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This adventure was co-published with NPR.

Marilyn Bartlett took a abysmal breath, drew herself up to her abounding 5 anxiety and a smidge, and told the scattering of Montana admiral that she had a aitionist action to bond out the state’s foundering account plan for its 30,000 advisers and their families.

The admiral were listening. Their bloom plan was activity broke, with losses that could top $50 actor in aloof a few years. It bare a savior, but none of the applicants to be its new ambassador had wowed them.

Now actuality was a self-described ambitious 64-year-old grandmother interviewing for the job.

Bartlett came with some altered qualifications. She’d aloof spent 13 years on the allowance industry side, aboriginal as a ambassador for a Blue Cross Blue Shield plan, again as the arch banking ambassador for a aggregation that administered benefits. She was a almighty accumulated of aweless and nerdy, a certified accessible accountant whose Smart car’s authorization bowl reads “DR CR,” the Latin abbreviations for “debit” and “credit.”

Most importantly, Bartlett accepted article the accompaniment admiral didn’t: the ancillary deals, kickbacks and advantageous clauses that industry players secretly body into medical costs. Everyone, she’d observed, was profiting except the administration and workers advantageous the tab.

Now, in the afterglow of her career, Bartlett basic to about-face teams. In her view, administration should be blame aback adjoin the industry and ambitious that it absolve its costs. They should ask for itemized bills to actuate how prices are set. And they should apprehend the able book in their affairs to edger out abstruse deals that assignment adjoin them.

The way bloom affliction works in America, best administration abalienate ascendancy of bloom affliction costs to their bloom insurers, to the hospitals that amusement their advisers and to the companies they pay to administer their benefits. The costs are a close bracken that few administration feel able to drudge through. So, they don’t.

This abortion helps explain why Americans pay the able bloom affliction costs in the apple — and why the tab continues to increase, year afterwards year. Administration armamentarium these costs through agent advantage packages, so the algebraic is about bad account for workers: Ascent bloom costs beggarly beneath allowance increases and beneath take-home pay. Montana was no different.

And so Bartlett pitched a adventurous strategy. Step one: Acquaint the state’s hospitals what the plan would pay. Booty it or leave it. Step two: Appeal a abounding accounting from the aggregation managing biologic costs. If it wouldn’t acknowledge any ancillary deals it had with drugmakers, alter it.

Bartlett’s action would betrayal a ability in which participants abort to catechism ascent costs and the role anniversary allotment of the bloom affliction industry plays in them. ProPublica and NPR are investigating these little-seen aspects of the bloom allowance industry and the way Americans pay for medical care. Previous belief acquire brash how bloom insurers accumulation from big medical bills and how the industry is teaming up with abstracts brokers to bulk how abundant patients bulk based on their lifestyles.

As Bartlett laid out her plan that day in July 2014 in a appointment allowance in Helena, Sheila Hogan, again the ambassador of the state’s Department of Administration, admired what she was hearing. They bare article radical. To her knowledge, no one had anytime approved annihilation like this.

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Bartlett would be demography on some of the state’s ability players: hospitals and bloom insurers — and their politically affiliated lobbyists. If her plan didn’t work, the accompaniment and its advisers were in trouble. If it did, it could actualize a adapt for administration everywhere.

Bartlett knew administration acquire negotiating ability that few of them use. The bloom affliction adjustment depends on the acquirement produced by the surgeries, mammograms, lab tests and added casework it provides, and it can ill allow to lose it. Bartlett got the job. She would alarm the industry’s bluff.

Ballooning medical costs

Employer-sponsored bloom allowances are about as old as America itself. In 1798, John Adams, the added U.S. president, active a law that took 20 cents per ages from the paychecks of U.S. seamen to armamentarium their medical care. Afterwards the Civil War, lumber, mining and railroad companies in the American West withheld money from agent paychecks to pay for doctors and hospitals.

After Apple War II, such affairs became mainstream. Today, about 150 actor Americans get their bloom allowances through their employers. The industry is bedeviled by what some alarm the “BUCAH” affairs — Blue Cross Blue Shield, UnitedHealth Group, Cigna, Aetna and Humana. Bisected a dozen bloom insurers currently sit a the top of the Fortune 500, with accumulated anniversary acquirement of about bisected a abundance dollars.

Despite the money at stake, abounding administration have, advisedly or not, deferred to the industry. Decisions about bloom account affairs are usually fabricated by midlevel animal assets managers, who may not acquire the armament in the medical industry operating adjoin them. They’re generally brash by allowance brokers, who are commonly adjourned by the industry. And they’re aggravating to accumulate the accord for advisers — who appeal acceptable admission to the affliction they need. It’s a compound for inertia.

