Friday, December 14, 2018

How's Doing?

Through six weeks OE6 is at 4,132,432 plan selections. This includes the period from November 1st through December 8th.

So how does it compare to years past?

2015  4,171,714
2016  4,015,709
2017  4,678,432

Not bad, considering the better economy has created more opportunity for people to gain employer sponsored insurance, Virginia expanded Medicaid, Trump rolled back the Obama rule to allow short term plans to last up to a year, and he saved taxpayers by slashing "marketing and outreach" funding to special interest groups.

No comment

R'unh ro!

[click to enbiggen]


Thursday, December 13, 2018

Medicare4All in a nutshell

Hello, and Welcome to McDoctor's!

You might have seem this in the news recently:

"New technology revolutionizing area McDonald’s with self-order kiosks"

Well, turns out MickyD's isn't the only place in town implementing this new technology. Recently, FoIB Holly R was at her new (to her) doctor's office, where she was checked in via a similar kiosk:

[click to embiggen]

(And note the hand sanitizer next to it. Heh)

"There's a bank of them with one human helper."

Imagine the airport, or the self-checkout line at the grocery store.

It makes a lot of sense in the medical setting, as well: easier HIPAA compliance, and the machines don't get a paycheck or insurance, or vacay or sick days. And this doc's figured out how to have a bunch of them: imagine how much that would cost as human office staff.

Welcome to the future.

Merry Health Wonk Review!

Our good friend Peggy Salvatore hosts this month's joyous compendium of wonky posts, do stop by to unwrap one for yourself. From Massachusetts to Colorado to Russia, there's something to celebrate.

Thanks, Peggy!

Wednesday, December 12, 2018

Interesting CMS Trick

So as Open Enrollment v6.0 winds down (with Saturday being the deadline for most of us), those of us certified to sell on the Federal Marketplace (aka "Exchange" or "HIX") received this email from the Centers for Medicare & Medicaid Services (CMS) this morning:

"As with previous years, some consumers who call the Marketplace Call Center during high-volume periods may be asked to leave their contact information to complete their enrollment after the December 15 deadline. This process will reduce hold times and allow those consumers to come back and complete their enrollment for January 1 coverage." [emphasis in original]


So how does that work?


"As we get closer to the deadline, the Marketplace Call Center may start prompting some callers to leave their contact information. This is an automated process enabled when volume is high. When someone calls, they will either be asked to leave their information or they will wait to speak to a representative. If a consumer is able to speak with a representative, they will be offered assistance with enrollment. There is no option for a caller to ask a representative to leave their information for a later enrollment."

Well that makes sense, sorta:

If the deadline is December 15, and we've known about the dates and the cutoff for many months, why are we coddling late-comers who've had plenty of time to make this happen before the last minute? I think we all know the answer to that:

"Has anyone noticed there's only abt 10m enrolled in exchanges & the (2013) baseline estimate is about triple that?"

Proving that the rocket surgeons in DC will do pretty much anything to goose those numbers.

Outstanding Customer Service Trick

We recently purchased a new refrigerator to replace our previous 27 year old one (don't judge). Obviously, this entailed removing the old fridge, revealing ancient secrets which would have delighted Dr Jones.

Among them were several long-lost gift cards to various places, including one from Carrabba's Italian Grill. Since there was no indication of how much was left on it, I got online and clicked over to their company website, where there was a handy feature where one could check gift card balances. Alas, the widget required not only the card number (which I obviously had), but a 4 digit "pin number," as well (which this card lacked).

Not to be discouraged, I used the handy online contact form to explain my plight and ask for help.

I got an email reply almost immediately, asking for the card number, which I provided. What came next was purely delightful:

Can you please provide your mailing address so we can send a replacement card out in the mail? Since this card was produced back in 2007 it was not printed with a pin, which is now required at the time of redemption.

Thank you,
Gift card team"
Waitaminute! That little guy had been trapped under (or behind) our refrigerator for 11 years? Yikes! And these folks are offering to replace it?


