Health insurance is great... until you actually need to use it. Each day, patients are denied treatment & medicine by insurers making billions in profit.🤒 vs💰
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Today's PBM market is an oligopoly. Just three corporate giants control roughly 80% of all prescriptions in the United States. And one of those megacorporations - CVS Caremark - is growing even bigger, which reduces competition.
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Large companies project healthcare rate increases of 9.2% to 11.1% for 2027. This marks some of the sharpest healthcare inflation large employers have faced in two decades, according to Business Group on Health’s 2027 Employer Healthcare Strategy Survey released this week.
earlier in the year.
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Patients and doctors in Northern Nevada are crying foul over a sudden insurance change that is forcing thousands to find new doctors mid-plan year. This comes months after Kaiser Permanente and Renown Health announced a joint venture that claimed it would expand access to care.
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UnitedHealth's new venture is certified bananas. 🍌
To protect their market share and pacify frustrated employers and regulators, UnitedHealth's PBM, OptumRx, launched its own version of @mcuban's "cost-plus" system. Which begs the question: If your insurance company’s own PBM tells you that prescriptions may cost less when you don’t use your insurance, what exactly is your premium paying for? Follow-up question: Why does your insurer even need a PBM?
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Health insurance conglomerates hold all the cards, and it's driving up the cost of care. Affordability requires transparency.
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Patients were fighting for treatment. UnitedHealth executives were allegedly cashing out.
UnitedHealth shareholders allege company executives sold more than $237 million in stock while serious risks remained hidden from investors—including accusations of Medicare fraud, and denials of medically necessary care.
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The FTC’s settlement with CVS Caremark over antitrust practices reads like a checklist of what’s wrong with the PBM business model:
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HealthCareDenied retweeted
PBMs say they are highly pass-through if you take out:
💸 GPO fees
💸 340B spreads
💸 drugmaker fees
💸 rebate exclusions
💸 effective rate spreads
💸 clawbacks
💸 transaction fees
💸 audit takebacks
💸 prior authorization fees
💸 specialty pharmacy markups
💸 integration fees
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More evidence that health insurance conglomerates have become TOO BIG TO CARE about affordability, as they continue to consolidate and reduce competition in the marketplace:
💰Small group insurers are proposing a median premium increase of 14%
💰The commercial group market 9%
💰ACA insurers are proposing a median premium increase of 15%
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Last year, California health plans were fined $214.3 million for violating the law—a 156% increase since 2020. The more they charge for health care, the more they break the law to delay and deny us what we've paid for.
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California's Dept of Managed Health Care takes action against health insurance companies that break the law. As health plans continue to deny and delay care, fines have increased by 156% from 2020 to 2025.
Pay more. Fight harder. Get less.
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Employers are being forced to choose between protecting workers’ health benefits and protecting their jobs.
In 2010, 83% of companies with fewer than 200 employees offered coverage. Last year, just 59% did, an all-time low.
We're paying more and getting less.
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Patients and doctors in Northern Nevada are crying foul over a sudden insurance change that is forcing thousands to find new doctors mid-plan year. This comes months after Kaiser Permanente and Renown Health announced a joint venture that claimed it would expand access to care.
Made with AI
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Patients and doctors cry foul after Kaiser Permanente and Renown Health notify more than 4,500 patients to find new physicians after insurance change. rgj.com/story/news/health/20…
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Today's PBM market is an oligopoly. Just three corporate giants control roughly 80% of all prescriptions in the United States. And one of those megacorporations - CVS Caremark - is growing even bigger, which reduces competition.
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HealthCareDenied retweeted
If a California company or employer group believes they are being overcharged for health premiums, or if their employees are facing wrongful billing, the California Department of Managed Health Care (DMHC) serves as an administrative investigator and public arbiter.
Ask your LLM to write a letter to DMHC, and ask for a review of your plan rates. Then tell your broker this is what you are doing.
I had a portfolio company do this. Their broker immediately came back and said that their previous bid, that they said was their final bid, was really only a starting point. They reduced the bid. We said not enough. And they are coming back to us again with a lower bid.
Employers predict an average 8.2% increase in the cost of their insurance plans, the largest spike in health care costs in over two decades, per WaPo
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🚨UPDATE: Over the summer, @HealthNet, one of the largest Medicaid insurers in the country, cut assisted living benefits for roughly 3,500 low-income seniors in California.
