Why do hospitals charge private insurance carriers 250-300% more than they charge Medicare for the same procedures?

Episode 1928 Transcript:

00;00;01;14 - 00;00;05;17

Cary Hall

And now America's Healthcare Advocate, Cary Hall.

00;00;05;19 - 00;00;22;07

Cary Hall

Hello, America. Welcome to America's Healthcare Advocate show broadcasting coast to coast across the USA. You're on the Air Radio Network. My producer today, Mr. Darren Wilhite. I'm your host, Cary Hall. This is your show, America. Thank you for joining us and making this one of the most listened to talk shows throughout the United States.

00;00;22;09 - 00;00;41;13

Cary Hall

By the way, we have a brand new affiliate in Florida, WBGS 1610 AM. And we want to thank them for coming on board. And Largo, Florida. I want to thank Mr. Al Christopher. He is the manager at the station there. We're very happy to be on board with the good folks at WBGS 1610 AM in Largo, Florida.

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Cary Hall

Welcome to the America's Healthcare Advocate Family. Also, we're on 14 podcast platforms now and on YouTube as well. So I think the last Numbers Dave supplied me with on our podcast platform show, we've had about 58,000 downloads of the podcast. I mean, people in Turkey are watching us, which is kind of interesting. And our YouTube numbers are somewhere around 257,000 of you are going up on YouTube to view the broadcast.

00;01;07;10 - 00;01;33;16

Cary Hall

So in addition to all the radio stations across the country, the amount of FM stations that we've been on for years and new ones we're bringing on podcast and YouTube has become a whole big new thing. So we thank all of you and appreciate you're watching and listening to America's Healthcare Advocate. If you are chronologically challenged and you're looking for Medicare, you can always call the lovely Joyce Thompson or Carolee Steele at Benefits by Design, RPS Benefits by Design.

00;01;33;23 - 00;01;55;29

Cary Hall

And that number is 877 385 2224. Look, anywhere in the country, I don't care where you're at, they can help you find a plan that's going to fit your needs and fit your budget. And as we get closer to open enrollment, keep in mind you want to give those folks a call and have them take a look at what you're doing now and see if there's something better out there that might make more sense.

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Cary Hall

And if you're an employer and you're looking for employer sponsored health care, maybe you're not happy with what you've got. Give Maria Alhers a call at RPS Benefits by Design. She's at 877 385 2224 as well, and she will be happy to help you and show you options you may not know about. All right. Joining me in studio, it's been a while.

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Terri Raimondi

It’s been a long while.

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Cary Hall

And I saw each other before we had dinner last night.

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Terri Raimondi

A year and a half ago.

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Cary Hall

At least a year and a half ago, Terri Raimondi, Terri’s been in the insurance industry, health care industry for about 34 years. You wouldn't know it by looking at it, but that's the truth. And she and I have worked together for probably 15 years, something like that, that she's for. Yet she's she is the one that introduced me to self-funded and taught me a lot about self-funded programs that we did that.

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Cary Hall

And when I had Benefits by Design, we had a lot of self-funded clients and a lot of that had to do with Terri that we had brought on board. She she runs a TPA (Third Party Administrator). She's very good at what she does. We're going to have a fascinating show today because in talk about health insurance and health care and how those two are interrelated and you're going to learn some things today.

00;03;03;02 - 00;03;22;06

Cary Hall

You're going to learn where is the money going? You know, they always say, follow the money. We're going to help you follow the money. And we're going to have that discussion about national health care and how it works. And why is it the Europeans spend less on health care and than we do. We're going to talk about all those things today with this national expert Terri Raimondi here in studio with me.

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Cary Hall

So let's just dive in a little bit. Terri, you've been at this for 34 years on the TPA side, on the health care side, you've seen a lot of change in the industry. What what? You know, I think we're seeing more change now than we've ever seen, where employers are moving away from a lot of the BUCA plans, if you will, and looking at other alternatives.

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Cary Hall

And what do you attribute that to?

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Terri Raimondi

The cost of health care increasing exponentially year over year. So with the BUCA plans, they have a canned plan and the prices are set and they really can't afford it anymore. So they're looking for alternatives to keep their employees in a great health plan and actually keep their employees because health care is so important.

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Cary Hall

So basically, if you're wondering what that acronym book stands for, it's Blue Cross, United, Cigna and Aetna. Those are the Humana. But Humana is out of the market on group so you don't get the.

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Terri Raimondi

BUCA, B U C A..

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Cary Hall

Yet anyway. So those are the plans and they're they're structured basically by the federal government because after ACA they basically lay down the parameters for what the health insurance carriers could do, how much money they could make, what they the whole nine yards. And so it flipped the switch in terms of how things are working or not working right.

00;04;42;16 - 00;05;09;12

Cary Hall

And that's another huge, you know, contributor to the fact that every year, especially if you're a small employer, you know, 100 lives or less, or even if you're 500 lives, in a lot of cases, you're seeing these costs continue to rise and there's no containment. And this continues to go on year after year after year. And the question you it's I remember when you and I would go to the operettas conferences, which is one of the first big captives in the country that offered self-funded plans.

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Cary Hall

And I remember that Cavanaugh and Clayton, the two guys that started thing would get up and they would show the charts and they would talk about if you're if you're in the building business or you're in the manufacturing business or whatever business you're in, you're supplier continued to increase you 10% every year or more. And that in today's world, that's a small number.

