Get Your Drugs Without a Doc

The FDA is considering allowing us to purchase some commonly used medications without a prescription from a doctor. Medications used for high blood pressure or diabetes may be obtained without first seeing a doctor.    


This practice is common in European countries where a pharmacist is allowed to "prescribe" and sell medications.

Under the changes that the agency is considering, patients could diagnose their ailments by answering questions online or at a pharmacy kiosk in order to buy current prescription-only drugs for conditions such as high cholesterol, certain infections, migraine headaches, asthma or allergies.

By removing the prescription requirement from popular drugs, theObama administration could ease financial pressures on the overburdened Medicare system by paying for fewer doctor visits and possibly opening the door to make seniors pay a larger share of the cost of their medications.

So how about birth control pills, or E.D. medication? 

And since this is the government, don't you find it odd that you may be able to purchase medication without a doctor's prescription but if you want to purchase OTC medication and have it covered by your HSA you need a prescription?

Going Nude

Can't afford your health insurance premiums? One Florida motel owner has a better idea.  


The owner of the Fawlty Towers motel in Cocoa Beach has been unable to pay his bills due to increased competition from larger, chain motels. In an attempt to save his business, starting tomorrow (May 1, 2012) the motel will be clothing optional.

Going nude wasn't a snap decision. Owner Paul Hodge first had to convince his skeptical wife. And he has yet to sway some of his concerned neighbors, who fear the soon-to-be nude motel will expose tourists, and local children, to some unwanted sightseeing.

His wife didn't like the idea? Gosh, who would have thought?

To prepare for his guests to bare all, Hodge hired a lawyer and consulted with the American Association of Nude Recreation. They apparently found no state or local laws that would stand in the way of Hodge's plan for unabashed indoor nudity.While that may be the case for Hodge's nude motel, other business owners may want to think twice before adding a naked twist to their business plans. Nudity may reclassify your business as "sexually oriented" (as one nude maid service in Texas recently found out), and may require new permits.

So what has all this got to do with health insurance?

Glad you asked.

Hodge says his nude motel plan is all about his bottom line. "It's sort of a make-or-break situation," he told Florida Today. "We can't pay ourselves in winter. We had to scrap health insurance. 

See? 


And you thought we just posted this to appeal to prurient interests . . .

Maternity Insurance at Costco?

Maternity insurance at Costco? You can buy a 5 pound bag of potato chips, 30 rolls of toilet paper and now in some states you can also buy health insurance. But can you get it with maternity insurance?

Business Insider offers this information about their health insurance, including maternity insurance.

In partnership with Aetna, Costco will dole out the Costco Personal Health plan in several states, according to a company press release – Arizona, Connecticut, Georgia, Illinois, Michigan, Nevada, Pennsylvania, Texas, and Virginia, with more to be added later in the year.

Costco is following the path of Wal-Mart by offering health insurance to their members but do you really get a good deal?

The short answer is, no.

A quick check on Georgia health insurance from Costco including maternity insurance resulted in this finding.

They only offer health insurance through Aetna.

Aetna does not offer maternity insurance coverage. In fact, they never have included maternity insurance as an option.

They only offer 5 plans in Georgia. If you really wanted health insurance from Aetna you can buy it through a Georgia insurance agent and have access to 10 different plans.

The rates for the Costco health insurance plan are slightly less but the coverage has been stripped. In other words, you get less coverage for a lower premium.

Well duh!

The less expensive plans (read higher deductible) do not cover ANY brand name drugs. One plan covers brand Rx only after a $4,000 deductible.

-There is NO maternity care, unless you incur "pregnancy complications." This could be a major deterrent for many consumers, especially considering how important families must be to business.

-Deductibles are sky-high, which is unfortunately a growing trend for private health care plans. For individuals, they range from $3,000 to $7,500 for in-network care and $6,000 to $10,000 for out-of-network care. For families, deductibles start from $6,000 to $15,000 for in-network and $12,000 to $20,000 for out-of-network care. 

Here's a clue to the folks at Business Insider. After Obamacare was signed all Georgia carriers stopped offering maternity insurance except one (BCBSGA). And don't forget that Aetna NEVER offered maternity insurance as an option.

Costco consumers who apply for insurance with Aetna will have to go through medical underwriting which means your premium can increase or you can be turned down.

Costco is a great place to shop for toilet paper but you can do much better on health insurance and your local insurance agent can show you maternity insurance options as well.

Another Ethical Conundrum

Every couple of years, we're required to do a remedial "Anti-Money Laundering"  (AML) course. Basically, it's to remind us to be alert for "suspicious" activity, such as large cash deposits on life policies (among other "red flags"). It's a licensing requirement, and isn't really a big deal (given online, takes maybe a half hour, tops).

I don't think I've ever had a client come in and pay actual cash for a policy, let alone a thousand dollars (the threshold). Still, I want to keep my license, so I do the course as required.

