I've linked to a story from today's London Daily Mail 31 December. Please read the entire article. I warn you it is not easy reading.
“[The patient’s] daughter-in-law Amanda . . . added: ‘All that he had at the end of his 101 years was his dignity and they took that away from him.”
Also take a few moments to scroll thru the comments left by Daily Mail readers.
No one should conclude that NHS works like this, routinely. But just as clearly this episode happened, none of the hospital staff seeemed particularly concerned about it, and many of the commenters don’t seem surprised either.
Is this, after all, the future we may look forward to in the US as we sail along toward single-payer, government-controlled health care system?
What evidence is there that the answer is anything but “yes”??
It is also eye-opening to read the cold, bloodless, and lawyerly form-letter “apology” from the Hospital. It’s almost as though the hospital is responding to a complaint about late meal delivery or some other trivial service glitch:
‘Some aspects of Brig Platt’s discharge from hospital in 2006 were unacceptable and the trust apologises for any distress that this has caused.’
Some aspects, huh? Of the discharge (and not of Mr Pratt’s mistreatment prior to his discharge?) And the “trust apologises” – well, that’s about as impersonal as one can get. Gahhhh.
Wednesday, December 31, 2008
Cavalcade of Risk #68: Up and Running!
Louise at Colorado Health Insurance Insider presents the EOY '08 Cavalcade of Risk. As usual, she does a GREAT job, including her own spin on each entry.
Do check it out.
Tuesday, December 30, 2008
Stress and the CEO
Alert reader Jeff M alerts us to this, um, alert:
Saving lifestyles, one exec at a time.
Nataline a Year Later: Even More Disturbing News
About this time last year, we reported on the sad case of Nataline Sarkisyan. Our post on December 21, 2007, began:
And it appears that this is, indeed, coming to pass:
Lead attorney Mark Geragos went on to rant that Cigna HealthCare "literally, maliciously killed" Nataline Sarkisyan."
Well, to be fair, that's what he's paid to say, even if it lacks actual, you know, truth:
Those who doubt that "public" benefit plans withhhold such vital services need only peruse Bob's post on Sabrina Holloway.
And, in fact, Cigna went out of its way to justify its refusal to cover such an experimental procedure. Unfortunately, they did cave, and agreed to pay for the risky surgery, which ultimately failed to keep poor Nataline alive.
As regular reader Matt H points out, that was really Cigna's biggest mistake:
"Cigna should have stuck to the contract. I bet they will have to pay a settlement now because of their change of mind."
That sounds about right:
Had they simply stuck to their guns in the first place, the outcome wouldn't have changed (Nataline wouldn't have survived), but they also would have a compelling defense. As it stands, by backing down in the name of PR, they face an uphill battle. My guess is that the case will be based on the simple question of timing: if Cigna had agreed to cover the surgery immediately, the argument will go, then Nataline would surely have survived. By "dithering" (i.e. actually following the correct process) Cigna reduced her chances of survival.
We'll never know, obviously, whether that would have been the case, but I think that Cigna erred in succumbing to public pressure. Had they stood their ground, such a lawsuit likely would have had little chance of success. As it stands, I think Cigna will be paying out quite a few more dollars.
If there's any silver lining, it's that perhaps other carriers will learn the correct lesson from this unfortunate event.
[Hat Tip: Reader Matt H]
UPDATE: In the comments, Chad asks a very good question:
"Why is there no condemnation for the doctors and hospital that withheld this supposedly vital, lifesaving treatment for want of payment?"
Indeed.
I made a similar observation in my original post last year:
"(T)he actual choice belonged solely to the parents and the provider."
Government Inefficiency
There are many social programs, funded by the taxpayer, and mismanaged by government administration. The story of Sabrina Holloway is just one of those.
Sabrina is a 39 year old mother of 8 covered by Medicaid. But "covered" isn't exactly true.
Therein lies the story.
Holloway is covered by Medicaid, the insurance program for the poor and disabled. But unlike other states’ Medicaid programs, Georgia’s does not cover an intestinal transplant for patients 21 years old and older.
Such transplants are covered for younger patients, but not someone older. Wonder why?
Without the surgery, Holloway likely would have died within two to three years, Katz had said.
Is the Medicaid system heartless?
The federal government gives state Medicaid programs leeway on which transplants to approve. Other states’ Medicaid programs —- which have their own coverage rules —- approve intestinal transplants for people Holloway’s age.
So federal health care programs allow each state to decide the level of treatment. So much for "universal" coverage.
Without the surgery, Holloway was fed intravenously at an estimated annual cost of $150,000.
So how much does the surgery cost?
The operation generally costs $200,000 to $400,000, doctors said recently. But Dr. Douglas Farmer, head of the intestinal transplant program at UCLA, said in June that a transplant could be less expensive for the state in the long run. He added that intestinal transplants can cost less than $200,000.
So how was it that she received the transplant?
It seems she relied on the charity of others at the Cleveland Clinic.
The Cleveland Clinic last week declined to disclose the cost of Holloway’s surgery and postoperative care. Officials there said they “made every attempt to obtain coverage from Georgia Medicaid.”
It begs the question.
If government run health care is so great, why do patients have to rely on charity?
Sabrina is a 39 year old mother of 8 covered by Medicaid. But "covered" isn't exactly true.
Therein lies the story.
Holloway is covered by Medicaid, the insurance program for the poor and disabled. But unlike other states’ Medicaid programs, Georgia’s does not cover an intestinal transplant for patients 21 years old and older.
Such transplants are covered for younger patients, but not someone older. Wonder why?
Without the surgery, Holloway likely would have died within two to three years, Katz had said.
Is the Medicaid system heartless?
The federal government gives state Medicaid programs leeway on which transplants to approve. Other states’ Medicaid programs —- which have their own coverage rules —- approve intestinal transplants for people Holloway’s age.
So federal health care programs allow each state to decide the level of treatment. So much for "universal" coverage.
Without the surgery, Holloway was fed intravenously at an estimated annual cost of $150,000.
So how much does the surgery cost?
The operation generally costs $200,000 to $400,000, doctors said recently. But Dr. Douglas Farmer, head of the intestinal transplant program at UCLA, said in June that a transplant could be less expensive for the state in the long run. He added that intestinal transplants can cost less than $200,000.
So how was it that she received the transplant?
It seems she relied on the charity of others at the Cleveland Clinic.
The Cleveland Clinic last week declined to disclose the cost of Holloway’s surgery and postoperative care. Officials there said they “made every attempt to obtain coverage from Georgia Medicaid.”
It begs the question.
If government run health care is so great, why do patients have to rely on charity?
Sunday, December 28, 2008
This Sceptered Isle - Part XI
Didn’t believe me about compulsory health care, eh?
Well then, now read this:
NHS chiefs are planning to order a massive 40 per cent increase in weight loss surgery for dangerously obese patients from Yorkshire.
After getting our attention with this lead paragraph the article goes on and on, but curiously never gets around to these two questions:
1. How exactly will NHS chiefs decide who will be ordered to undergo surgery?
2. What is the penalty if one should refuse the order?
Oh well, maybe these questions aren't so important. After all, Brits have every reason to trust that Her Majesty's government will always do the right thing.
Cheerio!
Well then, now read this:
NHS chiefs are planning to order a massive 40 per cent increase in weight loss surgery for dangerously obese patients from Yorkshire.
After getting our attention with this lead paragraph the article goes on and on, but curiously never gets around to these two questions:
1. How exactly will NHS chiefs decide who will be ordered to undergo surgery?
2. What is the penalty if one should refuse the order?
Oh well, maybe these questions aren't so important. After all, Brits have every reason to trust that Her Majesty's government will always do the right thing.
Cheerio!
Saturday, December 27, 2008
Alternative Health Care
Folks in Canada (and many other countries as well) have free health care. So why would they have a need for an alternative?
Timely Medical Alternatives is a firm that arranges private medical care for Canadians.
Why does TMA exist?
Timely Medical Alternatives is able to expedite most types of private medical services from diagnostics to virtually all types of surgery, including procedures not available within the Canadian healthcare system. Wait times for our clients are measured in days rather than in months or years.
How long will I have to wait for services under the Canadian system?
Private Health Care is increasing in demand across Canada more than ever before. The public health care system in Canada has a waitlist in every province and surgery dates are often cancelled or bumped due to a more urgent case arising or a shortage of beds being available.
Click on a Province to view waitlist numbers and options for private medical care in that area.
Will I get in trouble for using a private system?
Inmates in Federal prisons and politicians (among others) routinely jump the queue and we agree that this practice is outrageous. Jumping the queue occurs when convicted criminals and politicians are given preference over the rest of us.
So there is preferential treatment for inmates & politicians.
I suppose if you can't get elected the next best thing is to get arrested.
Timely Medical Alternatives is a firm that arranges private medical care for Canadians.
Why does TMA exist?
Timely Medical Alternatives is able to expedite most types of private medical services from diagnostics to virtually all types of surgery, including procedures not available within the Canadian healthcare system. Wait times for our clients are measured in days rather than in months or years.
How long will I have to wait for services under the Canadian system?
Private Health Care is increasing in demand across Canada more than ever before. The public health care system in Canada has a waitlist in every province and surgery dates are often cancelled or bumped due to a more urgent case arising or a shortage of beds being available.
Click on a Province to view waitlist numbers and options for private medical care in that area.