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Cary Hall

Would you look for other alternatives or part.

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Terri Raimondi

Of the new supplier? Right. Correct. And this fire?

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Cary Hall

Yeah. The problem in the health insurance industry is you can't keep going from plan to plan to plan because nothing really changes.

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Terri Raimondi

Right. You can jump from carrier to carrier and you may get a rate reduction for one year, but then it's going to catch up with you the next.

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Cary Hall

Year and it catches up because of.

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Terri Raimondi

The costs increasing. Right.

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Cary Hall

And the claims.

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Terri Raimondi

And the claims experience increasing. You can't manage what you can't measure and you don't get your experience, so you don't know what's driving your cost. So most employers under 500 lives don't get a lot of their claims experience, so they don't know what's driving their cost.

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Cary Hall

So let's go back to that common cause you used to use to talk about this. So we would you and I would do presentations together to employers to talk about how they should move off of some of the plans that they ran into the self-funded mode. You can't manage what you can't measure. What does that mean?

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Terri Raimondi

It means if you don't know what's driving your cost, is it diabetes? Is it heart disease? Is it prescription drugs? You can't make any changes in your plan to control those costs or maybe help your employees get healthier so they're not spending a lot of money on diabetics. They're not in the hospital having heart attacks. If you don't have that data, there's nothing you can do.

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Terri Raimondi

You can't help them in any way.

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Cary Hall

And unfortunately, especially for employers, 100 lives and below, they don't get access to that data. Right?

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Terri Raimondi

They don't some carriers will, if they do get any data, it's really old. Other than in Texas. Texas does is the one state in the country where it's mandated that they have to get their experience three times a year no matter what the size of the group. It's HB I don't know the exact name of the law, but they do get their experience in Texas.

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Cary Hall

Now that's passing. I didn't know that. So in Texas they are required. The carriers are required to give them that data three times a year. And that data is the claims data.

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Terri Raimondi

It is for claims. Okay.

00;07;19;20 - 00;07;26;26

Cary Hall

So why is that valuable? Okay, we just talked about it, you know, diabetes. But what can you. So I've got the data and what am I going to do with it?

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Terri Raimondi

Well, the premium, if you're looking at your claims experience, you can compare that against the premium you're paying to the carrier. If that numbers below 80%, the carrier is making money off of you. Right. So it gives you negotiation power. That's one. And again, with the employees, you need to know where they're going, what providers they're going to, because if they're more expensive providers, you can maybe steer them away from those providers and make plan decisions to steer them to low cost, high quality providers.

00;07;57;21 - 00;08;13;21

Cary Hall

So they're in in other words, your managing the care and therefore managing the costs. Correct? So I think a lot of people hear that, Terri, and they go, okay, yeah, what you're talking about is giving us cut rate care. You're not talking about giving us the kind of care that we want and you're shaking your head no explaining.

00;08;13;25 - 00;08;15;19

Cary Hall

That is not how this works.

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Terri Raimondi

No. Most high quality providers for the most part, are lower cost of care, not higher cost of care.

00;08;21;21 - 00;08;23;29

Cary Hall

And that's kind of hard, I think, for people to understand.

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Terri Raimondi

Yeah, most people don't believe it.

00;08;25;14 - 00;08;40;17

Cary Hall

Yeah, they don't, But. But we're going to talk about that. Okay. In the next segment, we're going to get into that. We're going to talk about that. So you'll give folks a chance because the next segment we're going to talk about so we're talking about the carriers right now. But in the next segment, we're going to switch we're going to talk about the hospitals.

00;08;40;17 - 00;09;00;02

Cary Hall

And I think you're going to find it extremely interesting. And we're going to talk about pharmaceuticals as well. So they are you know, the alternatives are out there. But employers, I think, a lot of times just don't know where to look. And if the broker is not motivated to bring them, you're smiling. Okay. Because there are a lot of lazy brokers out there.

00;09;00;04 - 00;09;10;02

Cary Hall

If the brokers touch is zipping your lips, look at this. There are a lot of lazy. If the broker is not motivated to show them alternatives, they stay in the same mode, right?

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Terri Raimondi

I would say maybe it's not lazy, maybe it's uneducated because doing a partially self-funded health plan, you know, some people don't understand it and they hear the word self-funded and they believe that that there's going to be no limit in what they're going to have to spend. And that's not true because there's coverages that you can purchase to protect yourself.

00;09;31;05 - 00;09;40;28

Terri Raimondi

So you can have a plan that looks just like a fully insured plan, but you're getting all your data and your managing your cost and you keep everything that you don't spend.

00;09;41;00 - 00;09;57;17

Cary Hall

And that's the important part. And that's that's the message we're kind of trying to get out here today is there is a better way to do this If you want to take the time to learn about it and do it. When we come back, the break. We're going to talk about the hospitals. You're going to find this one extremely interesting because there's a lot more involved here.

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Cary Hall

When I said follow the money than the health insurance carrier. So we come back to the break. Stay tuned. You're listening to America's Healthcare Advocate broadcasting here on the HIA Radio Network. Coast to coast across the USA, we come back. We got a lot more to talk about. Stay tuned.

