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PBMs: The “Tapeworm” Revealed

Warren Buffett famously said that medical spending was the “tapeworm” of the American economy. Many a tree has been killed demonstrating this point, but there has never been a single one-page image that would sear it into everyone’s mind, and rally the entire employer community behind the idea that there has to be a better way.

Until now. Here it is.

Source: Buried in something called Drug Channels.

There may be a few buyers who have generics on the formulary, but there are plenty that don’t:


 

There you have it: the shock-the-conscience unveiling of the Tapeworm (the pink), as far as drugs are concerned. This is just one drug, but this process likely repeats many many times for many generic drugs.  How is it that the process of distributing a drug and tracking who buys it sucks up much more of the value chain than actually making it?

How is it that the price paid of a container of generic Ambien can range from $3.25 (Drexi) to $136 (CVS)?


 

And don’t get us started on wellness. 

Balance (surprise) billing is a Quizzify favorite. It is a problem, period.

Even though, according to the New York Times and others, we actually solved the problem (for non-elective surprise bills), most employers — like with PBM markups — don’t realize they have a problem in the first place. They are simply picking up most of the tab without noticing something amiss. Sort of like ET hiding in the stuffed animals.

E.T. Hiding in the closet | Fantasy fiction books, Young adult ...

And that, in a nutshell, is the problem. The problem is that, for all the complaints about spending, employers don’t realize they have a solvable problem in the first place. As Dave Chase of Health Rosetta says, healthcare is already fixed. The fixes just have to be replicated.

 

 

Court-ordered 2021 EEOC wellness rules: an existential threat or huge opportunity?

The EEOC has published rules in draft form. They still need review by the Office of Managment and Budget, but that’s just a formality.

Incentives need to be cut back to “de minimis” for participation-based programs…but there is a way around the court ruling for those highly popular and effective (not!) outcomes-based programs.

Since the EEOC is basically pro-business these days, they have managed to circumvent the spirit of Judge Bates’ December 2017 decision, without violating the letter, and employers will be able to subject employees to fines of thousands of dollars starting in January.

However, it increasingly appears that outcomes-based programs, while arguably complying with the new rules regarding the Americans with Disabilities Act, violate the Affordable Care Act, because (with the well-documented, Validation Institute-validated exception of US Preventive Medicine), they fall short of the ACA’s standard of being “reasonably designed to reduce risk or prevent disease.” Just too many epic fails, all documented on this blog, including Koop award winners like Wellsteps, arguably the industry’s worst program now that Intereactive Health has gone bankrupt. (Ironically, it is also among the best-documented programs. Why they published their own self-immolation is anyone’s guess.)


Fortunately, there is a solution allowing you to maintain your existing incentive structure next year, and significantly reduce the cost while improving the performance of your program…and we will be covering it on Thursday at 1 PM ED. Register here.



PS Admit this is the first you are hearing of these new rules. And yet they are pretty close to a done deal in practice, even though the public can still comment soon.  Good luck with that.

 

The biggest scam in dentistry

If you or a loved one has had a small-to-medium-sized cavity filled in the last 6 years, on a molar, premolar, or baby tooth, you’ve fallen for the biggest scam in dentistry, a scam of a magnitude that would make the wellness trade association green with envy.


You are getting most cavities filled for no reason at all, other than for dentists to make money. 

It turns out the large majority of cavities can be treated with Silver Diamine Fluoride, or SDF. That solution — used in Japan for 60 years — arrests the decay and to some extent can remineralize the tooth.  The cavity can’t be too deep, and it has to be in place where it can be easily reached.  It also turns the decay black, so it’s probably not a good idea for front teeth, at least for people who are hoping to be swiped right.

Quizzifans among TSW Nation may think they’ve heard this song before. They’d be right. Quizzify has been asking questions about SDF and writing on this topic for years.

Marty Makary and some colleagues have also highlighted the benefits of SDF, and correctly predicted that dentists would be very tardy in adopting it.

The difference now?  Not unlike the wellness perps, it turns out that dentists’ own words are their own worst enemy. If you read this new Quizzify blog, peruse the quotes carefully, and link through to the sources, you’ll see what I mean: they’ve known all along this along.

