Thursday, January 18, 2018

From the Mailbag: Muddy P&C

Last week, FoIB Jeff M and I were chatting and the subject of the (horrific and now deadly) California mudslides came up. We wondered if (and/or how) one would be covered if one's house (literally) went downhill.

Eventually, we turned to Co-blogger Bob, who's a regular participant in an agents' forum, and asked him to research there for this on our behalf.

We were not disappointed.

The two most helpful replies:

"Most HO policies exclude flood and earth movement. The NFIP forms define what "mudflow" is. DIC policies may cover mudslides and earth movement, but if it's in an area blighted by wildfire, availability and affordability could be an issue for a DIC policy."

And:

"Hello! Here's what I heard back from our underwriter @ Safeco... I am based at CA.

'No coverage for mudslide, only possibly covered under Flood coverage depending on the % of water in it (a mudflow). There is no coverage for hotel/food etc. under the home policy either if evacuated due to the mudslide. Mudslide is covered under EQ if a result of an earthquake
.'"

Thanks, Bob (and IF folks)!

WooHoo - New Wonk Review!

Health Wonk Review co-founder (and all-around mensch) Joe Paduda gets the first 'Review of 2018 and hits it out of the park.

From  rx cost sharing in Germany to expanded association plans to industry corruption, and lots more. Enjoy!

Wednesday, January 17, 2018

Breaking: Goodbye Good Sam

It's been just a couple of weeks since we learned that Premier Health and United Healthcare had buried the proverbial hatchet; now we learn that the former is cutting loose what seems to have become quite the financial albatross:

"Good Samaritan Hospital, the fourth-largest hospital in the Dayton region, will close."

Premier Health appears to be streamlining its facility offerings, in line with its self-proclaimed "2020 strategic plan." The company says that Good Sam's services will still be available, just moved over to Miami Valley Hospital (about 5 miles, or 14 minutes, away). How that will work out is, of course, anyone's guess.

Stay tuned...

[Hat Tip: FoIB Debbie C]

Can’t say I’m surprised. You?

According to Gallup, “After four years of Affordable Care Act implementation, the percentage of adults with no health care insurance has hit 12.2 percent”

So is that an increase or a reduction? The linked article continues:

In the last quarter of 2016, the percentage of uninsured hit a record low of 10.9 percent. A year later, in the last quarter of 2017, the percentage of uninsured increased by 1.3 points—the largest single-year increase Gallup has seen since it began tracking the measure in 2008.”

Based on US population of approximately 320 million, each 1-percentage point increase to the uninsured rate is about 3.2 million people. Do the math.  The number of uninsured Americans increased by more than 4 million just at one enrollment - 2017!  (For any progressives who may struggle with math, 3.2 x 1.3  = 4.1). Don't forget the premiums for 2017 were set B.T. - Before Trump.  


Also note that after 4 years of Obamacare, and despite the “mandate”, Americans age 26-34 have the highest  uninsured rate = 20.1%.   Can’t say that’s a surprise either.

Data, Data, Who owns the data? Part #3,624

So here's an interesting (if tragic) scenario:

"An Afghan refugee named Hussein Khavari is being accused of raping and murdering 19-year-old medical student Maria Ladenburger, disposing of her body in a river."

He has since confessed to the crime, but is disputing some of the details that were obtained once the police were able to access his iPhone's health/activity data for the date of the crime. It seemed to confirm his guilt, but has raised some interesting questions (some of which we've seen echoed here: the Sam Bernadino tragedy comes to mind):

"Sean O’Brien, a researcher at Yale Privacy Lab [believes that it] would be much better... not to collect such surveillance data at all. Such data is best kept locally on devices whenever possible. If it is collected, those who handle it have a deep responsibility to defend the privacy of their users.”

It seems to me that there are (at least) two issues in play here:

First, as we've asked more than a few times before, who actually owns your data? It's not as clear-cut as one might think:

"Hugo Campos has [an ICD] buried in his chest to help keep him alive. But he has no idea what it says about his faulty heart."

The information the device accumulates is stored in a proprietary format, inaccessible to Hugo (or anyone else, for that matter). The iPhone data is also, after a fashion: the owner must either give up the password or the authorities must (try to) use brute force to unlock it themselves. And of course here there are significant 4th Amendment issues at play here (not so much in Germany).

On the other hand, the data can be prove useful in other ways, (alleged) crime-wise:

"Further investigating – including a review of a Fitbit activity tracker – showed the scene was staged and 43-year-old Jeannine Risley knowingly filed a false report."

