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  • With the waters of healthcare becoming murkier every day, employers and employees abdicate many of the cost-auditing responsibilities regarding their healthcare to their insurance company. Unfortunately, placing this level of trust in your company’s health insurance carrier leaves the proverbial fox to mind the hen house.

    Those who purchase health coverage through a commercial provider mistakenly believe their insurance company is actively advocating for them and monitoring the costs incurred for healthcare services. While this is far from the case, the shocking part of this reality is that the insurance companies are forcing you to pay more than you should for your company’s coverage.  

    Benefits of Self-Insured Plans

    A self-insured health plan can reduce healthcare premiums for your small business by reducing overhead and other management costs charged by big insurance plans. When you have a third-party administrator like Group Management Services manage your self-insured plan, you ensure your employees receive everything promised to them in their plan and limit you from spending more money than anticipated. 

    Negotiate prices: Insurance companies are billed by the hospital based on what the hospital thinks they should charge for their services. On the other hand, TPAs look at what the hospitals pay Medicare – which is often considerably less than what the hospital would bill to an insurance company – and negotiate healthcare costs from there. This can have significant impact on healthcare costs (in your favor). To learn more about this business model, I encourage you to read this article from the New York Times about the “$1,000 toothbrush.” 

    Eliminate Price Secrecy: The practice of provider and hospital consolidation in the marketplace creates an uneven playing field for insurance companies to negotiate true cost-savings for their members. A TPA like GMS will underwrite a custom policy for your group so you don’t pay for coverage that the group doesn’t need and monitors all claims to reduce your financial risk. 

    Audit bills: TPAs have the resources and knowledge to help your employee check each bill to ensure there is no double billing for equipment or health care services. A TPA can challenge prices for services that are beyond “reasonable and customary,” substantially reducing patient bills and keeping your claims down.

    Employee peace-of-mind: With the changing landscape of healthcare, you can assure your employees have job security along with quality and affordable health coverage. A TPA’s main concern is you and your employees, ensuring a more personable and attentive service experience. 

    Increased cash flow: Self-insured plans managed through a TPA brings the control of processing of health claims back in-house, minimizing losses and reducing administrative costs. 

    Self-insured plans through a third-party administrator like GMS can give you more control of your coverage and help cut costs, while still providing quality coverage to your employees. Interested in how a self-insured plan could help your business? Get a quote now or speak with one of GMS’ TPA experts. 

  • Healthcare is an important part of any small business. That’s why it’s important that you ask your medical insurance company about their services. It can be easy to turn a blind eye to what your insurance company is doing, but you should get a better understanding of how they’re serving you so that you can evaluate what they’re doing to help you. Here are four healthcare topics you should ask about.

    Image of a doctor. Healthcare administration can give small business owners the service they need.

    Plan Coverage

    It’s important to know exactly what your plan covers. This may seem a bit obvious, but you never want to be surprised when you get a bill. While you need to know the limits of your coverage, it’s also good to find out if you’re paying for unnecessary benefits. Not all benefits will fit you and your employees, so asking for more information can help uncover these areas and potentially save you money.

    Healthcare Cost Negotiation

    Don’t be afraid to ask your healthcare provider how they negotiate costs. Different negotiation strategies can lead to realistic healthcare pricing, so it’s good to inquire about what your provider is doing to make healthcare costs more manageable.

    Medical Bills Audits

    No one wants to get incorrectly charged on a bill. Ask your health insurance company about how they audit medical bills to make sure that you get the coverage you pay for. Double billing and other mistakes can happen, so it’s important to know that your bills are checked every time. If your insurance company is less than transparent about this, you might not be getting the attention you deserve.

    Customer Service

    You and your employees should never have trouble getting answers about your health insurance. Asking about a provider’s customer service can help you get an understanding about how well they will be able to assist your company when there are any questions or issues. If they’re not very forthcoming with information about the type of customer service they provide, they might not be that great at helping you when you have an actual insurance concern.

    Healthcare Administration Services

    You and your employees deserve to be more than just a number to medical insurance companies. Your business deserves high-quality service, which is why we offer employee benefit administration to help you get the care you need. Contact GMS today to talk to one of our experts about how a Professional Employer Organization like GMS can help you regain control of your healthcare coverage.

  • Don’t look now, but Fall is upon us and we are closer to the start of 2017 than we are the start of 2016.

    We have a Presidential election coming up in a few weeks, meaning that there will be a change in the leadership of this country, one way or another. Either way, expectations are running rampant about changes to healthcare plans in 2017 and the compliancy tied to those programs.

    Image of a sick employee. Contact GMS about healtchare compliance for businesses.