00;10;12;22 - 00;10;45;27

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00;11;13;02 - 00;11;31;12

Cary Hall

Welcome back. You're listening to America's Healthcare Advocates broadcasting coast to coast across USA here on the HIA Radio Network. You can find out more about us by going to the website America's Healthcare Advocate dot com. If you have a question or comment I had a lady the other day reach out to me. She was going to be on Cobra.

00;11;31;13 - 00;11;48;00

Cary Hall

It was ridiculously priced. She needed help. I got her some help and got her on an ACA plan because she was able to make that move. Even without open enrollment, it was a qualifying event. If you need help with something like that or it's a medical issue, please reach out to me through the website. America's Healthcare Advocate dot com.

00;11;48;06 - 00;12;12;22

Cary Hall

If you want to reach out to Terri, I'm going to I'm going to give this over the air. So if you got a pencil, you might want to write it down. It's Terri Raimondi T E R R I R A I M O N D I- Terri Raymondi @ me dot com. I'll do it one more time. TR i r a r a i imo in diy at mi.com.

00;12;12;22 - 00;12;27;02

Cary Hall

That's her email address. If you have a baby, just want to talk to her about how does this work? How do you do this? She'd be happy to chat with you. Send an email. She'll be delighted to connect with you and see if she can help your broker. You want to go to school, learn how to do this?

00;12;27;03 - 00;12;50;16

Cary Hall

This lady can teach you. She taught me. She can teach. You gave your employer. She's laughing, but she did okay. And she can do the same thing. All right, So I kind of teased this going out. So now let's talk about the help at the hospital system. So you. This is interesting because I'm going to go back to Obamacare, ACA, when everybody was throwing rocks at the insurance carriers, they were the bad guys.

00;12;50;17 - 00;13;11;04

Cary Hall

Okay. Nobody said a word about the hospitals. Now we get into this discussion about national health care, which is still out there, and it's on the agenda of the progressive liberal wing of this country. That's what they want. That's what they're pushing for because it's going to give us a better health care system like the Europeans have. We'll talk about that in a minute.

00;13;11;06 - 00;13;29;20

Cary Hall

But but when you when you look at that model and and and we start talking about national health care and we start talking about cost, we need to look at what is it? What where's the money going? Where is the money in the. Well, we know some of it goes to the health insurance carriers, a fairly small amount when you look at the whole pie.

00;13;29;22 - 00;13;44;07

Cary Hall

But let's talk about the hospital systems. You made a very interesting comment before we got in studio today and you said there are no as our piece like you see on your car when you go buy a car, there's no mystery on health care. Explain that.

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Terri Raimondi

So every hospital has a chargemaster. So if you need your gallbladder out, they can charge whatever they want. I mean, they have something called a chargemaster and there's no set price for anything. Each hospital sets their starting price. I'm going to call it a starting price for everything they do in that hospital. And it's called the chargemaster. The carriers negotiate a percentage discount off that chargemaster and they all have lost leader.

00;14;13;22 - 00;14;30;11

Terri Raimondi

So one carrier might say, I'll take a higher price on a gallbladder if you'll give me a lower price on a heart surgery. So that is how everything was done. I will say it may be changing with the transparency laws. Each hospital has to post their prices.

00;14;30;14 - 00;14;49;26

Cary Hall

Well, they have to. But then hospitals like Barnes-Jewish and St Louis are fighting tooth and nail. Not to. I don't even know if they're still doing it. If that information is being posted. They don't want that information out in the public marketplace because people who are willing to take the time, well, what is the cost of a hip replacement at this hospital versus this hospital?

00;14;50;01 - 00;15;01;02

Cary Hall

We'll give you some examples here in a minute. But that's the purpose of the transparency law that we don't have a lot of compliance with. I don't think. And I don't see any particular enforcement of that either.

00;15;01;05 - 00;15;18;14

Terri Raimondi

The government is trying to enforce it. I will say all the hospitals were required to do was post machine readable files. So you or I wouldn't be able to decipher the machine readable files. As of January of next year. Your carrier has to give you those prices. So the okay.

00;15;18;14 - 00;15;19;15

Cary Hall

Yeah, that's a big deal.

00;15;19;16 - 00;15;43;12

Terri Raimondi

So all those machine readable files will be digested. But the thing that's happening with machine readable files is hospitals are hiring consultants to take all those machine readable files and then go renegotiate their contracts. So if they see and it's getting better than Blue Cross on a gallbladder, they want that higher price. So instead of lowering the cost of health care, that could increase the cost of health care.

00;15;43;19 - 00;16;03;06

Cary Hall

So let's talk about the base. There's a base and it's set by CMS, and that's Medicare. So let's talk about how Medicare does that and then let's talk about what's that look like when it goes out to the general public. And it's not Medicare. So now it's the carrier that's negotiating. And what does that price structure look like from Medicare?

00;16;03;07 - 00;16;04;08

Cary Hall

So start with Medicare.

00;16;04;11 - 00;16;21;16

Terri Raimondi

So Medicare rates are determined again by CMS each year. A hospital CFO has to attest to the cost. I'm going to use a gallbladder. How much it costs them to do a gallbladder down to their electric bill. They establish that price, they send that to CMS, and then the Medicare rate is determined.

00;16;21;18 - 00;16;22;18

Cary Hall

That is by CMS.