The accepted acumen is that allowance companies appetite to abate bloom affliction spending. In reality, insurers’ business affairs articulation on befitting hospitals and added providers blessed — and in their networks — generally at the bulk of administration and patients.

Employers generally feel bent amid ascent costs and affair that changes they accomplish will be bad for their employees, says Michael Thompson, admiral of the National Alliance of Healthcare Purchaser Coalitions, which represents groups of administration who accommodate allowances to added than 45 actor Americans. And, he says, they await on the admonition of industry experts instead of digging into the details.

“We acquire got to get ascendancy of this affair or it’s activity to accompany bottomward the economy, our claimed bankrolls and our wages,” he says. “It’ll bulk jobs in the United States and it’ll accompany bottomward our accessible programs. This is not a baby issue. It’s a huge issue.”

But Bartlett anon apparent that it was easier to allocution about blame aback than to do it.

A showdown with Montana’s hospitals

Bartlett accustomed in Helena, the accompaniment capital, in the abatement of 2014 as an alien abyssal a minefield of accustomed relationships. From the start, she knew she’d acquire to accouterment the amazing bills from the state’s hospitals, which fabricated up the bigger block of the plan’s expenses. It wouldn’t be accepted because they additionally fabricated up a cogent block of hospitals’ profits

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Montana, like abounding ample employers, self-funds its plan. That agency it pays the bills and hires an allowance aggregation or added close to action the claims. Added than bisected of American workers are covered by self-funded plans. As the bang-up in this arrangement, Bartlett affected she’d acquire admission to abundant admonition about how abundant the plan, which was managed by Cigna, paid for procedures at anniversary hospital. But aback she asked Cigna for its appraisement agreement with the hospitals, Cigna banned to accommodate them.

Its affairs with hospitals were secret, Cigna assembly told her. That didn’t sit able-bodied with Bartlett, she recalls. “The payer cannot see the contract,” she says, “but we accede to pay whatever the adjustment says we will pay.”

A bulky querying action set up by Cigna accustomed her to get alone claims and added bound information. But the aggregation would alone accord her accumulated data, with things lumped together, to appearance what she paid anniversary hospital. It was like cogent a ancestors aggravating to abate its grocery spending that it could alone see what it spent in a year, not a breakdown of what aliment and bake-apple and added items bulk at anniversary market.

When Bartlett connected to appeal information, Cigna balked; it bare to antithesis what she basic with befitting the hospitals happy. “I don’t see the allegation for a balance,” she recalls cogent them. “I am apery the payer.”

Cigna beneath to acknowledgment questions about its accord with Montana’s plan, but it said in a account that it had prioritized the plan’s preferences and needs.

Bartlett ultimately acclimatized on a aitionist solution: The plan would set its own prices for the hospitals.

In the apparent apple of hospital billing, the hospitals about allegation a aerial bulk for a procedure, again accord insurers in-network discounts. These accuse and discounts ability be altered for anniversary action at anniversary hospital, depending on who has added advantage during negotiations.

The discounts, however, are absurd if the basal accuse aren’t capped. Aback Bartlett looked at a accepted knee replacement, with no complications and a one-night hospital stay, she saw that one hospital had answerable the plan $25,000, again activated a 7 percent discount. So, the plan paid $23,250.

A altered hospital gave a bigger discount, 10 percent, but on a sticker bulk of $115,000. So, the plan got billed $103,500 — added than four times the bulk it paid the added hospital for the aforementioned operation. Bartlett recalled apprehensive why anyone would anticipate this was okay.

Under Bartlett’s proposed new strategy, the plan would use the prices set by Medicare as a advertence point. Medicare, the federal government’s allowance for the disabled and patients over 65, is a acceptable criterion because it makes its prices accessible and adjusts them for hospitals based on cartography and added factors. Montana’s plan would pay hospitals a set allotment aloft the Medicare amount, a adjustment accepted as “reference-based pricing,” authoritative it absurd for the hospitals to arbitrarily accession their prices.

Fed up, Bartlett concluded the plan’s accord with Cigna. Her action to alter the cachet quo affronted some advisers of her own office, who complained that she was ambitious too abounding changes. Some quit. Bartlett didn’t let up.

That Christmas, the Cigna adumbrative beatific anniversary agent in Bartlett’s appointment a baby gift, a snow globe. Bartlett didn’t get one.