Two steps forward....

Tuesday, January 16, 2018

Throw Momma From the Plan

Have you ever bought something that sounded sooooo good at the time but later regretted it? Perhaps that salesperson made it seem absolutely wonderful but neglected to tell you a few things. You know, stuff that, had you known at the time, might have led you to a different decision. But the salesperson kept talking and talking and talking.

Some people without brains do an awful lot of talking, don't they? - Wizard of Oz

One of InsureBlogs favorite curmudgeon's, Wendell Potter, penned an article for Medicare Resources that caught my eye. Recent discussions with fellow agents regarding how Medicare treats SNF care led me to an article titled "Why Mom Went Back to Traditional Medicare".

This is allegedly a true story and the names have not been changed to protect the innocent.

As it seems Wendell's real mom had a real Medicare Advantage plan. At age 91 Mrs. Potter is in relatively good health for someone her age. But according to her son she might not have been so lucky had she stayed on a Medicare Advantage plan. Like a good son, Wendell switched his mom from the Advantage plan to original Medicare when she was "critically ill".

Many Medicare Advantage enrollees do exactly what Mom did after a serious illness or injury, and the MA plans they “disenroll” from couldn’t be happier to see them go. When they go back to traditional Medicare, the MA plans are off the hook for covering expensive care.

(The Medicare Advantage disenrollment deadline is Valentines Day every year, so mark your calendar for 2/14/2018).

According to Wendell, his reason for throwing Momma from the plan was this.
the head nurse took me aside and told me that another nurse – not at the facility but at Mom’s Medicare Advantage plan – had come to the conclusion that the skilled nursing was no longer “medically necessary.” This other nurse – a so-called “utilization management” nurse – had never laid eyes on my mother, much less treated her. But she was able to insert herself between my mother and her treating physician and, for all practical purposes, determine whether or not she would get the care her doctor said she needed.
Beyond being a dutiful son, Mr. Potter had RESEARCH to back up his decision.
Kaiser Health News quoted J. Michael McWilliams, the Harvard professor who led the research team, as surmising that “beneficiaries who developed serious ailments might leave the (MA) plans to get unfettered access to physicians and treatments through traditional Medicare.
Unfettered access as opposed to managed care that is baked in to Advantage plans.

Claims submitted to original Medicare are still required to meet medical necessity standards, but there are no utilization monitors overseeing the ongoing claim. Claims are adjudicated AFTER THE FACT rather than ongoing when you have an Advantage plan.

That's not as bad as it sounds.

If the attending physician cannot prove medical necessity for the treatment under original Medicare the beneficiary is not responsible for the claim. An exception occurs if the patient signed an Advance Beneficiary Notification form PRIOR TO the procedure or treatment.

ABN applies to claims with original Medicare, but not Advantage plans.

So Wendell was able to use the system to get Momma off the managed care plan and into an un-managed plan with original Medicare.

But he neglected to mention one thing.

Disenrolling from the Advantage plan the way she apparently did negated any guaranteed right to purchase a Medicare supplement plan. The way his article is worded it appears this was a VOLUNTARY disenrollment, not one triggered by moving out of the service area or because her current plan was discontinued.

Perhaps his mother was healthy enough to qualify for a Medigap plan, or perhaps not. He does not elaborate on this point.

Disenrolling from an Advantage plan does allow you to go to original Medicare without answering health questions. But without the protection of a supplement plan the beneficiaries exposure on Part B is unlimited.

Or as I like to explain it, your 20% share of Part B expenses continues until you get well, run out of money or die.

Only one of those results is optimum.

While the saga of Mrs. Potter and the nursing home makes for an interesting read it can be a bit misleading to those who think disenrolling means you can automatically enroll in a Medigap plan.

But now you know.

#MedicareAdvantageDisenrollment  #ManagedCare  #NursingHomeCoverage





Monday, January 15, 2018

Dr. Facebook

With so many wonderful and useful site where one can get medical information and "advice", we find it odd that people would troll social media for health information. Yet, according to Dr. Audrey Nath (Kevin MD) if you want REALLY GOOD advice you go to Facebook.

Here is a sample query as paraphrased by Dr. Nath.
“Help! My baby has a fever, what do I do? I have a pediatrician, but I
clearly trust you guys more than that guy,”
or, even better, “My child is ill and also having mental status changes that are rather concerning. Also, of equal importance, I need you to tell me exactly when the Mongolian spot on her back will disappear. Thanks in advance!”
Whatever happened to mom's advice about "never trust a stranger"?