00;16;22;18 - 00;16;33;01

Terri Raimondi

By CMS. Yes, the Medicare rate is determined by CMS. In contrast, a normal employer pays about 300% of Medicare.

00;16;33;03 - 00;16;37;10

Cary Hall

Well, how can that be? How does an employer pay 300%?

00;16;37;12 - 00;16;43;16

Terri Raimondi

How do they pay it? Because that's what's negotiated. That's what's negotiated with the chargemaster, with each of the carriers.

00;16;43;20 - 00;17;02;13

Cary Hall

So in other words, the carrier winds up having to pay the 300% or whatever they negotiate to 50, whatever the case may be. And that is then passed on to the employer. Correct. So now if we connect the dots, we have we have Medicare reimbursing with and we didn't talk about Medicare, but Medicaid is even below Medicare.

00;17;02;14 - 00;17;05;22

Terri Raimondi

I'm not a medicaid expert. I can tell you how Medicare works for on Medicaid.

00;17;05;22 - 00;17;18;27

Cary Hall

But Medicaid is actually below CMS. It's basically at cost. CMS is at whatever percentage over it above the chargemaster they allow, which is basically what CMA.

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Terri Raimondi

I'm not going to care. Yeah, I'm not sure what the percentages you know above their cost that they that.

00;17;25;07 - 00;17;27;26

Cary Hall

But they allow the hospitals to have a profit in there.

00;17;27;27 - 00;17;30;14

Terri Raimondi

Yes. Profit is built in a small profit is built in.

00;17;30;14 - 00;17;33;13

Cary Hall

So they're allowed a small profit but it ain't.

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Terri Raimondi

No, it's not 300%.

00;17;34;20 - 00;17;34;28

Cary Hall

Okay.

00;17;34;28 - 00;17;39;09

Terri Raimondi

So let's in three years make, make it up for the hospitals. Employers make up the difference.

00;17;39;10 - 00;17;41;02

Cary Hall

Okay. Repeat that again.

00;17;41;07 - 00;17;43;03

Terri Raimondi

Employers make up the difference.

00;17;43;06 - 00;18;05;03

Cary Hall

So now let's connect the dots. Okay. When you have this discussion about national health care, we're going to talk more about this next segment as well. But when you have this discussion about national health care, you better understand something. That three legged stool, which is Medicare, Medicaid and private health insurance. Private health insurance is holding up the other two legs.

00;18;05;03 - 00;18;06;10

Cary Hall

That stool. Am I right or wrong?

00;18;06;12 - 00;18;07;20

Terri Raimondi

You're 100% correct.

00;18;07;20 - 00;18;11;08

Cary Hall

Okay. And that's being passed on to who? The consumer.

00;18;11;11 - 00;18;11;26

Terri Raimondi

Correct.

00;18;12;00 - 00;18;14;17

Cary Hall

Okay. So when when you went.

00;18;14;19 - 00;18;16;20

Terri Raimondi

Because deductibles and out-of-pocket have all gone up.

00;18;16;26 - 00;18;41;13

Cary Hall

Okay. That's it. Okay. So when you wonder why. Let's go back to the health insurance discussion. When you wonder why your premiums are going up. There are two factors. One is obviously the health insurance carrier raising their prices based on whatever. Okay. But that's controlled now by the government under ACA. Okay. The second piece is the hospitals. And the bigger piece of the pie is the hospitals.

00;18;41;15 - 00;18;46;04

Terri Raimondi

Yes. Hospitals drive probably 80% of the cost of an employer health plan.

00;18;46;07 - 00;18;48;02

Cary Hall

Run that by me one more time.

00;18;48;04 - 00;18;50;07

Terri Raimondi

It's about 80% of the cost.

00;18;50;09 - 00;19;14;06

Cary Hall

Okay. There. There is the part that nobody talks about. And for some reason, there's no discussion of this. Okay? And I never really quite understood why. Which is why I asked Terri to come in here today and have this discussion. Okay. There. Therein lies large part of our problem. When you talk about our system versus the European system, we always hear this.

00;19;14;07 - 00;19;34;18

Cary Hall

Well, the European system is so much less money than the American system. Why is that? Why are we wasting so much money on health care? Well, when we come back from the break, we're going to explain now we're going to talk about that. We're not talking about prescription drugs to your kids. This is going to be very enlightening in terms of when you understand what we're paying here versus the Europeans and why it is what it is.

00;19;34;24 - 00;20;04;14

Cary Hall

Stay tuned. You're listening to America's Healthcare Advocate broadcasting here on the radio network. Coast to coast across the USA. We've got more. Don't go anywhere. Welcome back. You're listening to America's Healthcare Advocate show. Broadcasting coast to coast across the USA. My producer, Mr. Darin Willhite, he is the man behind the microphones doing all the audio. And my producer behind the camera is Dave Thiessen, who puts all this stuff together and gets it up on all 14 of those podcast platforms and YouTube.

00;20;04;14 - 00;20;22;17

Cary Hall

So once again, all these shows are posted up there on all the podcast platforms Apple, SoundCloud, Amazon, you name it, we're on it. Okay. So those are the podcast platforms. You can view this because we videotape all of these, obviously, and obviously if you want to listen to it again on the radio, you can do that as well.