    Potential Healthcare Changes to Consider

    What are these changes that are coming up? According to benefitsnews.com, the following are the top 10 compliance issues to consider when doing your benefits planning for 2017:

    1. Wellness
    2. Essential health benefits and ACA nondiscrimination rules
    3. Mental health parity
    4. Employer shared-responsibility strategy and reporting
    5. Preventive Care
    6. SBC model documents
    7. FLSA’s final overtime rules’ impact on employee benefit plans
    8. Expatriate group health plans
    9. HIPAA privacy, security and electronic transactions
    10. DOL fiduciary rule

    And as an added bonus:

         11. There is a push to make companies with fewer than 100 employees file a 5500 for not only their 401k offering, but also their healthcare benefits. 

    What Business Owners Can Do to Prepare

    For years, business owners would turn to Professional Employer Organizations (PEOs) to help reduce their premium costs in healthcare, risk management, and other HR concerns. In recent years, more and more companies are now looking to PEOs to not only help control their short-term healthcare costs, but also to help put together a game plan for controlling those costs in the future. One healthcare cost that is often overlooked is the cost of compliancy.

    If the list above has you worried about your benefits plans or at a minimum, wondering if you’re compliant, you might want to consider talking with an attorney or a PEO like GMS.  Not only does a PEO provide you the buying power necessary in today’s healthcare environment, they relieve small business owners of the regulatory liability that keep them awake at night.

    If you want to learn more about a PEO and if it’s right for you, contact us today and find out how we can help your business.  

  • Wellness programs have become very popular in recent years. In its 2017 Employee Benefits Survey, The Society for Human Resource Management (SHRM) found that 24 percent of organizations added to their wellness benefits, which was the biggest increase for any benefit during the year. 

    While more businesses are investing in wellness initiatives, some owners may ask how effective workplace wellness programs really are. The answer to that can depend on your goals.

    Employees using a workplace wellness program.

    How to Measure the Success of a Workplace Wellness Program

    To determine if a wellness program works, you need to define what you would consider success. It can be misleading to attribute the effectiveness of a wellness program to individual factors, like overall weight loss. Instead, the point of a wellness program is for employees to establish long-term healthy behaviors that help them improve their overall wellbeing.

    Can a wellness plan help instill long-term healthy behavior? A study in the U.S. National Library of Medicine found that people who participate in wellness coaching “improved their current health behaviors and learned skills for continued healthy living.” In turn, the improved health of these employees helps them be more productive, while their improved health can allow their employers to save money on costly healthcare benefits. 

    These small changes can have big effects, as the overall health of a group is one of the factors that determines how your group health insurance premium is calculated. For example, the American Lung Association cites that “employers can save nearly $6,000 per year for every employee who quits smoking.”

    Money isn’t the only factor. According to SHRM, “Three-fourths of organizations promote wellness to improve overall employee satisfaction and well-being, with just 25 percent hoping to reduce health care costs.” A wellness program can be about much more than just health savings and weight loss. It can also serve as a way for owners to show their employees that they have their well-being in mind and serve as an attractive benefit to attract and retain top talent.

    Small Business Guide to Health & Welness

    Is Your Wellness Program Set Up for Success?

    Like any other type of project, a wellness program needs to be run effectively to work. A Professional Employer Organization can help your business set up a dynamic program that includes several key components that foster healthier lifestyle decisions and sets your workers up for long-term success. Contact GMS today to talk to one of our experts about the benefits of a workplace wellness program or any other important employee benefits administration needs.

  • Following a 19.1 percent-32 percent hike in 2018, 2019 Obamacare rates are expected to rise by double digit percentage points, again. Though speculation by market experts have resulted in a slew of responses as to why premiums have continued to rise, 2019’s increase is one of the most cut and dry responses by insurers to current reform changes. Within this article, we’ll explore the proverbial straw that broke the camel’s back, which happens to be one of the pillars the ACA was built on: the individual mandate.

    Medical equipment sitting in front of rising costs of the current healthcare system.

    On Dec. 22, 2017, President Donald Trump signed a bill that effectively repealed the penalties associated with the ACA individual mandate. In a previously published blog post, I detailed the legislative headache this bill caused but the effects span much further than a complicated ruling by the Justice Department. As the financial implications begin to be rolled out to the public in the form of premium increases for ACA policies, let’s peel back the initial goals for the individual mandate and evaluate how we can improve on said goals during the next round of regulatory changes. 

    Improving the “Risk Pool”

    The ACA’s community rating system is geared towards diversifying risk within its pool of insured consumers. In short this means combining old, young, healthy, and ill individuals into one large risk pool from which insurers are to offer coverage. Ideally, this community pool would reduce the overall risk and stabilize premium rates. The mandate had an overarching goal of expanding this pool by including previous uninsured individuals. 

