer digital health tools and family-building benefits, while most agree on the importance of evaluating benefit offerings each year.</p><p>The most commonly delivered benefits are health, dental, and vision insurance, and paid sick leave, but employees desire benefits related to gym access, nutrition support, wellness activities, mental health support, chronic condition support, and family-building assistance.</p><p>Telehealth sees high utilization rates, with 72% of employees have participated in some form of virtual care appointment in the last 12 months, while mental health support, family-building assistance, and paid parental leave are used less. Healthcare navigation services are on employers' radar, with nearly 80% of employers motivated to include them to provide a better employee experience, improve health outcomes, and reduce costs.</p><p>Full story <a href="https://www.benefitnews.com/news/are-employers-picking-affordable-healthcare-benefits" target="_blank">here</a>. </p><p><br /></p>Craighttp://www.blogger.com/profile/14913599100409003265noreply@blogger.comtag:blogger.com,1999:blog-3761470026816062685.post-75446956755290672732023-03-25T11:33:00.006-07:002023-04-05T16:22:42.135-07:00Shred Me! One Man's Intriguing Response to Super Size Me (Eating Only McDonalds Patties for 2-Months Straight)<p>You may recall that in "Super Size Me," documentarian Morgan Spurlock explored the effects of consuming a diet consisting solely of fast food from McDonald's. He decided to eat only McDonald's food three times a day for 30 days while following certain rules like always accepting the option of "supersizing" his meals whenever offered. He documents the effects of this diet on his physical and mental health, as well as on his weight and general well-being.</p><p>The film received critical acclaim and sparked public discussions about the health impacts of fast food, leading to changes in the fast-food industry, such as the introduction of healthier menu options and the discontinuation of the "supersize" option in some fast-food chains.</p><table cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: right;"><tbody><tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhKMFReLS2EGsZKw77UVwWUS231KSj1_qopbm9QVwt_vKaURftVOwlBnD2ykeUHORmdv2kNq2YUS28u_uS5oR8_tGJp7yCCM6oWMNahRcEH-e7lSIf-X8KpApB2UJueXggFr2bU8GUujk8wOB_O7Cu8pZ3AJY6K4omL3gl5Hhu6IZN1cvcoetWrpHal/s677/Ron.png" style="clear: right; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" data-original-height="626" data-original-width="677" height="296" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhKMFReLS2EGsZKw77UVwWUS231KSj1_qopbm9QVwt_vKaURftVOwlBnD2ykeUHORmdv2kNq2YUS28u_uS5oR8_tGJp7yCCM6oWMNahRcEH-e7lSIf-X8KpApB2UJueXggFr2bU8GUujk8wOB_O7Cu8pZ3AJY6K4omL3gl5Hhu6IZN1cvcoetWrpHal/s320/Ron.png" width="320" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;"><span style="color: #666666; font-size: xx-small;">@garyfixstuff https://twitter.com/garyfixstuff/status/1626301885572386820</span></td></tr></tbody></table><p>Throughout the film, medical professionals monitored Spurlock's weight and blood health. At the start of the experiment, Spurlock weighed 185 pounds with a body mass index (BMI) of 23.2, which is considered healthy. </p><p>After just a few days of consuming only fast food, Spurlock began to experience negative health effects. He gained a significant amount of weight, and his BMI increased to 25.5, which is considered overweight. By the end of the experiment, he had gained 24.5 pounds, and his BMI increased to 30, or obese.</p><p>In addition to the weight gain, Spurlock's blood health also deteriorated over the course of the experiment. His cholesterol levels increased by 65 points, and his liver function tests showed signs of damage akin to that of an alcoholic. He experienced dramatic mood swings, headaches, and decreased energy levels. He would get flat-out hangry when he'd gone more than a few hours with his Mc-y-D fix, and then upon diving into a Big Mac, he'd be as mollified as a heroine junking staving off the demons. </p><p><b>But did Spurlock prove that all fast food is unhealthy, or did he highlight the deleterious effects of highly refined carbohydrates, the industrial byproduct of seed oils, and the chemical cocktail of preservatives? </b></p><p>One of the most intriguingly disturbing parts of the documentary was when Spurlock purchased an order of McDonald's fries and kept them in a container for 10 weeks to see how long they would last without molding or decomposing. He stored the fries in the container at room temperature and did not add any preservatives or chemicals to the fries. He also did not open the container or disturb the fries in any way. After 10 weeks, Spurlock checked the fries and found that they had not molded or decomposed whatsoever. </p><p>Well, I think we have our answers, as this chap loses weight, experiences no loss in athletic performance (rock climbing), and generally maintains similar blood health (with a remarkable improvement in triglycerides). </p><div style="text-align: center;"><iframe allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/Ey93GV-oKQY" title="YouTube video player" width="560"></iframe></div><div style="text-align: center;"><br /></div><div style="text-align: left;">If you want to skip to the results, jump to the 45-minute mark and just watch for about 20 to 25 minutes. Petty staggering how well things turned out. </div><div style="text-align: center;"><br /></div>Craighttp://www.blogger.com/profile/14913599100409003265noreply@blogger.comtag:blogger.com,1999:blog-3761470026816062685.post-69313731469419689462023-03-25T10:53:00.000-07:002023-03-25T10:53:01.155-07:001.2 Million Canadians Are Waiting for Care They Desperately Need<p><span style="color: #494e54;">According to the Canadian Institute for Health Information (CIHI), the median wait time for priority procedures in Canada in 2020 was 16.8 weeks, up from 10.9 weeks in 2019. Priority procedures are defined as procedures that are clinically necessary, but their delay could result in the patient's condition becoming more serious.</span></p><p></p><div class="separator" style="clear: both; text-align: left;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgqIXX2Q58OYotCetSL0mEBWYbdUMssu_aslLPl1iM-v0n65wDgb53b-JWaYP7pDijQNS2YL55_YG-V10Sz2dUCvyhtXRW00BfsVkx-QwPVma3YLVqEZCbAbEKKeXUrjUWe-amWB_n_Aqa8ThNFI55tsy7Uq06V0yLTaeYUryn2yR8nFym6Jk8Y371d/s1986/Dr.%20Wait.%20.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="1122" data-original-width="1986" height="226" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgqIXX2Q58OYotCetSL0mEBWYbdUMssu_aslLPl1iM-v0n65wDgb53b-JWaYP7pDijQNS2YL55_YG-V10Sz2dUCvyhtXRW00BfsVkx-QwPVma3YLVqEZCbAbEKKeXUrjUWe-amWB_n_Aqa8ThNFI55tsy7Uq06V0yLTaeYUryn2yR8nFym6Jk8Y371d/w400-h226/Dr.%20Wait.%20.png" width="400" /></a><span style="color: #494e54;">However, wait times vary </span><i style="color: #494e54;">widely </i><span style="color: #494e54;">depending on the province or territory and the specific medical facility. In 2020, the median wait time for priority procedures ranged from 10.6 weeks in Quebec to 32.9 weeks in Prince Edward Island. Even t</span><span style="color: #494e54;">he median wait time for cancer-related surgeries was 4.8 weeks. </span></div><p></p><p><span style="color: #494e54;">Patients are often forced to travel to a different province to try and get care more quickly. </span></p><p><span style="color: #494e54;">This is a summary of the current situation from the <a href="https://mises.org/wire/democracy-created-canadas-lethal-healthcare-system" target="_blank">Mises Institute</a>: </span></p><p><span style="font-family: inherit;"><span style="background-color: white; color: #494e54;"></span></span></p><blockquote><p><span style="color: #666666; font-family: inherit;"><span style="background-color: white;">Currently, there are approximately </span><a href="https://www.fraserinstitute.org/studies/waiting-your-turn-wait-times-for-health-care-in-canada-2022#:~:text=It%20is%20estimated%20that%2C%20across,waiting%20for%20treatment%20in%202022" rel="noopener noreferrer" style="background: rgb(255, 255, 255); box-sizing: border-box; text-decoration-line: none;" target="_blank">1.2 million Canadians</a><span style="background-color: white;"> stuck on a government waiting list for healthcare that they </span><em style="background-color: white; box-sizing: border-box;">need</em><span style="background-color: white;">. This is a death sentence for many of them, as it has been for </span><a href="https://www.fraserinstitute.org/article/while-politicians-dither-patients-die" rel="noopener noreferrer" style="background: rgb(255, 255, 255); box-sizing: border-box; text-decoration-line: none;" target="_blank">thousands</a><span style="background-color: white;"> of patients who </span><a href="https://nationalpost.com/news/canada/more-than-2000-patients-in-canada-died-while-waiting-for-medical-care-in-2020-report" rel="noopener noreferrer" style="background: rgb(255, 255, 255); box-sizing: border-box; text-decoration-line: none;" target="_blank">have gone</a><span style="background-color: white;"> before them. ...</span></span></p><p style="background-color: white; box-sizing: border-box; margin: 0px 0px 12.5px;"><span style="color: #666666; font-family: inherit;">Patients who endure considerable suffering as they languish on a waiting list—where many of them die—cannot be seen to have been given reasonable access to health services in the government’s Medicare system. The government also prevents them from having reasonable access to a private healthcare option.</span></p><p style="background-color: white; box-sizing: border-box; margin: 0px 0px 12.5px;"><span style="color: #666666; font-family: inherit;">Thus, <em style="box-sizing: border-box;">reasonable access</em> is an obvious deception, with benefits flowing to highly paid, power-hungry politicians, bureaucrats, and administrators wanting to maintain control over massive, inefficient healthcare bureaucracies at the federal and provincial levels. This deceitful behavior fits the definition of <a href="https://www.dictionary.com/browse/fraud" rel="noopener noreferrer" style="background: transparent; box-sizing: border-box; text-decoration-line: none;" target="_blank">fraud</a> and should be prosecuted as such.