00;20;22;21 - 00;20;40;23

Cary Hall

As we broadcast across the country here on the HIA Radio Network. All right. So now we're going to change gears here for a minute. We're going to talk about a minute from this whole segment and we're going to talk about this issue. We constantly hear about how the European health care system is is so much more efficient and lower cost than ours.

00;20;40;23 - 00;21;01;00

Cary Hall

Well, well, we probably have to save that efficiency part for another day, because that's a whole new discussion about how it takes six months to get in to see a doctor. If you've got a diagnosis of cancer or need an MRI in the UK or in France or Germany or some of these other some of these other countries, and then they control what you can and cannot do, you don't get.

00;21;01;06 - 00;21;21;04

Cary Hall

So I don't like this doctor. I don't like this specialist. Well, they you're going to go where they tell you to go because that's the way it works. All right. We have a different system, but there are huge inefficiencies in this system. And we just talked about part of the reason 80% of the cost increases that people see in their premiums every year come from the cost that hospitals charge.

00;21;21;10 - 00;21;35;20

Cary Hall

In terms of the way they do what they do in terms of the chargemaster. So let me give an example of that. If you want to take that, you want to really understand that if you're going to get a hip replacement or you're going to have an auto surgery, ask what it's going to cost, ask the question, okay.

00;21;35;26 - 00;21;42;05

Cary Hall

And then go up online and look up a hospital card. The Oklahoma Surgical Center familiar with it, Terri?

00;21;42;06 - 00;21;43;06

Terri Raimondi

I am familiar with them.

00;21;43;08 - 00;22;04;10

Cary Hall

Every procedure they have is posted. So I'm going to just I'm not quoting a number of just giving you example. So if you have 154,000 hip replacement at a hospital in one of the major hospitals in your metropolitan area, and you take a look at Oklahoma's surgery center, my guess is it's about 54,000. There. I think it might even be as low as 44,000.

00;22;04;12 - 00;22;27;23

Cary Hall

The point I'm making is that's what's called total transparency. Correct. Which is not what you see in the marketplace today. Remember what Terri said? There is no SRP in the health care system. So let's do some contrasting let's talk about two very popular drugs right now, which go V. Okay. And also mimic ozempic Ozempic. Thank you. Like Olympic but OZEMPIC.

00;22;27;23 - 00;22;29;15

Cary Hall

Okay so let's talk about.

00;22;29;17 - 00;22;30;29

Terri Raimondi

You could probably seeing the commercial.

00;22;31;00 - 00;22;43;04

Cary Hall

Yeah. Okay. So let's talk about the cost here. It's being charged by the, by, by the manufacturers through the PBMs, the pharmacy benefit managers. So we'll go V is how much prescription.

00;22;43;04 - 00;22;50;20

Terri Raimondi

Probably about between 1315 hundred. What Govee will give you you can say it either way it's for individual pens.

00;22;50;27 - 00;22;52;16

Cary Hall

For a year.

00;22;52;19 - 00;22;53;14

Terri Raimondi

Now that's for a month.

00;22;53;14 - 00;23;01;15

Cary Hall

Oh, that's for a month. So it's 1300 to 1500 for a month for this weight loss drug. And let's talk about Ozempic now.

00;23;01;22 - 00;23;07;20

Terri Raimondi

About 950 a month. But 50 cent pick is not approved for weight loss.

00;23;07;21 - 00;23;08;29

Cary Hall

But it's used it.

00;23;08;29 - 00;23;13;03

Terri Raimondi

Is used one of years, Right. Same active ingredient. But yes.

00;23;13;10 - 00;23;17;25

Cary Hall

So so what is happening is a lot of doctors that that is actually a heart drug, is it not?

00;23;17;27 - 00;23;18;21

Terri Raimondi

No, it's a diabetic.

00;23;18;26 - 00;23;34;27

Cary Hall

Diabetic drug. That's what I knew was had. Yeah. The primary function of that drug was diabetes. But they found that it works the same way as Wegovy. And so it's become extremely popular. And a lot of times people get prescribed these drugs, they go to the pharmacy, they can't get them because they're flying off the shelf so fast because it's become the new.

00;23;34;27 - 00;24;02;02

Terri Raimondi

Thing that or a lot of employers have blocked them. So these two new drugs are it's what everyone is talking about. So because they've been used so much and they've been successful, a lot of employers have seen such a big spike in their costs that they've just decided to put a lot of restrictions on people obtaining them. So a lot of times people are having success with one of these drugs and they go in to get their refill and they can't get it anymore because the employers just cut it off.

00;24;02;04 - 00;24;05;05

Cary Hall

But they can always have bariatric surgery.

00;24;05;08 - 00;24;05;22

Terri Raimondi

They could.

00;24;05;28 - 00;24;07;20

Cary Hall

And what's the cost of bariatric surgery?

00;24;07;20 - 00;24;09;29

Terri Raimondi

About $40,000. 40,000.

00;24;10;01 - 00;24;32;01

Cary Hall

So so do you see this is a microcosm of what's going on here? Okay. Yeah. Yeah. The employer reacts. A knee jerk reaction to get rid of this because it's costing them money. The person is let's say the purpose is morbidly obese and they're five foot nine and they're £320. Okay. And so now they're going to have all those surgeries because they're wearing their joints out.