It just doesn't get any better than that.

Thanks, Carrabba's, and kudos!

Tuesday, December 11, 2018

From Zero, A Hero

So the other day, I ran into a (newish) outfit called The Zero Card, which appeared to promise that now ubiquitous "free" health care. And since this didn't appear to be a state-sanctioned (or run) program, I was intrigued, and so I reached out to FoIB Dutch Rojas for introductions.

Dutch hooked me up with TZC's Chuck Foster, who graciously spent almost an hour with me explaining how the plan works, its limitations and benefits:

The Zero Card is based out of Tulsa, Oklahoma, and its plans are currently available in almost a dozen markets (with expansion plans in the works). It's available to self-funded groups exclusively (why that must be will become evident shortly), and operates as a sort of "sub-network" to a company's primary insurance-provided primary network.

From the employee's perspective, it couldn't be simpler (or better):

By choosing a provider associated with The Zero Card, all deductibles, co-pays and co-insurance is waived, the procedure or service becomes free to that patient. This in contrast to using the primary network which would entail potentially large out-of-pocket expenses. Best of all, the employee (or covered dependent) incurs no charge or fee. And because of how it's designed, there are no pre-authorization or second opinion hassles. Sweet!

But of course, the actual service does come at a price, and entails a bit more framework. From the employer's end, there's a percentage of claims ("spend") cost, but the plan is designed to nullify that: everything is in a bundled transparent price agreement, no "percent of medicare," etc.

Here's how it works:

The employer enters into an agreement with The Zero Card folks to offer the benefit, at no upfront cost. What TZC does then is adds 15% to the cost of the service or procedure; the idea is that they've saved the employer more than enough to compensate for this added expense.

How do they do that? Well, they go out to local providers (doctors, hospitals, facilities) and negotiate service "bundles." This results in more business for those providers, and helps to drive down the service costs. Chuck explained it like this:

In a typical plan, a service that costs $10,000 means that the employer is on the hook for $8,000, the employee for $2,000 [ed: excludes deductibles and co-pays].

The Zero Card folks have negotiated rates to a point that, even though the employer is on the hook for 100% (plus the 15% The Zero Card fee) that they still save money and, of course, have very happy employees. In order for this to actually happen, they strive for at least 35% savings off the traditional insurers' networks.

Another thing that Chuck stressed to me is their data analysis prowess: they are able to pinpoint how and what claims are paid in a way that really helps employers understand what's happening with their employees' and their plans. One can see where that could be a major benefit for both the employer and the employees.

Of course, this model really only works with self-insured group plans (because there’s no way to incorporate it into traditional fully-funded insurance plans), so it's limited, but as more and more carriers roll out self-funded plans for smaller and smaller groups, that's bound to mean market growth for TZC, too.

One thing we didn't discuss, but which occurred to me afterwards was what, if any, role they might play in the Association Health Plan space. Maybe next time.

[IB Thanks to Dutch and Chuck!!]

Monday, December 10, 2018

The Flipside of HSA's

As regular readers know, we've long been advocates of Heath Saving Accounts (HSAs). Unfortunately,the individual medical market no longer allows the kind of true catastrophic plans that make the accounts financially viable, but hope springs eternal.

For those lucky enough to have group and/or older individual HSA plans, though, the tax benefits remain a major draw. But what happens when one hits retirement age and offboards to Medicare?

Well, at that point, you can no longer contribute to the account itself, but can continue using it for medical expenses. But you can also use it as a (supplemental?) retirement vehicle, and apparently that's quite the popular option. As FoIB Allison Bell reports:

"Steve Neeleman, HealthEquity’s founder and vice chair, said employers are now asking for a “marriage of health savings accounts and other retirement plans.

Having the accounts managed by the same folks that manage the company retirement plans can be a big bonus:

"Integrated retirement plan-HSA systems could make it easier for employee clients to pull the records they need to have comprehensive discussions of their finances with their advisors."