Reason I bring this up is because of a notice I received today from my primary carrier. Towards the end, it says this:

"For your clients who cannot provide and ID, do not proceed until you call [the compliance official] ... Please do not notify your client or give any indication that he or she is being investigated for suspicious activity." [emphasis in original]

Here's the problem: as an independent agent, I represent the carrier, but I work for the client. This instruction puts me in an uncomfortable - perhaps untenable - position: is my first duty to the carrier (and/or the law) or my client? The actual "red flag" in this instance is that I'm supposed to see an official photo ID (driver's license, passport, etc) when dealing with folks whom I do not know who proffer large sums of cash. The key there is "whom I do not know;" that is, if a long-time client and current policyholder walks in with a wad of $100's, well that's different from a total stranger in that circumstance.

Even so, if they're in my office to buy a policy, then aren't they now my client? And how does that comport with my duty not to disclose?

I really don't know what I would do in that scenario, and that is indeed a major conundrum.

Long Term Care Insurance Pays

Long-term care insurance (LTCI) carriers really do pay LTCI claims.

The American Association for Long-Term Care Insurance (AALTCI), Westlake Village, Calif., has published long term care insurance benefit statistics in a report based on its latest industry survey.

The 10 carriers that participated in the survey said they paid $6.6 billion to a total of about U.S. 200,000 policyholders in 2011.

The customer with the biggest open claim is a woman who bought a policy when she was 43, went on claim 3 years later, and at last report, had been receiving benefits for more than 14 years. She paid $881 in premiums per year for 3 years before she stopped paying premiums because she was receiving policy benefits.

The man with the second largest known open claim paid annual premiums of $3,374 for 3 years, went on claim, and now has received $1.2 million in benefits over 6 years, AALTCI says.

AALTCI found that the 5 most common reasons for a policyholder to file a long term care insurance claim are Alzheimer's disease, stroke, arthritis, circulatory issues and injury.

About 8 million U.S. residents now have private LTCI coverage.

Why preventive care should not be covered

There was an interesting article in Friday's Plain Dealer regarding lung cancer screening. The real gem though was an indisputable example of consumerism working in healthcare and why PPACA's preventive coverage requirements are such a terrible idea.

"Last June, University Hospitals Seidman Cancer Center began offering $99 lung cancer screenings for people who have a referral from their primary physicians. On Monday the Cleveland Clinic Respiratory Institute will begin offering screenings for $125."

"UH and the Clinic offer low-dose CT at prices significantly lower than the $300 or more that a person would normally pay, since insurance does not cover the scans" [emphasis added]

If these tests were required coverage under PPACA they would instantly be three times more expensive. To dispel the myth that individuals can't shop for price, supply and demand doesn't apply to healthcare, or consumerism can't work just because University Hospitals and Cleveland Clinic obviously think there is a sufficient market to offer these services and Cleveland Clinic must think these consumers are price sensitive enough to lower their prices close to University Hospital's instead of charging their full normal price.

Why not unleash this power to cut cost 66% instantly on the 40%+ of healthcare that is not urgent or lacking competition?

Capitation, Rationing, The Rain, The Park, and Other Things

Kelley Beloff recently published an important and fact-filled post on physician reimbursement: specifically, fee-for-service vs. capitation.  I think this is an extremely important topic on its own, and it’s also important because it ties to many other key topics in medical delivery and finance – e.g., utilization management and rationing.  I expect we will be seeing much, much more on these topics.  Of course I can’t resist adding my 2 cents.  (Well, it started as 2 cents.  Sorry.)

The Irish playwright George Bernard Shaw was the author of many sharp opinions in the late-19^th and early-20^th centuries - opinions that often stung the comfortable classes of his time, and can still make us moderns uncomfortable.  I quoted Shaw when commenting on Kelly’s post about capitations:

"That any sane nation, having observed that you could provide for the supply of bread by giving bakers a pecuniary interest in baking bread for you, should go on to give a surgeon a pecuniary interest in cutting off your leg, is enough to make one despair of political humanity."

I think this insight is noteworthy.  It comes from the 100-year-old diatribe that introduced Shaw’s play, “A Doctor’s Dilemma”.  Shaw’s point was that fee-for-service payment is incentive for a physician to do more.  But doing more can also mean marginal or even unnecessary services that, as Shaw vividly pointed out, bring unnecessary risk of injury to the patient. 

We moderns find it easy to accept fee-for-service, because it is predominant and familiar, and we perceive it as normal; thus we tend to accept the personal risks that come from medical treatment.   On the other hand, we find it much easier to object to capitation – because we worry that capitation provides incentive for our physician to skimp on treatment.  Thus we perceive personal risk from receiving too little treatment ourselves.  This worries us, even as we read research that shows too much treatment is a general problem, not only for the public health but for the public purse, too. The difference in how these reimbursement methods are perceived is important to keep in mind when thinking about their pros & cons.  

Another commenter on Kelley’s post took exception to my quoting Shaw, based on Shaw’s rather repugnant ideas about what we today call medical rationing.  For example, Shaw said this:

"If you can’t justify your existence, if you're not pulling your weight in the social boat, if you're not producing as much as you consume or perhaps a little more, then, clearly, we cannot use the organizations of our society for the purpose of keeping you alive.”