00;24;32;01 - 00;24;42;03

Cary Hall

They've got to have hip replacement knee replacements. You know, they're diabetic. Clearly, they're going to be type one diabetic or type two, without a doubt. Okay. And when you look.

00;24;42;03 - 00;24;45;04

Terri Raimondi

At type two, I mean, something is for type two diabetes.

00;24;45;06 - 00;25;14;27

Cary Hall

So so that's part of the problem here. Okay. So so would you cut that off? The alternative the only alternative do they have to radically change? Where they're at is to go get bariatric surgery, which is 40 or $50,000 or more, depending on the hospital. We haven't done it. Okay. So that's part of the problem we have. There's no connectivity in this system to get people to do things that are going to help them maybe use this medication, whatever the case may be.

00;25;15;03 - 00;25;19;15

Cary Hall

But let's talk about now those same two drugs, and I want to go buy it in France or Australia.

00;25;19;16 - 00;25;26;08

Terri Raimondi

I give you the numbers. I don't remember. Remember what they are. I think one was $87 and the other one was 90.

00;25;26;11 - 00;25;47;10

Cary Hall

That's correct. So somewhere between between 80 and $90. So instead of paying 1349 that we pay here in the United States for WEGOVY or 936 or 939 that we pay for Ozempic, they're paying between 80 and $90. It's the same drug, folks. So is that the classic example of part of the problem we have here?

00;25;47;12 - 00;26;00;18

Terri Raimondi

It is. We pay for research and development. We pay for all the ads that are on television. I mean, personal opinion prescriptions shouldn't be advertised on television because people go to their doctor and say, I have this condition, I get this.

00;26;00;20 - 00;26;25;03

Cary Hall

That's it. That's how this whole weight loss thing started. Terri. I started putting a stop on television and people immediately start going, Doctor, I want this. And the doctor's like, okay, well, if you meet the criteria, I'm going to prescribe it. And then and they would come full circle to where we're at on the health care side. And so now we've got the hospitals with lack of transparency, we've got the PBMs selling this stuff at a number that there's money being made here.

00;26;25;05 - 00;26;25;19

Cary Hall

Okay.

00;26;25;25 - 00;26;30;22

Terri Raimondi

And premiums would have to be a whole show. Yeah. And I have some good people I could bring in Chuck about it.

00;26;30;24 - 00;26;39;08

Cary Hall

The pharmacy benefit manager, but they're like the middleman here. So when you pull all that together, that's the reason why our health care costs are where they are.

00;26;39;10 - 00;27;00;03

Terri Raimondi

Yeah, pharmacy costs have increased year over year. It could be anywhere between 20 to 30% of an employer's costs, depending on the mix of what their employees are taking. Where when I started in this industry, it was maybe 5%, maybe less. I mean, there wasn't even prescription drug cards when I started, but I'm old, so.

00;27;00;03 - 00;27;20;11

Cary Hall

You're not old. Okay, But but but your point is well made. So now we've kind of described the problem to you. It's a three part problem. Okay? It's a problem with the with the insurance carriers and what they charge. Okay, There's a margin there. Okay. Which is controlled by the government now. Okay. It's a bigger problem, a much bigger problem with the hospitals and what they're charged with.

00;27;20;11 - 00;27;40;26

Cary Hall

There's some transparency, but not a lot. And they have fought this thing tooth and nail in terms of the transparency side and then the prescription drug side. So how do you put all that together and put it in a recreate a health plan that's going to work? And I know you know how to do it because you've created one and you won an award for this called the Heartfelt Health Plan.

00;27;40;26 - 00;27;44;28

Cary Hall

I've looked at it. I've reviewed it. It's really quite remarkable. Talk about heartfelt.

00;27;45;00 - 00;28;05;00

Terri Raimondi

So as an employer where we have about 100 lives, our costs were increasing just like everyone else, even though we were we were in this industry. So we decided to take a hard look at what we were doing and make some radical changes to our health plan. So what we did is we implemented a reference based pricing health plan.

00;28;05;07 - 00;28;13;14

Terri Raimondi

And what that means is we do not have a PPO network. We pay all of our claims between 125 and 150% of Medicare.

00;28;13;17 - 00;28;20;18

Cary Hall

But payment and the carriers are paying 300% in Medicare. So you've dropped that in half, correct? Okay.

00;28;20;18 - 00;28;43;00

Terri Raimondi

Correct. Now, there could be some problems with that because providers don't always want to accept 150% of Medicare. But we're a self-funded health plan. And the first rule of ARISA, which governs self-funded health plans, is you have to pay a fair and reasonable value for health care. Medicare is the number one payer in the country, so that establishes fair and reasonable.

00;28;43;01 - 00;28;49;20

Terri Raimondi

Reasonable. I'm paying them 25 to 50% more than Medicare's paying. So if it went to court, they would lose.

00;28;49;23 - 00;29;17;08

Cary Hall

And and I will point out that they have lost. They have hospitals have lost time and time again when they walk into court. And I'm one of the ones that I remember distinctly was where the the the the plaintiffs, the attorneys that represented the person that had the plan and was billed for a balance bill that was walked in with a box of Band-Aids and a and a box and and said here's here's the price of the Band-Aids and the cutest in the hospital.

00;29;17;10 - 00;29;23;21

Cary Hall

It was like $60 $100. And then here's the retail price in the drugstore.