Will I get in trouble for using a private system?
Inmates in Federal prisons and politicians (among others) routinely jump the queue and we agree that this practice is outrageous. Jumping the queue occurs when convicted criminals and politicians are given preference over the rest of us.
So there is preferential treatment for inmates & politicians.
I suppose if you can't get elected the next best thing is to get arrested.
Friday, December 26, 2008
A Christmas Story: MVNHS© Style
Earlier this month, 36 year old Lynne Neilson arrived at Edinburgh's Royal Infirmary, and was forced to wait in an "assessment room" for hours. About 7:30 in the morning on December 5th, they got to the hospital as Mrs Neilson was experiencing labor pains. After they began to subside, the Neilson's were sent home with instructions to return when her contractions got closer.
Which, of course, they did.
Some 12 hours later, they returned to the hospital, but were told to wait. The contractions began coming closer -- and harder -- and Mr Neilson began pleading for help. Eventually, a midwife was called in, just in time to "catch the baby, who had the umbilical cord around her neck."
Whew!
Of course we're thrilled that the baby seems no worse for the experience (although that was certainly not a sure thing), but one wonders why Mr Neilson's repeated requests for help apparently fell on deaf ears. Meantime, the MVNHS© is "investigating the complaint and has apologized to the woman."
Oh, goody.
Cavalcade of Risk #68: Call for Submissions
Our 2008 EOY Cavalcade of Risk is hosted next week by Colorado Health Insurance Insider's Jay Norris. Submissions are due this coming Monday (the 29th), and Jay reminds you to include:
■ Your blog's url
■ Your post's url
■ The post's trackback URL (if available)
■ A (brief) summary of the post
PLEASE remember: ONLY posts that relate to risk (not personal finance tips and the like).
Thanks!
Thursday, December 25, 2008
The Wisdom of the Magi
One of the great, all time stories of Christmas is from O Henry. The Gift of the Magi is a love story about a woman who sells her long tresses to raise enough money to buy a watch fob for her husband.
The surprise comes when she discovers he has sold his watch to buy silver combs to place in her hair.
Each has made a sacrifice, with good intention, as a way of expressing their love for the other.
The Magi were rumored to have traveled from afar bearing gifts for a new born king. Their gifts of gold, frankincense and myrrh were just as appropriate for the recipient as the watch fob and combs were in O Henry's story.
Gold was a traditional gift for royalty.
Frankincense had many uses including medicinal properties for calming and restoring peace. It was also burned by priests as a way of carrying the prayers of the faithful to heaven.
Myrrh was used to treat wounds due to its' antiseptic qualities. It was also used by Egyptians as an embalming ointment. The significance of myrrh is probably lost on many who read the story of the wise men. This tiny baby was born to be a king but would only do so through death 33 years after his birth.
Gifts exchanged at this time of year are only one way of expressing love. The true gift is not the physical item but the thought that goes with it.
Della put a lot of thought into the gift of a chain for her husband's watch. She purchased it by putting her husband ahead of vanity. In turn, Jim expressed his love for Della by sacrificing something dear to him to in order have the money to purchase his gift for her.
Christmas is a time to think of others and putting their needs and wishes ahead of our own. Blessings on you and yours during this season of love.
The surprise comes when she discovers he has sold his watch to buy silver combs to place in her hair.
Each has made a sacrifice, with good intention, as a way of expressing their love for the other.
The Magi were rumored to have traveled from afar bearing gifts for a new born king. Their gifts of gold, frankincense and myrrh were just as appropriate for the recipient as the watch fob and combs were in O Henry's story.
Gold was a traditional gift for royalty.
Frankincense had many uses including medicinal properties for calming and restoring peace. It was also burned by priests as a way of carrying the prayers of the faithful to heaven.
Myrrh was used to treat wounds due to its' antiseptic qualities. It was also used by Egyptians as an embalming ointment. The significance of myrrh is probably lost on many who read the story of the wise men. This tiny baby was born to be a king but would only do so through death 33 years after his birth.
Gifts exchanged at this time of year are only one way of expressing love. The true gift is not the physical item but the thought that goes with it.
Della put a lot of thought into the gift of a chain for her husband's watch. She purchased it by putting her husband ahead of vanity. In turn, Jim expressed his love for Della by sacrificing something dear to him to in order have the money to purchase his gift for her.
Christmas is a time to think of others and putting their needs and wishes ahead of our own. Blessings on you and yours during this season of love.
Wednesday, December 24, 2008
Have Yourself A Merry Little Christmas
This season, give thanks to those you love, and who love you.
This season, give thanks to those who protect us, risking their lives in the process.
This season, be sure to give thanks to the One who made it all possible.
We wish you and yours enjoy a wonderful (and safe) Christmas.
Stark Raving
In this interview the Wall Street Journal provided California Congressman Fortney Stark an opportunity to blither about "health overhaul" and repeat that his overhaul idea is "a Medicare-like program” anyone could buy.
In other words, there are problems in health care so let's do something about insurance.
Real logical, Congressman.
Health care? Health insurance? The same things, right? No, they are not and unfortunately Stark is not the only one who ignores the difference between health care and health insurance.
Besides, what exactly is Stark's idea for insurance reform? Enroll more people in something “like” Medicare! How . . . creative! But practical?
Medicare’s financial problems are exceedingly well-documented. Its yearly expenditures are projected to exceed its income within the next few years. Medicare is financed on the notorious pay-as-you-go basis, and its unfunded liability is estimated to be $60 trillion (20X's the current U.S. annual budget). I understand that there are some like Stark who apparently believe that any program so hopelessly in debt as Medicare is a successful program because it is a government program. I differ.
What evidence is there that this Medicare financial train wreck will miraculously jump back on the rails if only EVERYONE were enrolled in it? The answer is, none.
And there ain’t gonna be such evidence unless something is done to improve the effectiveness and reduce the cost of the health care delivery system we have now. And that won’t happen until the cost of insurance is understood as a symptom of the underlying cost of health care delivery, not misunderstood as a disease itself. That is, not until the health care system becomes the primary emphasis for reform. Until then, expanding Medicare will just throw more of our tax money into a system that has shown neither the ability nor the inclination to control its costs.
In other words, there are problems in health care so let's do something about insurance.
Real logical, Congressman.
Health care? Health insurance? The same things, right? No, they are not and unfortunately Stark is not the only one who ignores the difference between health care and health insurance.
Besides, what exactly is Stark's idea for insurance reform? Enroll more people in something “like” Medicare! How . . . creative! But practical?
Medicare’s financial problems are exceedingly well-documented. Its yearly expenditures are projected to exceed its income within the next few years. Medicare is financed on the notorious pay-as-you-go basis, and its unfunded liability is estimated to be $60 trillion (20X's the current U.S. annual budget). I understand that there are some like Stark who apparently believe that any program so hopelessly in debt as Medicare is a successful program because it is a government program. I differ.
What evidence is there that this Medicare financial train wreck will miraculously jump back on the rails if only EVERYONE were enrolled in it? The answer is, none.
And there ain’t gonna be such evidence unless something is done to improve the effectiveness and reduce the cost of the health care delivery system we have now. And that won’t happen until the cost of insurance is understood as a symptom of the underlying cost of health care delivery, not misunderstood as a disease itself. That is, not until the health care system becomes the primary emphasis for reform. Until then, expanding Medicare will just throw more of our tax money into a system that has shown neither the ability nor the inclination to control its costs.
Tuesday, December 23, 2008
Unintended Consequences
One of the problems with having so many, um, "undocumented" immigrants is the strain on our health care system. Many (most?) of these folks have no health insurance, nor the means to pay substantial health care bills. And yet, out of compassion or necessity or law, continue to provide them with neeeded health care.
The problem, of course, is that someone has to pay, and that "someone" is often the greater community, because the providers are forced out of business:
While it's tempting to lay the blame for this on the health insurance system, it's really the fault of politicians and activists who refuse to acknowledge the not-so-hidden costs of a policy that tacitly (and not so tacitly) encourages such folks to make their home here, without the tedious process of doing so legally.
The result?
"Nearly 600 babies were delivered at Southern Hills Medical Center each year before the hospital suspended its obstetrics services Sept. 1...Southern Hills suspended obstetric services following the resignation of our largest group of obstetricians."
It's really not difficult to divine just why Southern Hills took a pass: after all, how long can they afford to render free services?
And what's the community's response?
If you said "well, obviously they're going to try to reduce the number of illegals straining the system," you're not paying attention:
"The nurses and healthcare activists hope that a new nearby Spanish-language billboard reading "Nosotros Merecemos" or "We Deserve" will raise awareness among residents to protest the hospital's decision and will force the facility to reopen the doors to its labor and delivery unit. " [ed: emphasis added]
And just how does one force a doc to deliver babies for free?
Aye, there's the rub.
UPDATE: And adding insult to injury, The Volunteer State's not the only commonwealth to feel the pain of footing the cost of illegals' health care:
The remainder, about $81 million, went to the state’s contribution to emergency Medicaid"
Ouch.
The Lone Star State's Health and Human Services Commission compiled these figures to bolster their plea for increased dollars from the Fed. But not everyone's on board:
"Rep. Lon Burnam, D-Fort Worth, said looking just at the cost of illegal immigrants doesn’t take into account the money they pump into the state."
Perhaps Rep Burnam should heed the lesson of the broken window.