</span></p><p style="background-color: white; box-sizing: border-box; margin: 0px 0px 12.5px;"><span style="color: #666666; font-family: inherit;">Thousands of Canadians die while they wait for the care that the government promised to deliver when they needed it. ...</span></p><p style="background-color: white; box-sizing: border-box; margin: 0px 0px 12.5px;"><span style="color: #666666; font-family: inherit;">If politicians were <em style="box-sizing: border-box;">personally</em> accountable for the damage they caused, guess what? They wouldn’t cause any damage! However, we cannot hold them personally accountable because equality under the law does not exist in a democracy.</span></p><p style="background-color: white; box-sizing: border-box; margin: 0px 0px 12.5px;"><span style="color: #666666; font-family: inherit;">In the private sector, you are accountable for your own actions. If you break your neighbor’s window, you pay for the replacement. If you are a politician and you break the window in the course of performing your official duties, you can charge the cost of the new window to taxpayers....</span></p><p style="background-color: white; box-sizing: border-box; margin: 0px 0px 12.5px;"><span style="color: #666666; font-family: inherit;">When citizens demand better service, politicians respond by saying, “Okay, but that means we have to take more of your money.” So, taxes are raised, more bureaucrats and administrators are hired, and the inefficient Medicare bureaucracies that politicians and bureaucrats regard as their personal fiefdoms grow ever larger. That’s why healthcare is the single largest item in many provincial budgets. ...</span></p></blockquote><p style="background-color: white; box-sizing: border-box; color: #494e54; margin: 0px 0px 12.5px;"><span style="font-family: inherit;"></span></p>Craighttp://www.blogger.com/profile/14913599100409003265noreply@blogger.comtag:blogger.com,1999:blog-3761470026816062685.post-69331222849686399902023-03-25T10:32:00.000-07:002023-03-25T10:32:21.020-07:00How Cigna Saves Millions by Having Its Doctors Reject Claims Without Reading Them<p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiF-qwANPKiqrVlx85sXPSMMNa4FQ6P15L4t2CbflXVDzbJ2wWAvjdPGZnvK1N_kAdT_t9rQKE9pOS8RYmPIEBO2qZii5gRP8Xam5wT6n1yf3ppval_JIVES0Eco7NVaqtnvk4DxPmrvgbM1rxLBbf7bw_n5ZqeNEP2LTJ2IaVSczYGc7G5RMRR33GC/s1656/AI%20Claim%20Denied.png" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em; text-align: right;"><img border="0" data-original-height="1116" data-original-width="1656" height="270" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiF-qwANPKiqrVlx85sXPSMMNa4FQ6P15L4t2CbflXVDzbJ2wWAvjdPGZnvK1N_kAdT_t9rQKE9pOS8RYmPIEBO2qZii5gRP8Xam5wT6n1yf3ppval_JIVES0Eco7NVaqtnvk4DxPmrvgbM1rxLBbf7bw_n5ZqeNEP2LTJ2IaVSczYGc7G5RMRR33GC/w400-h270/AI%20Claim%20Denied.png" width="400" /></a></div><div style="text-align: left;">AI is being used extensively in the area of the pre-authorization of your medical claims. Prior to approving a medical service or procedure, insurance companies often require a pre-authorization process where doctors must submit detailed information about the medical necessity of the service or procedure. AI algorithms can analyze this information to quickly determine whether the service or procedure meets the insurer's criteria for coverage.</div><p></p><p style="text-align: left;">Lawfully, AI is not supposed to autonomously make these decisions without human intervention. The final decision on whether to approve or deny a claim is supposed to rest with human reviewers who use the information provided by AI systems as one of many factors to consider. So what happens when those human reviewers are doctors that reflexively sign the denial in less than two seconds without reading or even opening the patient file? </p><p style="text-align: left;">Well, increased profits for the Government Healthcare Complex and a fresh glimpse at the utopia of AI medicine. This whole article is worth your time to read. It is an excellent glimpse behind the curtain. The following is from <a href="https://www.propublica.org/article/cigna-pxdx-medical-health-insurance-rejection-claims" target="_blank">ProPublica</a>: </p><blockquote dir="auto" style="background-color: white; border: none; margin: 0px 0px 0px 40px; padding: 0px;"><div dir="auto"><div dir="auto"><span style="color: #666666; font-family: inherit;">The company [Cigna] has built a system that allows its doctors to instantly reject a claim on medical grounds without opening the patient file, leaving people with unexpected bills, according to corporate documents and interviews with former Cigna officials. Over a period of two months last year, Cigna doctors denied over 300,000 requests for payments using this method, spending an average of 1.2 seconds on each case, the documents show. The company has reported it covers or administers health care plans for <a data-saferedirecturl="https://www.google.com/url?q=https://newsroom.thecignagroup.com/2023-2-3-Cigna-Reports-Strong-Fourth-Quarter-and-Full-Year-2022-Results-Establishes-2023-Guidance-and-Increases-Dividend&source=gmail&ust=1679848105060000&usg=AOvVaw0To_ua7W9k7_61XeS7ewfZ" href="https://newsroom.thecignagroup.com/2023-2-3-Cigna-Reports-Strong-Fourth-Quarter-and-Full-Year-2022-Results-Establishes-2023-Guidance-and-Increases-Dividend" style="border: 0px; box-sizing: border-box; font-feature-settings: inherit; font-kerning: inherit; font-stretch: inherit; font-variant-alternates: inherit; font-variant-east-asian: inherit; font-variant-numeric: inherit; margin: 0px; padding: 0px; text-decoration-color: var(--color-accent-30); vertical-align: baseline;" target="_blank">18 million people</a>.... </span></div></div><div dir="auto"><div dir="auto"><span style="color: #666666;"><br /></span></div></div><div dir="auto"><div dir="auto"><div dir="auto"><span style="color: #666666; font-family: inherit;">A Cigna algorithm flags mismatches between diagnoses and what the company considers acceptable tests and procedures for those ailments.... </span></div></div></div><div dir="auto"><div dir="auto"><div dir="auto"><span style="color: #666666; font-family: inherit;"><br /></span></div></div></div><div dir="auto"><div dir="auto"><div dir="auto"><span style="color: #666666; font-family: inherit;">'We literally click and submit,' one former Cigna doctor said. 'It takes all of 10 seconds to do 50 at a time.'... </span></div></div></div><div dir="auto"><div dir="auto"><div dir="auto"><span style="color: #666666; font-family: inherit;"><br /></span></div></div></div><div dir="auto"><div dir="auto"><div dir="auto"><span style="color: #666666; font-family: inherit;">Cigna does not expect many appeals. In one corporate document, Cigna estimated that only 5% of people would appeal a denial resulting from a PXDX review. </span></div></div></div></blockquote><p> </p>Craighttp://www.blogger.com/profile/14913599100409003265noreply@blogger.comtag:blogger.com,1999:blog-3761470026816062685.post-80062815511896131252023-03-24T12:05:00.002-07:002023-03-24T12:10:59.525-07:00 Half of Employers Plan to Cut Benefits in 2023<p>This is from <a href="https://www.benefitspro.com/2023/03/17/almost-half-of-companies-planning-to-cut-back-employee-benefits-in-2023-report-finds/" target="_blank">BenefitsPro</a>: </p><p></p><blockquote><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhob2_N1HlmiCYu6BNhDxicIwMGhNaF3A9fXbKThBRBHxxWO4KZs_OypoucRYX7ZHe_84JYaTeHdngXP7Tz-WpX3P0GjP7LmqiombgnjAkQjw_5lbtpQDy7tJXIwzkwuC3F--dc4WJ7BEq0iNixzrCv5h3SOZzVpyqMkrxSywIQdKAyNGhrC_vnPQDv/s1000/Benefit%20Cuts.png" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" data-original-height="997" data-original-width="1000" height="199" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhob2_N1HlmiCYu6BNhDxicIwMGhNaF3A9fXbKThBRBHxxWO4KZs_OypoucRYX7ZHe_84JYaTeHdngXP7Tz-WpX3P0GjP7LmqiombgnjAkQjw_5lbtpQDy7tJXIwzkwuC3F--dc4WJ7BEq0iNixzrCv5h3SOZzVpyqMkrxSywIQdKAyNGhrC_vnPQDv/w200-h199/Benefit%20Cuts.png" width="200" /></a></div>"According to a new report from Care.com, many U.S. employers are looking to revamp their benefits packages this year. The survey suggests that 95% of leaders are planning to re-examine their strategies, with nearly half of respondents – some 47% – looking to cut back benefits. ...[W]hen leaders were asked about what benefits they planned to cut, top answers included adoption/fertility assistance, commuter benefits, education and wellness resources, health and fitness discounts, and home office stipends."</blockquote><p></p><p><br /></p>Craighttp://www.blogger.com/profile/14913599100409003265noreply@blogger.comtag:blogger.com,1999:blog-3761470026816062685.post-38078672601473928642023-03-24T11:24:00.005-07:002023-03-24T11:24:49.593-07:00 Are Treatments for Therapy, Nutritional Counseling, and Supplements HSA/HRA/FSA Friendly?<p>FSAs (Flexible Spending Accounts), HSAs (Health Savings Accounts), and HRAs (Health Reimbursement Arrangements) are all types of tax-advantaged accounts that can be used to pay for qualified medical expenses.</p><p>Physical therapy, nutritional supplements, and gym memberships may be eligible expenses that can, in rare cases, be reimbursed using these accounts, but there are some specific rules and limitations about which, you must be cognizant. </p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhZ4OOvC_EykEdGsBBXAPLlnfX0JFf7UZtRdHCnM11V2GtBiBnhMizF_JWnM7-AdCCGiSK6LEvZp_pkSa2Qrt_8g_JWAB9T2ENGcSySK3uUziqNnXMiDtj8yo4PPgM_-U11C_FPR3LYxaQ9keaIlnJjt4RV9F91bLaGZzbiMKFZSLrwoLQx_ZxGZd6f/s1073/HRA%20Graphics.png" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" data-original-height="953" data-original-width="1073" height="284" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhZ4OOvC_EykEdGsBBXAPLlnfX0JFf7UZtRdHCnM11V2GtBiBnhMizF_JWnM7-AdCCGiSK6LEvZp_pkSa2Qrt_8g_JWAB9T2ENGcSySK3uUziqNnXMiDtj8yo4PPgM_-U11C_FPR3LYxaQ9keaIlnJjt4RV9F91bLaGZzbiMKFZSLrwoLQx_ZxGZd6f/s320/HRA%20Graphics.png" width="320" /></a></div><p></p><p>For FSAs, eligible expenses are determined by your employer's plan and may vary. You can usually use FSA funds to pay for physical therapy with a prescription from a healthcare provider. Nutritional supplements and gym memberships are likely not eligible expenses, unless they are prescribed by a healthcare provider for a specific medical condition.