Firstsource’s Post

Is this really a healthy development? The Affordable Care Act drove massive consolidations of primary care by health systems. Now the top insurance companies are stepping up to the plate to buy the remaining independents - to support their ever growing Medicare Advantage business. Private equity is also jumping in to take over the digital and telehealth markets. I am concerned that margin is taking over mission in healthcare. And, much of this may have evolved from years of Medicare reimbursements overvaluing specialty care and undervaluing primary care. In the meantime, corporate health plan members are struggling to get timely appointments for primary and chronic care. It seems, gone are the days of having a trusted and independent family doctor. Throughput and performance do not lead to better health. Thank goodness drug companies are available to make us happy and to sponsor our TV shows. https://lnkd.in/eJz_Fme4

In this week's episode of can't make this sh*t up Optum is buying Steward Health Care's physician group Yes, that Optum Yes, that Steward I can't even really Why is this a problem? Well, other than the obvious, here's how United will contiue to make unimaginable sums of money As a "health" insurance company, United can't make more than 15% ish in profit because of the medical loss ratio laws But, its subsidiaries sure as heck fire can Optum is a subsidiary 90,000 doctors are employed by Optum So, United jacks up the price of the services deliverd by these docs and groups It spends it's money on claims paid to the groups and hits its 85% MLR But the group is making a much higher margin than 15% And guess who ultimately gets that money? Ya, United I made a picture United's all-in cost is the cost of the physician group, not what it paid them That gets eliminated It's vertical integration The game isn't better healthcare The game is more money And they are real good at the game P.S. Want to see more of this poppycock? Check out The Healthcare Breakdown, where we talk all about the business of healthcare. Sign up here: https://buff.ly/47NeASx See you out there!

What policies lead to this kind of profit for the insurance company and made taking care of patients even more difficult? #Consolidation #MedicalInsurance #HealthcareAdvocacy #Healthcare #Medicine #Patients "UnitedHealth Group posts $5.5B profit in fourth quarter" https://lnkd.in/guEDxerq

🌟 Building Strong Partnerships - Nuvo Health and Physicians Mutual! 🌟 Last night, our leaders had dinner with the Executive team from Physicians Mutual. They’re in town to kick off one of their new Medicare supplement options, and they took our founder and president, Calvin Bagley, and COO, Karissa Bagley, to dinner for a sneak peek and to connect. (Our CEO, Jeremy Weiser, wasn't able to attend.) At Nuvo Health, we help Agents and Brokers succeed in the Medicare space. Part of being a resource for Agents and Brokers involves staying in-the-know about products, services, insurance companies, doctor networks, and more - and knowing the right people to help our Agents and Brokers. Our personal relationships with the Executive team at Physicians Mutual means that we have people to call when we need them, and they have a sounding board and partner in us. Calvin and Karissa had a great time catching up with long-time colleagues and meeting new leaders. Business is personal, and we continue to live one of our favorite core values: "Good People Doing Good Things." We purposely partner with other professionals who are also good people who do good things. The leadership team at Physicians Mutual was our style - fun, friendly, smart, and on a mission to help more people get great Medicare benefits. #NuvoHealth #Medicare #GoodPeopleDoingGoodThings #PhysiciansMutual Calvin Bagley Karissa Bagley Chad J Wells Hank Yarborough Tim Reed Kris Bashford Mike Story

How does it help your healthcare budget when three Prescription Benefit Managers, CVS Caremark, Express Scripts, and Optum Rx control 80% of the PBM market?  Your health plan needs a non-Big 3 PBM that gives you 1) full transparency and 2) pass-through pricing Transparent PBMs only make money through administration fees and have NO other financial incentives to make money from Rx rebates or spread pricing so ALL negotiated discounts and rebate arrangements are 100% reported and remitted to you, the sponsor of the plan: Example: Rx monthly cost per member = $70/mo. Rx TPA fee per member         = $10/mo. Rx spend per 1,000 employees = 1,000 x ($70 + $10) = $80,000/mo. If your current medical plan with 1,000 members pays more than $80,000/mo the first step is to authorize an audit of Rx costs with an independent audit firm like DCI Solutions that does NOT broker/sell insurance. Transparent PBMs let you know exactly where they make their revenue, including rebates with no hidden fees or hidden revenue. They show how the formulary (list of available drugs in your health care program) is chosen for both quality and affordability in mind.