Dentist in Marathon Man | Tales From A Hungry Life

 

 

Hit me with your best shot! Fire away!

Dear TSW Nation,

I’ll be the guest on a live webinar on Thursday at noon EDT, courtesy of The Zero Card.

The difference between this webinar and others is that the questions won’t be curated. I will answer every question, no matter how obnoxious.

If you are a wellness vendor or consultant, this is your chance to challenge any of my smackdowns. Surely somewhere in my 500,000+ words published (plus podcasts), you can find a mistake.

 

 

 

 

Wellness industry jumps the shark

So, before we get into the fun stuff, let me express my condolences to Interactive Health’s non-management employees, who probably had no idea their employer was living a lie. For them, I will make pdfs of my books on outcomes measurement free, provide a free coaching session on outcomes measurement, and basically try to be as helpful as possible in this job market. Just ping me on linkedin.


To paraphrase the immortal words of the great philosopher George Carlin, consider how stupid the average wellness vendor is. Now realize that half of them are stupider.

The winner in this race to the bottom?  Interactive Health, winning Deplorables Awards in 2017 and 2018.

Yesterday, in a shocking display of efficient markets, Interactive Health (IH) went bankrupt, stiffing enough creditors to make a President blush. I do feel badly for those creditors, though no one should offer credit to a company that can’t even pass its own IQ Test.)

Or perhaps IH ran out of money because they spent so much of it developing their “smoking recession program.”

And, proving that it’s not only great minds that think alike, Interactive Health got this effusive write-up from Ron Goetzel’s outfit. Ron, please never write a glowing case study of Quizzify. I’m not sure we could survive it.

Some of their greatest hits include:

See a pattern here? If so, then it’s safe to conclude they never would have hired you. You’re overqualified.


Wellness trade association concedes that wellness loses money

The Health Enhancement Research Organization HERO) and all its pilot fish have finally thrown in the towel on defending “pry, poke and prod.” No surprise, given that only one vendor out of 1000 (well, out of 999, I guess) has managed to consistently reduce risk. They (US Preventive Medicine) are too honest to claim savings for it.

Recall the write-up we did on the National Bureau of Economic Research’s wellness study a few weeks ago?  HERO has now accepted its validity, by refusing to comment on it. What alternative did they have? The dilemma for these people was that every single one of them used the following, same, observation to diss the study when it reported initial results:

Although the Jones et al study was titled “What Do Workplace Wellness Programs Do?” a more appropriate title might have been “What Did the University of Illinois Workplace Wellness Program Do, in a Very Short Amount of Time?”

So what are you supposed to do with all these mentions of a single year (or a “very short period”) once the second year shows the same thing? Here’s what Interactive Health would do…

 

 

 

 

 

 

Dog bites man: Large new study shows wellness loses money

So I just got word of another of Ron Goetzel’s signature moves–spreading rumors among my business contacts. (How’s that worked out, Ron?)

Typically the “tell” is that a contact will ask me: “Hey, is it true that you eat your young?”

I’ll reply: “Lemme guess. Goetzel.”

“How’d you know?” would be the response.

Just for the record, because things I say have a way of being misquoted or misinterpreted, I do not eat my young, my old, my middle-aged or anyone else. Not for breakfast, lunch, or dinner. Or even between-meal snacks.


This happened again last week. My signature response to Ron’s signature move is, invariably, when-they-go-low-we-go-high.  I simply shine a light on a wellness outcome, embarrassing him and his cronies.  With the exception of US Preventive Medicine, which somehow manages to noticeably reduce risk in a population, these are quite predictably unfavorable. That’s on a good day. On a bad day, they actually harm employees.

Unfortunately, there hadn’t been a good wellness outcome to analyze in months.

And then, yesterday, a deus ex machinaThe Journal of the American Medical Association just published the second year of the University of Illinois study showing, as usual, that:

Wellness. Doesn’t. Work.

This Seinfeld-like result showed no change in risk factors, after two years. The only “positive” was that more employees had PCPs, an outcome which could have just as easily been acheived by saying: “Hey, everyone, go get a PCP. We’ll give you the $100 we would have wasted by paying a wellness vendor.”