Grand Rounds is up!
Biochemist/molecular biologist Walter Jessen, blogmaster of Highlight Health, presents this week's collection of great medblog posts, with a holiday theme.
151A Update
Last week, we reported on regulators' efforts to change how Equity Indexed Annuities can be sold. Up 'til now, they were considered "fixed" products, meaning that any appropriately licensed life insurance agent could sell them. There was much concern, however, that these products were closer to "variable" ones (i.e. market-based returns) and should require special licensing and training to be sold.
There was much discussion of this in our comments section, for which we are very grateful.
In the end, the regulators won out:
"During an open meeting on Dec 17th the Securities and Exchange Commission adopted Rule 151A, which calls for the SEC to take over regulation of index annuities. This was opposed at the local, state and federal government levels as well as by many industry organizations including the NAIC, ACLI, NAIFA & NAFA."
[ed: this from an email I received this morning; no link as yet]
Of course, it will take some time for all the final pieces to come together, so folks who don't have their Series 6 may continue to sell Indexed products for a little while, at least. Long term, of course, the landscape will change, perhaps dramatically. The rules aren;t set to go into effect for another two years: it'll be interesting to see what impact this will have on production numbers between now and January 12, 2011.
Chanukah Cheartburn
Now that Chanukah's underway, a lot of familiar traditions seem to be getting a 21st century makeover. For example, I recently downloaded a (free!) app that turns my iPod Touch into a dreidl.
But this is literally over the top:
Now don't get me wrong: I love latkes (and make them every year). But seven pounds of these "crispy crepes?"
I don't think so.
Stupid Carrier Tricks: EOY Edition
The Yiddish word for "scandal" is "shanda;" the term implies not just shame, but a sense of shock. And it's the perfect word to describe the letter I received this morning (note the date: December 23) from Humana:
"This letter is to inform you about a change in Humana's participating network...the difficult decision to discontinue our contract with Premier Health Partners effective January 1, 2009."
The missive is dated December 10.
Even with a platoon of Cliff Clavens, it doesn't take almost two weeks for these things to arrive; it's obvious that they held it back. And this is important: Premier comprises almost half of the hospitals in the Dayton area, as well as a huge chunk of associated providers (physicians, etc). Dropping this little bombshell at the end of the year makes it nearly impossible to move Humana insureds to other carriers by the first of January, leaving them vulnerable to out-of-network charges at the height of cold, flu and accident season.
This is unconscionable.
Yes, carriers routinely update their networks: providers come and go throughout the year. But this is wholesale change, at a time when their insureds can not easily transition to other carriers. I find it unlikely that Humana wasn't aware of this impending train-wreck until now, and wouldn't be surprised if this was exactly the result they wanted: insureds with few options, and little (or no) time to make appropriate changes.
I am appalled.
My first order of business, of course, is to see if I can move at least some of my Humana insureds to other plans; if not by January, then at least by February. This is important: deductibles accrue beginning on January 1, and expenses that satisfy one carrier's deductible aren't applicable to another's. The later in the year we move folks, the more they're likely to be hurt.
Thanks, Humana, for nothing.
Monday, December 22, 2008
Carnival of Personal Finance is up
This week's Carnival of Personal Finance is now available at the Saving to Invest blog. Lots of good info, in an easy-to-follow format.
Sunday, December 21, 2008
Happy Chanukah 2008/5769
For me, the very best night of Chanukah (which begins this evening) is the first night of Chanukah: although we light candles every night of this festival, on the first night we say three blessings.The first blessing, which we recite each night, praises G-d "Who has sanctified us with His commandments and has commanded us to light the Chanukah lights."
The second blessing, which we also repeat each of the eight nights, blesses and thanks G-d for all the miracles he has wrought for us through the ages.
But the third blessing, the one which is said only the first night, is one we repeat at all joyous occasions, and is one of my very favorite prayers:
"Blessed are You, L-rd our G-d, King of the Universe, for giving us life, for sustaining us, and for enabling us to reach this season."
What a beautiful way to sum up all that we've been through, and continue to experience.
Have a warm, wonderful and meaningful Chanukah!
Thursday, December 18, 2008
Good News, Bad News: Carrier Edition
Not really sure what this means, but these two stories just popped onto the radar.
First, the good news:
[ed: West Chester is a suburb of Cincinnati, OH]
That's good news for the Queen City area, as job growth in this economy can only be viewed as "a good thing."
For our friends in The Nutmeg State, however, are about to see the other side of the equation:
Aetna's chairman and CEO, Ronald A. Williams, claims that "(t)hese actions will reduce our operating costs and allow us to manage through the economic downturn from a position of strength."
Not much one can add to that.
[Hat Tip: Rick Byrne]
Wednesday, December 17, 2008
Medicare Advantage Plans: A MOM's Perspective
[Welcome Insurance Forums readers!]
"MOM" in this case being Medical Office Manager Kelley Beloff (whose previous contribution here still gets hits). Over the course of the next few days, Kelley will be sharing with us her unique and helpful perspective on these "bad boys" of the Medicare Supplement (MedGap) world:
Part 1 The Medical Office and Medicare Patients
December usually brings thoughts of holidays, snow, egg nog, and a reprieve from the normal hectic days we all experience. As a Medical Office Manager, however, December brings thoughts of dread because between Nov. 15 and Dec. 31, all Medicare Recipients have the ability to choose a new Medicare plan. With this choice will come chaos into my office beginning January 1. How can a person practicing their right to choose a new insurance be a problem for me? After all, it is their insurance, and it has no effect on me, right? No.
Before Medicare Advantage Plans, all persons eligible for Medicare had one insurance carrier. Medicare was handled through the government and everyone had a “red, white, and blue” card. When a Medicare patient came into a Medical Office, you copied the “red, white, and blue” card (and yes, it is referred to as that in the biz.) Unfortunately, when the government designed Medicare Advantage Plans, the government did not get out of the health care business, and is still handling Medicare. Now there are two types of Medicare plans, Traditional Medicare (administered by the government) and Medicare Advantage Plans (administered by private insurance companies). This has led to an unbelievable amount of confusion.
There are three types of Medicare Advantage Plans: HMO, PPO and PFFS. The HMO and PPO plans have a deductible (not the government Medicare deductible) and co-pays (not the government Medicare co-pays). There are also in-network and out-of-network policies, depending on whether the provider is contracted with the insurance carrier of a Medicare Advantage plan. If a provider is contracted with the government (Medicare), this does not automatically mean the provider is contracted with the Medicare Advantage plan. Finally, one cannot purchase a MediGap policy to cover the costs (deductible, co pay, co insurance) associated with this new insurance. With Traditional Medicare, after the deductible is met, there is a 20% co-pay on each procedure performed in the medical office. In order to pay for these costs, many Medicare Recipients have a MediGap policy. This is a private policy purchased to cover the deductible and co pays.
The last type of Medicare Advantage plan is a PFFS. A PFFS is a great plan, so congress had to change it. Current PFFS plans are non-network policies: the patient can see any provider, as long as the provider agrees to the PFFS fee schedule, which is the Medicare Fee Schedule. However, some providers are not trusting of not having a network and will not see PFFS patients. These patients are welcomed at my practice, as I find the plans very flexible and always timely in their payments (reimbursements). As I said, Congress has changed these plans so that, in the next few years, PFFS plans will have to be network-driven.
This section deals with Medicare Advantage patients and the medical office. At the beginning of each year, medical offices collect new demographic and insurance information on their patients to ensure correct billing for the coming year. In the case of a Medicare patient, the receptionist asks if the patient has new insurance. In most cases the answer is "no, I still have Medicare." If the conversation stops there, the physician faces major billing headaches in approximately one month (I will cover this more thoroughly in Part 3). Why? Because the patient can have either Traditional Medicare with or without a MediGap program or a Medicare Advantage Plan. That plan is a HMO, PPO, or PFFS, and each plan carries its own deductible and co-pay. Hopefully, the receptionist will still ask for a copy of the patient’s insurance card, at which time the patient will drop two or three cards into the palm of the receptionist. The “red, white, and blue” card, maybe an old MediGap card and a brand new Medicare Advantage Plan card. Now the fun begins. The conversation usually goes like this:
Receptionist: “Ma’am/Sir, you have given me a Traditional Medicare Card, a Medicare Advantage Plan card and an expired MediGap card. What insurance do you have?"
Patient: “I have Medicare.”
Receptionist: “Yes, I know. Which type of Medicare: Traditional or a Medicare Advantage?”
Patient: “There is no difference, it is all Medicare." (Then they go into a monologue about being a longtime patient, never being questioned before, their other doctors don’t ask these questions, etc.)
Quiz: Has the patient told us type of insurance he/she has?
If you said no, you are correct, and this is what faces us in the Medical field every day. These patients simply do not understand that there is a difference between Traditional Medicare and Medicare Advantage Plans. The biggest problem is seniors do not understand that the “red, white and blue” card is not needed with Medicare Advantage Plans. On the day they turned 65 and received that card, they were always told that this was their insurance card forever. I have worked in this field for 5+ years, I am a Certified Medical Manager and I cannot convince my patients, or even members of my own family, that with a Medicare Advantage Plan, their “red, white, and blue” card is no longer active. I have actually told some members of my family to put their “red, white and blue” card in their dresser and never touch it again.