    Enforcing the Tax Penalty  

    To ensure that the ACA’s pool is properly diversified, a tax penalty was implemented to deter folks from electing to go without insurance and effectively remove themselves from the aforementioned risk pool. This “penalty” has been a serious point of contention over the last few years as it was made constitutional by being defined as a tax by the IRS rather than a penalty for lack of purchase. 

    Prior to it’s repeal, many believe the tax associated with the individual mandate was in fact too low. If one were to simply accept the tax penalty and go without coverage, they’d likely spend much less money than what a year’s worth of major medical premiums cost. This was a major concern for ACA supporters in that the very goal put in place to increase younger and healthier enrollment was doing quite the opposite. If early ACA adopters could redefine one detail regarding the bill, a higher tax to make the choice between going with or without coverage more difficult likely tops their list. 

    Premium Tax Credit

    For individuals that followed the direction of the mandate’s initiatives, a tax credit on premium was issued assuming you met certain financial guidelines. Generally speaking, subscribers would receive enough credit to keep their premium payments below 9.5 percent of household income. The amount of each subsidy issued was determined by your take home pay, but even individuals making up to four times the federal poverty limit were eligible for some form of tax credit. 

    Some experts believe that tax credits were extended too far and for too many individuals. Cutting back on the top 10 percent of earners still receiving tax credits would make a larger pool of funds available to those closer to the federal poverty limit. In an ideal world, this theoretical increase in available funds for lower earners would increase the likelihood of them implementing coverage. With most of those low earners being young post-grads, it would have behooved ACA implementers to entice those individuals into joining the risk pool by any means necessary. 

    Making Healthcare More Available and Affordable

    Hopefully the above factors and failures will open discussions to innovative and reflective reform changes. If nothing else, it should provide a blueprint for what to avoid when attempting to make our domestic healthcare more available and more affordable. 

    At GMS, we pride ourselves on relaying insightful and valuable information to our clients and their workforces. We offer unique benefit platforms and comprehensive consultation services. Reach out to your local office and inquire about how we can help you today!

  • With the soaring costs of healthcare in the U.S., many citizens feel they are left with little to no alternatives when it comes to significant surgeries and procedures. This has helped propel many to look into the latest trend of “medical tourism” in an effort to get the operations they need without breaking the bank.

    Citizens may be uneasy about the idea of receiving care outside of the United States, but there are some great facilities and specialists in other countries where the same level of treatment—or even better in some cases—can be received at a fraction of the price. That was the case for GMS employee Christine Mace when her husband Dan required hip surgery back in 2016.

    Health City Cayman Islands, a medical tourism destination.

    Finding Affordable Treatment Through a Medical Concierge

    Dan had been dealing with the pain for years and was willing to take any action necessary to resolve the issue.

    He had seen several doctors in the states, who eventually advised he would be required to have hip surgery to fix the issue. During a consultation with a specialist from Akron, Dan inquired when the doctor thought he’d need surgery on his other hip. The doctor’s reply was “in a couple years.”

    Chris Mace’s accounting background kicked in. She started researching the astronomical costs for a hip surgery in the U.S. and worried this would have a significant negative impact on the health insurance rates of her co-workers. She began researching alternatives to alleviate Dan’s pain. One day, Dan found an article in Parade Magazine about the idea of “medical tourism.” 

    Chris set up a meeting with GMS’ VP of Benefits, Beth Kohmann, to discuss other possibilities. The two contacted Akeso, a company who has a division specifically dedicated to assist in this process as a “Medical Concierge.” 

    Experts from Akeso discussed the problems Dan was having and began to do their research. They found that the Cayman Islands had a facility, Health City Hospitals, with some of best orthopedic and cardiac surgeons in the world. 

    Before he could even have his initial consult, Dan would first need to proceed with a full physical as well as a dental evaluation. This was a requirement of the Cayman facility so there would be no risk of bringing in a patient with existing infections that could detrimentally affect any other patients receiving treatment at their facility. The hospital boasts a 100 percent infection-free reputation. In that time, it was discovered that Dan had a Periodontal disease, and the pre-certification process helped assure the issue could be resolved without any severe affects to his dental health, an added bonus in the process. 

    Once they passed all the requirements, a meeting was set up with Dan, Chris, Beth Kohmann, and the potential surgeon from the Cayman hospital, Dr. Alwin Almeda. 

    Dan arrived shortly after their set time, and painfully walked to his seat at the table. The doctor focused on his gait and the clear pain shown on his face. By the time Dan was able to sit down, the doctor apologized and told Dan he would need to have him walk paces in front of the camera once again. 

