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But Wait, There’s More!

Well, the state pushed through the 16.3% increase despite making promises that would give us 60 days to come up with solutions. Labor took many steps to mitigate the rate increases and all were shot down by the representatives of the administration. It was apparent when during a zoom call with decision makers from both labor and management on a call, the person from management who had called the meeting put herself on mute and blatantly and dismissively turned her chair on a 90-degree angle from the screen and started texting. It was obvious to me that we were just a nuisance and that they had no interest in controlling costs and only continuing to feed their political donors in the Hospital Association.

A recent survey that was published by Patient Rights Advocate showed that 92% of respondents in a bipartisan survey strongly or somewhat support, “requiring hospitals and health insurance companies to provide real, actual prices – not estimates.” What was more disturbing in this survey was that 35% of the respondents to the poll stated that they had delayed medical care due to concerns of not knowing how much care would cost. I ask, what more do they need to change the current system? It seems to me that policymakers are siding against 92% of the electorate and like the old Soviet Socialist Party, are taking the paternalistic position that they know better.

In negotiations over the rate increases the CWA engaged their actuary to review the state’s actuarial analysis of the plan. They questioned several of the assumptions that were made and adopted (by a 3-2 vote of the Commission). It was pointed out that several assumptions in the report were artificially high. National trends were in some cases ignored. At the end of the day, there is only one assumption that we can make, the rates are artificially high or as they said during the big short, the books are being cooked. Conservatively, and with common sense approaches, 5% could be shaved off the rates.

But wait…there’s more. In the rate setting midyear analysis presented to the Commissions and Committees in March, the State’s actuary, on page 20, stated that changing the index for reimbursement for out of network claims to 175% of medicare rates would be a 6.1% savings on the rates. Labor brought that to the division and miraculously, it was only worth 2.6%. Can you smell the books cooking there? The other big issue that was much ado about nothing was the GLP-1 (weight loss drug) spend. The fact of the matter is that if we eliminate them for weight loss alone the savings is only 1.6%. The real problem is the specialty drug spend which was up 23.3%. Specialty drugs and injectable drugs administered at hospitals are marked up in some cases 7 times. I’m glad to see that these hospitals that care so much about us, are kind and compassionate to cancer patients. This is all while the state is dragging its bureaucratic feet on a solution that we have already presented that would have drugs placed on the formulary based on clinical efficacy, not just because they are the “shiny new car” on the market. Our total drug spend is up over 20% and we need to take control of the formulary from the Pharmacy Benefit Managers.

Now these are harsh words, but they need to be said. Hospital networks are not people. They don’t vote, and they are being given a pass by the government. We need to go to back to basics and make sure that government is acting in the interests of the people and not the hospitals. There is not one person reading this article that would buy a car and tell them to mail you the bill without looking at it. Engage with your providers, ask for the price of the service, and shop. When they are screwing you, they are screwing all of us.

We have just received information that the Division of Banking and Insurance has denied a request from Horizon to utilize American Specialty Health Network to administer Chiropractic, Physical Therapy, Occupational Therapy, Acupuncture and Speech Therapy for all Horizon customers both in and out of the State Health Benefits Plan.

The New Jersey State PBA led the initiative to disallow the implementation for three main reasons. First, the belief that the model that would be implemented would restrict access to much needed, non surgical options. Next, to help limit use of opiates for musculoskeletal injuries, which are suffered by our members on a regular basis. The last reason was because of the practices that were outlined in a 2012 consent order involving the network.

This denial does not mean that Horizon cannot make future application for these services and we ask our members to remain vigilant and responsive in our continued effort to protect our health benefits.