If you would like to read a more in depth piece on Medicare Advantage plans, here's the link to a 49-page workbook on this very topic. The one piece not covered in this workbook is how the receptionist at the physician’s office is to know which medical plan the patient has enrolled for this year.
In Part 2, we'll discuss the Government and Medicare Advantage Plans. Stay tuned.
You Can't Always Get What You Want
The Big Chill is one of my favorite movies for a lot of reasons.
JoBeth Williams, Glenn Close, Mary Kay Place . . . just to name a few.
But the story line was entertaining (at least to me) and the music was the best. The Rolling Stones have provided us (some of us at least) with some incredible songs over the years. One of those, "You can't always get what you want" plays a role in the Big Chill.
There are those who want lower insurance premiums but don't want lesser coverage, or at least what they perceive as lesser coverage. Doc copay's are not insurance but prepaid medical coverage. No one needs a doc copay but everyone wants a copay.
So to accommodate those who think insurance isn't insurance if it lacks a copay, carriers have been introducing lower premium plans that give more prepaid medical on the front end but strip away needed (catastrophic) benefits on the back end.
This is a move in the wrong direction.
Apparently the folks at the Philadelphia Enquirer feel the same.
They published a story about Karlin Brockington who used up all the money in her plan. Only one problem.
She has acute myeloid leukemia and she needs further treatment.
Brockington had been paying $19 a week from her paycheck for health insurance.
For 16 months, insurance covered chemotherapy, a bone marrow transplant, five months in hospitals.
But on Aug. 28, 2008, a letter came from her plan administrator. Brockington had reached her "lifetime maximum coverage of $2 million."
In five days, she would be uninsured.
In most cases $2M is adequate, but eventually that well can run dry in some situations.
This is one of them.
"The primary reason for . . . caps is to lower the cost of insurance so employers can cover as many people as possible," said Mary McElrath-Jones, spokeswoman for UnitedHealthcare, parent company of UMR, administrator of Brockington's health plan.
That is true, but, in this case at least, it is a weak argument.
The difference in a plan max of $5M vs. $2M is almost nill. For literally a few dollars extra per week the plan max could have been higher.
Had the plan "skimped" a bit on the front end, with say a higher copay for docs they most likely could have shifted the premium savings to the back end and provided a much better plan.
"What insurance is supposed to do best is handle the extraordinary thing that is rare," said Gary Claxton, health policy expert at the Kaiser Family Foundation. "So to some extent, these policies are not protecting the people who most need insurance. These people did everything they were supposed to do. They were paying their premiums. Insurance companies are finding ways to limit exposure of these policies to really sick people."
I concur.
I coach all my clients in ways to keep their premiums affordable while protecting them on the back end. My traditional line goes something like this.
"You don't have copay's for tires, brakes and oil changes on your auto insurance. Why do you need them for health insurance?"
For most folks, it makes sense.
I also caution them about internal limits on potentially catastrophic claims, especially Rx which can run $5k or more per month for one drug.
The problem of benefit caps and trying to deliver a viable product while containing costs isn't just limited to the private sector. Medicare has their issues as well.
In November 2007, Brockington was approved for Social Security disability, and began receiving $944 a month.
But that disability income is eaten by co-pays, living expenses, car insurance.
She will be eligible for Medicare - but not until next November. When Congress extended Medicare to include the disabled in 1972, it imposed a two-year wait, which still exists today.
Why isn't anyone calling for Medicare reform?
If not Medicare, then what about Medicaid?
Brockington then tried to get Medicaid, medical coverage for the poor. She applied in New Jersey, but because she owns a mobile home in Delaware, and is licensed to drive there, New Jersey told her to apply there, she said.
Delaware officials, she said, told her that with a $944 disability income, she earns too much to qualify for Medicaid. She plans to apply again soon in New Jersey under a program called Ticket to Work. She has been living in Lawnside for years with her mother and sister - commuting to work in Deptford long before she got sick.
Seems the government safety net plan doesn't want her either.
Seems a lot of people want to cover everyone for everything. It just isn't fiscally possible.
But it is possible to cover almost everyone when they truly need it most. And that can be done for a lot less than most people think.
JoBeth Williams, Glenn Close, Mary Kay Place . . . just to name a few.
But the story line was entertaining (at least to me) and the music was the best. The Rolling Stones have provided us (some of us at least) with some incredible songs over the years. One of those, "You can't always get what you want" plays a role in the Big Chill.
There are those who want lower insurance premiums but don't want lesser coverage, or at least what they perceive as lesser coverage. Doc copay's are not insurance but prepaid medical coverage. No one needs a doc copay but everyone wants a copay.
So to accommodate those who think insurance isn't insurance if it lacks a copay, carriers have been introducing lower premium plans that give more prepaid medical on the front end but strip away needed (catastrophic) benefits on the back end.
This is a move in the wrong direction.
Apparently the folks at the Philadelphia Enquirer feel the same.
They published a story about Karlin Brockington who used up all the money in her plan. Only one problem.
She has acute myeloid leukemia and she needs further treatment.
Brockington had been paying $19 a week from her paycheck for health insurance.
For 16 months, insurance covered chemotherapy, a bone marrow transplant, five months in hospitals.
But on Aug. 28, 2008, a letter came from her plan administrator. Brockington had reached her "lifetime maximum coverage of $2 million."
In five days, she would be uninsured.
In most cases $2M is adequate, but eventually that well can run dry in some situations.
This is one of them.
"The primary reason for . . . caps is to lower the cost of insurance so employers can cover as many people as possible," said Mary McElrath-Jones, spokeswoman for UnitedHealthcare, parent company of UMR, administrator of Brockington's health plan.
That is true, but, in this case at least, it is a weak argument.
The difference in a plan max of $5M vs. $2M is almost nill. For literally a few dollars extra per week the plan max could have been higher.
Had the plan "skimped" a bit on the front end, with say a higher copay for docs they most likely could have shifted the premium savings to the back end and provided a much better plan.
"What insurance is supposed to do best is handle the extraordinary thing that is rare," said Gary Claxton, health policy expert at the Kaiser Family Foundation. "So to some extent, these policies are not protecting the people who most need insurance. These people did everything they were supposed to do. They were paying their premiums. Insurance companies are finding ways to limit exposure of these policies to really sick people."
I concur.
I coach all my clients in ways to keep their premiums affordable while protecting them on the back end. My traditional line goes something like this.
"You don't have copay's for tires, brakes and oil changes on your auto insurance. Why do you need them for health insurance?"
For most folks, it makes sense.
I also caution them about internal limits on potentially catastrophic claims, especially Rx which can run $5k or more per month for one drug.
The problem of benefit caps and trying to deliver a viable product while containing costs isn't just limited to the private sector. Medicare has their issues as well.
In November 2007, Brockington was approved for Social Security disability, and began receiving $944 a month.
But that disability income is eaten by co-pays, living expenses, car insurance.
She will be eligible for Medicare - but not until next November. When Congress extended Medicare to include the disabled in 1972, it imposed a two-year wait, which still exists today.
Why isn't anyone calling for Medicare reform?
If not Medicare, then what about Medicaid?
Brockington then tried to get Medicaid, medical coverage for the poor. She applied in New Jersey, but because she owns a mobile home in Delaware, and is licensed to drive there, New Jersey told her to apply there, she said.
Delaware officials, she said, told her that with a $944 disability income, she earns too much to qualify for Medicaid. She plans to apply again soon in New Jersey under a program called Ticket to Work. She has been living in Lawnside for years with her mother and sister - commuting to work in Deptford long before she got sick.
Seems the government safety net plan doesn't want her either.
Seems a lot of people want to cover everyone for everything. It just isn't fiscally possible.
But it is possible to cover almost everyone when they truly need it most. And that can be done for a lot less than most people think.
Cavalcade of Risk #67 now online
InsuranceWriter Nancy Germond makes her Cavalcade of Risk debut with this week's collection of risk-related posts.
Super job, Nancy!
And you can do the same, just drop us a line to reserve your spot.
Tuesday, December 16, 2008
I Did Not Know That
[Welcome Lizardoid readers!]
Did you know that you can opt out of Medicare altogether? That is, once you retire, you can elect not to participate in Part A, at all? In my defense, this issue has never come up, and I couldn't begin to imagine why one might wish to do so (after all, we've already paid in a gazillion dollars in Medicare "premiums," aka taxes). But some folks, including retired Congresscritter Dick Armey, have chosen to do so.
Unfortunately, opting out of Medicare benefits also means opting out of Social Security benefits, as well.
You read that right: no Medicare, no Social Security.
Talk about pay to play!
As to why some folks might want to decline Medicare "insurance" benefits: well, it appears that they're regular IB readers:
That's gonna leave a mark.
So, Mr Armey (and several co-plaintiffs) are asking the U S District Court for D.c. to stop the Feds from cutting off their Social Security benefits. What's at stake, they believe, is our right to make choices about our health insurance and health care.
Be interesting to see how this goes.
[Hat Tip: Sonia Blumstein]
Told Ya So!
Regular readers may recall that we expressed grave doubts regarding marketplace activities by erstwhile insurance giant AIG. Specifically, now that you and I are their reinsurer, we were concerned that this created an uneven playing field, and that AIG would be tempted to play fast and loose with their conduct.
That didn't take long.