    Between the evaluation of his gait, as well as the X-rays obtained here in the states, Dr. Almeda was able to identify the issue. He asked if Dan had ever been able to cross his legs or sit cross legged on the floor. Dan replied that he had never been able to do so, not even as a child. Dan was stunned because no one had ever asked him that before. Dr. Almeda identified the issue as Femoroacetabular Impingement (FAI). Dan then asked the doctor when he thought the other hip would need surgery, to which the doctor replied, “NEVER!” The impingement was only in the right hip, and the left hip showed no signs of needing repair. (Note – this doctor was using the same scans taken as the Akron doctor.)

    When asked about his pain level on a standard 1-10 scale, Dan replied that his pain was at a 12. Dr. Almeda then informed Dan that he was a candidate because his level of pain matched what the doctor saw on the scan. The doctor then asked Dan why it had taken him so long to seek medical treatment to resolve his discomfort. Dan’s reply was “Fear and cost.” The doctor then replied that money should never be the reason someone is robbed of the finest quality of life they deserve. Dan knew this was the guy to resolve his issue. Dr. Almeda agreed that since Dan was cleared of all possible infections, he qualified as a patient at the facility.

    Traveling Outside the U.S. for Medical Treatment

    The Akeso rep listed off dates for Dan and Chris to travel to the Cayman Islands. They quickly set up plans to travel down a couple weeks later on Feb. 4 with the surgery on that following Saturday, Feb. 6.

    Akeso set up first-class airfare for the trip down. Once Dan and Chris arrived, they had a rental car already set up. Chris quickly realized when they got to the rental that cars travel on the opposite side of the road, which led to a friendly police escort the rest of the way to the hospital. 

    Health City Cayman Islands was born from the vision of Dr. Devi Shetty, a renowned heart surgeon who was Mother Teresa’s personal physician, and supported by Narayana Health Group of Hospitals. This brain trust founded Health City Cayman Islands as part of an effort to bring low-cost, high-quality medicine and care to the Cayman Islands and nearby outposts in Central and South America.  

    According to the Maces, the hospital was comprised of staff mostly from India. At home, they would not have the same financial opportunity that Health City provided. On top of fair compensation, employees have their housing and food paid for, and the organization even pays for them to travel back to their home country for one month each year. 

    “You could tell how much they genuinely cared about their patients and improving their quality of life,”  Chris said.

    A hospital and rehabilitaiton center in the Cayman Islands that was suggested by Akeso’s medical concierge division.

    The Medical Tourism Experience

    The staff walked them through the process and advised they would need to return for tests Friday and the surgery would be all set for Saturday. Dan was admitted into the hospital that Friday evening. The Maces were not prepared for what they saw when they entered his private hospital room. The room was approximately 30-by-30 feet with a beautiful garden view, huge private bathroom, living area, and desk. They explained that Dan would actually have his first therapy sessions right there in his room. Chris set up her office in the room and was able to work remotely while Dan was in surgery. All they had to do now was wait for the big day. 

    Their exemplary experience continued. The doctor paged Chris after the surgery was completed to tell her everything went as planned, and it was a success. After cutting into the hip, Dr. Almeda advised that the ball in the hip broke into three pieces because of the severity of the deterioration. It was also found, during testing, that Dan’s legs were not the same length. Dr. Almeda explained that since the surgery went so smoothly and he was already “in there,” he used bone putty to build up the pelvic bone, prior to installing the new prosthetic hip. The doctor felt that making both legs the same length would help Dan’s back, knee, and ankle pain. Dan was thrilled to find out he was an inch taller after the surgery! There was no additional cost for that part of the surgery. 

    Dr. Almeda accompanied Chris and Dan into recovery and stayed with them for three hours, discussing the entire process, viewing scans, and helping Dan stand that very same day. He helped alleviate any concerns they had moving forward. 

    Health City Cayman Islands kept Dan in the hospital until the following Thursday. After being discharged from the hospital, Chris and Dan went to the private residence to continue the recovery process. Chris went into the bedroom to do some organizing, leaving Dan watching TV. While in the bedroom, she suddenly heard Dan saying something directly behind her. She turned and realized he was up and walking without his walker. He was already so comfortable, that he didn’t even realize what he was doing. 

    They went back and forth to the hospital for PT for the remainder of their trip. Chris was treated to first-class dining at the hospital, which held a satellite kitchen from a four-star restaurant on the other side of the island. 

    When all was said and done, the whole experience came to a total of around $11,000 as compared to about $86,000 for just the hip surgery itself in the U.S. That cost included their first-class air fare to and from the island, a rental car, gas reimbursement, a $100-a-day food stipend, private residence on the beach, the hospital stay and surgery, and the PT that was required thereafter. A $3,600 refund towards deductible was also included in the deal. 

    Consider Alternative Health Options with the Medical Concierge Industry

    The idea of undergoing a life-changing surgery is overwhelming on its own. Then there are the consultations, scheduling, financial concerns, health insurance review, recovery, physical therapy, and so on. It is clear why people like Chris and Dan Mace have become advocates of Akeso, Health City Cayman Islands, and the medical concierge industry as a whole.