Cost savings?  Haha, good one.

It will be interesting to hear the wellness industry’s excuse for this one. Because after the first year, the excuse from the vendor-infested National Business Group on Health was: “The lack of first-year cost savings should not be surprising.” For the second year, I guess they’ll just cross out the word “first,” and replace it with “second,” using a sharpie.


How, one might ask, do these people even stay in business after 12 studies in a row show an epic fail?  Here is how. This is a comment on a previous article that was just recently forwarded to me:

I know I’m late joining the discussion, but I nonetheless felt the need to contribute. I worked as an analyst for one of the corporate wellness providers on Al’s shit list, so I have an insider’s perspective. I ran some of our client’s ROIs. People love to quote them – including some of the commenters below [Michael O’Donnell, Ron Goetzel, etc.] and the sad thing is that we often base our arguments on what these ROIs are, as though they are fact. They are not.

Our models are based off poorly reviewed industry research, which would be laughed at in the econ graduate program I attended. That aside, I produced an ROI using their model – a model that I would have been embarassed to defend to anyone.

The result was a negative ROI, but when I emailed my supervisor the result, he called me into his office and told me verbatim: “We aren’t allowed to have a negative ROI. Go fix it.” I argued with him about how our already crappy model would be completely devoid of integrity and would render the results meaningless if I were to cherry pick variables to yield a favorable outcome, but that fell on deaf ears.

Additionally, our contracts often had a clause that penalized us if we did not “deliver” on a pre-agreed upon ROI. Talk about incentivizing us to cheat! During my tenure I never once witnessed a client question our methodology in any meaningful way.

So it’s back on you, the employer, to put the kibosh on these wellness people, since they are clearly not on the honor system.

While you do that, I am going to go have something to eat. Perhaps liver, with a nice chianti.

Surprise bills meet COVID: What you need to know

Ooooh….yikes. We just did a webinar on this very topic, with Dave Chase and Doug Aldeen. And you missed it. We know what it feels like to miss things.

So, there is a reprise, covering surprise medical bills and COVID, being offered next Thursday, at 2 PM EDT, by our friends at a wellness company called Wellable. Yes, I know it seems out-of-character for us to use the phrase “our friends at a wellness company,” but there are plenty of upstanding wellness companies that we are thrilled to be associated with, like US Preventive Medicine, with whom we may do a joint webinar this summer.

Indeed many stranger things have happened. Case in point: Ron Goetzel himself — the very same Ron Goetzel who we have blown the whistle on multiple times — once publicly gave Quizzify a shout-out as being “lots of fun and very clever.”  That was before he tried walk it back, like in this Seinfeld episode. 


So what’s going on here?

No, we haven’t all just entered this.

Nor have pods taken over our bodies. (Though I suspect, if pods had taken over our bodies, they wouldn’t admit it.)

Quite the opposite, we find common ground with almost any ethical, competent company in this field, of which Wellable is one.

We invite you to join their webinar and look forward to answering your questions.

Spoiler alert: we have figured out how to solve your surprise bill problem, for most non-elective situations, by combining Marty Makary’s “battlefield consent” with reference-based pricing. You can implement this solution very easily. 

No need to take our word for this. Our solution was featured in the New York Times.


Seats are limited, so register as fast as you can…

 

 

Surprise billing and COVID: The Ultimate Podcast

 

Before continuing with this posting, we would like to acknowledge the heroic efforts of frontline healthcare workers, risking their own health and even lives to save others. These are not the people sending the bills. That would be the private equity-controlled hospitals and specialty groups. it is important to draw a bright line between these cohorts. 


You might have read somewhere that surprise bills are not allowed by hospitals taking funds under the CARES Act. This is true. The patient share is limited to what they would have paid in-network.

So who do you think is paying that bill?  Look at the person six feet to your left. Now look at that person six feet to your right. All three of you are.

This bill isn’t a price control for out of network providers. The bills don’t automatically get lower. Only the patients are protected.  This actually makes surprise-billing much easier, because the employee is not likely to complain if it’s not their bill. Who even reads the EOB? How many employees even know wht EOB stands for?