00;29;23;21 - 00;29;28;28

Terri Raimondi

Yeah, they brought in a receipt from CVS or the hundred dollar toothbrush. There's been ads on that, too. Okay.

00;29;28;29 - 00;29;42;28

Cary Hall

So do you are you starting to get the drift here as to how there is a way to do this and do it the right way and there is a way to provide. But so you've got this plan. We're going to come back from the break here. We don't have a lot of time. We're going to come back.

00;29;42;28 - 00;30;04;08

Cary Hall

We're going to talk about in this next segment. Okay. But you're still able to provide the important part of this is your people. You you're on this plan and your employees at your current employer are able to have access to excellent health care using this plan without paying the 300% markup that typical people are paying off this health insurance plan.

00;30;04;08 - 00;30;05;13

Terri Raimondi

That's correct.

00;30;05;16 - 00;30;24;29

Cary Hall

We come back from the break. We're going to we're going to unwind some more of this. You're going to learn how she does this. Again, if you want to email her, it's Teri. TR. I remind the RIAA IMO in die at IMI dot com mi.com. That is her email address. If you want to email her, you can do that.

00;30;24;29 - 00;30;40;09

Cary Hall

By the way, we're going to put this on the screen for all the podcast platforms. So if you want to go up on the podcast platform, find it, You certainly can. It'll be in a little crawl across the bottom of the screen so you can reach out to her if you're a broker, if you're an employee, or if somebody just wants information, she's happy to do it.

00;30;40;10 - 00;31;02;19

Cary Hall

All right. Stay tuned. We'll be right back after the break. You're listening to America's Healthcare Advocate broadcasting here on the HIA Radio Network. Coast to coast across the USA. Don't go anywhere. Welcome back. You're listening to America's health care epic show broadcasting coast to coast across the fruit of plain. My producer, the always perfect Mr. Dan, will hide behind the camera.

00;31;02;19 - 00;31;24;18

Cary Hall

Dave Thiessen. I'm your host, Kari Hall, in studio with me, Terri Mondy. And we are talking about all things associated with health care and health insurance in this country. We're trying to pack a lot in here. It's probably like drinking from fire hose if you do want to connect with her. Her email address is Terri to try romandie our air remote in the eye at me dot com.

00;31;24;18 - 00;31;38;15

Cary Hall

It'll also be across the screen of all the podcasts if you want to reach out to her. So let's keep going with this play. The heartfelt plan. So you put this in place, you had it run, you won an award for this plan. For the plan, decide who to win the award from.

00;31;38;18 - 00;31;52;15

Terri Raimondi

Health Rosetta, which is a national organization of brokers and vendors that really want to change the health care space, bring in more transparency, lower cost, create community health plans.

00;31;52;18 - 00;31;54;03

Cary Hall

All the things that we're talking about.

00;31;54;05 - 00;31;56;18

Terri Raimondi

Right, Right. It's a very it's a very great organization.

00;31;56;22 - 00;32;07;10

Cary Hall

And I've interacted with him that we're going to have some of those folks on this broadcast. But so Terri designed this plan, put it in place, and she has won awards for it. Let's talk about how some of the components of the plan.

00;32;07;17 - 00;32;28;11

Terri Raimondi

Yeah, so our plan has no deductible, zero deductible zero out-of-pocket. We have a $10 co-pay for physician office visits. And that's only because a lot of times when you go to the doctor, if they don't recognize your card, as long as you have a co-pay on it, they won't give you trouble. So that's something I've learned in my years of of doing these things.

00;32;28;11 - 00;32;30;21

Cary Hall

They get that co-pay. We're good to go right.

00;32;30;23 - 00;32;47;08

Terri Raimondi

And the prescription benefit manager that we use is called I Am and they have a program called CARES Series that they do in-house. So if any of our employees need to take a high cost medication, say HUMIRA, or there's a lot that when it comes to.

00;32;47;11 - 00;32;48;07

Cary Hall

$7,000.

00;32;48;08 - 00;33;10;21

Terri Raimondi

It's popular depending on their income, we can source that drug for free through a manufacturer's assistance program, which means it cost the plan nothing. It also costs the employee nothing. You get the drug actually shipped directly from the manufacturer to the patient. So they do that on our behalf to see if we can source some of those drugs for free.

00;33;10;24 - 00;33;31;19

Terri Raimondi

We've also put in some wording with regard to 501 hour, which you and I have not talked about, but every not for profit hospital in the country doesn't pay taxes because they don't pay taxes. They agree to give free care to those less fortunate. And it's not those that are covered on Medicaid. It's those people who kind of fall in the middle.

00;33;31;21 - 00;33;55;00

Terri Raimondi

You know what I mean? Maybe 1 to 200% of the poverty level. So they're not Medicaid eligible. They're not Medicare eligible. But none of those none of them do it. They make it very difficult for you to obtain that free care. So in our plan, if someone is eligible for that care based on the hospital's manual of that free care, we'll only pay up to $10,000.

00;33;55;00 - 00;34;04;06

Terri Raimondi

After that, we we will cut it off in the hospital. We'll have to use the program that they've told the government that they have in place to pay the rest of that claim.

00;34;04;08 - 00;34;24;23

Cary Hall

And I'm going to tell you something. I've had experience with this at a Catholic hospital system where one of my clients who was on Medicare was billed over and above what he should have been billed, and they were trying to collect it. And I it took me multiple tries, had multiple days phone calls to get to the people that would allow him to have access to that plan and write that off.