According to Financial Services Online (a service to which I subscribe):
"IRRESPONSIBLE AND UNFAIR? - Reports are surfacing that AIG, the recipient of a $150 billion taxpayer-funded bailout, is aggressively cutting its insurance rates in an attempt to win new business and boost market share. If underwriting losses become a problem, the U.S. government may have to provide more financial support. According to Liberty Mutual chief executive Edmund Kelly, "I think it's fair to say they're doing some very stupid things in the market. If (AIG units) are not reined in, it could be very destabilizing for the market."
Quelle surprise.
Grand Rounds, EOY Edition
Laurie Edwards, blogress at A Chronic Dose, hosts this week's collection of great medblog posts. Our own Mike Feehan's recent piece on health care vs health insurance was selected as an "Editor's Choice" ("best of the best")!
Do check it out.
Monday, December 15, 2008
Warning: Bad Renewal Etiquette
Last week, Bob wrote about higher auto insurance rates, and pointed out that such increases are part and parcel of a fiscally sound risk management program. Still, no one likes to pay more, so shopping around may be a good idea.
What not a good idea is this:
Remember, folks: shop, don't bop.
A public service announcement from the management of IB.
An Insurance Coverage Top 10
How can you not love a roundup of insurance-related legal mishaps that uses the term "insurance coverage hootenanny?" And that's just what legal-beagle Randy Maniloff (no relation) has put together for insurance professionals, amateurs and everyone in-between. These are cases that came before the courts over the past 12 months, including a tribute to the Texas Supreme Court and a Coverage for Dummies section.
Do check it out.
When Gummint Intervention is a Good Thing
So-called "Indexed Annuities" (aka "Equity Indexed Annuities") are an interesting product: part insurance, part investment, they're a hybrid that promise guaranteed returns with the potential for even greater profit for the buyer.
So what could go wrong?
One of the worst things a consumer can do when purchasing life insurance is to conflate "insurance" and "investment." In fact, it's illegal for the salesperson to call a life insurance policy "an investment." It's true that certain kinds of life insurance and annuity contracts (called "variable" in the trade) comprise a "sub account" which mimics a mutual fund, but they are first and foremeost insurance products, and need to be viewed as such.
Why is this so important?
The difference between "variable" products and the more pedestrian "fixed" ones is that the latter's rate of return is determined solely by the insurance company, based on its own investment returns (and other factors). They are comparable to bank accounts, in that one isn't going to get a spectaculr rate of return, but there is a guaranteed "floor," so that one gets at least something no matter what. The variable products push that "investment risk" off onto the insured, which can result in very high returns, or nasty losses, depending on the policy owner's choices.
[ed: this is, of necessity, a very brief explication of variable products. For a more detailed explanation, click here]
Many folks hear what they want to hear, and many agents tell a story that they think their prospective customer wants to hear. So variable products may only be sold by agents who have both "regular" insurance licenses and special "Series 6" (or, sometimes, 7) licenses, as well. These are issued by the NASD, and allow the agent to sell investment products. These require taking special classes and tests, are necessary only if one wants to sell these "variable" policies.
So far, anyway.
There exists a relatively new product, which lies somewhere between the fixed and variable worlds, called "indexed" life and annuities. These plans offer a guaranteed interest rate (or floor) like their fixed rate cousins, which the potential of market-related gains like variable products. Although not as complicated as variable plans, they do have more "moving parts" than fixed ones, and require much more understanding on the part of the consumer. Especially in turbulent econimic times such as these, such products are easily conflated with variable plans, which can lead to, um, unfortunate misunderstandings.
And so, Congress is currently considering [ed: nice alliteration!] legislation to require that the sale of these indexed products be regulated like variable ones, and thus subject to NASD oversight and licensing. Not surprisingly, the tone-deaf NAIFA (National Association of Insurance and Financial Advisors) is agin it, and is mustering its forces to fight these new requirements.
Their stated argument is that "concerns regarding suitability, disclosure and marketing methods are not the relevant criteria to consider in determining whether a financial product is or is not a security."
I'm in awe that they can say that with a straight face.
The very definition of security products is that they require suitability testing, not to mention more stringent disclosure and marketing criteria than their fixed rate cousins. Of course the NAIFA doesn't want barriers of any sort to these products: they represent a bold new frontier for increased sales. And since, as we've noted previously, the NAIFA exists primarily for the benefit of the carriers, this would be and unwelcome hindrance to their increased market share.
And they want agents and their clients to fight this for them!
Just. Mind. Boggling.
I plan to err on the side of the consumer, however, and will be writing my congress critter in support of "151A" (the licensing/disclosure law), and I urge you to do the same.
Mini Update: Interesting debate going on in the comments section, demonstrating once again that we have the best commenters in the blogosphere.
Carnival of Personal Finance is up
Sharon Harvey Rosenberg hosts this week's collection of personal finance posts. Stop by for some timely holiday shopping advice, and stay for some budget -cutting ideas.
Sunday, December 14, 2008
Medical Necessity
One of the precepts in getting your claim paid is the idea of medical necessity. Absent state mandates to the contrary, items covered by your health insurance policy involve treatment that is medically necessary.
Performing CPR on a heart attack victim is a medical necessity.
Having a plastic surgeon enhance your breasts is not.
Suturing a bleeding wound is a medical necessity.
Removing a tattoo is not.
But what happens when you ask your doc to induce labor so you can deliver before your insurance runs out?
Starla Darling was just days away from giving birth to her second child. The 27-year-old mother from Polk, Ohio, had a well-paying job with good health insurance at the Archway Cookie plant in nearby Ashland.
But during a visit to her parents' house, Darling received news that sent her into a panic. A neighbor, who also worked at Archway, told them the plant was closing and their health insurance was ending two days later.
Under normal situations COBRA would be an option. But the plant was filing bankruptcy and the group plan terminating. This eliminates the COBRA option.
But there could have been other HIPAA options. Perhaps Hank will enlighten us on options in Ohio.
"I flipped out," Darling said. "It was five minutes after she told me, I was on the phone with the doctor," Darling said. "I told her, 'I need to be induced.'"
A few hours later, Darling was in the hospital. The next day, she had to have an emergency C-section.
Inducing labor is sometimes done when the baby is overdue, or if the babies life, or the mothers life is in jeopardy.
Based on the information in the news article, none of these situations seem to have existed.
After the mad rush to give birth to baby Kathryn, Darling got some more bad news. A bill for nearly $18,000 arrived from the hospital. Even though Darling gave birth before she says she was told her insurance was supposed to run out, the company denied the claim.
The EOB would explain why the claim was denied. Of course it would be too easy for the reporter to do their job and enlighten us.
Instead it would appear that the claim was denied due to lack of medical necessity.
Darling applied for Medicaid while in the hospital. In many states, including Ohio, Medicaid covers medical expenses in special circumstances, such as pregnancy, if the expenses were incurred up to 90 days before the date of application and if eligibility requirements are met.
So you can apply for Medicaid and, if approved, include charges incurred up to 90 days prior. Why would anyone want to act responsibly if they can get the taxpayer to pony up and pay their bills?
Performing CPR on a heart attack victim is a medical necessity.
Having a plastic surgeon enhance your breasts is not.
Suturing a bleeding wound is a medical necessity.
Removing a tattoo is not.
But what happens when you ask your doc to induce labor so you can deliver before your insurance runs out?
Starla Darling was just days away from giving birth to her second child. The 27-year-old mother from Polk, Ohio, had a well-paying job with good health insurance at the Archway Cookie plant in nearby Ashland.
But during a visit to her parents' house, Darling received news that sent her into a panic. A neighbor, who also worked at Archway, told them the plant was closing and their health insurance was ending two days later.
Under normal situations COBRA would be an option. But the plant was filing bankruptcy and the group plan terminating. This eliminates the COBRA option.
But there could have been other HIPAA options. Perhaps Hank will enlighten us on options in Ohio.
"I flipped out," Darling said. "It was five minutes after she told me, I was on the phone with the doctor," Darling said. "I told her, 'I need to be induced.'"
A few hours later, Darling was in the hospital. The next day, she had to have an emergency C-section.
Inducing labor is sometimes done when the baby is overdue, or if the babies life, or the mothers life is in jeopardy.
Based on the information in the news article, none of these situations seem to have existed.
After the mad rush to give birth to baby Kathryn, Darling got some more bad news. A bill for nearly $18,000 arrived from the hospital. Even though Darling gave birth before she says she was told her insurance was supposed to run out, the company denied the claim.
The EOB would explain why the claim was denied. Of course it would be too easy for the reporter to do their job and enlighten us.
Instead it would appear that the claim was denied due to lack of medical necessity.
Darling applied for Medicaid while in the hospital. In many states, including Ohio, Medicaid covers medical expenses in special circumstances, such as pregnancy, if the expenses were incurred up to 90 days before the date of application and if eligibility requirements are met.
So you can apply for Medicaid and, if approved, include charges incurred up to 90 days prior. Why would anyone want to act responsibly if they can get the taxpayer to pony up and pay their bills?
Ill in Illinois?
Does the Illinois governor situation have anything to do with health insurance – that is, anything to do with the sorts of things we talk about at InsureBlog?
Well, in part yes, it does. Let's look at it.
Here is a link to a transcript of the hearing Friday December 12 in which Illinois Attorney General Lisa Madigan argued that the Illinois Supreme Court can, and should, declare the Governor “disabled” and therefore no longer “legitimately” able to carry out his official duties. Ignore her continual abuse of the terms “disabled” and “legitimately”. That is part of a political argument and has no place here.