In the intro to "A Doctor's Dilemma" Shaw stated the same thing another way:   

“In legislation and social organization, proceed on the principle that invalids, meaning persons who cannot keep themselves alive by their own activities, cannot, beyond reason, expect to be kept alive by the activity of others. There is a point at which the most energetic policeman or doctor, when called upon to deal with an apparently drowned person, gives up artificial respiration, although it is never possible to declare with certainty, at any point short of decomposition, that another five minutes of the exercise would not effect resuscitation. The theory that every individual alive is of infinite value is legislatively impracticable

Note  “organizations of our society” in the first citation, and "legislatively” in the second.  Shaw was talking about what we now call government rationing of medical services. 

I think Shaw advocated his position for the same reason that the Obama administration advocates the same position.  That is, in order to have an affordable national medical insurance scheme, there must be some reasonable way to control spending.  Shaw concluded that to control spending the government must deny at least some medical care.  The Obama administration has reached the same decision. In other words, both concluded rationing is necessary. 

NHS rations more explicitly, e.g., thru "NICE".  Other countries ration less explicitly e.g., the queue.  In the U.S. we have rationed largely on price.  But you can be certain that rationing explains why the Obama administration is trying to sell Physician Advisory Panels as necessary under PPACA.   

Shaw advocated a national medical insurance scheme in the U.K. 50 years before NHS arrived.  He felt he had suggested a reasonable basis on which to deny care.  This is a very uncomfortable subject.  But I ask you:  how can a national medical insurance scheme succeed with limited resources, if there is no limit to the expenditure of resources on anyone?  In other words without rationing, how can any national medical insurance scheme be “legislatively practical” within “the organizations of our society” - - to echo Shaw’s terms?   

Yet the issue before Shaw was not simply financial.  It was - and is - a moral and ethical issue, too.  This same moral and ethical issue is present in today's debate about the future of our medical care system.  Advisers to the Obama administration such as Ezekiel Emanuel (Rahm's brother, btw) sound just as rational - and just as repugnant - as Shaw.  However, it's no use to pretend the rationing issue will not exist if we simply ignore it, or to pretend we can safely disregard influential points of view with which we disagree. 

If you are interested, I highly recommend this article: "Principles for allocation of scarce medical interventions" Govind Persad, Alan Wertheimer, Ezekiel J Emanuel; Lancet 2009; 373:423–31.   A link to this article is found within this earlierInsureblog post.  

Thanks Of A Grateful Nation

The Wall Street Journal reported today, April 27, the estimated amounts of overall 2011 premium rebates required by Health Care Reform.  Premium rebates are payable annually by the insurance companies to their policyholders, beginning this year in August.   The reported rebate estimates come from Kaiser Family Foundation. Goldman Sachs has separately estimated similar rebate amounts for 2011.

HHS Secretary The Fair Kathleen opined that the rebate estimates show the health care law “is already strengthening the health care system.”  We'll see about that, Kathleen.

Returning to reality, the estimated average rebate payable to subscribers in small-group plans is $6.30 per month, and for subscribers in large-group plans is $6.00 per month. These estimated rebates thus equal about one half of one percent of the monthly average 2011 family-coverage group insurance premium or about 1.4% of the monthly average 2011single-coverage group insurance premium. Overall, way less than 2%.  

Keep in mind group policies cover the vast majority of privately-insured people. 

For the 7% or so of Americans who are covered by individual policies, Kaiser estimates average rebates of about $10.60 per month per policy, less than 6% of the monthly average 2011 individual policy premium. 

The thanks of a grateful nation are owed to The Fair Kathleen and The Cool Barack.

Yeah, about those MLR "rebates..."

As we've previously noted, when something looks "too good to be true," it generally is. Case in point, the now-estimated $1.3 billion in "rebates" headed towards "lucky" Americans later this summer:

"The nonpartisan [sic] Kaiser Family Foundation, which calculated total rebates at $1.3 billion, says that around $426 million will go to people who bought their own health plans; $541 million will go to large employers and $377 million to small businesses ... Goldman Sachs analyst Matthew Borsch estimated the total rebates at around $1.2 billion."

Hey, what's a few million dollars between friends, really?

The rub here is several fold. First, only fully insured plans are subject to the requirement (as Nate breathes a sigh of relief); since most large employers are self-funded, their plans are exempt (well, for as long as HHS Secretary Shecantbeserious says they are).

Second, we're talking about an average payout of about $127 per policyholder; it's unclear if that's per insured, or just to the premium payer. And don't just assume the latter: with this bunch, no such assumptions are safe.

Third, there's the little issue of taxes: if you're an individual, chances are your refund's going to be non-taxable (unless you've set up a Section 105 plan). But if you're part of a group plan, and your premiums come out pre-tax (such as under a Flexible Spending or POP Account), it appears that you'll be on the hook. And at a measly $127, don't bother waiting by the mailbox for a 1099.

Continuing on for those in group plans, there's the little matter of enforcement. That is, these checks will be going to the employer, not the employees individually. It's up to that employer to distribute the cash. Which presents two more little wrinkles:

How are the employees going to know whether or not that check actually arrived, and how much it was? And how do they make the employer cough it up? Lawsuits for $127?