The abrupt decision left dementia patients who require 24-hour care with few or no options.
Last month, California regulators cited HealthNet for violations they say “jeopardize member safety, disrupt continuity of care, and endanger medically vulnerable members.”
If Health Net does not extend benefits and create individualized transition plans for each affected member, the state may fine them $25,000 per member per day of violation, the letter states.
A disaster in the making: Californians face eviction as @HealthNet, one of the largest health insurers participating in Medi-Cal, cancels assisted living benefits.
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#5 on @mcuban's list: Make Enforcement Hurt
California health insurance companies are fined multiple times each year, but that doesn't stop the violations. Today, Blue Shield was fined $800K.
My testimony today at the Texas State capital
I’m the co-founder of CostPlusDrugs.com.
We started Cost Plus Drugs because the prescription drug market is too complicated, too opaque and too expensive.
Our model is simple: we show what we pay for a drug, add a transparent markup and pharmacy fee, and show the customer the price.
No games. No hidden spread.
And a large percentage of our customers already have insurance.
They come to us because our cash price is often lower than what their insurance plan asks them to pay.
That tells you something is wrong.
Here are five things Texas can do about it.
1. Let patients shop for cheaper drugs
If someone's insurance says a prescription costs $500, but they can buy the exact same drug for $100 cash, let them buy it for $100.
Then credit that $100 toward their deductible and out-of-pocket maximum wherever Texas has authority to do so.
Patients should be rewarded for saving themselves and their health plan money.
They shouldn't be punished for it.
That's how you create something healthcare desperately needs:
Price competition.
2. Standardize PBM and TPA contracts
Texas should require the state, cities, counties and school districts to use standardized model contracts and mandatory terms for PBMs and TPAs.
I've reviewed these contracts.
They routinely run hundreds of pages.
I've seen contracting packages longer than a thousand pages.
There is no human being—or group of human beings—on this planet who can stay awake and understand every provision in contracts that complicated.
I don't care how much coffee they drink.
I call it contractual terrorism.
The vendor only has to sneak a couple of tricks through hundreds of pages.
The employer has to find every one.
It can't.
I've developed a model PBM contract designed to eliminate the major tricks and hidden economics we've identified.
Texas can have it for free.
Use mine. Improve it. Open source it.
I don't care.
Just stop making every government entity negotiate these contracts from scratch.
3. Make the economics public
If taxpayers are paying the bill, taxpayers should know the price.
Pricing. Fees. Rebates. Guarantees. Pharmacy reimbursement. Affiliate compensation. Audit rights.
Make them public.
I'm not talking about patient information or legitimate security information.
I'm talking about the money.
You cannot have an efficient market without price discovery.
Without price discovery, you get information asymmetry.
And when one side knows dramatically more than the other, guess who wins?
Not taxpayers.
Not employers.
Not patients.
Open the contracts up and let competitors see what they have to beat.
That giant sucking sound you hear will be money moving away from healthcare conglomerates that are too big to care and back toward taxpayers, employers and patients.
In the immortal words of Charles Barkley:
I guarantee it.
4. Kill the gag clauses
PBM contracts are like Fight Club.
The number one rule of Fight Club is that you can't talk about Fight Club.
The number one rule of many PBM contracts seems to be that you can't talk about your PBM contract.
That's insane.
Let employers compare pricing, rebates, fees, guarantees and reimbursement terms.
Markets work better when buyers know what other buyers are paying.
5. Make enforcement hurt
If a healthcare company commits a serious violation, give them one mulligan.
But after a second material federal or Texas enforcement action within a defined period, make them ineligible for new Texas government contracts for a period of time.
Two strikes.
You're out.
Today, some of these companies can make billions, get caught, pay a fine and write it off more easily than I wrote off an NBA fine.
That's not deterrence.
That's a cost of doing business.
And Texas should spend more on enforcement.
If Texas spends $10 million auditing contracts and analyzing claims and prevents $100 million in unnecessary spending, that's not overhead.
That's a 10x return on investmen
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Consumers shouldn't be forced to pay $500 for a prescription under their health insurance plan if the same drug is available for $100. To lower health care costs, we need price transparency. @mcuban
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