</p><p>For HSAs, physical therapy, nutritional supplements, and gym memberships may be eligible expenses, again, if they are deemed medically necessary by a healthcare provider. In that case, you can use HSA funds to pay for these expenses as long as they are not considered cosmetic or meant for general health and wellness purposes.</p><p>For HRAs, the rules and eligibility requirements will vary depending on your employer's plan. It's important to check with your employer or plan administrator to see if physical therapy, nutritional supplements, or gym memberships are eligible expenses. In most cases, these procedures will only be covered if they are deemed necessary by a healthcare provider. </p><p>In general, it's important to keep receipts and documentation of your expenses, and to check with your plan administrator to make sure that the expenses you are considering are eligible before using your FSA, HSA, or HRA funds to pay for them.</p><p>The IRS recently issued new guidance on this topic. There was nothing earth-shatteringly new in their statement, but more clarity has been provided. Here is a summary of the IRS's pronouncement by <a href="https://tax.thomsonreuters.com/blog/irs-faqs-explain-when-health-fsas-hsas-or-hras-can-reimburse-nutrition-wellness-and-general-health-expenses/" target="_blank">Thompson Reuters</a>: </p><blockquote style="border: none; margin: 0 0 0 40px; padding: 0px;"><p style="text-align: left;"><span style="color: #666666;">For the cost of therapy to be a medical expense, the therapy must treat a disease—thus, amounts paid for therapy to treat a diagnosed mental illness are medical expenses, while amounts paid for marital counseling are not. Likewise, the costs of nutritional counseling and weight-loss programs are medical expenses only if the counseling or program treats a specific disease diagnosed by a physician (e.g., obesity or diabetes); otherwise, these costs are not medical expenses. The cost of a gym membership is a medical expense only if the membership was purchased for the sole purpose of affecting a structure or function of the body (e.g., a prescribed plan for physical therapy to treat an injury) or treating a specific disease diagnosed by a physician (e.g., obesity or heart disease). However, the cost of exercise for the improvement of general health is not a medical expense, even if recommended by a doctor.</span></p></blockquote><p><br /></p>Craighttp://www.blogger.com/profile/14913599100409003265noreply@blogger.comtag:blogger.com,1999:blog-3761470026816062685.post-33639426874552901012023-03-24T10:37:00.002-07:002023-03-24T10:37:29.490-07:00Self-Funded Healthplans Are Far More Common Than You Think<p><span style="font-family: inherit;">There are more self-funded than fully insured plans among companies with 100 or more employees (38,000 vs. 32,000). And if you are an employee at a company with 100 or more employees, you are twice as likely to be covered by a self-funded plan as a fully insured plan.</span></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiYVCShI7nPept1jn9m3LY1BAxH-45TewY6krNgqKFMkz1-ztIra3rIDmH7GDMwHIFjNBj-Hb8yclLTwUGBdzD5rk4WofS4bfWDQTUkZcuBYYY2i82-937SZtB0CgkRLzgG_pa3V2TPgxXV3hlmx5AnJstEyGfo0rKy7fF7iy0Xao4e02gn7Tehy6mN/s816/ASO.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="641" data-original-width="816" height="502" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiYVCShI7nPept1jn9m3LY1BAxH-45TewY6krNgqKFMkz1-ztIra3rIDmH7GDMwHIFjNBj-Hb8yclLTwUGBdzD5rk4WofS4bfWDQTUkZcuBYYY2i82-937SZtB0CgkRLzgG_pa3V2TPgxXV3hlmx5AnJstEyGfo0rKy7fF7iy0Xao4e02gn7Tehy6mN/w640-h502/ASO.png" width="640" /></a></div><p><span style="font-family: inherit;">Full <a href="https://www.dol.gov/sites/dolgov/files/EBSA/researchers/statistics/retirement-bulletins/annual-report-on-self-insured-group-health-plans-2023.pdf" target="_blank">report</a>. </span></p><p><span style="font-family: inherit;"><br /></span></p>Craighttp://www.blogger.com/profile/14913599100409003265noreply@blogger.comtag:blogger.com,1999:blog-3761470026816062685.post-36386178206428927492023-03-14T12:19:00.005-07:002023-03-22T10:53:19.071-07:00Tax Burden By State<p>I'm a sucker for all of these types of lists. This one is from <a href="https://wallethub.com/edu/states-with-highest-lowest-tax-burden/20494" target="_blank">Wallet Hub</a>. The map below is interactive, and you can hover over any state to see where it ranks. If you hit the Wallet Hub link you can review their methodology. </p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEixW9beBtax1Wu2z8Yy4ZOUykUj9W1B22Yvqb_i61WMuqQwkALtCUfMSEED0mTpbAbl7sTMBPWwAey0y7EfoJ3OODjv9fSkPsm4LUiqQQrPANcD3ZpgIq9wnxEaq5TMsx30aTrXT8oHsk1XGh6NuHQUM8qExxwD22GggYvfc_1y7yJJtYKZna4nwGHZ/s1024/Landscape.png" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1024" data-original-width="1024" height="400" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEixW9beBtax1Wu2z8Yy4ZOUykUj9W1B22Yvqb_i61WMuqQwkALtCUfMSEED0mTpbAbl7sTMBPWwAey0y7EfoJ3OODjv9fSkPsm4LUiqQQrPANcD3ZpgIq9wnxEaq5TMsx30aTrXT8oHsk1XGh6NuHQUM8qExxwD22GggYvfc_1y7yJJtYKZna4nwGHZ/w400-h400/Landscape.png" width="400" /></a></div><p>5 States with the lowest tax burden (best at bottom):</p><p></p><ol style="text-align: left;"><li>New Hampshire</li><li>Wyoming</li><li>Deleware</li><li>Tennessee</li><li>Alaska</li></ol><p></p><p>5 states with the highest tax burden (worst at top): </p><p></p><ol style="text-align: left;"><li>New York</li><li>Hawaii </li><li>Maine </li><li>Vermont</li><li>Minnesota</li></ol><div style="text-align: center;"><iframe frameborder="0" height="390" scrolling="no" src="https://cdn.wallethub.com/wallethub/embed/20494/geochart-2022.html" width="656"></iframe></div><div style="color: #888888; font-size: 12px; width: 556px;">Source: <a href="https://wallethub.com/edu/states-with-highest-lowest-tax-burden/20494">WalletHub</a></div><div style="color: #888888; font-size: 12px; width: 556px;"><br /></div>Craighttp://www.blogger.com/profile/14913599100409003265noreply@blogger.comtag:blogger.com,1999:blog-3761470026816062685.post-84102368038509090292023-03-12T19:35:00.006-07:002023-03-13T12:36:00.119-07:00 How Obamacare Doubles Your Cost for Preventive Care<p><span style="color: #222222; font-family: inherit; font-size: 12pt; white-space: pre-wrap;">It is good to see the legacy media covering an issue we began warning clients about more than a decade ago. Better late than never, I suppose. </span></p><p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiFns18_xWSTLzr3_fbtqDggMWjqA0toNncnIoRe4PXNruPA9kPKPEqS6RjQg54Tt3W5X0sPa1vUy3L0oqjMI8gHi6_4_T4CMlGiTOS_7wc2qmmhK94AgvB4TDOiN93b4-AsmkuoQsm6uG-GXiW_KREdtGSK0z3LPw2L19bdV5oD-qPMGSLwFFfiAeD/s695/Answers.png" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="544" data-original-width="695" height="313" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiFns18_xWSTLzr3_fbtqDggMWjqA0toNncnIoRe4PXNruPA9kPKPEqS6RjQg54Tt3W5X0sPa1vUy3L0oqjMI8gHi6_4_T4CMlGiTOS_7wc2qmmhK94AgvB4TDOiN93b4-AsmkuoQsm6uG-GXiW_KREdtGSK0z3LPw2L19bdV5oD-qPMGSLwFFfiAeD/w400-h313/Answers.png" width="400" /></a></div><div style="text-align: center;"><a href="https://twitter.com/WiseWondererDT/status/1624326902075822080" target="_blank"><span style="font-size: x-small;">Twitter link to image</span></a></div><p></p><span id="docs-internal-guid-2f280c45-7fff-80c5-de42-e30fe80b4ba4"><p dir="ltr" style="background-color: white; line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;"><span style="background-color: transparent; color: #222222; font-family: inherit; font-size: 12pt; white-space: pre-wrap;">Remember that “rule” in Obamacare that required all your preventive care and annual health exams be "free?" It was a blissful notion conjuring up unicorns flying across the sky, sprinkling fairy dust from their rainbow-colored stethoscopes. </span></p><p dir="ltr" style="background-color: white; line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;"><span style="font-family: inherit;"><br /></span></p><p dir="ltr" style="background-color: white; line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;"><span style="font-family: inherit;"><span style="background-color: transparent; color: #222222; font-size: 12pt; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">We told employers and employees then - don’t count on it. First of all, nothing is ever </span><span style="background-color: transparent; color: #222222; font-size: 12pt; font-style: italic; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">free</span><span style="background-color: transparent; color: #222222; font-size: 12pt; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">. The new law simply meant that all the preventive care you were supposed to get in a given year, would now be pre-paid with higher premiums. In other words, if you did not go to the doctor each year and maximize all of the preventive care that would be appropriate for someone of your health, age, and sex, you’d now be overpaying as all of our premiums increased by about 1 percent to cover the government mandated pre-payment racket. </span></span></p><p dir="ltr" style="background-color: white; line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;"><span style="font-family: inherit;"><br /></span></p><p dir="ltr" style="background-color: white; line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;"><span style="background-color: transparent; color: #222222; font-size: 12pt; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;"><span style="font-family: inherit;">So, how is this manifesting as double payment for many folks? </span></span></p><p dir="ltr" style="background-color: white; line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;"><span