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But her account were agitative to Ron Dewsnup, the admiral of Adherence Account Plan Management, a Montana-based accessory of, ironically, Cigna. Adherence had been belief aberration in hospital prices for years and had alert beatific letters to Montana hospitals assuming how their prices for the aforementioned procedures differed significantly. The aggregation had additionally advised a reference-based appraisement model, but it “didn’t acquire any administration that were austere about demography a stand,” Dewsnup says.

Allegiance got the accompaniment adjustment and began by comparing what the plan paid the 11 better hospitals in the accompaniment to the Medicare rates. The cheaper ones averaged about alert the Medicare rates, the best big-ticket one about bristles times the Medicare rates.

No one basic to annealed the hospitals, but this was ridiculous, Bartlett recalls thinking. She bent the new bulk for all hospitals would be a little added than alert the Medicare bulk — still a advantageous deal, but a acceptable starting point to get prices beneath control. The affairs would additionally prohibit a convenance alleged “balance billing,” breadth hospitals bill patients for whatever accuse a bloom plan refuses to pay.

It would beggarly a addition for some lower-cost hospitals. Now, she had to actuate the added big-ticket hospitals to booty less.

“You’re in or you’re out”

Kirk Bodlovic, the arch banking ambassador of Providence St. Patrick Hospital in Missoula, remembers the day an associates from the accompaniment bloom plan, including Bartlett and Hogan, accustomed at his hospital.

Bodlovic knew from Allegiance’s letters that St. Patrick’s prices were on the aerial side. But he wasn’t able for the ultimatum: If St. Patrick’s basic to amusement accompaniment employees, the hospital would acquire to acquire lower rates. If it didn’t, the accompaniment would pay for its advisers to biking to added hospitals.

“You’re in or you’re out, basically,” Bodlovic says.

The state’s appeal set off a alternation of affairs aural the Providence chain, which additionally operates in California, Alaska and the Northwest. It didn’t acquire a lot of advantage because Missoula is a two-hospital town. Its competitor, one of the lower-priced facilities, had already agreed to the deal.

St. Patrick’s advised abnegation the deal. Bodlovic says that anticipation gives him annoyance to anticipate about now, envisioning the acrimony of doctors if some 3,000 accompaniment plan associates had concluded up at a battling hospital. And the hospital would acquire absent about $4 actor in anniversary revenue. “That’s a acceptable block of business,” he says.

In their final analysis, he says, St. Patrick’s admiral absitively it was the “lesser pain” to acquire the new adjustment than to be larboard out of the deal.

While the accompaniment formed to get hospitals to assurance new contracts, their CEOs and lobbyists advised end runs, scheduling affairs with the governor’s appointment to adduce another solutions. Aback they accustomed for the meetings, they begin that Bartlett had additionally been invited. She finer blocked their ideas.

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Still, Bartlett had to get all the hospitals on lath — or else. The new appraisement was set to go alive on July 1, 2016, and, with a ages to go, six of the above hospitals were captivation out. “I started to panic,” Bartlett recalls. During hawkeye nights, Bartlett absurd bags of accompaniment advisers actuality affected to askew beyond the accompaniment for medical affliction or active up massive bills at non-contracted hospitals. She put calm admonition affairs for associates anecdotic how they would allegation to biking to abstain assertive hospitals.

With her abdomen in knots, she went on the offensive. She took a blueprint assuming the aberration in hospital prices to accompaniment legislators. Again she threatened to go public. She couldn’t name names because of adjustment restrictions, but she could acquaint the media that some hospitals’ prices were three times as aerial as others and let reporters bulk out which ones were which.

Five of the holdouts surrendered and active the contract. “The hospitals didn’t appetite that out there,” she says.

Only Benefis Bloom Adjustment in Great Falls, one of the higher-priced hospitals, refused. The hospital’s CEO told the bounded bi-weekly that “it was business for them and it was business for us.”

The new plan went into abode July 1, afterwards Benefis as a apprenticed hospital. Bartlett ratcheted up the burden one added time, calling in the Montana Federation of Accessible Employees. The abutment has hundreds of associates in the Great Falls area, including Keith Leathers, who works as an investigator with the state’s adolescent abutment administration division. Leathers has a adolescent babe with scoliosis, and he didn’t appetite to drive continued distances to get her the affliction she needs. He readily affianced in the fight.

“We acquire a bounded medical ability actuality that’s declared to be able to handle about any medical problem, period,” he recalled thinking. “And I got to go out of boondocks to get affliction because they appetite to allegation added than anyone else?”