And from the employer's perspective: how are they supposed to find Sally Jones, who left the company in early 2011? That's over a year before the checks go into the mail, and with our transient society, who knows where she ended up?

Good times, good times.

Cavalcade of Risk #156: Call for submissions

FMF hosts next week's CavRisk. Entries are due by Monday (the 30th).

To submit your risk-related post, just click here to email it.

You'll need to provide:

■ Your post's url and title
■ Your blog's url and name
■ Your name and email
■ A (brief) summary of the post ("Remarks")

PLEASE remember: ONLY posts that relate to risk (not personal finance tips and the like).

Thanks!

ObamneyCare© and The 1rst Amendment: UHC Clarifies

In a pair of emails, United HealthCare helpfully clears up any, um, misconceptions about how HHS Secretary Shecantbeserious is moving forward with coverage for convenience items birth control:

"On March 16, 2012, [Shecantbeserious] issued an advance notice of proposed rulemaking ... to develop alternative ways organizations objecting to coverage of contraceptive services for religious reasons can fulfill [ObamneyCare©] requirements to provide these services."

Here's an easy one: How about scuttling the mandate?

Oh, sorry: too simple and rational. My bad.

More at the link.

The second item focuses on the religious exemption part of the convenience items birth control mandate:

"Qualified religious organizations wishing to exclude contraceptive coverage from their health benefit plans must submit the appropriate [Torquemada-approved] certification with their renewal forms ... no less than 30 days before the next renewal date."

Bet nobody expected that.

Fix Medicare

A majority of Americans believe Medicare is broken and needs to be fixed. A recent survey revealed 83% of Americans felt this way and 51% said major changes were needed.


A Harris Interactive Poll had this to say about Medicare.

"There's a clear majority who think there is a problem that needs to be addressed, but (people also believe) if the changes are going to cost me money in terms of higher co-pays, higher deductibles or higher taxes, no thank you," said Humphrey Taylor, chairman of The Harris Poll.
When people were presented with nine proposals for slowing the rate of Medicare spending, the poll revealed strong approval (72 percent) for cutting the price Medicare pays for prescription drugs to pharmaceutical companies, and modest support for trimming fees to hospitals (47 percent favor, 28 percent oppose) and doctors (41 percent to 35 percent).

Translation - fix Medicare by making health care companies, hospitals and doctors agree to work for less money.

Sounds like a DC "fix".

Few favor higher taxes and out-of-pocket contributions, such as increased co-pays and deductibles. Fifty-three percent and 60 percent, respectively, oppose those options. But a majority said people with higher incomes should pay more for Medicare benefits than lower-income individuals (57 percent favor, 21 percent oppose).

Tax the rich, make the rich pay more for Medicare, but don't ask me to make sacrifices.


Isn't this the way everything in America is these days? Make someone else responsible. Make them pay. Don't expect me to sacrifice. They created this problem, not me.

With 49 million on Medicare now those numbers will grow to 80 million in the next few years as baby boomer's turn 65 and join the ranks of government health care paid for by working taxpayers.

Wonder how our children and grandchildren will feel about that?

A majority of adults (54 percent to 18 percent) polled agree that doctors and hospitals should be paid based on quality and results, rather than the volume of care provided. Even in Washington, D.C., Taylor noted, "there is an acceptance . . . that the traditional fee-for-service way of paying for things is a kind of toxic incentive and needs to be changed."

OK, but who determines the standard of care and how do they gauge quality?

Something tells me this Medicare problem won't be solved any time soon, and some folks will not be happy with the solutions.

Patient Assistance Programs

Patient Assistant Programs (PAP's) have been around for some time. If you have trouble paying for your prescription medication, you should explore PAP options.


What is a PAP?

These are programs set up by drug companies that offer free or low cost drugs to uninsured individuals who cannot afford their medication. Most brand name drugs are found in these programs.

Companies offer these programs voluntarily; the government does not require them to provide free medicine.

Who is Eligible?

Each program has it's own rules. Usually an individual must:

• Be a U.S. citizen or legal resident

• Have no prescription insurance coverage

• Have an income under 200% of the Federal Poverty Level

In some cases, patients who are on Medicare and have a Part D drug plan can still use the services of a PAP.  Ask your prescription drug plan carrier if they will help in applying for assistance.

Several years ago I became acquainted with these programs and have recommended them to friends and clients. Most are large national companies but some are small and "client friendly."
 
Susan Marx is a former client as well as a friend. I have called on her numerous times to help friends and clients find a way to pay for their medication.

SPIN (Special Patients in Need) is a Georgia based Patient Assistance Program with clients all over the country. You do not have to be a Georgia resident to use their services.

They can help you find a way to pay for thousands of Generic or Brand name medications.

SPIN offers a wide range of public assistance programs for low income individuals including free clinics, free cell phones, home mortgage assistance and more.

We invite you to contact Susan at Special Patients in Need if you are on Medicare, or if you are having difficulty in paying for your medications. We've included her website in our "Resources" section in the sidebar.

