Reviewing Contracts: An Essential Part of Health Plan Management

Reviewing Contracts An Essential Part of Health Plan Management

And you thought it was tough to decide on plan design, communication strategy and contributions for your medical benefits plan… Once the crush of implementation begins, the plan documents will start coming to your inbox and it’s critically important that you understand them completely. The obvious first steps would be to check the principal plan… [Read More]

Is Government-Provided Healthcare Better?

Cuban Healthcare Reform pic

I recently returned from a cultural excursion to Havana, Cuba. As a healthcare geek, of course I wanted to know about accessing care in a communist country. First, I must say that I was surprised to find that the country did not live up to the third world impressions which many people may expect –… [Read More]

Pharmacy Shenanigans

Prescription Drug Cost

In evaluating the cost of a medical benefits program, prescription drug costs and in particular, specialty drugs, stand out as the fastest growing and the most difficult to manage cost. As I review programs with clients, I find myself often pointing out that pharmacy is where all the profits are hidden. This has been no… [Read More]

Controlling Specialty Drug Spending

Drug Cost  Specialty Pharmacy

Another commentary from the National Blue Cross Consortium. As I mentioned in prior posts, large claims are on the rise. Last year, Blue Cross paid their first individual claim for more than $15M, and the frequency of claims over $1M tripled from 2010 to 2015. Specialty medications are a real focus area. There is a… [Read More]

The New Media Focus Is Pharmacy – Can Regulators Keep Up?  How Should Employers Protect Themselves? 

Drug Cost  Specialty Pharmacy

Turing Pharmaceuticals – the vilified hedge fund-owned prescription drug peddler that increased the cost of their 62-year-old drug from $13.50 to $750 per tablet overnight – has raised new cries for the legislative involvement in pharmaceutical costs which I have been writing about for a while (see related posts here, here and here). A recent Reuters study… [Read More]

The Pharmacy Game

The Pharmacy Game

I spend a lot of time thinking about the Pharmacy Benefit Management (PBM) business. The dominant players – Express Scripts, CVS Caremark, and OptumRx – own the vast majority of the business. So, why do I get calls every week from little-known or newer players in the business telling me they can blow the doors… [Read More]

Our Complex Healthcare System: No Loophole Will Go Undetected by Profit-Seekers


In 2012, in an effort to promote cost transparency, new regulations were issued requiring pharmacies to list all drugs included in a compounded medicine when seeking reimbursement. Previous protocol required that only the most expensive drug be listed, and reimbursement was based on the cost of that drug. At the same time, drug manufacturers escalated… [Read More]

Employers Find Solutions to Rx Gamesmanship That Increases Their Costs

Facing the erosion of profits due to high-cost brand name drugs coming off patent, the pharmaceutical industry has found a way to keep the profits rolling in. Pharma would like members who face higher copays and costs for name-brand medications with generic alternatives to stay on the branded drugs. To do so, they spend $3-$6… [Read More]

Communicating at the Brink


As I write this in December 2011, contract negotiations between Express Scripts, the Empire pharmacy benefit vendor, and Walgreens are not going well. This situation, like all tense carrier/vendor contract negotiations, brings up the question of how member groups should handle communications to their employees when a network disruption appears imminent. Should you hang in… [Read More]