    Your employees are your most important asset. By partnering with a PEO like GMS, you can get insight into these types of programs through the experts of our Benefits Department to make sure your people get the care they need at the price they deserve. We can help lay out all your options to keep your group well informed and healthy, while helping save you time and money in other areas from Payroll to Human Resources and Risk Management. Contact GMS today to talk to our experts about how we can help your business.

  • A recent article written by the Wall Street Journal  outlines some startling financial data in regard to our domestic health insurers and their cryptic billing process established by CMS (Center for Medicare/Medicaid Services). Although GMS typically focuses on the private insurance markets—as they are the most relevant for businesses—examining the continued failures of CMS may provide some insight as to why our domestic healthcare system operates so poorly and why prices for both public and private health insurance markets are sky-rocketing.  

    Costs associated with the U.S. healthcare system. 

    A Look into the Market’s Rising Prices

    Medicare is a socially-funded program meant to provide health benefits for tax-paying citizens age 65 and older and permanently-disabled individuals of all ages. Medicare, a majority of the CMS which also splits some funding with state and federal Medicaid programs, is typically divided into four parts, coined Medicare parts:

    • A (Hospital insurance)
    • B (Supplementary Medical insurance)
    • C (Medicare Advantage)
    • D (Medicare prescription drug benefit(s)) 

    Medicare is funded primarily by tax-payers and Medicare subscribers who are required to pay a monthly premium to utilize the benefits provided through CMS policies.

    What most citizens don’t know is that CMS is the largest buyer of healthcare policies in the world and files enough fraud, waste, and abuse statistics to land itself within the Fortune’s 500 top 50 based solely on the amount of money lost each year. That’s right, the fraud waste and abuse of Medicare in 2017 was enough to top revenue for entire organizations like Best Buy, Disney, and Fed-Ex. The figure also dwarfs the full budgets for programs like Homeland Security, the EPA, and NASA by tens of billions of dollars, if not more. 

    As astonishing as those statement may be, these trends have continued almost every quarter, year, and decade since 1965:

    Healthcare loss trends. 

    Contributing to this $60 billion eyesore is an antiquated billing system that largely remains confidential. What the WSJ highlighted (and what we’ll continue to discuss for the remainder of this article) are the overpayments made to Medicare Part-D insurers for inaccurate estimations of cost for upcoming fiscal years (FY). As detailed above, Part-D handles the Rx benefits for Medicare subscribers and is interestingly administered 100 percent by private insurers. 

    These “overpayments” surpassed the $9 billion mark from 2006-2015 and were paid out to private insurers on top of existing revenue for administering these Part-D plans. The question as to how $9 billion seemingly slipped through taxpayers’ hands and into the revenue stream of top-insurers is what’s intriguing… or maybe infuriating is the right word to use here. 

    The Bidding Process for Private Insurers

    In order to address that question, we’ll need to take a brief look into the bidding process for these private insurers and how re-payments by CMS are made on an annual basis.

    Every summer Part-D insurers send detailed cost-projections for what it would take to fund all Medicare Part-D subscribers’ prescription costs for the following year (about 40 million people). These projections are split into two main categories: Direct Subsidies and Reinsurance Subsidies.

    Direct Subsidies contain projections for the majority of services through Part-D. When insurers submit these bids and real costs fall below what was originally projected, CMS allows insurers keep a portion of the difference. Keep in mind that these “projections or bids” are what Medicare bills to taxpayers to ensure proper coverage. In this case, insurers are seemingly incentivized to inflate their bids (by an obvious but overlooked billing loophole) knowing they’ll get to keep some of what isn’t used by the Medicare Part-D population while taxpayers get to bear the financial brunt of these egregious errors. 

    Reinsurance Subsidies are siloed for Medicare subscribers that have extremely high-costing medications. These high-costing medications, sometimes referred to as “specialty” meds, can often times be upwards of $5,000 for a 30-day supply. Humira, a popular drug that’s used to treat Rheumatoid Arthritis among other chronic illnesses and is often advertised on television, will run you about $6,409 for a 28-day supply without applicable medical or prescription insurance. For these subsidies, insurers must pay back any overages in cost projections should they fall above what was actually spent. However, if insurers’ projections fall below what was actually spent, Medicare will fund the remaining amount. 

    Imagine you’re the controlling party for one of these large private insurers. If you could legally receive billions of dollars simply by “over-projecting” one of your bids and legally save billions of dollars by undercutting a different bid with the sum of those earnings or savings being pushed off to the subscribers you’re insuring and American tax-payers, what would you chose? 