style="background-color: transparent; color: #222222; font-size: 12pt; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;"><span style="font-family: inherit;"><br /></span></span></p><ol style="margin-bottom: 0px; margin-top: 0px; padding-inline-start: 48px; text-align: left;"><li><span style="background-color: transparent; color: #222222; font-family: inherit; font-size: 12pt; white-space: pre-wrap;">All our premiums went up 1% to prepay for it; and</span></li><li>If you aren't a hyper-diligent health-bill-nazi, you're likely being double-billed now when your doctor’s office keys in that you had a preventive exam as well as discussion, follow-up on, or evaluation of X. Where “X” can be any ailment, bump, sore, cut, tick, twitch, stressor, or annoyance in your life. </li></ol><p dir="ltr" style="background-color: white; line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;"><span style="font-family: inherit;"><br /></span></p><p dir="ltr" style="background-color: white; line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;"><span style="font-family: inherit;"><span style="background-color: transparent; color: #222222; font-size: 12pt; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">Our medical system even has a procedural code for “bitten by duck, initial encounter.” It is </span><a href="https://www.aapc.com/codes/icd-10-codes/W61.61XA#:~:text=ICD%2D10%20Code%20for%20Bitten,61XA%2D%20Codify%20by%20AAPC" style="text-decoration-line: none;"><span style="background-color: transparent; color: #1155cc; font-size: 12pt; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; text-decoration-line: underline; text-decoration-skip-ink: none; vertical-align: baseline; white-space: pre-wrap;">W61.61XA</span></a></span><a href="https://www.aapc.com/codes/icd-10-codes/W61.61XA#:~:text=ICD%2D10%20Code%20for%20Bitten,61XA%2D%20Codify%20by%20AAPC" style="font-family: inherit; text-decoration-line: none;"><span style="background-color: transparent; color: #1155cc; font-size: 12pt; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; text-decoration-line: underline; text-decoration-skip-ink: none; vertical-align: baseline; white-space: pre-wrap;">ICD-10</span></a><span style="background-color: transparent; color: #222222; font-family: inherit; font-size: 12pt; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">, in case you’d like your physician’s office to use it on your next visit. Please, if you do, don’t confuse that code with being “struck by a duck.” That is code </span><a href="https://www.unboundmedicine.com/icd/view/ICD-10-CM/882772/all/W61_62___Struck_by_duck#:~:text=W61.,duck%20%7C%20ICD%2D10%2DCM" style="font-family: inherit; text-decoration-line: none;"><span style="background-color: transparent; color: #1155cc; font-size: 12pt; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; text-decoration-line: underline; text-decoration-skip-ink: none; vertical-align: baseline; white-space: pre-wrap;">W61.62</span></a><span style="background-color: transparent; color: #222222; font-family: inherit; font-size: 12pt; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">. There are </span><a href="https://eohhs.ri.gov/sites/g/files/xkgbur226/files/2021-03/ICD10_FAQ.pdf" style="font-family: inherit; text-decoration-line: none;"><span style="background-color: transparent; color: #1155cc; font-size: 12pt; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; text-decoration-line: underline; text-decoration-skip-ink: none; vertical-align: baseline; white-space: pre-wrap;">155,000 codes</span></a><span style="background-color: transparent; color: #222222; font-family: inherit; font-size: 12pt; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;"> in the ICD-10 system, in case you were wondering. And yes, because I know it is burning in the back of your mind as you read my scintillating post, there are codes for subsequent encounters with ducks as well; and for mere “contact” with a duck. U.S. Healthcare has ducks covered. But Cornish game hens? Not so much. In that case, you’d have to go with “pecked by chicken,” under ICD-10 code W61.33. </span></p><p dir="ltr" style="background-color: white; line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;"><span style="font-family: inherit;"><br /></span></p><p dir="ltr" style="background-color: white; line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;"><span style="background-color: transparent; color: #222222; font-size: 12pt; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;"><span style="font-family: inherit;">To say that our system has been bureaucratized beyond recognition into some sort of Frankenstein monster of public-private plunder is an understatement. </span></span></p><p dir="ltr" style="background-color: white; line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;"><span style="background-color: transparent; color: #222222; font-size: 12pt; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;"><span style="font-family: inherit;"><br /></span></span></p><p dir="ltr" style="background-color: white; line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;"><span style="background-color: transparent; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline;"></span></p><div class="separator" style="clear: both; color: #222222; font-size: 12pt; text-align: center; white-space: pre-wrap;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgSlexeABPGYBMmkvv2S664S0Vi25AeXBCuQ-FZUBC-28LEhnE8CalN4CPdavw49ed5qvetdUrHVXcC-PT6VCZ2VQF2RJRRipUYWvRKblpqkcw0kWt2y9qetBYodAbsnXs1LrHgCPMIlrRpjh0s_7NwedzQXmZclwhWs6Terp-ZurX3K0jjQRq9E42j/s1085/Gov.%20Compulsory%20Spending.png" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1085" data-original-width="1079" height="640" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgSlexeABPGYBMmkvv2S664S0Vi25AeXBCuQ-FZUBC-28LEhnE8CalN4CPdavw49ed5qvetdUrHVXcC-PT6VCZ2VQF2RJRRipUYWvRKblpqkcw0kWt2y9qetBYodAbsnXs1LrHgCPMIlrRpjh0s_7NwedzQXmZclwhWs6Terp-ZurX3K0jjQRq9E42j/w637-h640/Gov.%20Compulsory%20Spending.png" width="637" /></a></div></span><p></p><blockquote style="border: none; margin: 0px 0px 0px 40px; padding: 0px;"><span><p dir="ltr" style="background-color: white; line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;"><span style="background-color: transparent; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline;"></span></p><div style="text-align: justify;"><span style="background-color: transparent; white-space: pre-wrap;"><span style="color: #666666;">The government controls a larger share of health spending in the United States (85%) than in 30 other advanced nations, including Canada (75%) and the United Kingdom (83%), each of which has explicitly socialized health systems.</span><span style="color: #222222;"> </span></span><a href="https://twitter.com/mfcannon/status/1608673596305707009" style="background-color: transparent; white-space: pre-wrap;" target="_blank"><span style="color: #298dcc;">Source</span></a><span style="background-color: transparent; color: #222222; white-space: pre-wrap;">.<span style="font-size: x-small;"> </span></span></div></span><p></p></blockquote><span><p dir="ltr" style="background-color: white; line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;"><span style="font-family: inherit;"><br /></span></p><p dir="ltr" style="background-color: white; line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;"><span style="background-color: transparent; color: #222222; font-size: 12pt; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;"><span style="font-family: inherit;">So, are preventive visits pre-paid and copay-free under Obamacare? Only if you have impeccable health and you and your doctor do not discuss your blood pressure, blood glucose levels, sun exposure, moles, sniffles, or whether you’ve been pecked by a Cornish game hen. Of course, some doctors get it and are more forgiving than others. There are cases where you can get away with your depraved, thieving ways and attempt to get free healthcare advice during your purely preventive visit by asking about that odd little bump that’s appeared in your nether regions. Bandit! </span></span></p><p dir="ltr" style="background-color: white; line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;"><span style="font-family: inherit;"><br /></span></p><p dir="ltr" style="background-color: white; line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;"><span style="font-family: inherit;"><span style="background-color: transparent; color: #222222; font-size: 12pt; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; text-decoration-line: underline; text-decoration-skip-ink: none; vertical-align: baseline; white-space: pre-wrap;">Real-world advice</span><span style="background-color: transparent; color: #222222; font-size: 12pt; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">: if your doctor asks you if there is anything else bothering you in your physical, and it is something minor about which you were mildly curious, say, “yes, I do have another question, but it is kind of a silly one and I don’t want to be billed for moving our visit beyond a purely preventive visit.” </span></span></p><p dir="ltr" style="background-color: white; line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;"><span style="font-family: inherit;"><br /></span></p><p dir="ltr" style="background-color: white; line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;"><span style="background-color: transparent; color: #222222; font-size: 12pt; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;"><span style="font-family: inherit;">A good doctor will gladly answer your question and not bill you. If your doctor doesn’t roll that way, it’s a decent sign that you may need a new doctor. </span></span></p><p dir="ltr" style="background-color: white; line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;"><span style="font-family: inherit;"><br /></span></p><p dir="ltr" style="background-color: white; line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;"><span style="background-color: transparent; color: #222222; font-size: 12pt; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;"><span