More ObamneyCare© Lies

The folks behind ObamneyCare© can't make their case legitimately, so they continue to offer up frauds as exemplars.

Latest case in point:

"A Des Moines woman who publicly thanked President Barack Obama on Tuesday for helping her obtain health insurance actually is receiving her coverage through a long-standing state program."

Regular readers won't be surprised, of course, but it's a great object lesson for those on the fence about the existing safety net's availability and efficacy. In this case, a former lawyer (why am I not surprised?) allegedly lost her health insurance along with her job a couple of years ago.

The story gets fishy after that:

"She bought private coverage for her two children"

Really? From whom? We know that the child-only health insurance market started drying up in mid-2010. Was Ms Ibson one of the lucky few whose kids snuck in under the wire?

The mystery deepens:

"[She] could not find it for herself."

Again, why is that? Was COBRA continuation available from her former employer and, if so, why didn't she take it? She claims that "[n]o one would insure me because of my pre-existing conditions," but offers no explanation as to what they are (were?) or with whom she applied.

Why is that?

And then there's this whopper:

"In fact, Ibson’s current coverage is provided by HIP Iowa, a state program for people whose health problems make them ineligible for most commercial insurance."

The program's been around for some 25 years, so it's not as if it needed any boost from DC. Nor is it a net drain on the taxpayer (unlike PCIP): "Most of the program’s subsidies come from fees paid by commercial insurers."

Heh.

There are two major issues with stories like this: first, that the media laps them up uncritically and second, that they so often turn out to be based on lies (or at least obfuscation).

Health Wonk Review: Shiny Happy edition now up

Jennifer Salopek, blogging at Wing of Zock (which, BTW, would make a great name for a rock band), makes a terrific HWR hosting debut. It's obvious that she's read every post, and offers her own insights to each entry.

Kudos, Jennifer!

Shingles Vaccine - Covered by Medicare?

Shingles is a painful. blistering skin rash caused by the varicella-zoster virus. The same virus that causes chicken pox is also responsible for shingles.


The National Library of Medicine has this to say about shingles.

After you get chickenpox, the shingles virus remains inactive (becomes dormant) in certain nerves in the body. Shingles occurs after the virus becomes active again in these nerves years later.
The reason the virus suddenly become active again is not clear. Often only one attack occurs.
Shingles may develop in any age group, but you are more likely to develop the condition if:

• You are older than 60
• You had chickenpox before age 1
• Your immune system is weakened by medications or disease

If an adult or child has direct contact with the shingles rash on someone and has not had chickenpox as a child or a chickenpox vaccine, they can develop chickenpox, rather than shingles.

There are shingles vaccines, but they cannot be administered when you have an active flare up. Two popular shingles vaccines are Zostavax and Varivax.

Your doctor may prescribe a medicine that fights the virus, called an antiviral. The drug helps reduce pain and complications and shorten the course of the disease. Acyclovir, famciclovir, and valacyclovir may be used.
The medications should be started within 24 hours of feeling pain or burning, and preferably before the blisters appear. The drugs are usually given in pill form, in doses many times greater than those recommended for herpes simplex or genital herpes. Some people may need to receive the medicine through a vein (by IV).
Strong anti-inflammatory medicines called corticosteroids, such as prednisone, may be used to reduce swelling and the risk of continued pain. These drugs do not work in all patients.
Other medicines may include:

• Antihistamines to reduce itching (taken by mouth or applied to the skin)
• Pain medicines
• Zostrix, a cream containing capsaicin (an extract of pepper) that may reduce the risk of postherpetic neuralgia

Cool wet compresses can be used to reduce pain. Soothing baths and lotions, such as colloidal oatmeal bath, starch baths, or calamine lotion, may help to relieve itching and discomfort.
Resting in bed until the fever goes down is recommended.
The skin should be kept clean, and contaminated items should not be reused. Nondisposable items should be washed in boiling water or otherwise disinfected before reuse. The person may need to be isolated while lesions are oozing to prevent infecting other people who have never had chickenpox -- especially pregnant women.

Your Medicare Part B covers preventive services, including vaccinations for influenza, pneumonia and Hepatitis B, but not shingles.

Most Medicare Part D plans will cover the shingles vaccine. Check your plan formulary.

Zostavax is a $200 shingles vaccine; Varivax is $100.

If you have trouble paying for your shingles vaccine (or other medications) consider contacting Susan Marx at SPIN (Special Patients in Need).

Speaking of Health Care and Buses...

Following on the (w)heels of Monday's post about mobile hangover care, we have this breast cancer-related item:

"An industry known for selling sex is doing its part to save women’s breasts – as well as their lives. Porn star Bree Olson ... used her assets to raise awareness for breast cancer by hosting a breast exam bus tour around New York City"

According to the American Cancer Society, almost 40,000 women are estimated to die from breast cancer this year. How many of these could be prevented with a simple screening?

And there's this: ObamneyCare© mandates that health insurance policies cover preventive screenings (mammograms) with no deductible or co-pay. So there's very little excuse for putting that off.

