Archive for the ‘Blog’ Category

Are You a Healthcare Prisoner in the Big Pharma Prison? “Follow the Money” and Find Out.

As we further explore the healthcare consumer in a healthcare prison, Big Pharma is an area we need to review and explore because companies are profiting hugely by raising prices to dizzying heights. Drugs that cost less than $400 a year in some countries cost $300,000 a year in the United States.

Eighty percent of the growth of profits in the 20 largest drug companies has resulted from price increases — not new drugs. Just raising prices.  The brunt of that pain is felt by the healthcare consumer because the drugs that we buy here are much more expensive than the prices elsewhere.

A few points need to be clarified regarding Your Doctor, Big Pharma and the Consumer before we can answer the question.

Your doctor contributes to the problem.  The following study is mind boggling:

In 2013, 1,122 (39.1%) of 2,873 Medicare Part D prescribers received gifts from pharmaceutical companies totaling $3.9 million in 2013. Compared to non-gift recipients, gift recipients prescribed 2.3 more claims per patient, prescribed medications costing $50 more per claim, and prescribed 7.8% more branded drugs. 

Physicians who received small gifts (less than $500 annually) had more expensive claims ($114 vs. $85) and more branded claims (30.3% vs. 25.7%) than physicians who received no gifts. Those receiving large gifts (greater than $500 annually) had the highest average costs per claim ($189) and branded claims (39.9%) than other groups.

Big Pharma by the Numbers:

First, most large drug companies spend more on sales and marketing than on research and development.  Anyone who watches television can attest to the growth and dominance of marketing to the consumer.

Second, since 1980 and the Bayh-Dole Act, drug companies can feed off research funded by the National Institutes of Health, which they acquire at late stages of development. The big companies can either license the drugs or buy out small biotech companies carrying out NIH-funded research. In short, much of the research going into these products is funded by taxpayers, not pharmaceutical revenues. Many companies have operating profits ranging from 15% to 30%.  The average S & P company had an operating profit of 10.4%

Third, the pharmaceutical industry has a massive lobbying presence, consistently spending over $200 million a year, according to the Center for Responsive Politics. It has more than two lobbyists for every member of Congress and spends tens of thousands of dollars per election cycle. That type of investment is only undertaken when there is a significant return expected. For example, Congress placed a provision in the 2003 Medicare Prescription Drug Benefit that prohibits Medicare from negotiating with drug companies on pricing. Now that’s a return on lobbying costs!

Fourth, Nielson estimated that $5.2 billion was spent on prescription drug advertising in 2015. The largest chunk of that amount was for television advertising.

And lastly, in 2013, biopharmaceutical companies led all other industries in corporate giving by donating 19.4% of pre-tax profits to charitable organizations. You probably won’t be surprised, though, that 90% of the contributions came in the form of in-kind product donations. High list prices for certain drugs can add up to some major bucks quickly. Still, it’s nice to know that the frequently vilified Big Pharma companies aren’t as heartless as they’re sometimes portrayed.

Now from a healthcare consumer prospective:

  • It is estimated that there are 110 million regular prescription drug users across the US.
  • 49% of us take at least one drug
  • 19% of us have skipped taking a drug or cut it in half
  • 14% of us chose not to fill prescriptions at all

Additionally, Big Pharma and insurance companies have developed relationships that have forced healthcare consumers to buy brand name versus generic drugs.  Insurance companies tell consumers the generics are not covered only brand names.  Unbelievable!!!!!

The above ‘costs of doing business’ result in the cost of healthcare for every healthcare consumer increasing at all levels. Furthermore, the practice of “gifting” medical professionals should be considered a crime—similar to rebating in the insurance industry.

Big Pharma gifts influence MDs script writing, which affects Medicare, Medicaid, and all healthcare insurance policies, coverages and, ultimately, premiums insureds pay.

If the above hasn’t convinced you are a healthcare prisoner in a healthcare prison I’m not sure what will.  Big Pharma locks us up and throws away the key. We clearly are prisoners. I rest my case!!!!!!

We have spoken with many healthcare consumers and they’ve shared scores of unbelievable stories. Talk to any of your friends, relatives or colleagues and I am sure they will have a Big Pharma story to tell.