Recently DirectPath released a report called the Health Care Literacy Gap. In it, they noted that 55% of employees already don’t complain about billing errors, because they don’t feel it’s worth the effort.

Why don’t they feel it’s worth the effort?  Let’s put it this way: when was the last time you didn’t complain about a billing mistake at a restaurant, hotel, etc. ?(Yes, we know it was more than a month ago. We are being figurative here.)  That’s because it’s your money.

But if the waiter or hotel manager came over and, instead of presenting a bill, said the whole thing was on the house? Would you ask to review the bill and point out mistakes? And that’s exactly what could happen if patients are held harmless from out-of-network charges due to COVID.

COVID treatment should be free in any case. But if you read the CARES Act closely, it appears that even patients testing negative who are then treated for something else may be immune from surprise bills. Once again, who do you think is paying?

And you can bet there will be more of them than ever in 2020. That’s because the private equity companies are counting on the facts not just that employees won’t complain, but that your overall healthcare spend will be way down…and as a result you won’t carefully review your individual charges.

This of course doesn’t include the surprise bills employees will get as a result of other emergency visits, admissions, and deliveries. Heart attacks aren’t going away.


Fortunately, there is a solution. You can implement it posthaste. It’s all wrapped up in this podcast. The podcast features not only me, but uberbroker David Contorno, ERISA guru Doug Aldeen, and Rachel Miner, who in addition to being a successful broker, actually had the unfortunate chance to have to use our surprise bill “hack” in a North Carolina emergency room. North Carolina provider are notorious for their high-multiple-of-Medicare pricing, but this hack you’ll be hearing about kept her bill to a paltry 2x Medicare, including for any out-of-network “ologists” consulting on her son’s case.

Simply by using this card, this consent taped onto your existing card,  or this download right into your Apple Wallet, available right here.

 

 

 

Corona-meets-surprise bills: six things you don’t wanna know

Thanks to corona, surprise bills are ba-ack. And as you read below, you’ll see why coronabills will be a thing in 2020.

You can listen to a new podcast on this exact topic when you go to work. That is, assuming, you either work in an essential industry that you need to actually go to, such as supermarkets, first-responding or healthcare (and thank you for that!!!), or you work at a place where you can easily socially distance, such as repairing Maytags, arguably the safest job on earth.


The private equity firms that own these out-of-network practices are no doubt relieved that surprise bills have magically disappeared from the headlines — but they have not magically disappeared from your claims spend. PE firms have not suddenly decided en masse to become good citizens. Quite the opposite – their other investments are foundering, with out-of-network providers being the bright spots in their portfolio. All thanks to surprise billing.

Here are three of the Six Things You Need to Know about Coronabills.

1. There is zero chance of federal surprise billing legislation this year

Consider the rather sketchy ad campaign run in “swing districts” last year by the private equity firms owning these practices. The theme was that if doctors don’t get paid enough, there won’t be enough doctors.

Well, as effective as that campaign apparently was in 2019 (you didn’t see any surprise bill prohibition passed into law, right?), imagine how effective it would be in 2020. All they would need is a few live shots of overwhelmed emergency rooms, which aren’t exactly hard to come by.

Prediction: it’s not just that nothing will pass. You won’t even see a bill make it out of Committee this year.


2. Because your total health spending will drop precipitously in 2020, you won’t carefully parse your bills

Executives pay more attention to healthcare spending – or any budget item – when it is rising. Elective procedures and doctor visits are so far off this year that total spend will decline. Hence you probably won’t even notice these surprise bills.


3. The canary in the coal mine would be employee complaints about surprise bills. Except that the copay is zero in many cases

As an ERISA plan, you don’t have to offer full coverage for treatment. But most of you will follow your carrier’s guidance. Which is to say, you will offer full coverage. Hence employees won’t be balance-billed. And that in turn means they won’t notice the total bill. Or, if they do notice, they won’t care. Bottom line: these bills won’t come to your attention.



Interested in more? Listen to the podcast or click through to Quizzify’s blog post on coronabills.

 

 

You need to slash benefits spending. Drexi is a start.

In employee health services, almost everyone with internet access is giving out awards for something-or-other.  Wellsteps, for example, gave out 25 of them at once, including several to companies that no longer exist, along with an award to itself. Therefore, it can safely be assumed that a beam of light leaving Wellsteps wouldn’t reach due diligence for several seconds.