style="font-family: inherit;">Now, if the issue is large enough that you want to discuss it and don’t care if it goes on for a few minutes, then by all means, ask. But know that your free exam just moved into an office visit for which you will pay a copay, co-insurance, or the visit cost if you are on a high-deductible health plan. But what would you rather do, finish this visit for free and then return in a few weeks to address the burning topic? If you do that, you’re doubling your time and will still pay for the visit. </span></span></p><p dir="ltr" style="background-color: white; line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;"><span style="font-family: inherit;"><br /></span></p><p dir="ltr" style="background-color: white; line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;"><span style="font-family: inherit;"><span style="background-color: transparent; color: #222222; font-size: 12pt; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">Here is how </span><a href="https://finance.yahoo.com/news/americans-surprise-medical-bills-health-care-loopholes-131630868.html" style="text-decoration-line: none;" target="_blank"><span style="background-color: transparent; color: #1155cc; font-size: 12pt; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; text-decoration-line: underline; text-decoration-skip-ink: none; vertical-align: baseline; white-space: pre-wrap;">Yahoo News</span></a><span style="background-color: transparent; color: #222222; font-size: 12pt; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;"> covered this </span><span style="background-color: transparent; color: #222222; font-size: 12pt; font-style: italic; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">new </span><span style="background-color: transparent; color: #222222; font-size: 12pt; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">phenomenon that’s been around for more than a decade (highlights are mine): </span></span></p><h1 dir="ltr" style="background-clip: padding-box; background-color: white; border-left: 3pt solid rgb(159, 197, 232); line-height: 1.38; margin-bottom: 0pt; margin-left: 36pt; margin-top: 24pt; padding: 0pt 0pt 6pt 2pt;"><span style="background-color: transparent; color: #005c98; font-size: 14pt; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;"><span style="font-family: inherit;">‘I got scammed’: Americans describe getting surprise medical bills via health care loopholes</span></span></h1><p dir="ltr" style="background-clip: padding-box; background-color: white; border-left: 3pt solid rgb(159, 197, 232); line-height: 1.38; margin-bottom: 0pt; margin-left: 36pt; margin-top: 0pt; padding: 6pt 0pt 12pt 2pt;"><span style="background-color: transparent; color: #222222; font-size: 11pt; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;"><span style="font-family: inherit;">Sometimes a simple coding mishap can result in a major headache for a patient, as was the case for Anthony, a 29-year-old based out of Norwalk, Conn.</span></span></p><p dir="ltr" style="background-clip: padding-box; background-color: white; border-left: 3pt solid rgb(159, 197, 232); line-height: 1.38; margin-bottom: 0pt; margin-left: 36pt; margin-top: 0pt; padding: 0pt 0pt 12pt 2pt;"><span style="background-color: transparent; color: #222222; font-size: 11pt; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;"><span style="font-family: inherit;">When Anthony visited his doctor for a routine annual checkup — which his insurance plan through Cigna advertised as 100% covered without a copay — he ended up receiving a bill for $132.09.</span></span></p><p dir="ltr" style="background-clip: padding-box; background-color: white; border-left: 3pt solid rgb(159, 197, 232); line-height: 1.38; margin-bottom: 0pt; margin-left: 36pt; margin-top: 0pt; padding: 0pt 0pt 12pt 2pt;"><span style="background-color: transparent; color: #222222; font-size: 11pt; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;"><span style="font-family: inherit;">This was because his doctor’s office coded the visit as an “office visit” instead of an “annual checkup or preventative care.” In an effort to clear up the confusion, Anthony called both Cigna and his doctor’s office, and Cigna assured him that it was simply listed under the wrong code and would be covered if the doctor’s billing department corrected it.</span></span></p><p dir="ltr" style="background-clip: padding-box; background-color: white; border-left: 3pt solid rgb(159, 197, 232); line-height: 1.38; margin-bottom: 0pt; margin-left: 36pt; margin-top: 0pt; padding: 0pt 0pt 12pt 2pt;"><span style="background-color: transparent; color: #222222; font-size: 11pt; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;"><span style="font-family: inherit;">“I submitted a complaint to Westmed, and they forwarded it to the billing department,” Anthony told Yahoo Finance. “They rejected my request several times. According to them, the office staff had the final word on the billing code. I was able to talk to the office staff directly too, but I’m not sure who was responsible for selecting the billing code there.” …</span></span></p><p dir="ltr" style="background-clip: padding-box; background-color: white; border-left: 3pt solid rgb(159, 197, 232); line-height: 1.38; margin-bottom: 0pt; margin-left: 36pt; margin-top: 0pt; padding: 0pt 0pt 12pt 2pt;"><span style="background-color: transparent; color: #222222; font-size: 11pt; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;"><span style="font-family: inherit;">“Wasted a bunch of time, and, frankly, I got scammed," Anthony said. "In the end, I got no explanation why they used the wrong code, and the bill was sent to collections. It’s going to hurt my credit score and in the U.S., that also means my ability to find a place to rent or even buy a house if I ever get the chance. It’s the kind of thing you lose sleep over.”</span></span></p><h3 style="background-clip: padding-box; background-color: white; border-left: 3pt solid rgb(159, 197, 232); line-height: 1.38; margin-bottom: 0pt; margin-left: 36pt; margin-top: 0pt; padding: 6pt 0pt 4pt 2pt; text-align: left;"><span style="background-color: transparent; color: #0e8dcc; font-size: 13pt; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;"><span style="font-family: inherit;">'They think short-term'</span></span></h3><p dir="ltr" style="background-clip: padding-box; background-color: white; border-left: 3pt solid rgb(159, 197, 232); line-height: 1.38; margin-bottom: 0pt; margin-left: 36pt; margin-top: 0pt; padding: 8pt 0pt 12pt 2pt;"><span style="font-family: inherit;"><span style="background-color: transparent; color: #222222; font-size: 11pt; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">A loophole in the ACA — commonly known as </span><a href="https://finance.yahoo.com/news/obamacare-enrollment-numbers-record-biden-victory-lap-202202359.html" style="text-decoration-line: none;"><span style="background-color: transparent; color: #1155cc; font-size: 11pt; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; text-decoration-line: underline; text-decoration-skip-ink: none; vertical-align: baseline; white-space: pre-wrap;">Obamacare</span></a><span style="background-color: transparent; color: #222222; font-size: 11pt; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;"> — is part of the reason why this issue persists in the U.S.</span></span></p><p dir="ltr" style="background-clip: padding-box; background-color: white; border-left: 3pt solid rgb(159, 197, 232); line-height: 1.38; margin-bottom: 0pt; margin-left: 36pt; margin-top: 0pt; padding: 0pt 0pt 12pt 2pt;"><span style="font-family: inherit;"><span style="background-color: transparent; color: #222222; font-size: 11pt; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">Under the ACA, insurers </span><a href="https://www.hrsa.gov/womens-guidelines" style="text-decoration-line: none;"><span style="background-color: transparent; color: #1155cc; font-size: 11pt; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; text-decoration-line: underline; text-decoration-skip-ink: none; vertical-align: baseline; white-space: pre-wrap;">are required to cover</span></a><span style="background-color: transparent; color: #222222; font-size: 11pt; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;"> preventive services such as cancer screenings, immunizations, and well-woman visits without cost-sharing, meaning that the individual receiving the services is not required to pay anything.</span></span></p><p dir="ltr" style="background-clip: padding-box; background-color: white; border-left: 3pt solid rgb(159, 197, 232); line-height: 1.38; margin-bottom: 0pt; margin-left: 36pt; margin-top: 0pt; padding: 0pt 0pt 12pt 2pt;"><span style="font-family: inherit;"><span style="background-color: transparent; color: #222222; font-size: 11pt; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">A </span><a href="https://www.sciencedirect.com/science/article/abs/pii/S0091743521002590?dgcid=coauthor" style="text-decoration-line: none;"><span style="background-color: transparent; color: #1155cc; font-size: 11pt; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; text-decoration-line: underline; text-decoration-skip-ink: none; vertical-align: baseline; white-space: pre-wrap;">study published</span></a><span style="background-color: transparent; color: #222222; font-size: 11pt; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;"> in 2021 in the journal Preventive Medicine found that</span><span style="background-color: yellow; color: #222222; font-size: 11pt; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;"> “in addition to premium costs meant to cover preventive care, Americans with employer-sponsored insurance were still charged between $75 million and $219 million in total for services that ought to be free to them.