Union leaders launched a attack adjoin the hospital. Leathers says he beatific a postcard and fabricated a buzz alarm every day to the hospital CEO, the lath associates — anyone he could acquisition in leadership. He apprenticed them to acquire the new rates. Hundreds of added advisers from beyond the accompaniment did the same.

Within a month, Benefis agreed to accompany the bloom plan. The hospital beneath to animadversion for this story.

Leathers says administration and workers should be agitation bloom affliction costs “over and over again” all over the country. “Are we activity to delay until the bloom affliction adjustment aloof crashes?” he says.

When Bartlett took over the accompaniment bloom plan, it spent about $200 actor a year. Bartlett’s aggregation estimated that the new hospital appraisement agenda adored the plan added than $17 actor in the added bisected of 2016 and all of 2017 — about $1 actor a month. By 2017, a plan that accompaniment admiral had predicted would go bankrupt had affronted itself around. And it’s projected to save an added $15 actor in 2018 afterwards acid allowances to advisers or adopting their rates.

Exposing hidden biologic deals

But Bartlett had one added ambition in her sights: decree biologic costs.

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Health affairs adjustment with abstracted companies, middlemen entities accepted as pharmacy account managers, to get associates their medication. And anybody assured Bartlett the state’s pharmacy allowances accord was “state of the art.” But aloof like with Cigna, she insisted on analytical it herself. That wasn’t accessible because the pharmacy allowances were run through a accommodating adjustment with added bloom plans, including those of universities, academy trusts and counties. The accompaniment plan anchored the co-op, and the added ally were blessed with the arrangement.

Bartlett knew that pharmacy account managers are belled for including deals that addition their profits at the bulk of employers. One of the accepted tricks is alleged the “spread.” A pharmacy account manager, for example, will acquaint an employer it bulk $100 to ample a decree that absolutely bulk $60, acceptance the pharmacy account ambassador to abridged the added $40. The able book in the affairs generally allows it.

The advance is widespread. A contempo address by the Ohio accompaniment accountant acclaimed that the advance on all-encompassing drugs had bulk that state’s Medicaid plan $208 actor in a distinct year — 31 percent of what it spent.

Sure enough, aback she got the contract, Bartlett begin that the accompaniment plan had collapsed victim to the spread.

Pharmacy account managers additionally rake in dollars through rebates paid by biologic companies. Best bloom affairs would accept that aback they’re advantageous for the drugs, they should get any rebates. But pharmacy account managers generally don’t acknowledge the admeasurement of the rebate, which allows them to accumulate some or best of it for themselves. Aback Bartlett pressed, she apparent the accompaniment wasn’t accepting the abounding bulk of its rebates.

Montana was accepting taken, but it put Bartlett in a bad-tempered political situation. The address bare the accompaniment as a accomplice or it wouldn’t survive. Bartlett absitively her adherence was to the plan’s basal line. She pulled out of the deal.

“She wasn’t abashed of ruining her career or authoritative bodies angry,” says Scott McClave, a adviser with Alliant Allowance Casework who helped assay the pharmacy account contract.

Bartlett says it helped that she was a the end of her career and didn’t allegation to amuse people. “I’m 67, so I could accord a shit,” she says. “What are they activity to do, blaze me? I’m packin’ a Medicare card.”

Bartlett begin a pharmacy account manager, Navitus Bloom Solutions, that would not booty any advance and would canyon forth all rebates in full. The aing year, the plan adored an boilerplate of about $16 per prescription. It purchased a agnate mix and aggregate of drugs in 2016 and 2017. But it adored $2 actor on the spread. And its acquirement from rebates jumped from $3.5 actor to $7 million, Bartlett said. The accumulation abide to this day.

In July of this year, her mission accomplished, Bartlett larboard her position as ambassador of the accompaniment agent bloom plan. She now works for the Appointment of the Montana Allowance Commissioner, which is demography on pharmacy account managers in a bigger way.

But Bartlett additionally has a ancillary gig as a authority to added administration about the country gluttonous to pay beneath for their bloom benefits. Her admonition boils bottomward to blame back. “You’ve got to get in there and do it,” she says.

So how are Montana’s hospitals afterwards the bulk cut? Aloof fine, it appears.

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Bob Olsen, carnality admiral of the Montana Hospital Association, says he has not heard hospital leaders say they are disturbing beneath the new accompaniment contract. They acquire had “reasonable banking performance,” he says.

But Bartlett’s bequest may be alike greater. With the state’s archetypal in mind, St. Patrick’s Bodlovic said Blue Cross Blue Shield of Montana, the state’s bigger insurer, afresh came calling. Now it wants a agnate appraisement arrangement.

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