But read the whole transcript and then consider these two little excerpts:
MS. MADIGAN: “. . . as you are aware, the state of Illinois is behind in paying its bills, in particular to Medicaid providers.”
MS. MADIGAN: “What we have delineated are all of the activities that were contained in the criminal complaint filed by the U.S. attorney . . . based on the apparent refusal to provide Medicaid reimbursement to Children's Memorial Hospital unless he received a campaign contribution from its CEO . . .”
These excerpts provide a revealing glimpse behind the curtains – they show how governmental control of the health care system is turned into political control of graft. It’s not a pretty picture: First step, withhold government funds. Then, extract political favors as a condition for freeing up the flow of government funds. Patients suffer – but hey who cares? You say, this is exceptional? Not representative of politics in general, you say? To which I say, yeah, right. And I also say, if more government control of health care is what you want, more situations like Illinois is what you will likely get. You, and the rest of us along with you.
Well, in part yes, it does. Let's look at it.
Here is a link to a transcript of the hearing Friday December 12 in which Illinois Attorney General Lisa Madigan argued that the Illinois Supreme Court can, and should, declare the Governor “disabled” and therefore no longer “legitimately” able to carry out his official duties. Ignore her continual abuse of the terms “disabled” and “legitimately”. That is part of a political argument and has no place here.
But read the whole transcript and then consider these two little excerpts:
MS. MADIGAN: “. . . as you are aware, the state of Illinois is behind in paying its bills, in particular to Medicaid providers.”
MS. MADIGAN: “What we have delineated are all of the activities that were contained in the criminal complaint filed by the U.S. attorney . . . based on the apparent refusal to provide Medicaid reimbursement to Children's Memorial Hospital unless he received a campaign contribution from its CEO . . .”
These excerpts provide a revealing glimpse behind the curtains – they show how governmental control of the health care system is turned into political control of graft. It’s not a pretty picture: First step, withhold government funds. Then, extract political favors as a condition for freeing up the flow of government funds. Patients suffer – but hey who cares? You say, this is exceptional? Not representative of politics in general, you say? To which I say, yeah, right. And I also say, if more government control of health care is what you want, more situations like Illinois is what you will likely get. You, and the rest of us along with you.
Friday, December 12, 2008
Cavalcade of Risk #67: Call for submissions
InsuranceWriter Nancy Germond hosts next week's Cavalcade of Risk. Submissions are due this coming Monday (the 15th), and she asks that you include:
■ Your blog's url
■ Your post's url
■ The post's trackback URL (if available)
■ A (brief) summary of the post
PLEASE remember: ONLY posts that relate to risk (not personal finance tips and the like).
You can submit your post via Blog Carnival or email.
Thanks!
We still have some hosting slots available for early '09 - just drop us a line to reserve yours.
Thursday, December 11, 2008
Mumbai's Aftermath: Catastrophic Claim Writ (Very) Large
In the P&C side of the insurance business, a "Cat Claim" is one that arises from some unexpectedly severe natural or man-made occurrence. Typically, these would be large hurricanes or major earthquakes, or large-scale terrorist attacks such as last month's tragedies in Mumbai.
While we (correctly) focus on the human cost of such events, there was a lot of property damage as the result of explosions, gun-fire and the like. As one might imagine, all those hotels and, of course, death claims are beginning to add up, and are straining India's insurance capacity:
Claims from just the three hotels involved are expected to top $120 million, which represents about half of insurers' reserves. As a result, premiums are expected to increase sharply, and soon, especially for terror-related cover. India's insurance laws cap single claims at about $150 million, but that may not be nearly enough to cover the damages to the three long-standing hotels, which housed priceless artwork and historic artifacts.
Of course, things can be replaced, while people cannot, but this serves to remind us that even having "adequate" coverage in place may not be enough. That goes for hotels and artwork, and it goes for ourselves, as well.
MassCare OK
Bob tipped me to a new transparency tool available to Massachusetts' health care consumers. It's called My Health Care Options, and it's an online resource to help folks find health care providers based on location, cost and outcomes.
Pretty cool:
You input your zip code (or city, etc), and then choose to search for hospitals, physicians, or a number of other providers. Once selected, you can also specify what kind of service to research: an operation, baby delivery, MRI or whatever. Based on preference, the results can be sorted by price, or how many ICU beds are available, or a host of other criteria.
There's even consumer ratings (how well they were treated, etc); kind of like "user reviews" at Amazon and the like.
It seems pretty user-friendly, too: you don't have to know CPT codes or other medical jargon, just the service or procedure's name (e.g. "angioplasty" or "Cesarean Section").
And the site will "bottom line" it for you, as well: while there are no actual dollar figures (which seems to me to be a requirement sadly missing here), there are comparative ratings to give you an idea of who's more expensive, and who's less. It may be that, since this seems to be a relatively new service, the actual costs haven't been included yet, but will be down the road. Let's hope so, and soon.
The service itself is provided by the Massachusetts Health Care Quality and Cost Council, which was set up as part of the original Mass Care program. Frankly, this may the best thing to come out of that endeavor.
Finally "Getting It"
Looks like health care consumers are finally getting it.
They are no longer willing to pay more for first dollar benefits. They are willing to abandon copay's and lower deductibles in exchange for no frills "bare bones" plans. (Shameless plug).
Only 19 percent of employees surveyed this year were willing to opt for higher premiums, compared with 38 percent last year.
That is a seismic shift.
But with this change to more personal responsibility comes good and bad.
The study also found that 66 percent of workers took steps to improve their personal care, up from 61 percent in 2007. However, 17 percent skipped a doctor's visit this year to save costs, and an equal percentage failed to fill a prescription or passed on medicine for the same reason.
I don't survey my clients to see who is "skimping" on care and who isn't. I do know that all of them are pleased with saving as much as 50% on premiums with no noticeable loss of coverage.
They are no longer willing to pay more for first dollar benefits. They are willing to abandon copay's and lower deductibles in exchange for no frills "bare bones" plans. (Shameless plug).
Only 19 percent of employees surveyed this year were willing to opt for higher premiums, compared with 38 percent last year.
That is a seismic shift.
But with this change to more personal responsibility comes good and bad.
The study also found that 66 percent of workers took steps to improve their personal care, up from 61 percent in 2007. However, 17 percent skipped a doctor's visit this year to save costs, and an equal percentage failed to fill a prescription or passed on medicine for the same reason.
I don't survey my clients to see who is "skimping" on care and who isn't. I do know that all of them are pleased with saving as much as 50% on premiums with no noticeable loss of coverage.
Health Wonk Review: Dragnet Edition
Be sure to tune in for this week's edition of wonky health care goodness, hosted by Vince Kuraitis, proprietor of the e-CareManagement blog (aided and abetted by Bill Gannon). It's an arresting version.
Wednesday, December 10, 2008
Pay As You Go© Insurance, Update: Good, Bad, Unsightly
As promised, this morning I attended a webinar on American Community Mutual's new product. In general, it was well done, and I have a much better handle on both the product and where it might fit into an agent's portfolio. First, though, I do need to apologize to our readers regarding one very important aspect of this plan: it is, indeed, a major medical plan, not an accident-only one. This is crucial, and although it was not obvious originally, the webinar made it clear that this is the case.
Second, I appreciated the moderator's introduction of the plan: he suggested that agents ask the insured "What's important to you? Premium cost? Co-pays? Carrier ratings?" He then suggested that folks often purchase benefits that they really don't need or use much, but pay for anyway. I was immediately reminded of Bob's admonition that "people tend to buy too much insurance."
There were exactly three benefits that I felt were worthwhile, of which only one really broke new ground. But that one is a doozy: regular readers may recall our ground-breaking investigative piece on how non-covered expenses aren't eligible for in-network discounts. This is especially critical when dealing with maternity: since almost all individual plans exclude coverage for normal childbirth, those expenses aren't discounted. As one might imagine, this can get pretty expensive. ACM gets around this with a unique and creative "hook:" normal childbirth expenses are covered at no additional premium, but subject to a separate $12,000 deductible.
Now you may ask: a $12,000 deductible?! That's way more than the actual cost; what's the point in having it at all?
While it's unlikely that the carrier would actually have to pay a childbirth claim, by extending the umbrella of "covered charge" over maternity, those expenses reap the benefit of in-network discounts.
I liked that the plan can be designed to include a 2 year rate guarantee, which could certainly help with budgets. And I like that it excluded entirely non-emergency ER expenses. This should go a long way toward discouraging folks from using the ER for primary care and the like.
But there are some major pitfalls in this plan, as well:
The base plan has no coverage for prescription drugs. While this may seem to be a minor quibble, it is, in fact, a significant flaw: what happens if one becomes diabetic, or develops MS or some other dread disease, which is treated almost entirely by medication? While it's true that one can add an (expensive) rider to provide this coverage, how many agents sell (and folks will buy) on price alone, leaving a gaping hole in the coverage?
I'm also concerned at the lengthy list of routine expenses that are automatically excluded during the first policy year, including tonsils, hemorrhoids and carpal tunnel (to name just a few). Even if one has no prior history of any of these issues, the plan excludes them from coverage for the initial 12 months.