But a mammogram-bus?

Hey, whatever it takes to get the word out.

Economics and Consequences

As the economy continues to founder, more and more folks find themselves "underemployed." That is, able to find a job or two, but only on a part-time basis. While that may, in fact, put food on the table and keep a roof over one's head, it creates another problem:

"Fewer workers say they have access to employer-sponsored health coverage."

That's because, in order to be eligible for group cover, one must consistently work a certain number of hours "on the job." So if you're racking up 20 hours at (for example) Fred's Shoes and another 20 at Joe's Cafe, that 40 total hours doesn't get you benefits at either place.

Here's another little clue that the reporterette missed, by the way:

"[E]ven when the unemployment rate fell between 2002 and 2005, it did not appear to have an impact on employer sponsorship of health plans"

Really? And what happened in 2010 that might have changed this calculus, Allison?

Here's a hint.

And now for the big bucks

It's been a while since we reported on efforts by some of the 58 states to force life insurers to keep better track of their customers and beneficiaries. Unfortunately, this doesn't mean that said states have been idle in their efforts:

"MetLife's Landmark Unclaimed Property Settlement Could Approach $700 Million - the settlement was a “huge milestone” ... because it was really changing industry practices by making MetLife ... check monthly and as of April 2103, quarterly, against the Social Security Death Master File."

Which sounds like a great idea, except for this:

"[A]s the SSA has itself acknowledged, the DMF is itself rife with potential errors and misinformation"

Oops.

So now it's become the insurance company's responsibility to track down long-lost relatives, and hope against hope that the information in that Social Security database is accurate.

Rotsa ruck with that.

Here's a question: if insurers are now to be required to track down beneficiaries, how come banks aren't required to track down customers with whom they've lost contact? Why is it okay for the states to have the "unclaimed funds" database but not force them to actively find those owners?

Sauce for the goose, and all that.

PBM = Pharmacy Benefits Merger?

From email:

"It was announced on April 2, 2012, that the FTC commissioners, in a 3-to-1 vote, allowed the merger of Express Scripts, Inc. (ESI) and Medco Health Solutions, Inc. (Medco), pharmacy benefit management partner for [several carriers]."

Perhaps anticipating the usual glitches, the email included this helpful codicil:

"Please assure your groups and members they should experience business as usual while the two companies integrate."

"Business as usual." Why am I not comforted by that?

Breaking Prostate Cancer news

This is heartening:

"[T]he new treatment, which involves heating only the tumours with a highly focused ultrasound, will mean men can be treated without an overnight stay in hospital and avoiding the distressing side effects associated with current therapies."

Having written life insurance on several PC survivors, I'm aware of how much pain and trauma can be involved. And although it's among the most curable of cancers (if caught early on), it's still no picnic.

This new technique holds great promise:

High Crimes and ObamneyCare©?

Maybe. Alert reader Paul D tips us to this little gem:

"The Missouri House thinks the dreaded federal health care reform law is a crime. Or at least a misdemeanor ... the Missouri state House has passed a bill declaring the Affordable Care Act unconstitutional and therefore "altogether void and of no force."

Book 'em, Dano, PPACA-one.

Mobile HangoveRx [UPDATED!]

From the "Finding New Health Care Markets" Department:

"Dalia ... was one of the first patients on the rollout day of a mobile treatment center for tourists who spent the night before drinking ... For a fee, they get a quick morning-after way to rehydrate, rejuvenate and resume their revelry."

Sure beats a Cuppa Joe or a 5-Hour Energy, right?

Well, it better: for almost $100 a pop, "patients" get a "basic IV of saline solution, B vitamins and vitamin C." Another $60 gets a second bag of the magic potion. Door-to-door service is also available (for a fee).

That potion, by the way, also includes a pain-killer and anti-nausea meds.

The service does have certain rules: no alcohol within two hours of treatment, and no service to folks who are still inebriated. Walk-ins and pregnant folks aren't welcome, either.

According to their website, they don't take insurance (and apparently aren't in any PPO networks). One wonders, of course, if the treatment is eligible under HSA, FSA or HRA plans [see update below].

The service is currently available only in Vegas, but who knows: next stop, Atlantic City?

UPDATE: Well, according to my gurus of all things 213d (FSA/HSA/HRA):

"A hangover isn't a medical condition.....generally speaking, FSA/HSA eligible expenses must be for the cure and/or mitigation of a disease or medical condition."

Drat!

Medicare Election Year Politics

Medicare and an election year. Strange bedfellows to say the least. What could be more tailor made for a re-election bid than playing political football with 12 million voters on Medicare?


Add in a political slush fund that does not require Congressional approval or oversight. Money that is controlled by the department of Health and Human Services. Marvelous (unless you are a senior on Medicare).


As the New York Post reports:

The most oppressive aspects of the ObamaCare law don’t kick in until after the 2012 election, when the president will no longer be answerable to voters. More “flexibility,” he recently explained to the Russians.

 But certain voters would surely notice one highly painful part of the law before then — namely, the way it guts the popular Medicare Advantage program.