</span><span style="background-color: transparent; color: #222222; font-size: 11pt; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">” …</span></span></p><h3 style="background-clip: padding-box; background-color: white; border-left: 3pt solid rgb(159, 197, 232); line-height: 1.38; margin-bottom: 0pt; margin-left: 36pt; margin-top: 0pt; padding: 6pt 0pt 4pt 2pt; text-align: left;"><span style="background-color: transparent; color: #0e8dcc; font-size: 13pt; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;"><span style="font-family: inherit;">Not-so-free procedures</span></span></h3><p dir="ltr" style="background-clip: padding-box; background-color: white; border-left: 3pt solid rgb(159, 197, 232); line-height: 1.38; margin-bottom: 0pt; margin-left: 36pt; margin-top: 0pt; padding: 8pt 0pt 12pt 2pt;"><span style="background-color: transparent; color: #222222; font-size: 11pt; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;"><span style="font-family: inherit;">Because of these loopholes, patients often find themselves billed for routine procedures that typically are fully covered by their health insurance.</span></span></p><p dir="ltr" style="background-clip: padding-box; background-color: white; border-left: 3pt solid rgb(159, 197, 232); line-height: 1.38; margin-bottom: 0pt; margin-left: 36pt; margin-top: 0pt; padding: 0pt 0pt 12pt 2pt;"><span style="background-color: transparent; color: #222222; font-size: 11pt; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;"><span style="font-family: inherit;">Several individuals, who asked to remain unnamed due to privacy concerns, shared with Yahoo Finance the forms they were required to sign in order to be seen for routine physicals and other preventive exams.</span></span></p><p dir="ltr" style="background-clip: padding-box; background-color: white; border-left: 3pt solid rgb(159, 197, 232); line-height: 1.38; margin-bottom: 0pt; margin-left: 36pt; margin-top: 0pt; padding: 0pt 0pt 12pt 2pt;"><span style="background-color: yellow; color: #222222; font-size: 11pt; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;"><span style="font-family: inherit;">In one of the forms, an individual was told that if they discussed any new or chronic medical issues with their doctor, their insurance would be billed for both an office visit and a preventive health exam.</span></span></p><p dir="ltr" style="background-clip: padding-box; background-color: white; border-left: 3pt solid rgb(159, 197, 232); line-height: 1.38; margin-bottom: 0pt; margin-left: 36pt; margin-top: 0pt; padding: 0pt 0pt 12pt 2pt;"><span style="background-color: yellow; color: #222222; font-size: 11pt; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;"><span style="font-family: inherit;">For another individual, their form indicated that if they discussed new acute conditions or a worsening chronic condition, if a diagnostic test was ordered, or if a treatment changed, they would also be subject to two separate bills.</span></span></p><p dir="ltr" style="background-clip: padding-box; background-color: white; border-left: 3pt solid rgb(159, 197, 232); line-height: 1.38; margin-bottom: 0pt; margin-left: 36pt; margin-top: 0pt; padding: 0pt 0pt 12pt 2pt;"><span style="background-color: transparent; color: #222222; font-size: 11pt; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;"><span style="font-family: inherit;">“There are a lot of gray areas but generally, those shouldn’t be billed,” Jenifer Bosco, a staff attorney at the National Consumer Law Center, told Yahoo Finance. “In the worst case, some providers do engage in what’s referred to as upcoding where they will try to bill for things or get reimbursed at a high rate for things that really should be either preventive or should be billed at a lower rate.”</span></span></p><p dir="ltr" style="background-clip: padding-box; background-color: white; border-left: 3pt solid rgb(159, 197, 232); line-height: 1.38; margin-bottom: 0pt; margin-left: 36pt; margin-top: 0pt; padding: 0pt 0pt 12pt 2pt;"><span style="font-family: inherit;"><span style="background-color: transparent; color: #222222; font-size: 11pt; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;">For example, a preventive colonoscopy meant to screen for cancer is required to be covered at 100% by health insurance providers. However, if a polyp is discovered and removed from the patient during that screening, that procedure </span><a href="https://www.npr.org/sections/health-shots/2022/05/31/1101861735/colonoscopy-cost-cancer-screening" style="text-decoration-line: none;"><span style="background-color: transparent; color: #1155cc; font-size: 11pt; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; text-decoration-line: underline; text-decoration-skip-ink: none; vertical-align: baseline; white-space: pre-wrap;">becomes a “surgery”</span></a><span style="background-color: transparent; color: #222222; font-size: 11pt; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;"> rather than a screening and is billed as such.</span></span></p><p dir="ltr" style="background-clip: padding-box; background-color: white; border-left: 3pt solid rgb(159, 197, 232); line-height: 1.38; margin-bottom: 0pt; margin-left: 36pt; margin-top: 0pt; padding: 0pt 0pt 12pt 2pt;"><span style="background-color: transparent; color: #222222; font-size: 11pt; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;"><span style="font-family: inherit;">“It makes zero sense charging the cost of something or the cost to the patient for something while they’re literally mid-procedure,” Bosco said. “You can essentially bill two visits for the same time, which I think intuitively just doesn’t make a lot of sense to most people. If you’re going in for one visit, how can you be charged for two and also be losing that free preventive visit at the same time?”</span></span></p><p dir="ltr" style="background-clip: padding-box; background-color: white; border-left: 3pt solid rgb(159, 197, 232); line-height: 1.38; margin-bottom: 0pt; margin-left: 36pt; margin-top: 0pt; padding: 0pt 0pt 12pt 2pt;"><span style="background-color: transparent; color: #222222; font-size: 11pt; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;"><span style="font-family: inherit;">According to the Preventive Medicine study, patients were saddled with a total of $12.8 million for preventive colorectal screenings in 2018, while wellness visits incurred charges of up to $73.1 million.</span></span></p><p dir="ltr" style="background-clip: padding-box; background-color: white; border-left: 3pt solid rgb(159, 197, 232); line-height: 1.38; margin-bottom: 12pt; margin-left: 36pt; margin-top: 0pt; padding: 0pt 0pt 0pt 2pt;"><span style="background-color: transparent; color: #222222; font-size: 11pt; font-variant-alternates: normal; font-variant-east-asian: normal; font-variant-numeric: normal; vertical-align: baseline; white-space: pre-wrap;"><span style="font-family: inherit;">“It feels a little bit like a bait and switch, and that’s not on the doctors,” Shafer said. “That’s just how we’ve set up the reimbursement guidelines and everything else. It’s frustrating.”</span></span></p><p dir="ltr" style="background-color: white; line-height: 1.38; margin-bottom: 12pt; margin-top: 12pt;"><br /></p></span>Craighttp://www.blogger.com/profile/14913599100409003265noreply@blogger.comtag:blogger.com,1999:blog-3761470026816062685.post-55645069016825075092023-03-09T19:38:00.004-08:002023-03-10T11:07:27.010-08:00Volunteering for Trouble<h3 style="text-align: left;"><span style="color: #298dcc;">The Compliance Traps, Administrative Nightmares, Subtle Discrediting & Employee Frustration Voluntary Benefits Often Bring</span></h3><p><i style="font-family: inherit;"><span style="line-height: 107%;">Special guest column by Dagny
Taggart | March 2023</span></i></p><p class="MsoNormal"><span style="font-family: inherit;">As a wee lass, my grandmother used to admonish, “don’t go
borrowing trouble.” <o:p></o:p></span></p><p class="MsoNormal"><span style="font-family: inherit;">I only fully internalized or “grokked,” as the kids say,
that message once installing voluntary benefit plans. <o:p></o:p></span></p><p class="MsoNormal"><span style="font-family: inherit;">In the eyes of the ginormous corporations that have devoured
nearly all the insurance brokerage market, I’m reasonably sure this makes me a
bad broker. Because, you see, once you are publicly traded, your stock prices
and your national VP’s job are tied inextricably to the holy grail of
growth. Client retention is nice and may
even earn you a pat on the head or some other form of little doggie treat, but <b><i>growth</i></b>,
my lass, well, that shall set ye free! <o:p></o:p></span></p><p class="MsoNormal"><span style="font-family: inherit;">I’ll never forget a conversation with a notoriously
unscrupulous brokerage owner in the San Francisco Bay Area. We were at some
stuffy, pompous, self-congratulatory industry meeting where brokers take a
temporary leave from the golf course to discuss how to best grow revenue (your
premium). <o:p></o:p></span></p><p class="MsoNormal"><span style="font-family: inherit;">The greasy, slick-haired, dark pinstripe-suited,
mafioso-looking founder told our CEO, “I’ll never understand why you put so
much stock in retention. Once a client has identified that you cannot service
them as promised, it will still take them nine to eighteen months to leave for
a new broker. You can sell a handful more groups in that time!” <o:p></o:p></span></p><p class="MsoNormal"><span style="font-family: inherit;">Even though that was nearly 25 years ago, very early in my
career, I always remembered the message. <o:p></o:p></span></p><p class="MsoNormal"><span style="font-family: inherit;">And I hated it increasingly each year I practiced. <o:p></o:p></span></p><p class="MsoNormal"><span style="font-family: inherit;">As a brokerage office is purchased by a bank, merged with
another bank, and repacked to a private equity firm like every other financialized
product in our country, brokers are inevitably hounded with the mantra of
growth. New sales conquest lists are circulated monthly, sometimes weekly, to
prod already organically competitive salespeople to climb over each other to
push more premium dollars through their P&Ls. One company I worked with
even created a gameshow-like point system to maximize salesy behavior.