Tells us what you think.


Escaping the Healthcare Prison; Are You a Healthcare Prisoner?

If one would judge by the rhetoric and lip-service coming from the healthcare industry, all is fine and getting better. The reality, however, is the healthcare landscape has changed significantly in a very short period of time and not for the betterment of the patient or consumer. Healthcare consumers and patients are finding themselves virtually captive.   Healthcare consumers are asked to do more, pay more and receive less value for each dollar spent. While healthcare consumerism receives much media attention, the reality is healthcare providers and payers are very content with the status quo.


In market based businesses, consumers require pricing information and a means to determine the quality of goods or service they’re receiving. In other complicated industries involving high consumer volume, like financial services, travel, retailing or automobiles, the government regulates the quality aspect and commercial enterprises provide pricing transparency. Healthcare is void of both. Providers nor payers have any intention of relinquishing the control.   Making it easy for the consumer to navigate the maze is counter productive to the current business model The lack of transparency isn’t unintentional, therefore, creating transparency must be intentional.


What’s the big secret? Why does pricing need to be so convuloted?  Pricing transparency is a hot topic. Industry insiders will argue against pricing transparency because they claim it’s to complicated for consumers to understand. Payers guard pricing like Coke protects the soda formulas. Compare trying to find a price for a healthcare service to any other consumer good or service!!!  Take a look at a hospital bill to really see the insanity. There will be a laundry list of incomprehensible items followed by individual pricing that will sum to a very large total followed by a relatively large discount resulting in what someone is expected to pay. This is an artifact of the Byzantine health insurance world when patients had little to no financial exposure to paying for healthcare services. Even though the marketplace has dramatically changed, incumbents have chosen not to.    States and the Federal government have done very little to help the healthcare consumer.  It’s laughable compared to other industries.


I believe we are healthcare prisoners in a virtual prison.  The following will explain what I mean.


Let’s define a healthcare consumer/patient, healthcare prisoner, and a virtual healthcare prison.


First a healthcare Consumer/Patient: Simple……Any person wanting to protect themselves from a catastrophic healthcare event or anyone who requires medical care.


Second, let’s define a Healthcare Prisoner
A Healthcare prisoner is a person buying health insurance or obtaining medical care.

 Third, let’s define the Virtual Healthcare Economic Prison.

With the passage of the Patient Protection and Affordable Act, effectively all Americans have been granted access to the healthcare economic prison. It’s now only a question of what degree. A Virtual Healthcare Economic Prison is any organization that extracts financial resources from patients/consumers or provides healthcare services to patients/consumers. These Virtual Prisons are…. the government (social security tax/Medicare/Medicaid), employers (health benefit premiums/workers compensation), insurance companies (protection depositories), hospitals, big pharma or other allied healthcare providers just to name a few.  They are prisons because our healthcare choices are dictated by these entities through unknowable contractual terms. These relationships are almost entirely based upon financial arrangements.   They protect us as long as we are cooperative and meet our financial commitments and follow the rules.


Studies show in 2017, Preferred Provider Organization (PPO) health insurance coverage for a family of four cost an employer approximately $27,000. The employees share was approximately $12,000. On the health exchanges the average cost for a family of four without subsidies was approximately $21,000. (No telling how comparative the policies might be.) Several studies have shown consumers over-purchase health insurance by 24%. The value of services received for this payment is highly dependent upon a well-informed consumer/patient. Transparency will arrive when it is an expectation of the consumer/patient.




I realize some will disagree.  Some will agree.  I know for sure the healthcare consumer will agree.  We have spoken to many of them.  The consumer is the only one that counts.


Let us know what you think….



Today, we define a healthcare patient as receiving healthcare services; we define a healthcare consumer as making healthcare choices.  Undoubtedly a very big difference that requires a shift in focus.  The healthcare consumer is responsible for the overall management of their health needs and out of pocket costs. Out of pockets costs are defined as deductibles, co-pays, co-insurance, premiums, and other related costs. The typical consumer does not plan for healthcare.  Consumers, annually, select a health insurance plan based on premium cost and hope they are healthy enough to avoid large out of pocket costs.  A Personal/Family Health Plan should be the first step to proactively managing healthcare options and costs. The Plan should be all inclusive from selecting a health insurance plan to creating a budget.  Radical? Yes…but by not planning for healthcare the result could be disastrous with health and financial consequences.