Among other advantages (follow the link for more).

A Holly Jolly Linkfest

Courtesy of FoIB Holly R.

Camp Fire kills carrier:

"The local Merced County Insurance Company — whose client base is overwhelmingly located in the wildfire-prone Sacramento Central Valley area — announced this week that it was closing shop because it can’t pay out the expected fire-related insurance claims."

Facing at least $64 million on claims, and with only $23 million of available assets, the company sought - and has received - bankruptcy protection. Fortunately for their clients, the California Insurance Guarantee Association (sort of like FDIC for insurance companies) will step in and cover their losses.

In an interesting twist, Dutch medical authorities have discovered medical ethics. Readers may recall our recent post about a Dutch doc in the dock:

"Dutch doctor faces first euthanasia prosecution"

Well, it seems that another of the country's traditions is about to expire:

"Two major Dutch hospitals say they will stop importing human body parts from American firms, which they have been doing without any regulation for a decade."

Parts is parts, as the saying goes, but apparently this practice was a bridge too far for even the Dutch:

"The move comes amid investigations by U.S. law enforcement into some so-called body brokers - companies that obtain the dead, often through donation, dissect them and sell the parts for profit. "

More details at the link.

  The Much Vaunted National Health Service© is also in the news for coming clean on their own little shanda:

"The family of a former soldier who took his own life have won a six-figure payout after NHS chiefs admitted a catalogue of failings in his care."

The 29 year old paratrooper, Aidan Knight, had served in Iraq for half a decade. He finally bailed, having "seen too much death." He'd been trying to get professional counseling for two months, unsuccessfully. In a case of "too little, too late," the MVNHS© has apologized and cut a cheque.

Better than nothing, one supposes.

Friday, December 07, 2018

Pearl Harbor Day 2018

77 years ago today:

Thursday, December 06, 2018

DPC & HSA: A Contrarian's View

We're big fans of Health Savings Accounts and, more specifically, of true catastrophic major medical plans, which would be ideally suited for "wrapping around" Direct Primary Care subscriptions. Currently, DPC fees are not eligible for HSA reimbursement, and there are a lot of folks (myself included) who would like to see that corrected.

On the other hand, it turns out that what seems like a simple idea may not, in fact, be such a slam-dunk:

"A quick analysis of this bill by DPC docs was startling. This “simple fix” was suddenly no longer simple, and it wasn’t really a fix at all."

This was in response to new legislation, called the Primary Care Enhancement Act (PCEA), that has been bandied about the hallowed halls of Congress for a little while. Once it finally got through that meat-grinder, what came out was a stripped down, essentially useless bit of fluff without real-world application or benefit:

"DPC agreements could only include services represented by codes for “evaluation and management” office visits (CPT 99211-5). That means that Pap tests, wellness exams, simple in-office testing, strep tests, urinalysis, EKGs or any office-based procedures would need to be excluded."

Ooops. Again, the goal was to make more widely available a model that took obviously non-insurance services (pap smears, physicals, etc) out of the bloated (and unnecessarily expensive) ObamaPlans and put them back where they belonged: with the patient. By then allowing these fees to be run through one's HSA (just like contact lens solution and baby sunscreen) one's net cost is then reduced, making this an even more affordable option.

Alas and alack, it appears that this is not to be:

"The bill fixes the wrong Internal Revenue Code ... it makes DPC an exempted health plan ... [which] creates conflict in the 25 states that passed legislation declaring DPC is not a health."


And that just scratches the surface of what's wrong with this ill-advised effort. Do click through for more gory details.

[Hat Tip: Dr Lee Gross]

Wednesday, December 05, 2018

Medicare4All: An Economics Lesson

From our friend Michael Bertau:

[click to embiggen]

This in response to a request for a comparison of Medicare reimbursement levels to commercial (private sector) carriers.