One response to a question related to stomach distress.
“Grape juice is a remedy for any gastroenteritis, given that it changes the pH of stomach acid, and therefore, has some sort of antiviral effect.”
If grape juice is all that is needed take them to communion. Sure, some churches use real wine but even Apostle Paul said a little wine is good for digestion.

With sterling advice like this it makes you wonder why doc's charge so much for a consultation. And remember that Facebook does not charge a dime for membership.

Gives a whole new meaning to socialized medicine.

#Facebook #MedicalAdvice


Sunday, January 14, 2018

This Sceptered Isle - Part MMXVIII

Britain’s NHS is seeking to charge co-pays for certain patients.  Up to now, NHS has always claimed to be “free” for everyone . . . Free at the point of service, anyway. (I suggest you read the entire linked article.  Its headline is a bit misleading.)

While charging of co-pays would be a departure, it should come as no great surprise.  In the first place, NHS financial problems have been public for quite a while.  And, after all, NHS is just another insurance company - albeit a giant, national monopoly. Aside from the political control of its management and budgets, NHS behaves very much like private insurance companies around the world. Specifically, NHS has a large bureaucracy that determines what medical services are reimbursed, and under what terms.  Also, NHS is financed by premiums that must must cover its costs - although NHS “premiums” are disguised as taxes.

And now - co-pays?

What next?  Refusal to cover services of non-approved physicians and hospitals?

Will NHS end up a British HMO?

Friday, January 12, 2018

And The HIT Just Keeps on Coming

Obamacare imposes a "fee on insurance companies" for fully insured plans that is referred to as the HIT (Health Insurance Tax). Last year this tax was in a one year moratorium thanks to Congressional relief. But this year it is back in full effect.

The tax on health insurers is non-deductible, meaning for every $1.00 in taxes the insurer will need to take in $1.54 (assumes 35% corporate tax rate). For 2018, the amount this tax must generate is $14.3 billion - meaning insurers must generate $22 billion of additional premiums to pay for it. Insurers have to pay their portion based off of market share so the larger presence they have the greater the amount they have to charge. This also makes it a moving target from year to year.

The tax applies to all fully insured coverage including:
  • Individual On Exchange
  • Individual Off Exchange
  • Small Group Fully Insured - Both ACA and Pre ACA
  • Large Group Fully Insured - Both ACA and Pre ACA
  • Medicare Advantage
  • Medicare Part D
  • Medicaid Managed Care

To offer transparency, many insurers are breaking out these taxes on renewals for consumers to see. But, for most employer plans - where a large amount of this revenue is generated - this tax isn't transparent to employees.

Employers offer a total compensation package to employees. Wages and benefits are the biggest drivers of what makes up an employee's compensation. The HIT hurts employee wages and benefits while providing zero value to the business.

How bad does the HIT hurt employers? For my clients it's extremely painful. Reviewing my January 2018 renewals I found the average cost per employee is $356.50. That doesn't seem like much right?Until we do the math and show that this tax averages a cost of $0.17 per hour.

This puts an employer in a tough position. Do they give a $0.25 an hour raise but increase premium contributions by $0.17 an hour? Do they cut benefits by $0.17 an hour? Or, do they decline to expand, cut overtime, or reduce staff to pay the tax? These are tough decisions employers have to make that are all done behind the scenes.

Employees see these decisions to increase the amount deducted from their paychecks, higher deductibles, higher copays, more restrictive provider networks, and higher prescription costs as if the employer or the insurer is screwing them.

The reality is Obamacare's HIT is causing the problem. It's been screwing employees since 2014 and every year it will get worse.

The next time someone says Obamacare doesn't impact employer sponsored insurance remember the HIT. It's the sucker punch that keeps on coming.

Half Empty or Half Full?

You are probably familiar with the phrase "Is the glass half empty or half full?". A popular meme says, the problem is obvious. You need a smaller glass. Better idea, more wine.

This may be the solution when you are talking about wine. But how about health care?

No, not health insurance. Health CARE.

A recent Kaiser Foundation report addressed the issue of "robust physician networks" in popular Medicare Advantage plans. (Full report here).

Many people are confused about Medicare Advantage plans, especially those that do not charge a premium. (Free insurance. How can they do that?).

Excellent and logical question and one that comes up quite a bit. Most folks on Medicare are smart enough to know if someone offers you a product or service at no charge there must be strings attached.