Still popular, the Medicare Advantage plans have taken hits in recent years causing many seniors to abandon the plans and return to original Medicare and a Medigap plan.

But as part of its hundreds of billions in Medicare cuts, the Obama one-size-fits-all plan slashes reimbursement rates for Medicare Advantage starting next year — herding many seniors back into the government-run program.

Medicare open enrollment is an annual occurrence with floating start and ending dates that generally fall in November and December of each year. The annual election period may start after this years presidential election, but seniors will start to get their Annual Notice of Change several weeks before the election.

But the administration’s devised a way to postpone the pain one more year, getting Obama past his last election; it plans to spend $8 billion to temporarily restore Medicare Advantage funds so that seniors in key markets don’t lose their trusted insurance program in the middle of Obama’s re-election bid.

The money is to come from funds that Health and Human Services is allowed to use for “demonstration projects.” But to make it legal, HHS has to pretend that it’s doing an “experiment” to study the effect of this money on the insurance market

Spend $8 billion to "study" something it is already doing.

A Government Accounting Office report released this morning shows, quite starkly, that there simply is no experiment being conducted, just money being spent. Understandably, the GAO recommends that HHS cancel the project.

It must be an election year.

Sounds like business as usual in DC.

A (Not So) Mighty Fortress

Time again for an update on the on-going battle between life insurers and would-be viatical investors. This time out, the Fortress Investment Group bought a thousand "junk" policies in the hopes that at least a few would pay out the big bucks.

What's a "junk" policy, you ask?

Well, it's a new term to me, as well; it seems to refer to policies other investors had dumped on the market as it became more and more apparent that collecting on them was getting to be problematic. There are two diametrically opposed forces at work here: the (bogus) insurable interest issue and the (very real) issue of fraud.

Part of the problem, of course, stems from the fact that some carriers - Phoenix apparently among them - fell on hard times through the last decade, victims of the economic downturn and their own financial strategies. Faced with the possibility of paying out hundreds of thousands, perhaps millions, of dollars, these carriers are fighting tooth-and-nail to hold onto their assets.

Can't say I blame them.

Auto-erotic Death Claim

Content Warning: While this is, in fact, a post about a specific type of life insurance claim, it refers to a rather unsettling (and adult-themed) "proximate cause."

Accidental Death policies are something of an enigma to me: the idea that one needs (more) life insurance only if death occurs by accident, as opposed to illness, seems absurd. You either need the coverage or you don't; the bank doesn't care if you die of cancer or gun-shot, it wants its money. Now.

We've touched on this subject before, but a recent ruling by a circuit court opens up a rather, um, unusual can of worms:

"A widow has won a bitter victory — her husband’s death by electrocution to the genitals has to be revisited by their insurance company."

Apparently, the late Mr Martin chose to engage in a "specialty" sexual practice, and was electrocuted while so engaged. The Hartford Life insurance company, after investigating the claim, determined that, even though he most likely didn't set out to kill himself, the activity was such that he should have been aware of the possibility (the fact that he was an electrical engineer by trade may have been a clue).

The court, though, made an interesting point:

"The Hartford’s stance “would exclude injuries resulting from merely negligent acts, even if the insured did not intend to injure himself."

A fair cop, really. What if he'd been bungee jumping or skydiving? The principle that these are highly dangerous activities would let the carrier off the hook, right? Heck, driving or flying can be characterized as "dangerous," as well; where does The Hartford get to draw the line?

I'm still not a fan of these kinds of policies, but I have to side with the US Second Circuit Court of Appeals here.

Now Playing...

The world's smallest violin:

"An increasing number of Democrats are taking potshots at President Obama’s healthcare law ... I think we would all have been better off — President Obama politically, Democrats in Congress politically, and the nation would have been better off — if we had dealt first with the financial system and the other related economic issues and then come back to healthcare,” said Rep. Brad Miller (D-N.C.)" [emphasis added]

Ya think?

Then what were you thinking when you decided to pass the bill to learn what was in it?

By the way: interesting prioritization there: the President first (of course!), then your political party, then last (and definitely least) your country.

[Hat Tip: FoIB Holly R]

Friday Afternoon LinkFest

■ On the tech front, Humana's developed a new app "that helps employees make sound healthcare decisions." Over the next few years, according to Humana, more than a half a billion folks will be using their smart phones to help them manage their health care.

Who knew?

■ From the "Scant Comfort" files:

"Cost increases for health care are perhaps finally slowing down, with employer health benefit expenditures not expected to increase in 2012 at the same explosive growth in recent years. Costs for all types of medical plans are expected to increase by 9.9% for 2012"

This is what drives me so crazy: it is not health care costs, it's health insurance costs, you moronic cretins. And these folks are supposed to be a premier industry resource?

Sheesh!

■ FoIB Holly R tips us to this item from the "Department of D'uh:"

"Hospitals targeting well-insured patients, report says ... Targeted expansion to “capture” well-insured patients is a hot trend across the country ... Hospitals that are dominant in their market are the most likely to be pursuing geographic expansion"

For real?

And this is a surprise, why?