00;34;24;23 - 00;34;40;18

Cary Hall

And they did. But it was a fight. And the end, when I ask why is this not Why don't you make this available? People say no, but well, they don't. And what Terri saying is absolutely correct. They're supposed to do it, but good luck finding out about it. Okay.

00;34;40;20 - 00;34;42;27

Terri Raimondi

Because it's buried on the website somewhere.

00;34;43;00 - 00;35;01;03

Cary Hall

Yeah, maybe. Okay. And if you call, they're going to play dumb. It's going to be more difficult to get to. But but you guys, you've got professionals doing this. You know how to go back to him and say, hey, you're you're a50, one hour. Yes, five over one hour and you're required to do this by law. Therefore, we're only going to pay $10,000.

00;35;01;06 - 00;35;01;25

Terri Raimondi

That's correct.

00;35;01;29 - 00;35;14;03

Cary Hall

And it works. It works. So do you get the drift here? You've got different components. What is it like five different components now that you've plugged into this thing? Primary care prescription.

00;35;14;08 - 00;35;33;22

Terri Raimondi

I didn't even get to the primary care yet. Let's talk to the last thing that we just implemented because we save so much money. So our costs are probably about half to what they were about three years ago. We spent about half as much money. The employee's contributions are half of what they were three years ago, and we haven't increased them in three years.

00;35;33;25 - 00;36;04;19

Terri Raimondi

So the plan is running extremely, extremely well. So what we've done with that money is a couple of things. We implemented short term disability for all of our employees at no cost. Wow. We increased our dental plan the calendar year maximum. We also changed our dental plan so that your annual cleanings don't count towards your dental maximum. Believe it or not, you know, if you need a big dental surgery or you have anything done on your mouth when you go for your second cleaning, it's not covered.

00;36;04;19 - 00;36;27;28

Terri Raimondi

If you hit your max. I learned that because it happened to me. Yeah. So we changed our plan to make sure that that annual exam doesn't count towards your towards your annual max. And we've just implemented direct primary care, which means that now all of our employees will have a doctor access to a doctor, primary care doctor, 24 seven and we're implementing that for September.

00;36;27;28 - 00;36;29;27

Terri Raimondi

So we're very proud of that.

00;36;29;29 - 00;36;49;29

Cary Hall

So the purpose in asking you to come in here today was to define the problem. We know what the problem is. Okay, We talked about it. Okay? The carriers are locked into these plans that the government dictates they offer. Okay? They're only allowed a certain amount of money and and the costs continue to go up and they pass that cost along.

00;36;50;01 - 00;37;07;27

Cary Hall

And 80% of the problem lies with the hospitals in the hospitals that the pharmaceutical companies. That's where the money is going. Okay. And we can have another discussion about pharmaceutical. If we don't do the research, who's going to do it and where are these drugs coming from? That's a legitimate question. But the point in doing this was to present the problem and present a solution.

00;37;08;02 - 00;37;25;20

Cary Hall

Is this a universal solution? No, but it's a start. And that's why I wanted Terri to come in here and talk about this. They did it with 100 lives. It can be done with 50 lives, right? Right. Yeah. It doesn't have to be 100 lives. The point is, there are ways to do this in the industry and this group.

00;37;25;20 - 00;37;27;01

Cary Hall

Rosetta Stone.

00;37;27;04 - 00;37;27;10

Terri Raimondi

Health.

00;37;27;10 - 00;37;30;10

Cary Hall

Rosetta Health. Rosetta is the Rosetta Stone.

00;37;30;13 - 00;37;32;27

Terri Raimondi

So if you want to learn Spanish or something.

00;37;32;29 - 00;37;50;18

Cary Hall

To help the Rosetta, that's what they're doing. That's what this is all about. And again, the purpose of doing this show today was to give you if we try to educate people, okay, that's what we're trying to do. If you're a broker, you want to hear about this, you need to reach out to tell everybody, okay, you need to have this conversation.

00;37;50;20 - 00;38;08;05

Cary Hall

How did you do that? How can we implement that? What can we do? How would you put that together? It can be done. Okay. But you have to do the work to make it happen. If you're an employer, maybe you're the H.R. director. This would be something you probably ought to take a look at, especially when you think about the fact that they've increased dental benefits.

00;38;08;11 - 00;38;30;16

Cary Hall

They put in short term disability, they've done all these things with that money that was going to that health insurance plan, and it's not going there anymore. Her email address. Terri t. R. I. R. I. m0ndi. Terri Randi at mi.com. That is her email. Thank you for flying in here from Chicago today just to do this.

00;38;30;16 - 00;38;33;11

Terri Raimondi

Show me America. I'm excited.

00;38;33;16 - 00;38;53;01

Cary Hall

Yeah, you did a great job. And now I leave you with this thought from Albert Einstein. The one who follows the crowd will get no further than the crowd. The one who locks alone will likely find himself in places no one has ever been bought. Does that fit today's show? Remember, friends, It's a funny thing about life. If you refuse to accept anything but the very best, you most often get it.

00;38;53;03 - 00;38;57;11

Cary Hall

Thank you for listening to America's Healthcare Advocate. Goodbye, America.