But the $0 premium plans are a marketing gimmick by the carriers, not something baked into Medicare rules.

That is a discussion for another day.

Regarding doctor networks and Medicare Advantage plan consumers are once again faced with the question. If I like my doctor can I keep my doctor?

The answer is "yes".

Advantage plans do not forbid you from seeing certain doctors. You are free to use any doctor you wish . . . as long as you are willing to pay for that privilege.

From the KFF report (linked above):

 As of 2017, 19 million of the 58 million people on Medicare (33%) are enrolled in a Medicare Advantage plan, yet little is known about their provider networks.

"Little is known about provider networks". I wonder how many of those 19M people really understand networks and what that means. In particular, what happens if you are in treatment at the end of the calendar year and your doctor(s), hospital(s) and clinic(s) are not in network the following year?

According to Kaiser, 78% of Advantage plans did not include all doctors who practiced in the service area. On average, less than half (46% per the survey) of physicians did not participate in Advantage plans. Some plans included 60% of physicians who practiced in a particular county while other plans had less than 10% of doctors participating.

The report included the following eye openers:

  • 20% of plans had fewer than 5 thoracic surgeons
  • 18% of plans had less than 5 neurosurgeons
  • 16% of plans had fewer than 5 radiation oncologists
Remember, you are free to use any doctor you wish, including your own, but using someone that is not on the approved list can be harmful to your wallet.


And some doctors, including your regular one, may refuse to see you if you have an Advantage plan.

The size and composition of Medicare Advantage provider networks is likely to be particularly important to enrollees when they have an unforeseen medical event or serious illness. However, accessing the information may not be easy for users, and comparing networks could be especially challenging. Beneficiaries could unwittingly face significant costs if they accidentally go out-of-network. Differences across plans, including provider networks, pose challenges for Medicare beneficiaries in choosing among plans and in seeking care

If you opt for a Medicare Advantage plan, make sure you understand the rules and are willing to play by them. Otherwise you may be in for a rather costly surprise.

You can pick a plan with a broad network and fewer restrictions for using non-par providers, but you can expect to pay more.

Higher premiums. Higher copay's. Higher deductibles. Higher out of pocket limits.

And how DO they offer plans that don't charge a premium?

Maybe I will address that next time . . .

#MedicareAdvantage #NarrowNetworks #HalfEmptyHalfFull



Thursday, January 11, 2018

Doctors, Doctors, Everywhere

and all the networks did shrink. Doctors, doctors, everywhere but man does it really stink.

Access to health CARE was never a problem until Obamacare.

Most people, including those without health insurance, could AFFORD to see a doctor for routine care. But now many have little left over to pay a doctor after paying HUGE health insurance premiums.

But wait, there's more!

Even if you can afford the premiums AND have money left over to pay for your care, there is a new problem.
People who bought policies from Centene, a large for-profit health insurance company, filed a federal lawsuit on Thursday claiming the company does not provide adequate access to doctors in 15 states.
 “Members have difficulty finding — and in many cases cannot find — medical providers,” who will accept patients covered under policies sold by Centene, according to the lawsuit filed in federal court in Washington State. - NY Times
You have government dictated and designed health insurance but no place to use it.

Isn't that a fine kettle of fish?

#Obamacare

Sharing, Caring and Talking

So Politico's Paul Demko reached out to me yesterday to ask about Health Care Sharing Ministries (HCSM), and specifically about whether or not I'd decided whether or not to market them. He was also interested in connecting with any (former?) clients who'd made the leap from Major Med to HCSM.

I was intrigued, and we agreed to speak this morning. In the meantime, I contacted several folks I knew who'd gone that route, especially hopeful that one in particular will respond.

Why her?

Well, because she was actually referred to me by a mutual friend at our synagogue. We had looked into ACA major med plans for her, but she ultimately chose a Ministry. Since these tend to be church-based I was intrigued, and Paul thought that would be really interesting to hear more about, as well.

Ultimately, we had a very nice conversation, and I told him that I'd let him know if I was able to connect with any of these folks so that I could send them his way (if they agreed that would be a good idea).

I don't know when (or even if) this article will be published, but will post a link to it here once it is.

Wednesday, January 10, 2018

Interesting Carrier News

Good news:

"Aflac is doubling its 401(k) match and adding additional employer-sponsored benefits as part of what the company says will be a $250 million investment initiative over the next three to five years."