And notwithstanding the recent Wellstone legislation, the plan specifically excludes "treatment for mental or nervous disorders, or emotional conditions." It's that last part that truly worries me: who defines an "emotional condition?" Way too subjective, and too easy to deny that claim.
I've not changed my mind about ACM: this is not a carrier with which I choose to do business, and this new plan does nothing to change my stance. On the other hand, it's not the worst idea I've ever seen, and contains at least one very good idea (the maternity non-benefit).
Not Ready for Prime Time
Depressed about the economy?
Worried about your job or how you will pay the bills?
How about a few laughs?
Patton Hyman of Barnet, VT should do stand up comedy.
In reference to Sen. Baucus' proposal for health care reform, Mr. Hyman notes the following.
His reform "will simply [love that word!] preclude insurers from discriminating against those who are sick." This is analogous to saying that property and casualty insurers should be precluded from charging higher rates or denying coverage to (i.e., discriminating against) people who store gasoline in the basement.
Mr. Hyman fails to indicate if the gas hoarder is also a smoker. That info is probably PHI (protected health information).
But he did offer this additional argument.
Properly conceived, "insurance" is a plan for spreading the cost of a known but specifically unpredictable risk. Take fire insurance as an example. I make monthly payments for fire insurance that are a small fraction of the cost of rebuilding my house. That is possible only because a pool of homeowners does likewise, and the insurer can calculate the risk of the occurrence of the casualty and spread the cost over the pool of insureds. However, if I can buy insurance for the same rate after my house has burned, then it's impossible for the premium to be spread, because everybody else can do likewise; in which case, the premiums would have to approach or equal 100% of the loss. Allowing those who are already ill to purchase health "insurance" on the same basis as the healthy is like letting someone buy fire insurance after the house has burned.
So what are you saying Mr. Hyman?
That someone diagnosed with cancer would be unwilling to pay a cost plus premium for their care?
How inconsiderate!
With Sen. Baucus's system, once everybody finds out they can wait to buy insurance until they are sick, watch what happens to the premiums
You mean, like, they might go up?
You are kidding, right?
Who knew?
Worried about your job or how you will pay the bills?
How about a few laughs?
Patton Hyman of Barnet, VT should do stand up comedy.
In reference to Sen. Baucus' proposal for health care reform, Mr. Hyman notes the following.
His reform "will simply [love that word!] preclude insurers from discriminating against those who are sick." This is analogous to saying that property and casualty insurers should be precluded from charging higher rates or denying coverage to (i.e., discriminating against) people who store gasoline in the basement.
Mr. Hyman fails to indicate if the gas hoarder is also a smoker. That info is probably PHI (protected health information).
But he did offer this additional argument.
Properly conceived, "insurance" is a plan for spreading the cost of a known but specifically unpredictable risk. Take fire insurance as an example. I make monthly payments for fire insurance that are a small fraction of the cost of rebuilding my house. That is possible only because a pool of homeowners does likewise, and the insurer can calculate the risk of the occurrence of the casualty and spread the cost over the pool of insureds. However, if I can buy insurance for the same rate after my house has burned, then it's impossible for the premium to be spread, because everybody else can do likewise; in which case, the premiums would have to approach or equal 100% of the loss. Allowing those who are already ill to purchase health "insurance" on the same basis as the healthy is like letting someone buy fire insurance after the house has burned.
So what are you saying Mr. Hyman?
That someone diagnosed with cancer would be unwilling to pay a cost plus premium for their care?
How inconsiderate!
With Sen. Baucus's system, once everybody finds out they can wait to buy insurance until they are sick, watch what happens to the premiums
You mean, like, they might go up?
You are kidding, right?
Who knew?
Can Anyone in Washington Read?
While the primary focus is on the economy, there are still folks in Washington that want to expand Medicare to all, or at least those in the 55 - 64 age range. The argument is, we already have a health care plan in place that covers "everyone" over age 65, why not expand it to others?
Well other than the fact the Medicare is broke, I can't think of any reason why they shouldn't expand Medicare.
Except maybe this reason . . .
Glenda Fried had no problem getting her PCP to accept Medicare. Others are not so lucky.
They talked of having to make at least 15 calls before finding a new primary care physician who participated in the taxpayer-funded medical insurance program largely for those 65 and older
Seems docs are willing to take cash, but not Medicare, and sometimes not willing to take ANY insurance.
Phone call after phone call was met with apologetic office mangers saying that Dr. X wasn't taking any new Medicare patients or Dr. Y wasn't taking any type of insurance at all.
Some offices we know say it takes 3 - 4 months to get paid by Medicare. When they do get paid it is not enough to cover the actual cost of the visit. In other words, the docs lose money when they treat Medicare patients.
Health-care experts and advocates for the region's elderly say the problem is partly a reflection of how worried physicians are about changes in reimbursement rates from the federal government. Some physicians say they are afraid of accepting new Medicare patients and discovering later that the amount they receive for treating them will be decreased. Exacerbating those worries are concerns about the slow pace of reimbursement and the layers of paperwork it requires.
And this is a system that Washington wants to expand?
Seems the Emperor has no clothes.
Well other than the fact the Medicare is broke, I can't think of any reason why they shouldn't expand Medicare.
Except maybe this reason . . .
Glenda Fried had no problem getting her PCP to accept Medicare. Others are not so lucky.
They talked of having to make at least 15 calls before finding a new primary care physician who participated in the taxpayer-funded medical insurance program largely for those 65 and older
Seems docs are willing to take cash, but not Medicare, and sometimes not willing to take ANY insurance.
Phone call after phone call was met with apologetic office mangers saying that Dr. X wasn't taking any new Medicare patients or Dr. Y wasn't taking any type of insurance at all.
Some offices we know say it takes 3 - 4 months to get paid by Medicare. When they do get paid it is not enough to cover the actual cost of the visit. In other words, the docs lose money when they treat Medicare patients.
Health-care experts and advocates for the region's elderly say the problem is partly a reflection of how worried physicians are about changes in reimbursement rates from the federal government. Some physicians say they are afraid of accepting new Medicare patients and discovering later that the amount they receive for treating them will be decreased. Exacerbating those worries are concerns about the slow pace of reimbursement and the layers of paperwork it requires.
And this is a system that Washington wants to expand?
Seems the Emperor has no clothes.
I'm Not Buying This
The uninsured . . . universal health care . . . can't pay for health care . . .
Sometimes the noise is deafening. Of course most of the time the complaints are without merit.
Here is one of those. The New York Times published a report on overcrowding in ER's due to (at least in part) the number of uninsured.
One emergency room doctor in Iowa, Dr. Thomas E. Benzoni, said he recently saw a mother come in with her two children for what he thought was routine care. When he asked her why she had not gone to her family doctor, she said she did not have health insurance.
You don't need health insurance to go to a doc for routine care. This is tantamount to saying you can't get your oil changed in your car because you don't have auto insurance.
“I don’t know what else she was supposed to do,” Dr. Benzoni said.
Here's a thought. Why not pay for the office visit out of pocket?
Certainly much less expensive than paying ER charges for a routine visit. That can turn a $100 office visit into a $500 trip.
Until hospital ER's do a better job of triage, and turning away those who do not truly need emergency care, this problem will only get worse.
It is like the folks who call 911 to get the phone number for Domino's Pizza.
Time to stop coddling these folks and force them to grow up.
Sometimes the noise is deafening. Of course most of the time the complaints are without merit.
Here is one of those. The New York Times published a report on overcrowding in ER's due to (at least in part) the number of uninsured.
One emergency room doctor in Iowa, Dr. Thomas E. Benzoni, said he recently saw a mother come in with her two children for what he thought was routine care. When he asked her why she had not gone to her family doctor, she said she did not have health insurance.
You don't need health insurance to go to a doc for routine care. This is tantamount to saying you can't get your oil changed in your car because you don't have auto insurance.
“I don’t know what else she was supposed to do,” Dr. Benzoni said.
Here's a thought. Why not pay for the office visit out of pocket?
Certainly much less expensive than paying ER charges for a routine visit. That can turn a $100 office visit into a $500 trip.
Until hospital ER's do a better job of triage, and turning away those who do not truly need emergency care, this problem will only get worse.
It is like the folks who call 911 to get the phone number for Domino's Pizza.
Time to stop coddling these folks and force them to grow up.
Tuesday, December 09, 2008
Cancer Closes In
It always amazes me when talking with a prospective client and they tell me they don't really need Rx coverage since they don't take any medication.
Or they say they just need something for doctor visits since the don't plan on getting sick.
My response is always, "Go through an emergency room and ask for a show of hands on how many had PLANNED on being there 24 hours ago."
I figure if they can be flip so can I.
The problem is, none of us ever PLAN on having an accident. Otherwise, it wouldn't be called an accident, would it?
And no one PLANS on getting sick . . . especially something like cancer.
Heart disease is still the number one killer, but not for long.
Cancer is closing in.
Globally, an estimated 12.4 million people will be diagnosed with some form of cancer this year and 7.6 million people will die, the U.N. World Health Organization's International Agency for Research on Cancer said in a report.
It is worth noting that is a GLOBAL estimate, not U.S.
U.S. stats may be different, especially the death ratio.
Trends that will contribute to rising cancer cases and deaths include the aging of populations in many countries -- cancer is more common in the elderly -- and increasing rates of cigarette smoking in poor countries.
Apparently those Surgeon General warnings don't appear on cigs sold in poor countries . . .