I sent a letter to Senator Ben Cardin and other members of the Senate Finance Committee strongly suggesting they expand the discussion at today’s hearing with UnitedHealth Group CEO and use the opportunity to explore the harms to patients and consumers as a result of anti-competitive practices by major health insurers & their pharmacy benefit managers (PBMs). UnitedHealth Group controls one of the nation’s largest health insurers, one of the three largest #PBMs, a specialty pharmacy, and also employs one of every ten physicians in the United States. This raises concerns as to whether United-paid physicians are prescribing medications that are in the best interests of patients or that will generate the greatest profits for its affiliated subsidiaries. Lax antitrust enforcement has allowed the PBM industry to become essentially an oligopoly. A competitive marketplace needs three essential elements: consumer choice, transparency, and a lack of conflict of interests. The drug prescribing landscape controlled by giant health insurance/PBM/pharmacy corporations fails on all three counts. This provides relevant, multiple lines of inquiry that the Senate Finance Committee should raise today with UHG’s CEO. https://bit.ly/4dhRbeJ

I'm hosting an experimental dinner; a first in a possible series. Human Alignment Dinner #1: U.S. Healthcare Everyone laments all the misalignments of incentives in the U.S. healthcare system such as: (1) big pharma companies optimizing profits by selling more pills than people need (think: oxycontin epidemic) and other "sickcare at scale" issues (2) the issues with the 80/20 rule placed on health insurance (3) possible high degree of over-prescription of treatments/surgeries such as knee surgeries (4) truncated 3-5yr financial investment window of health insurances that prevent them from investing in long-term health of their customers (due to our employer-sponsored insurance paradigm)... ...and other such "whoops" misalignments between increased financials and the health of the people the industry is meant to serve. The more I dig in, the more I find that these misalignments are often a result of accidents in history (ex: employer-sponsored insurance or provider-centric EHRs) or good intentions with blindspots (ex: 80/20 rule?) and less so some evil person or corporation. And the more time we spend blaming vague evil entities or rational financial players acting in their rational financial best interest in what is a broken game, the less time we're talking about constructive ideas to realign the incentives and thus address the root causes of the broken game. If you're also someone (or know someone great) who's been mapping out all these misalignments, so that we may collectively better understand them to have a shot at creating new non/for-profits and other entities that better realign incentives, then give me a holler. I'd love to have you at one of these dinners.

Is Big Health Care too big? The U.S. government is now investigating that question: The DoJ has launched an antitrust investigation into UnitedHealth Group, the largest U.S. health care company, according to the The Wall Street Journal and the Examiner News. Last year, Erika Fry and I looked into that very question for a Fortune cover story about the tremendous—and accelerating—growth of United and CVS Health, the country’s second-largest health care company. As we reported in May: Health care executives, investors, and some practitioners argue that this “vertical integration”—marrying primary care clinics and physicians’ practices to insurance, pharmacy benefit management, data analytics, and a host of related businesses—is, or will be, good for everyone. Companies can deliver care more efficiently and conveniently, providing more services to lower-income patients and other underserved populations, and heading off the chronic conditions and serious illnesses that drive up costs. …But the broader benefits are, so far, a matter of debate—and the focus of much skepticism among doctors, patients, lawmakers, and industry critics. “Everything about the incentive structure that exists, when you have providers and insurers and pharmacy benefit managers coming together under one roof, to me spells ‘conflict of interest,’ ” says Sara Sirota, a policy analyst at the American Economic Liberties Project, a nonprofit focused on antitrust advocacy. “That’s going to harm services and prices for patients.” The health care giants point to early signs of improvement, and promise even bigger benefits further down the road. In the meantime, they keep growing at a blistering pace. Which means it’s more urgent than ever to ask: Who benefits from Big Health Care’s growth—and will it really make America healthier? https://lnkd.in/eJvkytCM https://lnkd.in/e8m3KzBi

I'm trying to figure out why don't health plans offer multi-year contracts. Value to insurers: lock-in ARR / prevent customer churn. Value to members: insurance plan incentivized to pay for preventative care The best explanation I've heard why this doesn't happen came from Rebecca Mitchell, MD: Payers don't know how medical prices will inflate beyond a year, making pemium pricing / underwriting difficult. Surely this could be easier at an payvider though, yeah? I imagine the health plan at Kaiser could get better insight into future year physician contracts, hospital contracts, etc. Why else doesn't this happen today?

Assuming the chart is accurate, or close. Let's realize that insurance provides no treatment and other than paying the bills does exactly nothing for health. They like to call themselves health plans, so we don't call them bill payers. Then there are many other forms of intermediary that also do not provide any care or health. The system has converted from transactions to financially support caregiving, into caregivers and patients supporting profit taking transactions. This is upside down.