The company says that these are a direct result of the recent tax bill.

Nice.

Interesting news:

"Gladys is apprehensive about getting her blood drawn ... With Legacy Optimizer Indexed Universal Life insurance. Gladys can apply without needing to provide blood work or visiting a doctor"

This from the folks at North American, for folks who need the protection (and the potential for cash value growth) but have trypanophobia.

Financial news:

"Low 2016 Individual Health Margins Trimmed Insurers' Rebate Bills"

As expected, MLR itself put the squeeze on carrier profitability (and notice that as MLR has increased, agent comp has declined, even though there should be no direct correlation).

And there's this:

"[F]ewer insurers earned enough to owe rebates to the enrollees."

Thus offering even more proof (as if it was needed) that the ObamaCare's end-goal has always been Single Payer.

Always.

Tuesday, January 09, 2018

Companion Life takes a hit


Related: About 20 or so years ago I had a similar situation with a client. Small group health plan with $15,000 life and AD&D ("Accidental Death and Dismemberment);" the idea was that the death benefit doubled if one died from an accident (as opposed to illness). One of the employees, a young man (of course), decided to play chicken with a Ford Explorer (he was riding a motorcycle).

To my surprise, they actually care-flighted him to the hospital (to no avail, of course).

We submitted the death claim, which was approved for the underlying amount, but the AD&D portion were denied because the wording (more explicit than was the case here) said no "double indemnity" if alcohol was involved.

I had a few questions about that wording, too, but never had the opportunity to raise them.

Top 30, Baby!

The folks at Feedspot have graciously named us as one of the Top 30 Health Insurance blogs.

Blogs are ranked based on:

Google reputation and Google search ranking


Influence and popularity on Facebook, twitter and other social media sites
 

Quality and consistency of posts.
 

Feedspot’s editorial team and expert review

We're in pretty august company, too, including 404Care.gov's blog, Blue Cross and Aetna blogs, and our friend David Fluker's, too.

Monday, January 08, 2018

Another day, another MVNHS© shanda [UPDATED]

The Much Vaunted National Health System© strikes again:


[Hat Tip: FoIB Holly R]


UPDATE: Oh, and this, via FoIB Michael Cannon:

"Every hospital in the country has been ordered to cancel all non-urgent surgery until at least February in an unprecedented step by NHS officials."

Also courtesy of the MVNHS©, natch.

Thursday, January 04, 2018

Compare & Contrast: CanuckCare vs MVNHS©

Our Neighbors to the North©'s latest offering:


Interesting self-correction by Dr Langer:

"Yes, it’s not ‘free’, it’s no-cost at purchase. People like me pay for it through our taxes. As it should be" [emphasis added]

To which the only rational response is: Why?

But it gets better (for certain values of "better"):

"N.H.S. Overwhelmed in Britain, Leaving Patients to Wait ... At some U.K. emergency wards, patients are waiting more than 12 hours to be cared for."

Again free health "care." But as we keep asking, what good is "free" health care if one can't actually, you know, receive it?

We already see that happening here as a result of ObamaCare's narrow networks and sky-high out-of-pocket costs (even leaving premiums aside).

/sigh

[Hat Tip: FoIB Holly R]

Wednesday, January 03, 2018

Two steps forward, one back

So in December, we began moving several small groups to Anthem (mostly from United Healthcare)(Heh). But we weren't alone, and they are severely backlogged.

How backlogged? Well, my rep told me that groups approved on December 21st are still not all keyed in. Which is a problem for groups approved late last month or even earlier this week.

Here's why that can be an issue: in the early morning hours of January 1st, one of my client's daughters suffered severe frostbite (long story). In fact, she had to spend time in the burn ward, and we're still not sure whether they'll be able to save her feet. As one can imagine, there's a heck of an ER and burn unit bill, and surgery is likely.

I've been on the phone with the hospital about this numerous times over the past few days; she'll be covered, but the billing situation is a mess (fortunately, this just happened so nothing's actually been billed yet).

She also mentioned that there seemed to be (at least) two factors involved here: first, of course, is the aforementioned exodus from UHC. But a close second is, interestingly, the implosion of the individual market, especially here in southwest Ohio: a lot of smaller employers who had been on the fence about installing a group plan took the plunge as a result of that implosion.

So, not a bad problem to be sure (hey, lots of new business means lots of new premium dollars), but a service mess for at least a while.