Not so with Valid Vendor of the Month Award, given out by our alter-egos at Quizzify. These awards are real. How can you be sure? Not just that each of the Valid Vendors are validated by the Validation Institute, though that’s a great head start.

More specifically, Quizzify is so confident of its Valid Vendor selections that they are placing 33% of their own fees at risk for the performance for each Valid Vendor of the Month. While many vendors won’t even put a third of their own fees at risk for their own performance, Quizzify is putting a third of its own fees at risk for another vendor’s performance. The ground rules –and all disclosures—are at https://www.quizzify.com/valid-vendor-awards

Below is Al Lewis’s story, reprinted from Quizzify.


I recently met Bill Miller, who runs Drexi. Drexi is a tech company disrupting the pharmacy space with next-generation PBM services compelling enough to win the 2020 Health Value Award from the Validation Institute, as was announced this week (3/30). They also have direct-to-consumer memberships that offer discounts on brand and generics at participating chains, bypassing the standard PBM markup that they charge for “managing” your purchase of a few pills.

 

Bill told me this. “Sounds great,” I replied, “But it wouldn’t work with me.”

“Why not?” he asked.

“Because I was paying $136 out of pocket for 90 5-milligram zolpidems (Ambiens) at CVS. I tried Optum’s mail order. Same exact price. Then I heard I could purchase them through the dispensary at my PCP’s practice and pay only $18.40.”

In case there is someone reading this who has never been snookered by a PBM “negotiating” for you, here’s what a receipt looks like, for a covered benefit for a generic medication:

Now let’s compare my CVS receipt for $136 — the price that my PBM had thoughtfully and painstakingly procured on my behalf with CVS, no doubt after several tense negotiating sessions in a smoke-filled room – to the receipt from the dispensary at my nonprofit physician practice.
I bought these zolpidems for a mere $18.40, knocking fully 86% — 86% — off the CVS price. No way Drexi can beat that, I thought.

“Well, let me at least try,” Bill offered.

“Fine,” I replied, using the tone of voice I normally reserve for a wellness vendor buttonholing me at a conference to explain that while every other wellness vendor lies and loses money, they really do get behavior change and dramatically reduced costs.

Bill searched on Drexi for “90 5-milligram zolpidem”.

“Is there a Walgreen’s near you?” he asked.

Indeed there is. Turns out that, had I used a Drexi card, I could have gone right across the street from the CVS to the Walgreens and paid $10.40, which I made a note to do in April. This would be a 43% reduction off my 86% reduction. What a savings! What a story!


But wait…there’s more. Now how little would you pay?

That wasn’t remotely the end of the story, as it turns out…I’m pretty close to a Wegman’s, where it turns out I could have gotten those very same 90 pills for: $3.60. This would be a 67% discount off my 43% discount off my 86% discount. Here is the Drexi screenshot.

Yes, way cheaper even than Walgreens. But I live fairly close to a Walgreens, and it’s a much more pleasant bike ride, so I figured I would just go there. I was already way ahead of the game with the $10.60, and it was a nice day for a ride. (Just in case anyone is keeping score at home, I didn’t do anything irresponsible. This trip took place on a date early enough in March that I still could reasonably expect my 401k to support my retirement.)


And the envelope please…

Between the time Bill Miller showed me the Walgreens price and the date of my visit, Drexi had negotiated an even better deal with Walgreens: I paid – get ready — $3.25.

Was this a perfect experience? In the broad sense in which that word often gets used these days, yes. On the downside, the pharmacy tech did spend a little bit longer processing my card than typically with my regular insurance. (That may be because I was a first-time user.)

Note: there is an admin fee. The retail-user fee (that I pay) is $7/month for unlimited prescriptions. Since I am saving about $15/month off my already deep-discounted price from my PCP practice, the extra $7 is a no-brainer for me. Plus, Walgreen’s is closer, stays open later, and usually runs a 2-for-1 sale on my go-to OTC remedy, Refresh Plus lubricant eye drops.

And that’s why Drexi is the April Quizzify Valid Vendor of the Month.

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