However, cigarette companies are finding new customers in developing countries. Seffrin noted that 40 percent of the world's smokers live in just two nations -- China and India.
So the Marlboro man is now speaking Mandarin, I suppose.
Decades ago, cancer was considered largely a problem of Westernized, rich, industrialized countries. But much of the global burden now rests in poor and medium-income countries.
Many of these countries have limited health budgets and high rates of communicable diseases, while cancer treatment facilities are out of reach for many people and life-saving treatments are seldom available, Boyle said.
So other countries, like maybe places with universal health care, might not have as many options for cancer patients.
Or they say they just need something for doctor visits since the don't plan on getting sick.
My response is always, "Go through an emergency room and ask for a show of hands on how many had PLANNED on being there 24 hours ago."
I figure if they can be flip so can I.
The problem is, none of us ever PLAN on having an accident. Otherwise, it wouldn't be called an accident, would it?
And no one PLANS on getting sick . . . especially something like cancer.
Heart disease is still the number one killer, but not for long.
Cancer is closing in.
Globally, an estimated 12.4 million people will be diagnosed with some form of cancer this year and 7.6 million people will die, the U.N. World Health Organization's International Agency for Research on Cancer said in a report.
It is worth noting that is a GLOBAL estimate, not U.S.
U.S. stats may be different, especially the death ratio.
Trends that will contribute to rising cancer cases and deaths include the aging of populations in many countries -- cancer is more common in the elderly -- and increasing rates of cigarette smoking in poor countries.
Apparently those Surgeon General warnings don't appear on cigs sold in poor countries . . .
However, cigarette companies are finding new customers in developing countries. Seffrin noted that 40 percent of the world's smokers live in just two nations -- China and India.
So the Marlboro man is now speaking Mandarin, I suppose.
Decades ago, cancer was considered largely a problem of Westernized, rich, industrialized countries. But much of the global burden now rests in poor and medium-income countries.
Many of these countries have limited health budgets and high rates of communicable diseases, while cancer treatment facilities are out of reach for many people and life-saving treatments are seldom available, Boyle said.
So other countries, like maybe places with universal health care, might not have as many options for cancer patients.
More Questions than Answers
What would you do if you found out that your physician was prescribing placebos for your acute medical condition? That's far from a rhetorical question:
My first question is: who's paying for them? If the carrier's being billed, wouldn't the EOB (Explanation of Benefits) give away the game? And if it's not being submitted, then the patient's paying out of pocket for the fake; but are they being charged for the "real McCoy?"
And if this is supposed to be for treatment, how's it being coded? Again, wouldn't the EOB give some indication of what was going on?
And if the treatment consists of a series of placebos (or even some placebos and some med's), how is the provider being reimbursed? Aren't there some ethical considerations in what's being charged for what is essentially a phony treatment? Or has "First, do no harm" devolved into "Don't ask, don't tell?"
[Hat Tip: Holly Robinson]
Flip Flop
Twenty years ago the primary health related concern was how to treat AIDS.
68 percent of the respondents said AIDS was the nation's biggest health woe while 1 percent cited the cost.
Today the worry is about the overall cost of health care.
Concerns about the access and cost of health care far outweigh the worrisome challenges posed by obesity, cancer, heart disease, AIDS and diabetes,
55 percent - said the availability and financial challenges of the entire system
One positive about this survey . . . those polled indicated a worry about the cost of health care, vs. the cost of health insurance.
The two are related, as the cost of health care drives the cost of health insurance.
But this observation caught my eye.
"Health care has never saved a single life. That's more of a theological question. What health care is supposed to do is delay death, overcome disability and pain, and provide medical security
I'm not sure I buy that initial statement . . . health care has never saved a life.
I suppose you can argue the back part of the statement supports the first part. If you save a life it does not mean the individual will never die, so it is true that health care just delays death.
Still, it is a convoluted statement.
In 2007, total national health care expenditures topped $2.3 trillion, or 16 percent of the gross domestic product
But don't overlook this.
providers also suffer; some $60 billion a year in medical bills goes unpaid,
That figure is understated.
The unpaid bills don't include cost shifting. Most bills that are not paid by the patient or a third party are simply added on to the bills of those who DO pay for their care. The rest result in a loss to the provider.
68 percent of the respondents said AIDS was the nation's biggest health woe while 1 percent cited the cost.
Today the worry is about the overall cost of health care.
Concerns about the access and cost of health care far outweigh the worrisome challenges posed by obesity, cancer, heart disease, AIDS and diabetes,
55 percent - said the availability and financial challenges of the entire system
One positive about this survey . . . those polled indicated a worry about the cost of health care, vs. the cost of health insurance.
The two are related, as the cost of health care drives the cost of health insurance.
But this observation caught my eye.
"Health care has never saved a single life. That's more of a theological question. What health care is supposed to do is delay death, overcome disability and pain, and provide medical security
I'm not sure I buy that initial statement . . . health care has never saved a life.
I suppose you can argue the back part of the statement supports the first part. If you save a life it does not mean the individual will never die, so it is true that health care just delays death.
Still, it is a convoluted statement.
In 2007, total national health care expenditures topped $2.3 trillion, or 16 percent of the gross domestic product
But don't overlook this.
providers also suffer; some $60 billion a year in medical bills goes unpaid,
That figure is understated.
The unpaid bills don't include cost shifting. Most bills that are not paid by the patient or a third party are simply added on to the bills of those who DO pay for their care. The rest result in a loss to the provider.
Grand Rounds: Presidential Q&A Edition
Alvaro Fernandez hosts this week's round-up of the best medposts at the SharpBrains blog. In a fascinating and creative twist, he presents his 'Rounds as a Question and Answer session with our President-Elect.
Very cool!
Sunday, December 07, 2008
Collateral Damage
[Welcome Tenant Manager Online readers!]
Home foreclosures.
Job loss.
Bank failures.
Health care providers are feeling the squeeze like many others.
Georgia hospitals, doctors and other medical providers are reporting financial pain from an increase in patients who can’t pay bills —- or who postpone care.
That trend stems, in part, from the rise in Georgia’s unemployment rate, which has swelled the ranks of those without health insurance. In addition, many Americans who have insurance face higher deductibles and other out-of-pocket costs, making a medical bill harder to pay.
I understand, but I also have a problem when health insurance is tied to your job.
If money is tight, I understand raising deductibles (which is something that should be done even if money isn't tight). I have difficulty with those who can afford health insurance but simply refuse to buy it. There are people who believe it is the responsibility of their employer to provide health insurance. If they don't have a job with insurance, they don't feel a compulsion to pay for it themselves.
That makes no sense to me.
The recession also has caused more people to cut back on elective surgeries, scheduled procedures and appointments, and prescription drugs, according to surveys and medical professionals.
Again, some of this makes sense, some not.
I can understand postponing elective procedures.
What I don't understand is cutting back on necessary meds.
People will sometimes cut back or eliminate BP or cholesterol meds. They claim they don't feel any different when they skip the meds so they feel there is nothing wrong with skipping the med.
Why not look for a lower price med rather than stopping meds altogether?
Dr. Harry Strothers, a family physician in East Point, said many patients with chronic diseases are canceling appointments or not showing up. He cited a woman who had an abnormal mammogram.
“She has put off seeing a surgeon because she has a 20 percent co-pay to pay,” Strothers said. “She doesn’t have the money.”
Delaying necessary services can cause more problems later, Strothers said, adding that patients are also not filling prescriptions.
“Going without a medication for hypertension, diabetes or high cholesterol will take its toll later,” Strothers said.
Some things are not worth scrimping on.
Home foreclosures.
Job loss.
Bank failures.
Health care providers are feeling the squeeze like many others.
Georgia hospitals, doctors and other medical providers are reporting financial pain from an increase in patients who can’t pay bills —- or who postpone care.
That trend stems, in part, from the rise in Georgia’s unemployment rate, which has swelled the ranks of those without health insurance. In addition, many Americans who have insurance face higher deductibles and other out-of-pocket costs, making a medical bill harder to pay.
I understand, but I also have a problem when health insurance is tied to your job.
If money is tight, I understand raising deductibles (which is something that should be done even if money isn't tight). I have difficulty with those who can afford health insurance but simply refuse to buy it. There are people who believe it is the responsibility of their employer to provide health insurance. If they don't have a job with insurance, they don't feel a compulsion to pay for it themselves.
That makes no sense to me.
The recession also has caused more people to cut back on elective surgeries, scheduled procedures and appointments, and prescription drugs, according to surveys and medical professionals.
Again, some of this makes sense, some not.
I can understand postponing elective procedures.
What I don't understand is cutting back on necessary meds.
People will sometimes cut back or eliminate BP or cholesterol meds. They claim they don't feel any different when they skip the meds so they feel there is nothing wrong with skipping the med.
Why not look for a lower price med rather than stopping meds altogether?
Dr. Harry Strothers, a family physician in East Point, said many patients with chronic diseases are canceling appointments or not showing up. He cited a woman who had an abnormal mammogram.
“She has put off seeing a surgeon because she has a 20 percent co-pay to pay,” Strothers said. “She doesn’t have the money.”
Delaying necessary services can cause more problems later, Strothers said, adding that patients are also not filling prescriptions.
“Going without a medication for hypertension, diabetes or high cholesterol will take its toll later,” Strothers said.
Some things are not worth scrimping on.