[Hat Tip: FoIB Liz M]

Tuesday, January 02, 2018

Breaking: UHC and Premier Kiss, Make up

After spending most of the year on the outs, health insurance behemoth United Healthcare and big-time medical care provider Premier Health have reached "a new, multi-year relationship ... the agreement ensures access to Premier Health’s physicians and facilities for Medicare Advantage plans and restores access for commercial plans effective Jan. 1, 2018."

This was a major stumbling block for most of 2017, and one wonders just how badly the disagreement hit UHC's bottom line (I know of more than a few groups who bailed solely because of this issue).

Will be interesting to see who's next....

[Hat Tip: FoIB Amanda A]

Monday, January 01, 2018

Medical Migration? Medical Tourism? Medical Exile? Whaaaaaa?

Three random topics.    Or    so    I    thought.

1. Medical Migration?  A former employee of the Johns Hopkins Health System has accused the System of violating state and federal regulation by admitting out-of-state patients in preference to Maryland residents.  In other words, the Hospital is “migrating” out-of-state patients into Maryland.

Maryland sets an annual global budget for each of its hospitals.  The federal government also participates in the regulations, by requiring that the hospitals comply with the state-set budgets.  I suppose the feds’ interest is that they finance Medicare and share in the financing of Medicaid.  But the global budgets apply only to residents of Maryland.  Hospital revenues from out-of-state patients – “medical migrants” - are outside the global budgets and thus produce unregulated additional revenues for the hospitals. 

Hopkins’ former employee alleges Hospital management pressured staff to migrate out-of-state patients into Hopkins Hospital, taking beds that might otherwise have been available to Maryland residents, and generating revenues that Maryland residents would not have generated.  Hopkins has responded that “Our census shows that the majority of our patients are from Maryland and that the number has steadily increased over the past several years” - which is fine as far as it goes, but does not directly or fully answer the issue.  A judge will have to sort all this out.

2.  Medical Tourism?  This term describes a growing international trend among patients seeking medical care outside their own country. It has been a recurring topic at InsureBlog over the past few years - here is an old post from 2007; there are many others. 

Medical migration is similar to medical tourism because both have similar motivations and similar ends:  the unbreakable linkage between money and medical care, and access to medical care that may not be locally available. The Johns Hopkins situation is not exactly medical tourism because it involves movement between states in the same country, not between two different countries. Yet it may be evidence that U.S. patients are becoming more willing to travel for their medical care.   And, of course, it’s also evidence of hospitals’ continuing creative efforts to improve their revenues.  


 What’s that?  Scotland is “exiling” certain patients to other countries in the U.K. for medical treatment? 

It’s complicated.  It seems Scotland has allowed at least 460 NHS specialist positions (plus an additional unspecified number of nurse positions) to go unstaffed.  As a result, a growing number of Scottish patients face unexpected travel for specialist or routine nursing care.  NHS Scotland is sending these patients to England, Wales, or Northern Ireland.  NHS actually anticipated this as an infrequent contingency, so there are funding and administrative means in place to handle referrals.  But the recent, sharply increasing volume of such referrals was not anticipated.  Scotland has apparently been managing – or mismanaging - its understaffing problem by “exiling” patients to obtain care outside their own country, rather than filling the vacant specialist positions inside Scotland.  

The available information is hard to interpret.  For example, how does Scotland reimburse other U.K. specialists?  How does the sum of those reimbursements compare to the sum of the salaries and other employment costs for the 460 specialists the Scots would otherwise employ?  I can’t help but suspect one of those numbers is a fair bit larger than the other.

So why tie these three phenomena together?  Movement. 

Specifically, the movement of a growing number of patients willing - or obliged - to travel far from where they live, in order to access medical care.  Movement of patients within the U.S. to access medical care has been a  slow-growing thing for some years.  But in other parts of the world, such patient movement seems to be growing faster, and is more common across national borders.  And the worldwide phenomenon is not exclusively physician- or patient-driven. Governments are facilitating and, in some cases (i.e. Scotland), are requiring such travel. 

Is patient movement likely to improve care? Will it improve access? Balance patient loads? Result in better match of patient needs with services across local, national, and international medical care delivery systems?  Or will it be not so beneficial?  Will these trends instead end up exposing a world delivery system largely unprepared to meet the rising demand for medical care? Is this the start of some classic B-movie, in which a flooding river causes the dam to spring small leaks, as rising waters spill around and over the dam, and no one is listening to the few townspeople who notice what is happening?

Time will tell.  Meanwhile these phenomena are related, and do bear watching.