Of course hospitals (and any other provider that wants to stay in business) needs to shore up their revenues, and it doesn't take a rocket surgeon to know that increasing services and/or locations is the way to go.

An American Doctor Looks at Britain's NHS

What happens when an American doc compares Obamacare to the British National Health Service? It is not a pretty sight:

My time in the British National Health Service in the 1980s was a tremendous learning experience. England still has incredible clinicians who can do remarkable work with scarce resources. The truth, however, is that working at an NHS hospital is like taking a time machine back 20 years. The infrastructure, equipment, surgical tools and medications are backward by comparison to any medium-sized hospital in the United States. The irony is that many nations afflicted with Obamacare systems have moved toward private, decentralized approaches. When teaching medical students about health care economics, I point out that the cell phone revolution began when President Ronald Reagan dismantled the market monopoly of AT&T.

I told you it was scary, yet this is what the American public wants.

Or do they?

I believe that a decentralized, patient-focused approach can work. Health insurance can be less expensive if more insurance companies compete with products that people actually want, not those their employer or the government think they need.

Actually, carriers do provide products that people want.

Cost efficiencies will happen when people use at least part of their own money to pay for health care. Futile, ridiculously expensive end-of-life treatments occur when the bill can be off-loaded onto unsuspecting taxpayers. Lastly, enormous savings will follow reform of the medical malpractice circus.

Copay plans, low deductibles, unlimited doctor visits and small payments for ER visits are quite popular which continues to fuel demand for this kind of plan. High deductible HSA plans, while popular, only comprise around 20% of plans in force.

There is some truth to what Dr. Galyon says, who wants to be the one to tell your terminally ill family member if they want to continue living they will have to absorb the cost themselves?

Malpractice claims comprise a relatively small direct cost that is factored in to health care prices, but redundant testing for CYA purposes is excessive.

BREAKING: MLR = More Lovely Revenues [UPDATED]

"UnitedHealth Group Inc. had no complaints about the effects of the new medical loss ratio (MLR) on first-quarter earnings ... MLR-related adjustment added $130 million to its profits for the quarter."

Why does HHS Secretary Shecantbeserious love insurance carriers so much?

UPDATE (from comments): Bob notes some additional issues with this:

What is really fun is when the rebate goes back to an employer who is then supposed to divvy up the rebate among all participants if the plan was contributory. This would include participants only on the plan a few months and those who are no longer employed.

Which is one more nail in the employer-based health insurance coffin. Imagine that nightmare.

Bob also observes:

The rep told me at least one carrier ... is going to charge back any commissions paid to agents an amount equal to the rebates offered on their clients.

As we noted regarding insureds' tax liability, this also opens a major can of worms: that charge-back means that the agent (and his agency, if applicable) will have to re-file the previous year's taxes. OTOH, one supposes this will be a gold mind for the CPA's.

Old Dog, New Trick

Regarding the recent VEBA post, I did want to mention something else I learned in that class: Short Term Medical plan alternatives.

As Bob noted a while back, Short Term Medical (STM) plans are a convenient and relatively inexpensive way to bridge the gap between coverage (eg new job waiting period) but do have some definite drawbacks.

Thing is, folks are drawn to STM for (primarily) price and simplicity. Most folks can't imagine actually needing to use it (to be fair, most folks don't anticipate "using" their car or home insurance, either); it's mostly "peace of mind" coverage.

For me (and, I suspect Bob), the two major problems with STM plans are that they don't cover pre-existing conditions (especially relevant when one plan expires and a new one begins), and coverage expires when the policy does (with some very specific and rare exceptions).

Still, convenience and price are powerful motivators, and so most of us continue to offer these plans to our clients and prospects.

So what, you may be thinking, does this have to do with that CE class I keep bringing up?

Just this:

The instructor was also very concerned about the pitfalls of STM, and suggested using [her company's low-cost, no-frills] plan. The downside to this method is that underwriting can take longer for this than a STM, but using the electronic application process can significantly shorten the processing time. The pricing on this plan is (ostensibly) comparable to the STM, but this method offers two distinct advantages:

Since it's major medical, you keep the plan as long as you want to (3 months or 30). And if you end up not lasting through the new employer's waiting period, you're all set with insurance while you keep looking.

But there's another, more serious but generally less well known issue: the "active at work" clause. No, it doesn't mean that you're setting new production records. Rather, it means that group insurance plans require you to be actively at work on the first work day of eligibility. This seems innocuous, until you consider what might happen if that first day is the Monday following the weekend during which you totaled your car, and you're still in the ICU: your STM ended Sunday night, and your new group plan isn't in place (you're not "actively at work," are you?).

Creek. Paddle. Some assembly required.

Using the (inexpensive) no-frills major medical plan, however, obviates all of this. Whether or not you're at work on Monday is irrelevant, and you don't have to worry that the plan ends at midnight.

Two caveats: first, a given person might qualify for the STM but not the "regular" medical plan. And second, these "no frills" plans will cease to exist come 2014 (Thanks, ObamneyCare©!).

[Hat Tip: Beverly D]