Rebate Game on Overdrive

White Pills with a bottle and American Dollars

Every time I turn around there is another shell to watch in the game of rebate pricing. And just when you thought the pharmacy benefit manager (PBM) pricing structure couldn’t get more convoluted, it is… Most employers are already aware that PBMs provide significant rebates every time brand drugs are dispensed. As the cost of… [Read More]

Anthem’s Entry Signals Further Stop Loss Market Growth

Arrows up isolated, many different styles, illustration vector

The tectonic plates continue to shift underneath the health insurance market. Ten years ago, most medical carriers were predominantly “risk-bearing” entities – taking in premium dollars and in return, paying claims. But as those claim dollars rose and the Affordable Care Act (ACA) introduced additional fees to the insurance market more employers moved towards self-funding,… [Read More]

Another Band-Aid: Pharmacists Shopping for Patients

Cropped shot of shelves in a pharmacy

As anyone who has ever filled a prescription knows, the arcane and mind-numbingly complex pricing framework for drugs makes it both impossible to know what the drug will cost in advance of filling the prescription and similarly challenging to shop for a lower-cost alternative. With hundreds, if not thousands, of pharmacy benefit manager (PBM) and… [Read More]

Participation: Is It a Good Thing or a Bad Thing?

prepare filling item form, business background

One of the central tenets of underwriting medical plans is to avoid adverse selection at all cost. Adverse selection results when a plan is designed or priced in such a way that it only adequately incentivizes sicker employees to enroll; failing to attract good risk to offset the bad. For this reason, most insurers historically… [Read More]

Preventive Care that Actually Saves Money… Dental

Toothbrush and toothpaste in the bathroom close up.

Over the last two decades, the healthcare industry has tied itself in knots in order to validate the business case behind preventive medical care. And although preventive care services offer a variety of benefits – social and humanitarian, for example – the data seems almost conclusive that economics is not quite one of them. Too… [Read More]

Frustration of Fraudulent Claims

Folder with close up on the word claims and a note where it is written under investigation. Concept of insurance fraud, 3d Illustration

It’s a well-documented reality across nearly all lines of insurance coverage that fraudulent claims account for 5–10% of total claims processed. And despite the industry’s best efforts to combat fraudulent activity, it’s largely accepted as a “cost of doing business” in the world of insurance. What has frustrated several of my self-funded clients however, is… [Read More]

Are Drugs Cheaper Using Cash?

The concept of paid medicine with pills on a money background

This past weekend, a far-reaching exposé was published by the New York Times and ProPublica highlighting how, in many instances, individual members can save money paying cash when compared to using their insurance for their generic prescriptions. While this is not a new issue, the investigation reviewed the top one hundred prescribed medications, finding that 40% of the time… [Read More]

Why Employers Should Practice Medicine

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Every businessperson will tell you that the key to reducing costs in any industry vertical is by reducing the amount of friction in the transaction. Friction is created every time an additional party is brought to the transaction because that party will likely have its own profit incentive, thereby increasing the cost of the product… [Read More]

The Softening and Widening Stop Loss Market

Vintage processing of an open for business sign in small town America.

For the last several years, we’ve highlighted the dramatic market trend of employers adopting self-funding and the rationale supporting the move. As premium dollars have left the insured medical market, lots of those dollars have moved to the reinsurance markets with employers offloading the tail risk associated with their self-funded arrangements. Meeting the demand have… [Read More]

Anthem Gets Tough with Hospitals

Anthem Gets Tough with Hospitals2

One of the greatest frustrations our self-funded (and to a lesser extent, fully-insured) clients voice is that – despite the hundreds of thousands or millions of dollars they pay the insurers to assist in managing their health plan spend – too often it appears the insurers are complicit in the rising healthcare spend by not… [Read More]