    The Grave Reality of the U.S. Healthcare System

    Given the above details, the first question that comes to mind might sound something like this: “So Medicare Part-D allows 100 percent administration of a federally subsidized program by private insurance companies, but also allows said companies to submit their own budget forecasts and allows them to keep some of that allocated money if they’re wrong in creating those budgets?” With an 11 percent error rate in 2016 Medicare payments, it’s not hard to see how this staggering $9 billion figure is only a fraction of what the programs wastes annually. Applying these malpractices to a $3.5 trillion-dollar industry (the United States healthcare system, which is showing steady annual spending growth and will likely eat over 25 percent of the GDP within the next decade) and the grave reality of what’s at stake is easily recognizable. 

    I would highly encourage anyone interested to read more about the WSJ’s findings, but will conclude with the following:

    As the economic epidemic of our healthcare system continues to worsen, it’s articles like this from the WSJ that bring to light how much taxpayer money is truly wasted through an irresponsibly administered system like CMS. The issues found here can be replicated time and time again throughout various programs in our healthcare system and are a big piece of why healthcare costs, specifically insurance premiums, continue to climb. 

    Although it’s not always enjoyable to put these concerning statistics and unsavory business practices in frame for our readers, the transparency that GMS owes to our clientele will always reign. If you’re interested in working with realistic brokers to create modern solutions for your group’s health plan, contact GMS to speak with a dedicated healthcare professional.

  • When Donald Trump ran for the Presidency in 2016, a major plank of his platform was the repeal and replacement of the Affordable Care Act. In fact, pretty much every Republican in 2016 ran on that promise.

    In the summer of 2017, several Republican Senators and every Democrat Senator torpedoed that promise by not agreeing to a plan. Since then, this administration has made several attempts to sink the ACA where they could.

    A gavel of a judge blocking new association health plan rules meant to sink the affordable care act.

    The Trump Administration’s Attempts to Sink the ACA Through AHPs

    The first, and perhaps most powerful as far as Washington D.C. is concerned, attempt is the decision to no longer enforce the individual mandate. If you recall, there was supposed to be a financial penalty on any individual who didn’t have an insurance plan through an employer or on their own. The problem with that plan was always twofold:

    • If you weren’t working or weren’t filing taxes, there was no way for the IRS to collect that penalty.
    • In many instances, the penalty was less costly than the insurance itself.

    The administration began creating new rules for Association Health Plans (AHPs). These AHPs allowed “businesses and individuals [to] band together to create group health plans that offer less expensive coverage than the ACA.” In other words, Associations could pull together multiple employers and individuals into a larger group, offering better rates. In most cases, the trade-off was no protections for what was deemed “minimal coverage.”

    Recently, a federal judge ruled that the Trump Administration attempted an “end run” around the ACA and, in effect, violated the Affordable Care Act.

    Affordable Healthcare Options for Business Owners

    If you are a business owner and you thought these plans were a way to get out from under the considerable financial burdens of the ACA, you may be back at square one.

    Well, there may still be a multiple-employer healthcare option for you. If you would like to learn more about the large group buying power of a Professional Employer Organization (PEO), as well getting additional HR services and regulatory and tax protections, please contact GMS to talk to one of our experts today.

  • As we approach the 2020 political season, healthcare remains an eternal “hot topic” issue; one that acts as an economist’s reoccurring bad dream. Much like a bad dream, the obvious warning signs of our domestic system’s atrophy disappear into the cognition of the economist’s mind and are forgotten by mid-morning. The economist, much like the rest of the country, has an eerie feeling due to this reoccurring healthcare nightmare, but can’t quite seem to pinpoint the root of their discomfort or begin to answer the lingering paradox of “How can we make healthcare in the U.S. financially sustainable?”

    The answer to that question is a large, complex, and convoluted issue to tackle. An alternative approach is to look at our ongoing mistakes as an industry and start to peel back some of the fraud, waste, and abuse at least long enough to get our collective head above water to propose a semi-legitimate long-term solution. 

    A doctor pocketing money from a staggering healthcare bill. 

    Diagnosing a Questionable Healthcare Diagnosis

    Individuals, facilities, insurance entities, CMS, and providers are just some of the key players necessary to stop the financial hemorrhaging. Not often enough do we evaluate the role of the physician from an economic standpoint and their direct effect on the industry. A recently released edition of “Bill of the Month,” a crowdsourced investigation of medical bills by Kaiser Health News and NPR, allows us to do just that. 

    To paraphrase the article: A New York City patient went to a PCP (Primary Care Physician) with symptoms of a head cold. About to leave on vacation, this individual thought nothing of a typical provider visit to address some minor discomforts before traveling. A throat swab, a quick round of antibiotics, and a $25 co-pay sends this patient (aka consumer, customer, client, etc.) seemingly out the door without a hitch. 