Referrals to decision-makers, cold calls made, meetings attended, and spam sent
all earned various forms of atta-boys from the official brass. Meanwhile, 20-plus-year
veterans who consistently renewed multi-million-dollar books of stable clients
were regarded as an annoying relic to a bygone era in American Business: a time
when steady service, professionalism, and integrity hindered the mantra of <b><i>G-R-O-W-T-H</i></b>.
<o:p></o:p></span></p><p class="MsoNormal"><b><span style="color: #002060; line-height: 107%;"><span style="font-family: inherit;"> </span></span></b><b><span style="color: #002060; line-height: 107%;"><span style="font-family: inherit;"><span style="font-size: medium;">Enter Voluntary Benefits</span></span></span></b></p><p class="MsoNormal"><span style="font-family: inherit;">Voluntary benefits offer a quick fix for a stagnant book of
steady, satisfied clients. It is the cocaine bump from the countertop in the club
bathroom when a partier doesn’t have the energy or personality to peacock with
the amplified type-As. With voluntary benefits, an employer can roll out
additional life, disability, accident, cancer, critical illness, pet, home,
auto, gap, dental, vision, or hospital insurance at no cost to the employer and
only for those employees who want to purchase it. As the pitch goes, it rounds
out your offering, maximizes choice, and gives people more opportunity to cover
what is important to them. Who could be against that? <o:p></o:p></span></p><p class="MsoNormal"><span style="font-family: inherit;">And I must admit, as a budding, libertarian-minded little
brokerita, I bought into the concept. Voluntary benefits were, after all, <i>voluntary</i>
and offered commission to the brokerage of an additional 15 percent to 55
percent, depending on the line of insurance offered. Employees win, the
employer wins, and the broker wins! <o:p></o:p></span></p><p class="MsoNormal"><span style="font-family: inherit;">Alas, there is no free lunch. Imagine a product that is <i>half</i>
commission. How can an insurer afford to sell you something that is half
commission? <o:p></o:p></span></p><p class="MsoNormal"><span style="font-family: inherit;"><i><u>Hint</u></i>: it is not by undercharging for the
product. <o:p></o:p></span></p><p class="MsoNormal"><b><span style="color: #002060; line-height: 107%;"><span style="font-family: inherit;"> </span></span></b><b><span style="color: #002060; line-height: 107%;"><span style="font-family: inherit;"><span style="font-size: medium;">What’s the Real Message?</span></span></span></b></p><p class="MsoNormal"><span style="font-family: inherit;">As much as every broker and I want them to be, your
employees are not benefit experts. Let’s be frank: your HR team probably isn’t
either – at least most aren’t. In fact, your employees hate dealing with
benefits, particularly the insurance side, so much that they spend an average
of <a href="https://www.hrdive.com/news/on-average-employees-spend-18-minutes-enrolling-in-benefits/555041/">eighteen
minutes</a> making open enrollment decisions. By contrast, they will spend <a href="https://www.hrdive.com/news/on-average-employees-spend-18-minutes-enrolling-in-benefits/555041/">four
hours</a> on the decision to buy a cell phone. Priorities. <o:p></o:p></span></p><p class="MsoNormal"><span style="font-family: inherit;">No array of glossy brochures, automated video open
enrollment meetings, or highly entertaining broker personalities [ahem] will
drastically change that. A fantastic broker and presentation package <i>might</i>
get their attention for forty-five minutes. And I know because I regularly do
[smiling]. <o:p></o:p></span></p><p class="MsoNormal"><span style="font-family: inherit;">When we add V.D. (what I call voluntary dental) to your
plan, as an example, we will divert attention away from where eighty percent of
your benefits budget goes – toward medical. Why would we do that? Of course, if
all you offer is medical and V.D., that is not a problem. But most employers
offer employer-paid medical, life, dental, vision, employee assistance
programs, and disability. Communicating that to employees takes the entire
forty-five minutes. If we attempt to add the laundry list of other items from
earlier in the article, we confuse and frustrate your audience. <o:p></o:p></span></p><p class="MsoNormal"><span style="font-family: inherit;">But what else are we effectively saying? <o:p></o:p></span></p><p class="MsoNormal"><span style="font-family: inherit;">Our benefits are not good enough to cover you and your loved
ones should tragedy befall you or your family. Sure, we offer you a few
employer-sponsored items, but you probably need to buy all the other items this
pushy salesperson is here to deliver. There is a watering-down effect, and you
taint the vital quality plans like group disability and medical with the
lottery-esque nature of cancer or accident policies. It’s what my 20-year-old
daughter would call a “low-key dis.”</span></p><blockquote style="border: none; margin: 0px 0px 0px 40px; padding: 0px;"><p class="MsoNormal" style="text-align: justify; text-indent: 0px;"><span style="background-color: white;"><span style="font-family: inherit; text-indent: -0.25in;"><b><span style="color: #298dcc; font-size: medium;">Pro Tip:</span></b> </span><span style="color: #444444; font-family: inherit; text-indent: -0.25in;">Brokers don’t buy the
laundry list of benefits. Brokers buy medical, disability, and life if we have
dependents and are in a phase of life without enough assets to cover mortgages
and college tuition. Everything else is superfluous. One of the best things we
can do as insurance and human resources professionals is to help educate our
employees on the real need for insurance. Insurance is for the huge risks we
cannot plan for or save for: death, disability, and serious medical issues. We
can and should be able to save and plan for dental, vision, accidents, pet
issues, etc. If one can’t, then they just aren’t trying. If you set aside the
money you’d pay in premium toward your dental, vision, etc., you will have that
money when the need arises; and you will not have to hand over 15% to 50% in
commission and another 10% for carrier profit.</span></span></p></blockquote><p class="MsoNormal"><b><span style="color: #002060; line-height: 107%;"><span style="font-family: inherit;"><span style="font-size: medium;">Administrative Hell </span><o:p></o:p></span></span></b></p><p class="MsoNormal"><span style="font-family: inherit;">Much like third-party administrators and human resources
information systems, voluntary benefit providers systematically over-promise
and under-deliver. Here is a partial list of what every employer should expect when
installing new voluntary benefit plans:</span></p><p class="MsoNormal"></p><ul style="text-align: left;"><li><span style="font-family: inherit; text-indent: -0.25in;">The c</span><span style="font-family: inherit; text-indent: -0.25in;">arrier will not enroll all of your
employees correctly. There will be some with misspelled names, incorrect dates
of birth, wrong benefit plans, and incorrect family tiers. Some may be dropped
from enrollment entirely for no good reason.</span></li><li><span style="font-family: inherit; text-indent: -0.25in;">This will increase the HR department's workload
and hours will be spent on the transition. It will also cause disruptions to
the organization due to meetings, forms that need to be completed, and the inevitable
discontent from some employees.</span></li><li><span style="font-family: inherit; text-indent: -0.25in;">If a company is going to add voluntaries, the
CEO or other high-ranking executive should announce the change - and the
business reason why - before the meetings.</span></li><li><span style="font-family: inherit; text-indent: -0.25in;">Depending on the type of product you offer, you
may have to meet minimum participation levels. This means, for example, if 20%
of your employees don’t elect to buy additional life insurance, you will not be
able to offer it to any of them. And you may have just had 15% of them sign up.