It's a very useful way to visualize what would happen under even the most rosy of M4A scenarios; that is, what physician in their right mind would agree to take that kind of financial haircut?

As Michael goes on to explain, "[i]t's more of a local question anyway. We've got quite a few safety net hospitals in our networks, for example, who are spending 70%+ of their bed/days on Medicaid/Medicare. That's quite a big hole in their finances to fill with private pay."

In layman's terms, it means that the current (imperfect at best) system is currently bailing out the gummint-run one. What happens when that "safety net" goes away?

And as long as we're piling on, there's this. According to the gentleman who actually did the study that's received the most attention:

"It is likely that the actual cost of M4A would be substantially greater than these estimates, which assume significant administrative and drug cost savings under the plan, and also assume that health care providers operating under M4A will be reimbursed at rates more than 40 percent lower than those currently paid by private health insurance.”


[Hat Tip for Meratus link: Leo Perez]

Tuesday, December 04, 2018

Tuesday Linkfest

■ Just a thought in clarification of Justice Roberts' ObamaTax observation:

[click to embiggen]

I'd never seen it explained that way before, but that is, in fact, pitch perfect.

■ Harv Randecker (of the National Association of Alternative Benefits Consultants) alerts us to some interesting HSA news:

"Disenrollment from HSA-Eligible Health Plans Increases Employer Health Benefit Costs"

That is, deleting these types of plans actually increases ESI (Employer Sponsored Insurance) costs:

"There is evidence that individuals who disenrolled from HSA-eligible health plans were more likely to have certain health conditions than those who remained enrolled in HSA-eligible health plans"

But is the cart pulling the horse?

"Individuals with multiple conditions were even more likely to disenroll"

It's certainly a possibility.

■ This is interesting: you know all those GoFundMe campaigns to help raise money for folks facing catastrophic medical bills? Well, FoIB Rob M warns the folks behind them to tread carefully:

"[M]any people on ACA exchange policies likely also utilize GoFundMe and other "Crowdsourcing" tools to raise money for their medical expenses even if they also receive ACA subsidies ...  some funds raised via GoFundMe accounts counted as taxable income*, that means they also may* count against your ACA subsidy eligibility." [emphasis in original]

That is, if you're worried about clawback (and you should be), then you need to be aware of this potential money trap.

And by the way, great catch there by our friend Charles Gaba.

Monday, December 03, 2018

Chag Chanukah Sameyach!

Case Study: DPC & ACA

So, working on an interesting, perhaps one-of-a-kind case:

Sally, 62 years young, has a very limited income, a few meds, and a need for health insurance. Fortunately, she qualifies for a substantial subsidy: so substantial, in fact, that one of the plans would cost her $0 in premiums [ed: Hi, Jeff!]. On the other hand, that plan has a substantial out-of-pocket liability of its own, to the tune of $7900, which represents a rather significant portion of her income were she to encounter a major, catastrophic expense.

And speaking of catastrophic expenses, one of the problems with the Direct Primary Care model has been the lack of plans to provide coverage for major claims (eg heart attacks and cancer treatment). On the other hand, it does offer affordable primary care (of course), and often includes deeply discounted prescription drug costs.

Well, it turns out that we may have our first legitimate "you got my DPC in my ACA" case:

We checked DPC Frontiers, and it turns out there are a couple of practices located near Sally, and with affordable rates (about $100/month). Coupled with that "free" ACA plan to act as the DPC "wrap," it looks like we have a winner:

Catastrophic coverage in case she gets hit by a bus, or cancer
Not defined by or limited to in-network doc's (other than, perhaps, specialists), and so not deterred by narrow networks
Perhaps my biggest DPC bugaboo is unnecessary (and costly) duplication of coverage, which this basically resolves
From what I have gathered, DPC doc's also have access to low(er) cost prescription meds, which obviates the need to ACA-plan rx coverage
Seems like a win-win to me.

Unfortunately, of course, this will continue to be the exception, rather than the rule, until we get true catastrophic plans back.