    Upon returning from vacation, this healthcare consumer has a staggering $28,395.50 bill from their provider relating to the previous “head cold” visit. This physician ultimately sent the throat swab (claiming to test strep, among a myriad of other unlikely diagnoses) to a non-network lab facility with which this patient’s insurer (BCBS) did not have an established contracted rate. Normally, these tests run through an in-network provider would run the same insurer about $653 – a 191 percent price difference coordinated through the discretion of this physician. 

    As I read through the article, a handful of painfully obvious questions came to mind. Namely:

    1. Why intentionally use an out-of-network lab service?

    a. The physician office had applicable and valid insurance info from the patient and could easily check for a list of in-network providers. They chose to use an out-of-network facility.

    2. Why were so many unnecessary tests run for likely influenza (common cold) diagnosis?

    a. “In my 20 years of being a doctor, I’ve never ordered any of these tests, let alone seen any of my colleagues, students, and other physicians, order anything like that in the outpatient setting,” said Dr. Ranit Mishori in Kaiser Health News. “I have no idea why they were ordered.”

    b. “There are about 250 viruses that cause the symptoms for the common cold, and even if you did know that there was virus A versus virus B, it would make no difference because there’s no treatment anyway.”

    3. Why were antibiotics prescribed for a viral infection? 

    a. There’s a lesser-known, but just as frightening scenario where continued unnecessary antibiotic use within the general population will lead to widespread antibiotic resistance that will affect not only our healthcare industry but veterinarian and agricultural industries as well. Antibiotics cannot effectively treat viral infections. 

    Here’s the kicker from Kaiser Health News: “The third reason for the high bill may be the connection between the lab and Kasdan’s doctor. Kasdan’s bill shows that the lab service was provided by Manhattan Gastroenterology, which has the same phone number and locations as her doctor’s office.”

    Undoubtedly, this physician or practice is getting a kickback from the lab’s profit by billing this patient’s insurer an absurd and unnecessary amount. Coincidentally, Kaiser Health News points out that “Manhattan Gastroenterology” (the out-of-network lab running these tests) “is registered as a professional corporation with the state of New York, which means it is owned by doctors.” Maybe this primary care doctor in particular? 

    Now the point of this blog isn’t to uncover fraudulent billing practices. Those occur every minute of every day within our healthcare system. Rather, its aim is to point out that if we want anything close to a sustainable system for the baby-boomer generation’s progress into older age, or for the generations that follow, we’re all responsible to do our part in turning this thing around. That means you too, physicians. 

    Regardless of which individual ends up settling the $28,000 bill from this PCP, the moral of the story is that billing tens of thousands of dollars to the healthcare system opposed to hundreds, by choice, are the decisions that, when multiplied and repeated over decades, gets us to where we are today: a seemingly insurmountable amount of debt. Furthermore, and most important to employers, high claims like these that could and should be otherwise avoided will ultimately lead to higher insurance premiums in future years for the employer and its employees. 

    What can we (healthcare consumers) do to mitigate national healthcare debt?

    Staying informed, asking the right questions, and taking ownership of our personal health habits are surefire ways to reduce the expenditure and volatility of our health system. Working with consultants from an employer-centric company like GMS can only help educate employers on the successes and failures within our system and how those points can be used towards the advantage of those offering benefits while mitigating unnecessary financial loss. 

    GMS is an employer for employers, constantly striving to provide transparency and sustainability for those we serve. Contact a local office today to begin your healthcare partnership with GMS.

  • “Normalcy”, “Normality”, “Normal”; No more. I’ve never heard the verbal and written abuse of a seemingly, well, normal, word as much as the six-letter description of what is supposed to be over the past three months. For those of us familiar with the U.S. healthcare system, we’ve discarded the word “normal” from our vocabulary long ago.

    As many of us anxiously await the “end” of the most recent global pandemic one common phrase has stood out among healthcare industry experts as the most detrimental aspect of the recent outbreak: “overwhelming the healthcare system.” In short, overwhelming the healthcare system can be illustrated by imagining the hospitals in our areas completely overrun with so many COVID diagnoses that it affects the ability for facilities to manage and effectively treat regular hospital patients (not spurred by the pandemic) resulting in worsened health outcomes for all. Luckily, we will avoid a blanketed overwhelming scenario in the U.S. due to this pandemic, but that doesn’t relieve the concern of a looming explosion of chronic illness that is likely to take a similar path within the American population.

    An overlay of helathcare system charts from overwhelming chronic illness over basic medical equipment. 