Now you get to go back and tell those 15%, “nevermind.”</span></li><li><span style="font-family: inherit; text-indent: -0.25in;">The first bill will not be accurate. The client must
audit the first bill immediately upon receiving it and notify the carrier of
changes. A binder check for the first month's premium is required with the
master group application and will be credited on the first or second billing
cycle. Therefore, your first few bills are not likely to be accurate.</span></li></ul><p></p><p class="MsoNormal"><span style="font-family: inherit;">And that list assumes you already boast a savvy and robust
HR team. If you have new or inexperienced folks on the team or if you
experience regular turnover in HR, these matters can grow unruly in a hurry. <o:p></o:p></span></p><p class="MsoNormal"><span style="font-family: inherit;">One Midwestern company I worked with churned through three
different benefit managers in eighteen months. HR was responsible for sending
an evidence of insurability form to employees who applied for more than the
voluntary life’s $100,000 guaranteed issue amount. That crucial detail was lost
in the shuffle. So, tensions rose when the employer experienced the death of an
employee who thought he’d purchased $300,000 of life insurance, and the carrier
asked the employer where the evidence of insurability was. I’ll shortcut to the
answer: to make the deceased widow whole, the employer had to self-fund the
additional $200,000 in life benefits, and the Director of Human Resources lost
his job. A forgotten form from a benefit manager on a voluntary life plan ended
a career and cost this employer $200,000. <o:p></o:p></span></p><p class="MsoNormal"><span style="font-family: inherit;">If you are reading this and unsure what an evidence of
insurability is, do not offer voluntary benefits. That risk is too significant
for you and your organization at this time. If you are going to provide
voluntary life or disability, make darn sure that your broker explains these
potential nightmares to you. <o:p></o:p></span></p><p class="MsoNormal"><b><span style="color: #002060; line-height: 107%;"><span style="font-family: inherit;"> </span></span></b><b><span style="color: #002060; line-height: 107%;"><span style="font-family: inherit;"><span style="font-size: medium;">Compliance Nightmares</span></span></span></b></p><p class="MsoNormal"><span style="font-family: inherit;">Beyond the previous chilling story, a whole other compliance
issue can arise with voluntaries. Suppose there happens to be a legal dispute
between one of your employees and your voluntary vendor. In that case, that
vendor will almost certainly argue that the plan is covered by Employee
Retirement Income Security Act (ERISA) and that the employee’s lawsuit should
be filed against the employer instead of the insurer. If the court agrees, the legal
burden shifts to the employer. And in case you were wondering, yes, this one
also gets HR folks fired. Courts regularly rule that a voluntary plan is an
ERISA plan, even if the employer never intended to sponsor the plan formally. <o:p></o:p></span></p><p class="MsoNormal"><span style="font-family: inherit;">And if that happens, and the plaintiff’s attorney is worth
his salt, they’ll also file claims against the employer for all the ERISA
reporting, disclosure, and fiduciary requirements that weren’t followed. Two of those penalties would be:</span></p><p class="MsoNormal"></p><ul style="text-align: left;"><li><span style="font-family: inherit; text-indent: -0.25in;">$149 per day penalty for failing to provide Plan
Document and SPD; and</span></li><li>$2,097 per plan per day for failing to prepare
and file Form 5500.</li></ul><p></p><p class="MsoNormal"><span style="font-family: inherit;">Furthermore, the legal standard for what mandates that ERISA
covers a plan is <i><u>not</u></i> a bright-line test. It is akin to the federal employee vs.
independent contractor standard, if you are familiar with that. It is a “totality of circumstances” test that
requires the plan to: <o:p></o:p></span></p><p class="MsoListParagraphCxSpFirst"></p><ul style="text-align: left;"><li>be completely voluntary without any employer contributions; </li><li>not allow the employer to endorse or “take credit for” the plan;</li><li>not allow the employer to receive consideration for collecting and remitting premiums; </li><li>not use the employer’s name, or associate the voluntary plan with the employer-sponsored benefit plans; </li><li>not communicate the voluntary benefits at Open Enrollment with all of the employer-sponsored ERISA-covered plans; </li><li>not recommend the plan to employees; </li><li>never say ERISA applies; </li><li>not allow the use of the employer’s cafeteria plan; and </li><li>not assist employees with claims or disputes.</li></ul><p></p><p class="MsoNormal"><span style="font-family: inherit;">In some cases, judges ruled that employers endorsed plans
because they announced the programs in memos written on company stationery. I’m
reminded of the old Jeff Foxworthy routine, ya might be <s>a redneck</s> ERISA
if …</span></p><p class="MsoNormal" style="text-align: center;">
<iframe allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" allowfullscreen="" frameborder="0" height="315" src="https://www.youtube.com/embed/RboPCdiP_AI" title="YouTube video player" width="560"></iframe> </p><p class="MsoNormal"><span style="font-family: inherit;">Failing any of the above bullets might make your plan an
ERISA plan, depending on the court’s assessment of the action's severity and/or
frequency. Of course, failing to abide
by more than one further tips the scale in the direction of ERISA.</span></p><p class="MsoNormal"><span style="font-family: inherit;">Benefit attorneys who litigate these types of cases regularly
report that 80% to 90% of voluntary benefit plans are, in fact, ERISA plans
once litigation commences and the voluntary provider makes this reflexive
initial motion. <o:p></o:p></span></p><p class="MsoNormal"><b><span style="color: #002060; line-height: 107%;"><span style="font-family: inherit;"><span style="font-size: medium;">And With All of That, There Are Some Places for Them</span></span></span></b></p><p class="MsoNormal"><span style="font-family: inherit;">With all that said, is there ever a time when voluntary
benefits are a good idea? Yes, they can be appropriate and even desirable in a handful
of circumstances. <o:p></o:p></span></p><p class="MsoNormal"><span style="font-family: inherit;"><b><span style="color: #0070c0;">Voluntary home and/or auto
insurance</span></b> is often just a link to a carrier that employees can quote
themselves. It is done at any time of the year and regularly gets employees an
additional 5% to 10% off, in addition to any other discounts for which they may
qualify. Employers regularly can and do stay out of these offerings. <o:p></o:p></span></p><p class="MsoNormal"><span style="font-family: inherit;"><b><span style="color: #0070c0;">Pet Insurance</span></b>. As
with home and auto, it is typically just a link to a vendor that can and will
offer your employee a modest discount because they work for you. Like with home
and auto, I’ve never seen a pet plan morph into an ERISA plan. <o:p></o:p></span></p><p class="MsoNormal"><span style="font-family: inherit;"><b><span style="color: #0070c0;">Voluntary Group Life and
Disability</span></b>. These are often no-brainers. Notice that I said group
coverage here. I do not like the idea of individual, 1099’d, 100% commissioned
enrollers sitting across from your employees and asking them what momma and the
baby will do when they die. No, this is
the option to buy additional life and disability above and beyond the core
employer offering. We communicate it in a group setting, and then treat it like
an ERISA plan as it is linked to your underlying life and disability. But know,
all my caveats in this piece's “Administrative Hell” section apply. If you
don’t have a seasoned, stable, savvy HR staff, you may want to consider holding
off on these lines for a bit. </span></p><p class="MsoNormal"><span style="font-family: inherit;"><b><span style="color: #0070c0;"></span></b></span></p><div class="separator" style="clear: both; text-align: center;"><span style="font-family: inherit;"><b><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhBcbRMyZRg6cLvmOHDreGKQ07jKZtT8ulZ83H6mWhvsOCyaFuFJN8gtWq_8BTXPnZaZsZfDDUsXQkHv-D5gfXfKUEsIJl-BEyej1PArErkOnMWp9VuwUP8-P-pq5xW8JN1Ysh9YbYwUnIkNVquiFAKY8yEs9iOE2TgGo5Yr3qtlp01IYHY55pcNJpW/s632/White.jpg" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" data-original-height="632" data-original-width="632" height="200" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhBcbRMyZRg6cLvmOHDreGKQ07jKZtT8ulZ83H6mWhvsOCyaFuFJN8gtWq_8BTXPnZaZsZfDDUsXQkHv-D5gfXfKUEsIJl-BEyej1PArErkOnMWp9VuwUP8-P-pq5xW8JN1Ysh9YbYwUnIkNVquiFAKY8yEs9iOE2TgGo5Yr3qtlp01IYHY55pcNJpW/w200-h200/White.jpg" width="200" /></a></b></span></div><span style="font-family: inherit;"><b><span style="color: #298dcc;">Union Demanded Plans.</span></b><span style="color: #0070c0;"> </span>Other than what I’ve mentioned here, I’d pass on
the voluntary stuff. But I do know that there are times when a workforce
demands it. I have seen that from time to time in union environments. In that
case, partner with an exceptional broker to find a voluntary provider with a
long, stable track record. Believe it or not, I have encountered those in my
career. They aren’t totally fictitious unicorns but are exceedingly rare,
glorious beasts to behold in the wild. </span><p></p><p class="MsoNormal"><span style="font-family: inherit;"><b><i><span style="color: #002060;"></span></i></b></span></p><div class="separator" style="clear: both; text-align: center;"><span style="font-family: inherit;"><b><i><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjTJLS5vupQ2ALzhoDgZRPtce7hsz7CmnhYqv5nV8RKJM4Y-VbD94TRxR-MUZYD9hivXljSBU85CPK1k55yuhD8IP-4-2PPR7fF8JuiCq1N1cJ-moU2W4GUiwux-80tHEtyPT9lzQw4ULX41jjhpuY81b6z1JDRPWXB6a2Om3-8QSUErn11CsCmLmRG/s92/Dagney.png" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="92" data-original-width="82" height="92" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjTJLS5vupQ2ALzhoDgZRPtce7hsz7CmnhYqv5nV8RKJM4Y-VbD94TRxR-MUZYD9hivXljSBU85CPK1k55yuhD8IP-4-2PPR7fF8JuiCq1N1cJ-moU2W4GUiwux-80tHEtyPT9lzQw4ULX41jjhpuY81b6z1JDRPWXB6a2Om3-8QSUErn11CsCmLmRG/s1600/Dagney.png" width="82" /></a></i></b></span></div><span style="font-family: inherit;"><span style="color: #0b5394;"><b><i>Dagny Taggart</i></b><span> </span><i><span style="line-height: 107%;">is a retired and recovering broker and attorney who spends most of her days in a walled compound in Galt’s Gulch, Colorado, walking
her Labrador and watching the squirrels cavort. After a 30-year career in
benefits, she retired in her early 50s and now consults with large employers
and brokerages on healthcare, benefits, and ERISA. </span></i></span><o:p></o:p></span><p></p><p class="MsoNormal"><br /></p>Craighttp://www.blogger.com/profile/14913599100409003265noreply@blogger.com