The average healthcare consumer has limited experience navigating the healthcare system, including those who work in the healthcare industry.  Many of us have heard friends and relatives express their frustration managing options, care, and costs, resulting in incorrect billing, high costs, out of network charges and denied services. One example is a recent survey that shows the consumer lacks understanding of basic health care terms. The following are the results:

  • 45.3% Co-Insurance
  • 35.2% Max out of pocket
  • 30.8% Covered Services
  • 27.2% Premium
  • 25.6% Deductible
  • 23.5% Co-pay

The degree of misunderstanding is astonishing.

The healthcare system is a maze that healthcare consumers cannot navigate easily. Healthcare consumers are afraid, frustrated, confused and angry.  All healthcare sectors, including Doctors, Hospitals and Insurance Companies, have contributed to the growing confusion.

Many talk about consumerism in healthcare but don’t understand healthcare consumer needs and wants. Clearly, the healthcare consumer has not been prepared to manage their healthcare finances as the above survey demonstrates.  The healthcare system has failed the healthcare consumer.

Our responsibility is to educate and guide the healthcare consumer through the maze.  With that said, the following company and web site has been established:


Our Vision…The Need….The Mission Statement

Our company has a vision that all healthcare consumers have easy access to reliable and timely healthcare information, education, and tools required to plan and manage their healthcare needs.

Consumers need understandable healthcare information to make informed decisions regarding their medical and financial future.

Healthcare Consumer Navigator Center is a national company with a business mission to guide consumers through the complex healthcare system.  Healthcare Consumers will be provided tools, guides, information and education to navigate the complexities of the healthcare systems.


Take a look and lets us know your comments and thoughts.




Did Your Health Insurance Company Deny Your Bill?


I have experienced denied claims and they can be very frightening and frustrating. My first reaction was how is this possible when I pay for health insurance.  Most of us do not really know what our health insurance covers and what are the procedures to secure payment.  Hopefully, the following can help.

Health insurance companies deny healthcare bills for a variety of different reasons. Normally there is a legitimate reason for the denial.  The healthcare consumer should be prepared for such an event.  They occur more than you may think.  Healthcare providers receive the denials from the insurance company and automatically bill the consumer.  The consumer is now responsible financially for  the bill.  The following are common reasons bills are denied.

  1. Medically Unnecessary Services

The medically unnecessary denial is a denial that insurance companies use when a claim does not meet their medical criteria for payment. This can occur when your healthcare provider has improperly or did not fully document your medical service.

  1. Medical Service was not Pre-Authorized

Many healthcare services require the healthcare provider to obtain an authorization from the insurance company, prior to service, to obtain payment.  Healthcare providers sometimes miss obtaining a pre authorization.  If this occurs, the healthcare consumer can call the ordering doctor and healthcare provider to appeal the denied claim.  Most insurance companies will grant a retro pre authorization which means they approve the service after the service was rendered. .  If not, the healthcare provider should not bill you.

  1. Non-Covered Charges or Services

Some healthcare services can be excluded for payment as defined in your health insurance policy.  These excluded services are generally those not frequently used by the healthcare consumer or are very expensive procedures.  Before receiving or scheduling services, contact your insurance company to insure they are covered.

  1. Wrong Information on the Claim

Healthcare providers and insurance companies can make errors that will result in a denied claim.  Examples for these types of errors are:

  • Wrong Insurance Information
  • Wrong Patient Information
  • Transposed Information on the Claim
  • Wrong Information in the Insurances Companies Computer System

Anything can go wrong.  Be prepared to deal with these situations.

Insurance companies will send the healthcare consumer an Explanation Of Benefits (EOB) that will have specific codes explaining why a claim has been denied.  Take the time to understand the reason for the denial.  The reasons will lead you to the next steps in appealing the denials

The Healthcare Consumer Navigator Center has a step by step process  as to how to appeal denied claims.

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