    The Potential Impacts of Overwhelming Chronic Illness on the U.S. Healthcare System

    For the remainder of this post, we’ll isolate one of these chronic illnesses to get an idea of what overwhelming our healthcare system with chronic illness would look like financially. In its various forms, this illness affects, has affected, or will affect approximately 152.3 million Americans. Of those 152.3 million individuals:

    • 68.3 million are currently diagnosed, previously have been diagnosed, or have the disease but have yet to be officially diagnosed
    • 84 million are in a “pre-disease” situation where they are at high risk of being diagnosed or are on a quick path to the fully blown disease
    • 90 percent of those 84 M in the pre-disease stage aren’t even aware they’re at risk 

    To put these numbers into perspective, below is a graph comparing the number of COVID-19 diagnosis in the United States (as of 4/25/20) vs. the aforementioned chronic illness:

    A chart comparing COVID-19 cases to a chronic illness. 

    From sheer diagnosis numbers alone, this chronic illness should appear way more drastic to our hospital system than our current pandemic (obviously, the numbers surrounding COVID are subject to change as we learn more). This would assume that all diagnosed patients end up in our hospital system which isn’t a guarantee. To compensate for that lack of future clinical data, we’ll substitute what we know from a financial aspect on how impactful this chronic disease could be to our HC system. To do this I’m going to use some “creative” arithmetic. Bear with me.

    A Hypothetical Financial Projection

    To try and make this as accurate as possible, we’re going to take inflation into account. To do so, we’ll use the generation markers for Baby Boomers (55 – 76 years old) as a starting point for our projection. The financial data surrounding this chronic illness is largely from 2017 so we’ll use three years of inflation projections to get us into 2020 USD, and then another 21 years of projections to completely age-out the current Baby Boomer population (ending in 2041). 

    From 2017 – 2020 we’ve experienced about $0.05 in inflation. Now, unrealistically, we’re going to assume that every three years we will continue to have a $0.05 inflation hike. This projection would put the U.S. at a $0.35 inflation hike between 2020 and 2041. 

    Now we can apply our existing data. According to an organization specializing in this disease, $327 billion is spent annually to treat those diagnosed. Referencing our population data, those diagnosed represents a small minority of those likely to develop the disease as a whole: 34.2 million diagnoses vs. 152.3 million diagnoses, pre-diagnoses, and former diagnoses. If we can break down our data to represent the cost of an individual diagnosis, we can then scale for inflation and a more accurate financial point to include all of those at risk, not just those who have been officially diagnosed. Here’s the math step by step:

    1. $327 Billion spent in 2017 for all American Diagnoses * 1.05 =  $343.35 Billion USD in 2020 currency (1.05 represents the inflation rate between 2017-2020).
    2. $343.35 Billion (2020 Dollars) * 1.35 = $463.5225 Billion (2041 Dollars – Assuming we see a $0.05 inflation hike every 3 years between 2020 and 2041). 
    3. $463 Billion dollars is a huge chunk of change even on a national scale. What this figure doesn’t include are the pre-diagnosed, un-diagnosed, and formerly diagnosed Americans that are at a higher likelihood to develop or re-develop the disease. This $463 Billion figure represents only 34.2 million of the 152.3 million Americans at risk:
    4. $463,522,500,000 / 34,200,000 diagnosed = $13,553.29 per diagnosis per year. It’s important to keep in mind that these costs are the total impact on the healthcare system.
    5. $13,553.29/diagnosis * 152.3 Million Americans at risk = $2.064 Trillion per year in theoretical financial impact towards the US healthcare system in 2041 for this chronic illness. 

    If you’re still wondering which chronic illness we’ve used to project these outcomes, it’s Diabetes Mellitus. These figures represent solely the cost of treating diabetes itself (insulin, test strip, A1C monitors, physician services, glucose monitors, etc.), not the complications that can stem from the disease. Some common complications are stroke, heart disease, neuropathy, eye and skin complications (like glaucoma and deep skin infections or sepsis), etc.

    These numbers are meant to be staggering. This is a projection for one chronic illness out of hundreds, with hundreds more to be developed or contracted between now and 2041. If our healthcare system was at the brink of being overwhelmed during the COVID pandemic, what capacity can we expect the system to hold for a chronic illness that will affect 197.58 percent more Americans and cost billions if not trillions of dollars? The good news, type II Diabetes (a heavy, heavy majority of diabetes diagnoses statistics) is reversible through proper medication, diet, exercise, and lifestyle changes. The bad news? Many other chronic illnesses are not. 

    Steps for a Sustainable Healthcare System

    If this pandemic has shown us some shortfalls within our healthcare system, now is the time to correct them. Individual education and individual ownership of lifestyle choices are immediately impactful changes we can all make to ensure the healthcare system is sustainable for future generations. If we can successfully manage our own health, we won’t need to rely on a potentially ineffective healthcare system. 

    Contact GMS to discuss how we are partnering with local businesses to control and stabilize their healthcare programs for years to come. Our industry experts are prepared to discuss the future of healthcare and how it may affect your business, your employees, and you.