Jeff Evans, CRM, ACSF Passionate Risk/Insurance Educator-Coach-Author on LinkedIn: Making the most of health plan shared savings programs (2024)

I had to share this article from William Sarraillebecuae he does a great job of addressing the why the Affordable Care Act's MLRs and the Vertical Integration of Healthcare and Health insurance are NOT the "cures" they are supposed to be. I've often commented on how the MLRs work against us because their limits incentivize insurance carries to push cost higher, i.e. - 15% of a $600 premium is more than 15% of a $500 premium, but it's still only 15% (and meets the MLRs). But here you get to hear if from someone else.He also does a good job of explaining how Vertical Integration provides the oppportunity to further manipulate the MLRs by controlling who claims are paid to as well as what precriptions might be dispensed. All of this creates further conlicts between doing what is right for the patient versus right for the Verticlal Integrated company that owns the physician, PBM, ASCs, or other healthcare service providers.

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Thakn you Chris deacon for pointing out the importance of understanding the true motivations behind many healthcare systems' interest in "improving care".As Chris states, "It's crucial to recognize that these "opportunities" may be less about patient outcomes and more about maximizing revenue through increased patient engagements."She references one hospital system CFO's recent comment, "As we look at the future landscape, the competition for customers will take this industry to another level. We're investing now to be ready to compete." Notice that he did not use the term patient, but rather customer. At least to me, this would seem to indicate more concern for a person's "business" versus their care. The top concern being how do they attract and retain the "customer's" business to maximize the financial opportunity. Instead of how do we deilver high-quality care at a reasonable price. Chris concludes quite accurately that, "This perspective counsels against any optimism that patients as people, rather than patients as profit, are at the center of this strategy."

PLEASE LISTEN - This is helpful for everyone.Here's another great video from Eric Bricker, MD, talking about Direct Primary Care. For the employers we've implemented this with it has been a huge success! Employees love it and claims against the health plan have been reduced.

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Grat article on Health system consolidation.

Do you use a broker or an advisor for your employee benefits?Broker: - Resells the same status quo BUCA retail insurance plans for commissions - Gets a raise for you renewal premium increases - Receives retention bonus for keeping you with same insurance carrier - Has a built in conflict of interest (makes more when you pay more)Advisor: - Consults clinet for best possible results - Sits on Employer's side of the strategy table - provides full transparency of compensation (no hidden fees or kickbacks) - Gets paid on success of outcomesIf you're using a broker, here's what the top brokerage CEOs are making. Just a thought, but if this is what their compensation packages look like, who's best interests do you think their looking after first, yours or their shareholders'/owners'?

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Surprise! Surprise! Surprise! Healthcare costs expected to continue to increase.In Milliman's 2024 Medical Index report healthcare costs are expected to increase another 6.7%, with individual cost increasing to $7,151 and the cost for a family of 4 reaching $32,066.How can employers continue to go along with this? Do they realize the impact on their bottom line, their employees, or their community?There are solutions available. Why not consider them? Worried about disruption? Which is worse, possible disruption or employees not being able to afford their healthcare? If not sure, survey your employees. Would they rather receive high-quality care at little or no out-of-pocket or pay increasing copays and deductibles to see "their" doctors? You might be surprised at the number of employees willing to change doctors for reduced costs, especially when guided to high-quality providers. Record numbers of employees are deferring care because of cost which leads to their conditions worsening, care needed often becoming more complex, and the overall cost of to employers increasing in the form of high claims. Deferred care does not mean less expensive care. It is almost always more expensive, growing exponentially.https://lnkd.in/gAduUBDh

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This is very interesting information from Chris Deacon. This is crazy! Why are taxpayer funds being spent on cybersecurity for hospitals? As she notes the budgets for these facilities have budgeted for "Revenue Cycle Optimization" software so they can more efficiently up-code, unbundle bundled codes, and basically bill for as much as possible that might be related to whatever services may, or may not, have been done. Keep in mind that "Revenue Cycle Optimization" is the hospital industries term, the rest of us call it FRAUD. RCO sounds so much more ethical than calling it what it is.Which is more important, increasing, or "optimizing" the amount of their billings, whether valid charges or not, or protecting their patients/clients information? (rhetorical question)Or, maybe their thinking that if they launch these new "Revenue Cycle Optimization" programs they will have the revenue to address cyber security?

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Interesting post on Optun offering a more drug pricing model. From a company that profits at every move, I can't help to wnder, "What's the catch?"I also can't help but wonder what their definition of transparency is? Or, shared savings? Optum 80% vs. client 20%?Optum/UHG does not do anything that doesn't make them money so there has to be an agle here.

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The Next ER Visit - "You are now being recorded . . . "Here's a great post from Chris Deacon further illustrating how healthcare is an business first and foremost. Patients may be on the list of importance ut it's hard to say where. BTW - the cost of implementing this strategy will be added to your exhorbitant cost of health care.My other question is will this new technology interpret "I think you may need XYZ test done . . . " as it was done? Or, will it take all of the possible illnesses/ailments discussed and automatically up-code to the highest cost condition? Kind of like a Level II Er visit being up-coded to a Level IV ER visit.

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